Clinical Imaging 48 (2018) 90–105
Contents lists available at ScienceDirect
Clinical Imaging
journal homepage: www.elsevier.com/locate/clinimag
Mimics of acute appendicitis—Alternative diagnoses at sonography, CT, and
MRI; specific imaging findings that can help in differential diagnosis
Huseyin Toprak, Temel Fatih Yilmaz, Seyma Yildiz⁎, Ihsan Turkmen, Serpil Kurtcan
Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
1. Introduction
Acute right lower quadrant abdominal (RLQ) pain is one of the most
common causes of presentation to emergency department. In most pa-
tients presenting with acute right lower quadrant pain, acute appen-
dicitis needs to be excluded, especially in male patients. However, a
broad spectrum of pathologies may mimic acute appendicitis both
clinically and on imaging findings [1–5]. Therefore, to make a differ-
ential diagnosis in patients with acute RLQ pain with suspicion of acute
appendicitis is very important to avoid misdiagnosis which may result
in delayed treatment or lead to the removal of a normal appendix [6].
The two most common imaging modalities in use are contrast enhanced
computed tomography (CT) (with a sensitivity and specificity higher
than 90%), especially in old and obese patients, and abdominal ultra-
sound (US) (with a sensitivity and specificity higher than 80%), espe-
cially in children and young female patients [7,8]. In a situation in
which normal or inflamed appendicitis could not be demonstrated by
US, clinical follow-up, scoring systems including Alvarado, laporo-
scopy, CT and magnetic resonance imaging (MRI) can be used in the
diagnosis of the acute appendicitis [9]. Abdominopelvic MRI should be
preferred in young females especially in pregnant patients due to the
risk of radiation. In this review, we discuss conditions presenting with
acute abdominal pain mimicking acute appendicitis. Imaging findings
of these mimics along with features that help us to differentiate them
from appendicitis will be emphasized. Disorders such as mucocele, and
endometriosis presenting usually with chronic abdominal pain, and
disorders such as abdominal wall hernias can be diagnosed by thorough
physical examination were excluded.
2. Normal and pathologic appendix
On sonography, a normal appendix has a maximum outer diameter
of 6 mm with graded compression, is surrounded by homogeneous
noninflamed fat, is compressible with wall thickness of less than or
equal to 3 mm, and often contains intraluminal gas. Identification of a
fluid-filled, non-compressible, blind-ended tubular structure with a
diameter more than 6 mm is consistent with acute appendicitis on US
[9]. Presence of an appendicolith, cecal apical thickening, increased
⁎
Corresponding author.
E-mail address: seyildiz@bezmialem.edu.tr (S. Yildiz).
http://dx.doi.org/10.1016/j.clinimag.2017.10.001
Received 25 February 2017; Received in revised form 13 September 2017; Accepted 2 October 2017
0899-7071/ © 2017 Elsevier Inc. All rights reserved.
MARK
echogenicity of periappendiceal fat and hypervascularity of the ap-
pendix wall on color Doppler sonography are additional radiological
findings [6,8]. When the appendix is filled with air and measured less
than 9 mm in diameter, it should be considered as normal on CT
[10,11]. CT findings of acute appendicitis include distended appendix,
more than 6 mm; periappendiceal fatty stranding and infiltration; ap-
pendiceal wall enhancement or thickening; presence of appendicolith;
cecal apical wall thickening compared with the normal thickness of the
wall of the ascending colon; and presence of extraluminal fluid col-
lection or gas bubbles around the appendix (Fig. 1) [10,12–15]. When
an appendix filled with air and measured less than 9 mm in diameter is
demonstrated on CT, this should be considered as normal [8].
3. Conditions mimicking acute appendicitis
3.1. Epiploic appendagitis
Epiploic (or omental) appendages, are 50–100 pedunculated fatty
structures that arise from the antimesenteric serosal surface of the
colon, to which they are attached by a vascular stalk and arranged in
two separate longitudinal rows next to the anterior and posterior tenia
coli over the external aspect of the colon, with the exception of rectum
[16]. Torsion of epiploic appendages, with resultant vascular occlusion
or venous occlusion that leads to ischemia, has been implicated as the
cause of acute epiploic appendagitis which is a benign self-limiting
inflammatory process [17]. Sigmoid colon is most common location for
epiploic appendagitis. This condition may be mistaken for appendicitis
when present in the right lower quadrant. US findings in patients with
primary epiploic appendagitis include a hyperechoic noncompressible
ovoid or round solid mass surrounded by a subtle hypoechoic line near
the colonic wall at the point of maximal tenderness, absence of changes
in the colon wall itself, and lack of central blood flow on Doppler US.
This subtle hypoechoic line that surrounds the hyperechoic mass cor-
responds to the hyperattenuating ring on CT scans [18]. On helical CT,
the lesion shows a characteristic appearance as an oval shaped
1.5–3.5 cm fat-attenuation paracolic mass with a hyperattenuating rim
associated with the serosal surface of the adjacent colon [19] (Fig. 2).
Occasionally, adjacent colonic wall thickening and mild inflammatory
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 1. 23-year-old man with acute appendicitis. Axial

