Pe d i a t r i c I m a g i n g • R ev i ew
Phillips et al.
Imaging Diagnosis of RLQ Pain
Pediatric Imaging
Review
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FOCUS ON:
Grace S. Phillips1,2
Marguerite T. Parisi1,2
Felix S. Chew 2
Phillips GS, Parisi MT, Chew FS
Keywords: abdominal pain, CT, emergency radiology,
pediatric imaging, right lower quadrant pain, ultrasound
DOI:10.2214/AJR.10.7271
Received June 27, 2010; accepted after revision
December 20, 2010.
1
Department of Radiology, Seattle Children’s
Hospital, 4800 Sand Point Way NE, Seattle, WA 98105.
Address correspondence to G. S. Phillips
(grace.phillips@seattlechildrens.org).
2
Department of Radiology, University of Washington
School of Medicine, Seattle, WA.
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AJR 2011; 196:W527–W534
0361–803X/11/1965–W527
© American Roentgen Ray Society
AJR:196, May 2011 W527
Imaging Diagnosis of Right Lower
Quadrant Pain in Children
Objective. This article reviews, through clinical case presentation and correlative im-
aging, a variety of conditions that cause right lower quadrant (RLQ) pain in children.
Conclusion. This case-based review allows the reader to improve his or her under-
standing of the differential diagnosis and radiographic appearances of the entities that cause
RLQ pain in children.
A
cute right lower quadrant (RLQ)
pain is a common, but nonspecif-
ic, presenting symptom of a wide
variety of diseases in both chil-
dren and adults. Children, unlike adults, often
have difficulty in localizing the site of pain. In
addition, there is considerable overlap in the
clinical symptoms, as well as in the physical
and laboratory findings, of the various diseas-
es that present with RLQ pain. We use a series
of illustrative case scenarios and their corre-
sponding radiographic findings to improve
the reader’s knowledge of the differential di-
agnosis of acute RLQ pain in children.
Scenario 1
Clinical History
A 16-year-old boy with a remote history
of appendicitis (9 years prior) presented with
a 1-week history of abdominal pain and fe-
vers to 102°. The pain was initially diffuse
and then became localized to the RLQ, with
maximum intensity 5 days before presenta-
tion. Laboratory analysis was notable for an
elevated WBC count of 13,800/μL with ban-
demia. Urinalysis was negative. An abdom-
inal CT study was obtained (Figs. 1A–1C).
Description of Images
CT images show a mixed solid-and-cys-
tic inflammatory mass within the RLQ with
associated extraluminal gas (Figs. 1A and
1B). There is significant inflammation of
surrounding mesenteric fat, thickening of an
adjacent loop of small bowel (Figs. 1A and
1B), and mildly prominent mesenteric lymph
nodes. The cecum and terminal ileum are
minimally involved (Fig. 1C), making stump
appendicitis and inflammatory bowel dis-
ease less likely. The prominent lymph nodes
are likely reactive.
Conclusion
Meckel diverticulum, a remnant of the om-
phalomesenteric duct, is typically located in
the RLQ within 2 ft (61 cm) of the ileocecal
valve. The incidence of Meckel diverticulum is
approximately 2% of the population. Patients
with symptomatic Meckel diverticulum typi-
cally present within the first 2 years of life.
Meckel diverticulum remains a challeng-
ing clinical and radiographic diagnosis.
The acute presentation of Meckel divertic-
ulum—RLQ pain, vomiting, and blood per
rectum—can mimic acute appendicitis and
intussusception. Other entities, such as mes-
enteric adenitis, may also present with acute
RLQ pain in children.
Nuclear medicine pertechnetate scanning
(Meckel scan) (Fig. 2) remains the mainstay
of diagnostic imaging for imaging patients
with suspected Meckel diverticulum. A ra-
dionuclide Meckel scan is based on uptake
of 99mTc-labeled pertechnetate by ectopic
gastric mucosa within the omphalomesenter-
ic duct remnant. When a Meckel diverticu-
lum does not contain ectopic gastric mucosa,
the scan will be falsely negative. Both Meck-
el diverticulum and gut duplication with ec-
topic gastric mucosa will show radiotracer
uptake. A lateral view will help to distin-
guish a Meckel diverticulum (located ante-
riorly) from posteriorly located urinary tract
activity, which is the most common cause of a
 Phillips et al.
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A B C
Fig. 1—16-year-old boy with remote history of appendicitis and 1 week of abdominal pain and fevers.
A–C, Axial (A) and coronal (B and C) contrast-enhanced CT images (CT dose index volume, 15.02 mGy; dose-length product, 922.99 mGy × cm) show mixed solid-cystic
inflammatory mass within right lower quadrant with associated extraluminal gas (arrow, A and B). There is significant inflammation of surrounding mesenteric fat, thick-
ening of adjacent loop of small bowel (arrowheads, A and B), and mildly prominent mesenteric lymph nodes. Cecum (asterisk, C) and terminal ileum are minimally involved.