(A) and coronal contrast-enhanced abdominopelvic CT
(B) show enlarged appendix with a diameter of 10 mm
medial to iliac vessels (white arrows) and fat stranding
around the dilated appendix (arrow head). Appendix
also shows wall enhancement. C = Cecum.

Fig. 2. 40-year-old man with right lower quadrant abdominal pain. Axial (A, B) and coronal (C) contrast enhanced abdominopelvic CT scan show fat-containing lesion (thin arrows) with
hyperattenuating rim, fat stranding and with “central dot” (thick arrow) in right lower quadrant adjacent to cecum (C), consistent with epiploic appendagitis.

Fig. 3. 47-year-old man with right-sided diverti-

culitis. Axial (A, B) and coronal (C,D) abdomi-
nopelvic CECT shows multiple diverticula (ar-
rows) with pericolonic fat stranding (arrowhead).

91
H. Toprak et al.
changes of the surrounding fat secondary to spread of inflammation
may be seen. The presence of central “dot” of increased attenuation due
to the thrombosed vein within the inflamed appendage seen in about
half of the cases is useful for diagnosis.
3.2. Right-sided colonic diverticulitis
A colonic diverticulum is an abnormal sac which intestinal mucosa
prolapses through muscular layers [20]. Right-sided colonic diverticu-
litis is an uncommon but clinically significant complication of right
92
Clinical Imaging 48 (2018) 90–105
Fig. 4. Omental necrosis in a 56-year-old woman.
Transverse grayscale ultrasound image of right
lower quadrant (A) demonstrates heterogenous
hyperechoic nonmobile noncompressible fixed
mass (arrows) consistent with inflammed fat
tissue. Axial (B) and coronal (C) contrast en-
hanced CT demonstrate heterogenous fatty mass
with hyperattenuated streaks (thick arrows) lo-
cated between anterior abdominal wall and right
colon with minimal adjacent colonic wall thick-
ening (arrowhead).
Fig. 5. Right distal ureter in a young man. Non-
contrast axial (A) and coronal (B,C) CT scan show
radioopaque 7 mm calculus at distal ureter
(arrow). Coronal CT scan (C) shows dilatation of
right renal collecting system (arrows).
sided diverticula that causes right iliac fossa pain and closely mimics
acute appendicitis [21]. It has a tendency to occur in younger patients.
It is more likely to bleed. Surgical treatment is commonly required.
Differentiating right-sided diverticulitis which is a self-limiting condi-
tion from appendicitis can be difficult, and a large proportion of right-
sided diverticulitis has been misdiagnosed clinically as acute appendi-
citis [22]. The helical CT findings usually consist of asymmetric mural
thickening of the cecum, presence of diverticula and pericolonic fat
stranding [19] (Fig. 3). Thickening of the lateral conal fascia and ab-
scess in anterior pararenal space may also be seen.
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 6. Transverse pelvic sonograms (A,B) reveal a hemorrhagic cyst in the right ovary with reticular pattern of internal echoes (thin arrows). Transverse pelvic sonogram (C) also shows
retracted clot (thick arrow). Doppler image shows no vascularity within the lesion.

Fig. 7. Axial (A) and coronal (B) contrast en-

hanced abdominopelvic CT demonstrate slightly
enlarged mesenteric lymph nodes (arrows) in a
18-year-old man with right lower quadrant pain
and mild fever.

93
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 8. Transverse sonogram (A) shows a complex cystic mass in the right lower quadrant consistent with abscessed mesenteric lymph node in a 10-year-old girl with abdominal and
fever. Color Doppler image (B) shows prominent vascularization around the lesion.

Fig. 9. DW images of the same patient show a hyperintense lesion (A) and a low ADC (B) indicating restricted diffusion (arrows). Axial T1-weighted contrast enhanced MRI (C) shows
peripheral contrast enhancement and axial T2-weighted MRI (D) shows complex cystic lesion with fluid-fluid level. Mesenteric lypmhadenopathy with central abscess formation was
pathologically proven.

3.3. Omental infarction
Segmental omental infarction is a relatively uncommon cause of
acute abdomen resulting from vascular compromise of the greater
omentum. About 15% of cases occur in pediatric age group. Its diag-
nosis appears to be increasing in frequency, probably as a result of the
increased use of CT for suspected acute appendicitis, diverticulitis and
renal colic. Ultrasound shows a large solid, hyperechoic, and non-
compressible, non-mobile fixed mass, deep to the area of focal
tenderness. CT demonstrates a heterogeneous fatty mass usually greater
than 5 cm between anterior abdominal wall and ascending or trans-
verse colon, adherent to parietal peritoneum and contains strands of
soft tissue attenuation (Fig. 4). It is usually on the right side, but may be
on the left [23].
3.4. Urolithiasis
Urinary tract disorders especially urinary tract obstruction caused

94
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 10. Infectious ileocolitis in 5-year-old boy. Transverse sonograms (A,B,C,D) show wall thickening of the terminal ileum and cecum with enlarged mesenteric lymph nodes consistent
with infectious ileocolitis (C). Color flow Doppler ultrasound image (E) shows increased mural flow.

Fig. 11. Sonograms demonstrate the typical thickening of cecum (A, B) and ileum (C) in active Crohn's disease with wall layer retention. Transverse sonogram (D) shows fistula originated
from terminal ileum with bright echogenic foci consistent with gas. Transverse sonograms (E,F) show a 8-mm inflammed appendix (arrows).