false-positive study. Other false-positives may
be seen with intussusception, volvulus, and
inflammatory bowel disease. In children, the
sensitivity of a radionuclide Meckel scan in
the detection of Meckel diverticulum contain-
ing ectopic gastric mucosa is 85–90% [1]. The
sensitivity improves with the use of histamine
H2 receptor antagonists (cimetidine).
In the child that presents acutely with
RLQ pain, cross-sectional imaging is often
the first imaging examination performed.
The sonographic features of an inflamed
Meckel diverticulum (Fig. 3) are relative-
ly nonspecific and can mimic both an in-
flamed appendix and a gut duplication cyst.
Ultrasound will show an abnormal RLQ cys-
tic structure, which may have a “gut signa-
ture,” arising from the distal small bowel.
The term refers to the sonographic pattern
of a hypoechoic outer wall, corresponding
to the muscularis propria, and a hyperecho-
ic inner wall, corresponding to the mucosa
and submucosa. The sonographic gut signa-
ture may be seen in structures arising from
the gastrointestinal tract, including the ap-
pendix, duplication cysts, and Meckel diver-
ticulum. Multiple authors have noted that the
inner wall of Meckel diverticulum is typical-
ly more irregular or crenulated in compari-
son with those seen with acute appendicitis
or duplication cysts [2–5].
Additional gray-scale sonographic find-
ings of Meckel diverticulum have been de-
scribed. Depending on location, either Meck-
el diverticulum or duplication cyst may show
some mobility with gut peristalsis. In a study
by Daneman et al. [2], two of nine Meck-
el diverticula had a teardrop shape. Howev-
er, this sonographic feature was not found to
be a common or discriminating sonographic
feature of Meckel diverticulum in later stud-
ies [3]. Compressibility also does not help to
distinguish these entities because an inflamed
Meckel diverticulum may be either compress-
ible or noncompressible [5].
Color Doppler imaging or angiography may
also show anomalous vessels in association
with Meckel diverticulum. These anomalous
vessels represent persistence of the vitellointes-
tinal artery arising from the superior mesenter-
ic artery. Anomalous vessels are not present in
cases of duplication cysts or appendicitis.
A recent study by Olson et al. [6] suggests
that Meckel diverticulum is increasingly en-
countered on CT in children who present
with abdominal pain. The three common
CT appearances of Meckel diverticulum
are, first, an isolated small-bowel obstruc-
tion; second, an intussusception with small-
bowel obstruction; or, third, a cystic inflam-
matory mass [6].

Scenario 2
Clinical History
A 3-year-old afebrile girl presented with
a 2-day history of RLQ pain, nausea, and
vomiting. Tenderness to palpation with RLQ
guarding was noted on physical examina-
tion. WBC count was 11,900/μL. Ultrasound
was performed (Figs. 4A–4C).