95
H. Toprak et al.
by a calculus commonly present with acute right lower abdominopelvic
pain. On ultrasonography, dilated pelvicalyceal structure with accom-
panying proximal ureteral dilatation is the most common finding of
urinary obstruction. On computed tomography dilated collecting
system, fatty stranding around ureter and kidney, and calculus re-
sponsible for obstruction are most common findings (Fig. 5). Visuali-
zation of normal appendix help in differentiating this condition from
96
Clinical Imaging 48 (2018) 90–105
Fig. 12. CT scans of same patient. Axial contrast
enhanced CT scan (A) demonstrates a fistula tract
extends from terminal ileum to right psoas
muscle (thin arrow). Coronal contrast enhanced
CT scan (C) demonstrates thickened inflamed
terminal ileum with mucosal enhancement. Axial
(B) and coronal (D) contrast enhanced CT scans
demonstrate inflammed minimally dilated ap-
pendix (arrowhead), thickened cecum and term-
inal ileum (thick arrow).
Fig. 13. 37-year-old man with Crohn's disease
involving appendix. Coronal (A) and (B) sagittal
contrast enhanced CT scans demonstrate cir-
cumferential wall thickening at ileocecal valve
level and dilated inflamed appendix.
acute appendicitis due to fact that dilated ureter may mimic acute ap-
pendicitis radiologically [6].
3.5. Hemorrhagic ovarian cyst
Hemorrhagic ovarian cysts, especially on the right side are the most
frequent cause of abdominopelvic pain mimics appendicitis in young
H. Toprak et al.
women. Sonographic appearance of the hemorrhagic ovarian cysts
varies with the amount of hemorrhage and time of the sonographic
examination. On ultrasonography well circumscribed complex cystic
lesion with low- level echogenicity in a fine, lacelike, or reticular pat-
tern and some degree of posterior through- transmission are the major
findings and also if ruptured free fluid located in pelvis is seen [24]
(Fig. 6). Hemorrhagic ovarian cysts may also appear as solid masses on
ultrasound, especially in acute stage. On CT, a hemorrhagic ovarian cyst
appears as a well-circumscribed structure with attenuation (25–100
HU) greater than that of simple fluid. Rupture of the ovarian cyst re-
sulting in free high-attenuated pelvic fluid and/or fat stranding may
mimic acute appendicitis [19]. More acute clinical presentation of
rupture of a hemorrhagic ovarian cyst, presence of high density in-
traabdominal fluid in all abdominal quadrants, and absence of free air
97
Clinical Imaging 48 (2018) 90–105
Fig. 14. Axial (A) and coronal (B) CECT shows
striated nephrogram (arrows) in right kidney
consistent with acute pyelonephritis.
Fig. 15. 60-year-old man with fever and acute
right abdominal pain. Axial (A) and coronal (B)
contrast enhanced CT images demonstrate short
segment thickening of the ascending colon (ar-
rowheads) with extensive pericolonic gas and fat
stranding. (arrows). Right colonic carcinoma
with perforation was confirmed surgically.
consistent with perforated appencitis may help in differential diagnosis.
3.6. Mesenteric adenitis
Mesenteric adenitis is a benign and inflammatory situation of me-
senteric lymph nodes which mostly mimics acute appendicitis with
severe abdominal pain. Visualization of normal appendix is necessary
for the diagnosis. On US hypoechoic, ovoid and multiple lymph nodes
are seen at mesenteric areas. On CT, clustered enlarged multiple lymph
nodes in the RLQ are seen (Fig. 7) [25]. Rarely abscess formation may
be seen as a complication of mesenteric lymphadenitis (Figs. 8, 9).
H. Toprak et al.
3.7. Infectious ileocolitis
Infectious ileocolitis is one of the diseases mimicking acute appen-
dicitis which is frequently caused by Yersinia, Campylobacter and
Salmonella organisms. The characteristic CT and US features of in-
fectious ileocolitis include wall thickening of the terminal ileum,
cecum, and ascending colon and enlargement of the mesenteric lymph
nodes (Fig. 10). On Color Doppler US increased mural flow is seen
(Fig. 10). Depiction of the normal appendix without periappendiceal
inflammatory changes helps to exclude appendicitis [2].
3.8. Crohn disease
Crohn disease has a propensity to involve the terminal ileum and
the cecum and less commonly the appendix. On US, wall thickening,
creeping fat, mesenteric lympadenopathy, and strictures can be seen
(Fig. 11). On color Doppler US, hyperemia is present in active phase of
the disease. CT findings of Crohn disease include discontinuous asym-
metric wall thickening, increased contrast enhancement of the thick-
ened bowel wall, minimal narrowing of the bowel lumen, creeping fat,
and enlarged mesenteric lymph nodes (Figs. 12 and 13). Complications
such as abscesses, fistulas, obstruction, and perforation can also be
demonstrated with CT and US (Fig. 13). Long segmental circumferential
wall thickening of the terminal ileum and cecum, and inflammation
98
Clinical Imaging 48 (2018) 90–105
Fig. 16. Ischemic enteritis in 48-year-old man
due to superior mesenteric vein thrombosis. Axial
(A), coronal (C) and sagittal (D) CECT show hy-
podense thrombus within the lumen of the su-
perior mesenteric vein (arrow). Axial (B) and
coronal (C) CECT show mural thickening of the
ileal segments (arrowhead).
that is centered away from the appendix and secondary sign as fi-
brofatty proliferation are the major features that help differentiate
Crohn disease from the reactive changes seen in appendicitis [26].
Perforated appendicitis resulted in nonvisualization of appendix with
extensive inflammatory changes may mimic complicated Crohn disease.
Demonstration of normal or inflamed appendix in Crohn disease may
help in differential diagnosis.
3.9. Acute pyelonephritis
Acute pyelonephritis is a common appendicitis mimicking condition
especially if it occur at right side. Flank pain and urinalysis may help in
differential diagnosis clinically. The main sonographic findings of
pyelonephritis are localized or generalized enlargement of kidney,
compression of the renal sinus, poor corticomedullary differentiation,
focal areas of decreased echogenicity (edema) or increased echogeni-
city (hemorrhage), and poorly marginated masses [27]. On CT, nu-
merous low attenuation wedges and streaks in the renal parenchyma
with associated focal or diffuse enlargement and perinephric fat
stranding are present and allow to differentiate from acute appendicitis
(Fig. 14) [8].
H. Toprak et al.
Fig. 17. Meckel's diverticulitis. Transverse ultrasound images (A,B,C) in a child with right lower quadrant pain and fever who was referred for probable appendicitis reveal a tubular
structure originating from ileum consisting with Meckel's diverticulitis (Arrows). Color Doppler images (D,E) demonstrate hypervascularity (arrowheads).
3.10. Colonic malignancy
Acute right lower quadrant pain, usually due to perforation or ob-
struction, may be the initial presentation of a malignancy involving the
ileocecal region, such as adenocarcinoma, lymphoma, gastrointestinal
stromal tumor, or metastasis. On US and CT, asymmetric colonic wall
thickening, short segment involvement, and sudden change from a
normal to an abnormal segment of colon are the key features that help
to distinguish this from other pathologies. When perforation occurs,
this condition radiologically may mimic perforated acute appendicitis
due to fat stranding, free air and fluid collections in the right lower
quadrant (Fig. 15) [28].
3.11. Mesenteric ischemia
In older patients, bowel ischemia is the one of the most common
causes of abdominal pain. The first imaging modality in a patient with
suspected bowel ischemia is contrast enhanced CT to demonstrate the
thrombus material in mesenteric vessels and to see secondary changes
such as bowel wall thickening, fat stranding and pneumatosis in-
testinalis if infarction occurs (Fig. 16) [29]. Enhancement of the bowel
wall in ischemia can be normal, increased or there can be lack of en-
hancement.
99
Clinical Imaging 48 (2018) 90–105
3.12. Meckel diverticulitis
Meckel diverticulum is located on the antimesenteric border, ap-
proximately 60 to 100 cm from the ileocecal valve. On US, the inflamed
cystic Meckel diverticulum will manifest as a thick wall mass with “the
gut signature” and wall hyperemia on color Doppler (Fig. 17). On CT,
Meckel diverticulitis appears as a cystic mass with surrounding in-
flammation, which is sometimes associated with small bowel obstruc-
tion (Fig. 18). However, an inflamed Meckel diverticulum can bear
striking resemblance to acute appendicitis on imaging, appearing as an
enlarged tubular mass surrounded by inflammatory changes [30].
Origin of enlarged tubular mass (Meckel diverticulum from ileum, ap-
pendix from cecum) may help clinicians in differential diagnosis.
3.13. Ovarian torsion
Ovarian torsion is a gynecologic emergency which can mimic ap-
pendicitis. It comprises 2–3% of gynecologic emergencies. Gray-scale
ultrasound findings include an enlarged ovary, ovarian mass, free fluid,
follicles at the periphery of an enlarged ovary, thickening of a cyst wall,
and a twisted pedicle (Figs. 19, 20). Color Doppler US examination may
show no flow in the affected ovary (Figs. 19, 20). Doppler findings may
change depending on the degree and chronicity of the torsion, and with
the presence of an adnexal mass. Addition to US findings, features that
H. Toprak et al.
Fig. 18. Axial CECT scans (A,B) in a young woman with acute right lower quadrant
abdominal pain show a blind-ending tubular structure arising from distal small bowel
consisting with Meckel diverticulum (Arrowheads). Note the inflammation of the sur-
rounding fat (arrows).
Fig. 19. Right ovarian torsion. Transabdominal US images (A,B) in a young woman with acute right lower abdominal pain show enlarged right ovary with increased heterogenous
echogenicity consistent with hemorrhage. On color Doppler evaluation (C,D) no flow was seen in the right ovary.
100
Clinical Imaging 48 (2018) 90–105
are better seen with CT or MRI include subacute ovarian hematoma and
abnormal or absent ovarian enhancement, and diffusion restriction
consistent with infarct on diffusion weighted images (Figs. 21, 22, 23)
[31].
3.14. Intussusception
Intussusception is a common gastrointestinal emergency especially
in pediatric patients. It involves the invagination of a segment of small
bowel into a segment of adjoined intestinal lumen and is the most
common cause of small bowel obstruction in children. The incidence of
intussusception is approximately 0.2%. Commonly, the terminal ileum
telescopes into the colon and causes right lower quadrant pain like
acute appendicitis. Ultrasound may show small bowel intussusception
as a crescentin-doughnut or multilayered “onion skin” round mass on a
transverse scan and as the short segment sandwich sign on longitudinal
scan (Fig. 24). On CT, there are three findings that are characteristic:
intraluminal soft tissue mass with an eccentric fat density due to in-
vaginated mesentery (target pattern), reniform or bilobed mass with
peripheral high attenuation due to thickened bowel wall (reniform
pattern), and a sausage-shaped mass with alternating areas of high and
low attenuation due to bowel wall, mesentery, and intestinal gas, fluid,
or oral contrast (sausage-shaped pattern) (Fig. 24) [32].
3.15. Rupture of ectopic pregnancy
Ectopic pregnancy occurs when the developing blastocyst becomes
implanted at a site other.
than the endometrium of the uterine cavity. Ectopic pregnancy has
an incidence of approximately 2% of all reported pregnancies and ac-
counts for 9% of all pregnancy-related deaths. On US atypical locali-
zation of gestational sac with free fluid at lower abdominal regions can
be seen. On MRI, tubal rupture may be seen as disruption of tubal wall
enhancement and the presence of acute hematoma, as shown by distinct
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 20. Transabdominal transverse sonograms (A,B) of a young woman with acute abdominal pain demonstrate a large cyst (arrows) with mural nodule (arrowhead) adjacent to
enlarged right ovary (O). Color Doppler images (C,D,E) demonstrate no flow within ovary and around the cystic lesion. Right ovarian torsion which led to necrosis caused by a
cystadenofibroma was confirmed at surgery.