Fig. 2—15-month-old boy with painless rectal bleed-
ing. Anterior view from 99mTc-pertechnetate scan
shows focus (arrow) of abnormal, increased uptake
in right lower quadrant. Normal activity is present
within stomach and urinary bladder. Meckel divertic-
ulum with ectopic gastric mucosa was subsequently
surgically resected.
Fig. 3—3-year-old boy with inflamed Meckel diver-
ticulum. Transverse color Doppler sonogram of
right lower quadrant shows targetoid, hyperemic
mass with crenulated inner wall. Distinctive hyper-
echoic inner wall and hypoechoic outer wall typify
gut signature.
Description of Images
A transverse gray-scale pelvic sonogram
(Fig. 4A) shows an asymmetrically enlarged
right ovary (11.8 mL) with a peripheral cyst.
Normal-sized left ovary measures 2.7 mL.
There is decreased color flow (Fig. 4B) with-
in the right ovary compared with the left. On
spectral interrogation of the right ovary (Fig.
4C), a venous waveform is detected. Normal

W528 AJR:196, May 2011

 Imaging Diagnosis of RLQ Pain

arterial and venous flow was present within
the left ovary (not shown).
Conclusion
Ovarian torsion is an important consider-
ation in the female child who presents with
acute RLQ pain. Although ovarian torsion
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Peripheral cysts may be seen in the torsed
ovary, but this finding is not as common as
unilateral ovarian enlargement. Multiple
cysts may also be seen in other clinical set-
tings, such as polycystic ovarian disease and
Van Wyk and Grumbach syndrome [18],
which consists of juvenile hypothyroidism,
of nonviability such as ovarian tissue decom-
position [20, 21]. Cystectomy of an enlarged
ovarian cyst has fallen out of favor for two
reasons. First, the edematous torsed ovary is
friable and prone to damage with manipula-
tion. Second, most ovarian masses associated
with torsion are functional cysts rather than

is more common in adults, 15% of ovarian precocious puberty, and ovarian enlarge- neoplasms [20]. The incidence of malignant
torsions occur in children [7]. Common pre- ment. In a study of 12 children with ovar- neoplasms in torsed ovaries in the pediatric
senting symptoms of ovarian torsion include ian torsion, Kiechl-Kohlendorfer et al. [19] population is extremely low, approximate-
lower quadrant abdominal pain, nausea, em- found that the specific sonographic finding ly 2% [21]. The edematous ovary may rarely
esis, and fever [8–11]; therefore, ovarian tor- of a fluid-debris level in follicular cysts is an- obscure an underlying mass. If there is con-
sion may be difficult to differentiate from other pathognomonic sign of ovarian torsion. cern for an underlying neoplasm causing tor-
acute appendicitis, early or ectopic pregnan- Variable results have been reported using sion, detorsion with follow-up ultrasound can
cy, or other entities such as pyelonephritis. Doppler sonography for evaluating suspect- be performed, followed by interval oophorec-
Torsion occurs more commonly on the right ed ovarian torsion. Servaes et al. [17] report- tomy if a mass is subsequently identified [20].
than on the left [7, 12, 13], which adds to the ed the presence of either arterial or venous
difficulty in distinguishing ovarian torsion flow in 64% of the 41 torsed ovaries studied. Scenario 3
from acute appendicitis. Classically, the ab- They concluded that the absence of arterial Clinical History
sence of fever may help to distinguish ovar- and venous flow was not a useful indicator of A 5-year-old girl presented to the emergency
ian torsion from appendicitis. torsion in their series. The presence of flow department with abdominal pain. Physical ex-
Ovarian salvage depends on timely diag- on color Doppler imaging in a patient with amination was remarkable for suprapubic full-
nosis and surgical detorsion. Because ovar- gray-scale findings concerning for torsion ness. Transabdominal pelvic ultrasound was
ian torsion can have a variety of gray-scale does not exclude torsion but, rather, suggests performed (Figs. 5A and 5B).
appearances, the sonographic diagnosis of that the ovary may be viable. Therefore, sus-
ovarian torsion remains challenging. Unilat- picion of torsion should persist in the pres- Description of Images
eral ovarian enlargement is invariably pres- ence of compelling gray-scale findings re- Midline longitudinal images (Figs. 5A and
ent in ovarian torsion [10, 14, 15] and is de- gardless of Doppler findings so that prompt 5B) from pelvic sonography show a mixed-
picted in Figure 4A. The sonographic finding surgical management can be instituted. echogenicity, thin-walled cystic structure lo-
of a twisted vascular pedicle with a whirl- Laparoscopic detorsion of the torsed ova- cated posterior to the nearly empty urinary
pool sign is considered a definitive sign of ry is the preferred treatment. Oophoropexy is bladder (Fig. 5A) and abutting the inferior as-
ovarian torsion [16], particularly in adults. generally not recommended because the risk pect of the uterus (Fig. 5B). The cystic struc-
This finding has not been well studied in of retorsion is considered low [20]. Oopho- ture was remote from the bilateral adnexa.
children [17]. rectomy is generally reserved for clear signs
Conclusion
The sonographic findings in this patient
represent hydrocolpos secondary to an im-
perforate hymen. The age of presentation
of hydrocolpos and hydrometrocolpos is bi-
modal, with patients typically presenting ei-
ther in the neonatal period or at menarche
[22, 23]. Imperforate hymen is the most
common cause of hydrometrocolpos in pa-
A tients who present after the neonatal period
[24]. Transverse vaginal septum, partial vag-
inal agenesis, and vaginal stenosis are also
known causes of hydrometrocolpos, but pa-
tients with these entities typically present in
the neonatal period or early infancy.
There is an association between hydrometro-
colpos and congenital urogenital, gastrointesti-
nal, skeletal, and cardiac anomalies, particularly
in patients who present in the neonatal period.
B C Reed and Griscom [23] studied 26 infants with
Fig. 4—3-year-old afebrile girl with 2-day history of right lower quadrant pain, nausea, and vomiting. hydrometrocolpos and identified 71 associated
A and B, Transverse gray-scale (A) and color (B) pelvic sonographic images show enlarged right ovary (arrow- anomalies in 18 patients. In that series, fistulous
heads) with single peripheral cyst (C, A), and normal-size left ovary (arrow) with several follicles (B). Color flow
within enlarged right ovary is decreased compared with left ovary, which shows normal color flow. tracts were noted in 11 patients, with rectovagi-
C, Doppler interrogation of right ovary detects venous waveform only. nal fistulas described as the most common type.

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 Phillips et al.
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A B
Fig. 6—3-year-old girl with umbilical erythema and
Fig. 5—5-year-old girl with intermittent right abdominal pain and suprapubic fullness. pain. Longitudinal midline sonogram shows mixed-
A and B, Longitudinal midline pelvic sonograms show mixed-echogenicity, thin-walled cystic structure (asterisk, echogenicity complex fluid collection (asterisk)
outlined by cursors), located posterior to nearly empty urinary bladder (BL, A) and abutting inferior aspect of indenting anterosuperior wall of urinary bladder (BL).
uterus (arrowheads, B). Infected urachal remnant was confirmed at surgery.

Bicornuate uterus was the most common geni-
tal tract abnormality and was present in seven
patients. Imperforate anus was present in 12
and malrotation was seen in two. Renal hypo-
plasia involving one or both kidneys was more
common than unilateral renal agenesis [23].
Hydrometrocolpos is also associated with men-
strual irregularities, endometriosis, infertility,
spontaneous abortion, prematurity, and sexual
difficulties [22].
Ultrasound of girls with hydrocolpos re-
veals a thin-walled cystic structure posterior
to the urinary bladder and abutting the uter-
us. Internal contents of the fluid-filled struc-
ture may be anechoic or may contain internal
echoes. In hydrometrocolpos, there is also
distention of a fluid-filled endometrial cav-
ity in communication with the dilated fluid-
filled vagina. Entities such as an appendiceal
abscess and Meckel diverticulum may be
distinguished from hydrocolpos on imaging
because they should not extend from the cer-
vical region. Furthermore, a Meckel divertic-
ulum may communicate with or at least be in
close proximity to bowel.
An urachal remnant (Fig. 6) may also
present on imaging as a cystic lower abdomi-
nal mass. An urachal remnant is caused by
failure of involution of the embryonic ura-
chus, which extends from the umbilicus to
the urinary bladder. The spectrum of urachal
remnants includes sinus tracts, cysts, fistulas,
and diverticula. When an urachal remnant
becomes inflamed, typically the inflamma-
tion will be centered in the midline, between
the anterosuperior aspect of the urinary blad-
der and the umbilicus [25].
Scenario 4
A 16-year-old girl presented to the emer-
gency department with acute abdominal pain
and diarrhea. Physical examination revealed
a soft abdomen with severe lower abdominal
tenderness, guarding, and rebound. WBC
count was 16,000/μL. C-reactive protein val-
ue was elevated at 13.6 mg/dL. A contrast-
enhanced abdominopelvic CT examination
was performed (Figs. 7A–7C).
Description of Images
Multiplanar contrast-enhanced CT imag-
es (Figs. 7A–7C) show inflammatory chang-
es within the sigmoid colon with hyperemia,
extraluminal gas, and mesenteric stranding
abutting a dilated loop of distal ileum. Proxi-
mal small-bowel loops are normal in caliber
and appearance. Abnormal wall thickening
is noted in portions of the terminal ileum.
Although orally administered enteric con-
trast material is present within the rectum,
enteric contrast material is notably absent
from the descending colon, suggesting en-
terorectal fistula formation.