Fig. 21. Axial (A) and coronal (B) contrast en-

hanced CT scans demonstrate large cystic mass
adjacent to right ovary (arrow). Enlarged right
ovary demonstrates peripheral heterogenous
contrast enhancement. Surgery confirmed
ovarian torsion due to large cystic mass.

low signal intensity located outside the implantation site on T2-
weighted images. On CT, a complex adnexal mass with diffuse hemo-
peritoneum can be seen. High-attenuation focus, indicative of active
bleeding may also be seen (Fig. 25). On CT, findings of ruptured tubal
pregnancy include the aforementioned CT appearance of an ectopic
pregnancy accompanied by hemoperitoneum [33].
3.16. Torsion of pedunculated subserous myoma
Pedunculated subserous myoma torsion is a rare cause of acute
abdomen and mimics acute appendicitis and ovarian torsion. On T2
weighted images of MRI heterogeneous signal intensity with T2 hy-
perintense cystic regions present at large and well circumscribed lesion
with lack of enhancement on contrast enhanced images. Diffusion

101
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 22. Axial, coronal, and sagittal T2-weighted images (A,B,C) demonstrate a complex cystic mass with fluid-fluid level (black arrow). Enlarged right ovary with multiple peripheral
milimetric cysts (black thick arrow). Unenhanced axial T1-weighted MR image (D), contrast enhanced fat-saturated coronal (E) and axial (F) T1-weighted images demonstrate no contrast
enhancement of the complex cystic lesion and right ovary consistent with ovarian torsion.

Fig. 23. Right ovarian torsion due to a hemorrhagic cyst in a 13-year-old girl with right lower quadrant pain. Axial fat-saturated unenhanced T1-weighted (A) image demonstrates
hyperintense hemorrhagic ovarian cyst within the enlarged right ovary (black arrow) Axial (B) and sagittal (C) fat-saturated contrast enhanced T1-weighted images demonstrate no
contrast enhancement of the right ovary (arrowhead). Axial (D) and sagittal (E) T2-weighted MR images demonstrate hyperintense hemorrhagic cyst within the ovary and simple cyst in
the periphery of the ovary. Sagittal fat-saturated contrast enhanced T1-weighted image (C) also demonstrates rim enhancement of the simple cyst (white arrow). DW image (G) shows
hyperintense signal change medial to hemorrhagic cyst and ADC image shows (F) low signal in the same area indicating restricted diffusion (black thick arrows).

restriction is also present (Fig. 26). Demonstration of both normal ovary
and the connection of lesion with uterus is the way to differentiate it
from ovarian torsion [34].
3.17. Pelvic inflammatory disease and tubo-ovarian abscess
A tubo-ovarian abscess (TOA) usually results as a complication of
untreated or inadequately treated acute pelvic inflammatory disease
and a common appendicitis mimicking condition of female patients.
Ultrasound (US) especially transvaginal (TVUS), is the most commonly

102
H. Toprak et al.
utilized imaging modality in cases with suspicion of PID/TOA.
Ultrasound examination of TOA usually will show a complex adnexal
structure with thick walls, internal echoes likely pus with cellular debris
and septations Color Doppler US may show increased peripheral vas-
cularization. During the TVUS examination patients may exhibit sen-
sitivity over the area of the fluid collection [35]. A tubular
103
Clinical Imaging 48 (2018) 90–105
Fig. 24. Long segment ileoileal intussusception in
a 69-year-old man with acute abdominal pain.
Coronal (A) and axial (B) contrast enhanced CT
scans show long segment ileoileal intussusception
with invaginating mesenteric fat (arrow).
Transverse sonogram (C) in the same patient
shows multiple concentric rings of representative
of invaginating intussuscipiens and the in-
tussusceptum (arrowhead).
Fig. 25. Ectopic pregnancy rupture in a 28-year-
old woman with acute pain and clinical suspicion
of acute appendicitis. Axial (A) and coronal (C)
CT scans show high attenuated fluid collection in
the pelvis (arrows). Ring like high attenuation
foci surrounding the right adnexa, indicative of
active bleeding consistent with ruptured ectopic
pregnancy. Ectopic pregnancy rupture in a 42-
year-old woman with acute pain. Axial (B) and
coronal CT (D) scans show cystic lesion with ge-
stational sac consistent with ectopic pregnancy
(arrowheads). CT scans also show high atte-
nuated fluid in the pelvis and around the liver.
Coronal CT scan shows metallic intrauterine de-
vice (black arrow).
configuration is more suggestive of a pyo- or hydrosalpinx, and may be
confused with a dilated appendix on CT or US, especially when in-
volvement is limited to only right fallopian tube. Contrast- enhanced CT
usually shows thick enhancing wall fluid density adnexal mass
(Fig. 27). This mass may contain fluid-fluid levels or gas. On MRI, TOA
is usually seen as a pelvic mass with low signal intensity on T1-
H. Toprak et al. Clinical Imaging 48 (2018) 90–105

Fig. 26. Pedunculated subserosal fibroid with torsion in a pregnant patient. The patient presented to the emergency department with acute pelvic pain. Axial T1-weighted (A), axial (B)
and coronal (C) T2-weighted MR images demonstrate pedunculated subserosal fibroid superolateral to the uterus (arrowheads). Axial diffusion weighted image (D) and the corresponding
ADC map (C) revealed significant diffusion restriction with low ADC value especially in the periphery of the lesion consistent with infarct (arrows). Note: Contrast material was not used
because the patient was pregnant.