A B C
Fig. 7—16-year-old girl with acute abdominal pain and diarrhea.
A–C, Axial (A), coronal (B), and sagittal (C) contrast-enhanced CT images through abdomen and pelvis (CT dose index volume, 14.17 mGy; dose-length product, 729.39
mGy × cm) show inflammatory changes within sigmoid colon, with hyperemia, extraluminal gas (arrows, A and C), and mesenteric stranding abutting dilated loop of distal
ileum (asterisk, A and C). Abnormal wall thickening is noted in portions of distal ileum (T, B). Although orally administered enteric contrast material is present within rec-
tum, enteric contrast material is notably absent from descending colon (arrowhead, A and B), suggesting enterorectal fistula formation.

W530 AJR:196, May 2011

 Imaging Diagnosis of RLQ Pain

Conclusion
The incidence of inflammatory bowel dis-
ease in the pediatric population is 5.3 per
100,000 children younger than 16 years.
Crohn disease is twice as common as ulcer-
ative disease in the pediatric population. In
adults, the reverse is true, with ulcerative
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clysis is more invasive than SBFT because it
requires the placement of a nasojejunal tube
often while the patient is under sedation,
with its inherent risks.
In recent years, CT enteroclysis enterogra-
phy and MR enteroclysis enterography have
gained favor in the evaluation of the small
In experienced hands, ultrasound has also
proven useful in the initial diagnosis and eval-
uation of complications of Crohn disease [30].
Scenario 5
Clinical History
A 1-year-old boy with abdominal pain

colitis much more common than Crohn dis-
ease [26]. Predisposing factors to Crohn dis-
ease include white race, Jewish ethnicity, and
use of oral contraceptives. In children it is
often difficult to distinguish Crohn disease
from ulcerative colitis because of the con-
siderable overlap in presenting symptoms
(pain, bloody diarrhea, weight loss), endo-
scopic findings, and histology [27]. There is
also considerable overlap between inflam-
matory bowel disease and infectious enteritis
and colitis. The Crohn disease activity index
(CDAI) is a generally accepted standardized
method of estimating Crohn disease activity.
The gold standard for the diagnosis of in-
flammatory bowel disease in children re-
mains endoscopy with histologic or patho-
logic diagnosis. However, imaging often
plays an important role not only in the ini-
tial diagnosis of inflammatory bowel disease
but also in monitoring therapeutic response,
disease activity, and complications. The con-
ventional method of evaluating the small
bowel has been small-bowel follow-through
(SBFT) or small-bowel enteroclysis. Entero-
bowel in children. Compared with SBFT,
contrast-enhanced abdominopelvic MDCT
has the additional advantage of more easi-
ly showing extramural disease and compli-
cations such as abscess, phlegmon, fistula,
and obstruction. Compared with SBFT, ab-
dominopelvic MDCT imparts approximately
twice the radiation dose to the patient [28].
Of note, the radiation dose of both SBFT and
abdominopelvic MDCT is technique depen-
dent. Regarding SBFT, additional overhead
radiographs and fluoroscopy time can alter
the radiation dose [28].
Toma et al. [29] showed that MR entero-
clysis enterography is less sensitive but is
equally specific compared with CT entero-
clysis enterography for bowel wall thicken-
ing, bowel wall enhancement, and lymph-
adenopathy. Compared with CT enteroclysis
enterography, MR enteroclysis enterography
has the advantage of sparing the child expo-
sure to ionizing radiation. Contrast-enhanced
fat-suppressed T1-weighted images gener-
ally provide the best correlation between
MR findings and CDAI [27]. Paolantonio et
al. [27] found that MR findings on fat-sup-
pressed T2-weighted sequences also corre-
lated with disease activity, although not as
strongly as contrast-enhanced fat-suppressed
T1-weighted images.
presented to the emergency department. Ab-
dominal radiography and ultrasound were
performed (Figs. 8A–8C).
Description of Images
A supine abdominal radiograph (Fig. 8A)
shows a paucity of bowel gas in the RLQ:
the absence of air in the cecum was noted
on a left lateral decubitus view (not shown).
There is normal gaseous distention of por-
tions of nondilated transverse and descend-
ing colon, with abrupt cutoff of colonic air
by soft-tissue density in the right upper quad-
rant, referred to as the “colon cutoff sign.”
Transverse sonographic images of the RLQ
(Figs. 8B and 8C) show a targetoid, complex
soft-tissue mass with concentric regions of
increased and decreased echogenicity and
evidence of internal blood flow.
Conclusion
Intussusception is second only to appen-
dicitis as a cause of an acute abdomen in
young children [31]. The typical age of pre-
sentation is between 3 months and 3 years.
Intussusception is more common in males
than females, with a male-to-female ratio of
3:2 [32]. There is a seasonal trend to intus-
susception, which is more common in the
spring and autumn; this trend suggests the

A B C
Fig. 8—1-year-old boy with abdominal pain.
A, Supine abdominal radiograph shows paucity of bowel gas in right lower quadrant (RLQ), with absence of air in cecum on left lateral decubitus view (not shown). There
is normal gaseous distention of portions of nondilated transverse and descending colon, with abrupt cutoff of colonic air by soft-tissue density (asterisk) in right upper
quadrant (colon cutoff sign).
B and C, Transverse sonographic gray-scale (B) and color (C) images of RLQ show targetoid complex soft-tissue mass (arrowheads) with concentric regions of increased
and decreased echogenicity. Evidence of internal blood flow is seen in C.

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 Phillips et al.
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A B C
Fig. 9—1-year-old boy with abdominal pain, same patient as in Figure 8.
A and B, Fluoroscopic spot images from air enema show retrograde passage of air through colon to level of rounded intraluminal soft-tissue density (asterisk), initially
within hepatic flexure. There is subsequent progressive movement of colonic air column (B).
C, Final fluoroscopic spot image from air enema shows successful reduction of ileocolic intussusception, as evidenced by resolution of soft-tissue defect and reflux of air
into small bowel (SB).