Fig. 27. Tubo-ovarian abscess in a 40- year-

old female patient presented with pelvic
pain and fever. Transverse pelvic color ul-
trasound image (A) demonstrates a complex
cystic mass with minimal vascularization
(white thick arrow). Axial (B) and coronal
(C) contrast enhanced CT scans demonstrate
a 4 cm mass lesion with peripheral contrast
enhancement consistent with tubo-ovarian
abscess (short arrows). Axial CT (B) scan
also demonstrates fat stranding medial to
the lesion (long arrow). Axial contrast en-
hanced CT scan (D) obtained inferior to B
demonstrates infected loculated fluid with
thin peripheral enhancement in Douglas
pouch (long arrow).

weighted images and heterogeneous high signal intensity on T2-
weighted images. The signal intensity of the abscess content depends on
its viscosity and protein content [36].
4. Conclusion
In conclusion, there are many surgical and non-surgical conditions
mimicking acute appendicitis. Acute appendicitis is the one of the most
frequent cause of abdominal pain and is the first suspected diagnosis
especially in children and young male patients with typical pattern of
pain. US is the first imaging modality about the diagnosis of acute ap-
pendicitis. In patients with excessive subcutaneous fat tissue in whom
the diagnostic value of US decreases, and in elderly patients in whom
other major pathologies in which sensitivity of US is low such as colonic
malignancy and mesenteric ischemia, CT imaging should be the first
imaging tool. It is very important to see normal appendix, and this
feature can be used to avoid from unnecessary appendectomy and to
treat the main problem of patient.

104
H. Toprak et al.
Conflict of interest
There are no conflicts of interest.
References
[1] Macari M, Balthazar EJ. The acute right lower quadrant: CT evaluation. Radiol Clin
N Am 2003;41:1117–36.
[2] Birnbaum BA, Jeffrey Jr. RB. CT and sonographic evaluation of acute right lower
quadrant abdominal pain. AJR 1998;170:361–71.
[3] Ripolles T, Martinez-Perez MJ, Morote V, Solaz J. Diseases that simulate acute
appendicitis on ultrasound. Br J Radiol 1998;71:94–8.
[4] Shelton DK. Imaging findings in patients with right lower quadrant pain: alternative
diagnoses to appendicitis. J Comput Assist Tomogr 1997;21:693–8.
[5] Jain KA, Ablin DS, Jeffrey RB, Brant WE. Sonographic differential diagnosis of right
lower quadrant pain other than appendicitis. Clin Imaging 1996;20(1):12–6.
[6] van BredaVriesman AC, Puylaert JB. Mimics of appendicitis: alternative nonsurgical
diagnoses with sonography and CT. AJR Am J Roentgenol 2006;186(4):1103–12.
[7] Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, et al. US or CT for
diagnosis of appendicitis in children and adults? A meta-analysis. Radiology
2006;250:378–86.
[8] Sim JY, Kim HJ, Yeon JW, Suh BS, Kim KH, et al. Added value of ultrasound re-
evaluation for patients with equivocal CT findings of acute appendicitis: a pre-
liminary study. Eur Radiol 2013;23:1882–90.
[9] Toprak H, Kilincaslan H, Ahmad IC, Yildiz S, Bilgin M, Sharifov R, et al. Integration
of ultrasound findings with Alvarado score in children with suspected appendicitis.
Pediatr Int 2014;56:95–9.
[10] Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology
2000;215:337–48.
[11] Tamburrini S, Brunetti A, Brown M, Sirlin CB, Casola GCT. Appearance of the
normal appendix in adults. Eur Radiol 2005;15:2096–103.
[12] Choi D, Park H, Lee YR, Kook SH, Kim SK, et al. The most useful findings for di-
agnosing acute appendicitis on contrast–enhanced helical CT. Acta Radiol
2003;44:574–82.
[13] Pinto Leite N, Pereira JM, Cunha R, Pinto P, Sirlin CCT. Evaluation of appendicitis
and its complications: imaging techniques and key diagnostic findings. AJR Am J
Roentgenol 2005;185:406–17.
[14] van Randen A, Lameris W, van Es HW, ten Hove W, Bouma WH, et al. Profiles of US
and CT imaging features with a high probability of appendicitis. Eur Radiol
2010;20:1657–716.
[15] Raman SS, Lu DS, Kadell BM, Vodopich DJ, Sayre J, Cryer H. Accuracy of non-
focused helical CT for the diagnosis of acute appendicitis: a 5-year review. AJR
2002:178.1139–1325.
[16] Almeida AT, Melão L, Viamonte B, Cunha R, Pereira JM. Epiploic appendagitis: an
entity frequently unknown to clinicians—diagnostic imaging, pitfalls, and look-
alikes. AJR Am J Roentgenol 2009;193(5):1243–51.
[17] Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic
105
Clinical Imaging 48 (2018) 90–105
appendagitis and its mimics. Radiographics 2005;25(6):1521–34.
[18] Jain TP, Shah T, Juneja S, Tambi RL. Case of the season: primary epiploic appen-
dagitis: radiological diagnosis can avoid surgery. Semin Roentgenol
2008;43(1):4–6.
[19] Yu J, Fulcher AS, Turner MA, Halvorsen A, Helical CT. Evaluation of acute right
lower quadrant pain: part I, common mimics of appendicitis. AJR Am J Roentgenol
2005;184(4):1136–42.
[20] Shin JH, Son BH, Kim H. Clinically distinguishing between appendicitis and right-
sided colonic diverticulitis at initial presentation. Yonsei Med J
2007;30(48(3)):511–6.
[21] Bilic Komarica E, Zvizdic Z. Right sided perforated ascending colonic diverticulum
mimicking acute appendicitis. Acta Inform Med 2012;20(4):269–70.
[22] Gilmore T, Jordan C, Edelstein E. Right-sided diverticulitis mimics appendicitis. J
Emerg Med 2013;44(1):29–32.
[23] Kamaya A, Federle MP, Desser TS. Imaging manifestations of abdominal fat necrosis
and its mimics. Radiographics 2011;31:2021–34.
[24] Potter AW, Chandrasekhar CAUS. CT evaluation of acute pelvic pain of gynecologic
origin in nonpregnant premenopausal patients. Radiographics 2008;28:1645–59.
[25] Patlas MN, Alabousi A, Scaglione M, Romano L, Soto JA. Cross-sectional imaging of
nontraumatic peritoneal and mesenteric emergencies. Can Assoc Radiol J
2013;64:148–53.
[26] Dambha F, Tanner J, Carroll N. Diagnostic imaging in Crohn's disease: what is the
new gold standard? Best Pract Res Clin Gastroenterol 2014 Jun;28(3):421–36.
[27] Dell'Atti L, Borea PA, Ughi G, Russo GR. Clinical use of ultrasonography associated
with color Doppler in the diagnosis and follow-up of acute pyelonephritis. Arch Ital
Urol Androl 2010;82:217–20.
[28] Ridereau-Zins C. Imaging in colonic cancer. Diagn Interv Imaging 2014;95:475–83.
[29] Reginelli A, Genovese E, Cappabianca S, Iacobellis F, Berritto D, Fonio P, et al.
Intestinal Ischemia: US-CT findings correlations. Crit Ultrasound J 2013;15(5).
(Suppl 1–7).
[30] Kotecha M, Bellah R, Pena AH, Jaimes C, Mattei P. Multimodality imaging mani-
festations of the Meckel diverticulum in children. Pediatr Radiol 2012;42:95–103.
[31] Duigenan S, Oliva E, Lee SI. Ovarian torsion: diagnostic features on CT and MRI
with pathologic correlation. AJR Am J Roentgenol 2012;198:122–31.
[32] Nelson MJ, Paterson T, Raio C. Case report: transient small bowel intussusception
presenting as right lower quadrant pain in a 6-year-old male. Crit Ultrasound J
2014;22(6(1)):7.
[33] Kao LY, Scheinfeld MH, Chernyak V, Rozenblit AM, Oh S, Dym RJ. Beyond ultra-
sound: CT and MRI of ectopic pregnancy. AJR Am J Roentgenol
2014;202(4):904–11.
[34] Yüksel-Hatz S, Chilla BK, Tokic I, Singer G, Hohl M, Kubik-Huch RA. Torsion of a
pedunculated subserous myoma — a rare differential diagnosis of the acute ab-
domen. Praxis 2010;6(99(1)):45–50. Bern 1994.
[35] Velcani A, Conklin P, Specht N. Sonographic features of tubo-ovarian abscess mi-
micking an endometrioma and review of cystic adnexial masses. J Radiol Case Rep
2010;4(2):9–17.
[36] Rakheja R, Makis W, Hickeson M. Bilateral tubo-ovarian abscess mimics ovarian
cancer on MRI and (18) F-FDG PET/CT. Nucl Med Mol Imaging 2011;45(3):223–8.