possibility of an underlying viral cause [32].
Approximately 90% of intussusceptions are
ileocolic, and most cases are idiopathic. A
pathologic lead point is found in only 3–10%
of children, approximately 5 years old or
younger, with intussusception [32]. In pa-
tients older than 5 years presenting with in-
tussusception, the possibility of a patholog-
ic lead point, such as Meckel diverticulum,
lymphoma, or a duplication cyst, among oth-
ers, should be considered.
Radiographs are relatively insensitive for the
diagnosis of intussusception. One classic radio-
graph finding is the colon cutoff sign (Fig. 8A),
with a focal soft-tissue density in the expected
location of gas-filled colon. Hooker et al. [33]
found that the left lateral decubitus view im-
proves the diagnostic accuracy for intussuscep-
tion over the supine view. Furthermore, the left
lateral decubitus radiograph is an important
adjunct to screening ultrasound to exclude free
intraperitoneal air before proceeding with an
enema. The mainstay of imaging for suspect-
ed intussusception is screening abdominal ul-
trasound. Ultrasound is accepted as a sensitive,
specific, and noninvasive method for the detec-
tion of intussusception without the use of ion-
izing radiation. Typical findings on ultrasound
are a targetoid mass with concentric rings of
varying echogenicity.
Surgical consultation is recommended be-
fore attempting air or water-soluble contrast
enema reduction of an intussusception be-
cause there is a small (< 1%) risk of perfora-
tion [34]. Enema reduction is contraindicated if
there are peritoneal signs on physical examina-
tion or free intraperitoneal air on radiographs.
Air enema reduction of intussusception (Figs.
9A–9C) is successful in 80–90% of cases and
is associated with a slightly lower perforation
rate compared with water-soluble contrast en-
ema reduction [34]. Water-soluble contrast ma-
terial may be used if there is high clinical sus-
picion for a pathologic lead point or if dilated
gas-filled small-bowel loops preclude confir-
mation of successful reduction.
Scenario 6
A 19-month-old girl presented to the
emergency department with abdominal pain
and fever. Laboratory analysis showed an el-
evated WBC count of 26,000/μL. Sonogra-
phy of the RLQ was performed (Figs. 10A
and 10B).
Description of Images
A longitudinal sonogram of the RLQ (Fig.
10A) shows a tubular, noncompressible, hyper-
emic, blind-ending structure that measured 8
mm in caliber arising from the cecum. There
is inflammatory change in the adjacent fat.
Deep to the tubular structure, there is a circum-
scribed heterogeneous collection of hypoecho-
ic material. In the superior aspect of the collec-
tion, there is a 7-mm echogenic structure that
shows posterior acoustic shadowing.
Conclusion
Appendicitis is the most common abdomi-
nal surgical emergency in children [35]. The
incidence of appendicitis is approximate-
ly 25 per 10,000 children ages 10–17 years.
Inflammation of the appendix is caused by
acute obstruction of the appendiceal lumen.
The natural history of an untreated appen-
dicitis is progressive superimposed infec-
tion and ischemia of the appendix, ultimate-
ly leading to perforation. The appendix in
neonates is typically funnel-shaped, which
is thought to protect them from appendicitis
[36]. By 1–2 years of age, the appendix as-
sumes an adult-type, tubular shape [37].
Appendicitis remains a diagnostic chal-
lenge in children. Children typically present
earlier in the course of disease than adults,
but children are less likely to have the classi-
cal symptoms of generalized abdominal pain
that subsequently localizes to the RLQ ac-
companied by nausea, emesis, and fever [38].
The classic symptoms of periumbilical pain
that migrates to the RLQ and tenderness at
McBurney point are more often seen in older
children with nonperforated appendicitis [35].
The perforation rate for appendicitis is
higher in children than in adults. In children
younger than 4 years old, perforation rates can
be as high as 80–100% [37]. Klein [39] found
that the time between presentation and perfo-
ration is shorter with decreasing age. In chil-
dren younger than 5 years old, the time be-

W532 AJR:196, May 2011

 Imaging Diagnosis of RLQ Pain
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A B
Fig. 11—8-year-old girl with appendicitis. Coronal
Fig. 10—19-month-old girl with abdominal pain, fever, and elevated WBC. contrast-enhanced CT image (CT dose index volume,
A and B, Longitudinal sonographic gray-scale (A) and color Doppler (B) images of right lower quadrant show 5.39 mGy; dose-length product, 253.43 mGy × cm)
tubular, noncompressible, blind-ending structure (white arrowheads) that measures 8 mm in caliber, with shows rim-enhancing fluid collection in right lower
associated wall hyperemia visible in B. Deep to tubular structure, there is circumscribed, heterogeneous, quadrant with central hyperdensity (arrow) and sur-
hypoechoic collection (black arrowheads, A). In superior aspect of collection, there is 7-mm echogenic rounding inflammatory changes in adjacent mesen-
structure (asterisk, A) that shows posterior acoustic shadowing. teric fat and cecum (asterisk).

Fig. 12—1-year-old girl with abdominal pain and
mesenteric adenitis. Longitudinal sonogram of right
lower quadrant shows multiple enlarged lymph nodes
(arrowheads) with maximum caliber of 1.1 cm.
tween presentation and perforation may be as
short as 6 hours, whereas in children between
5 and 12 years old, the interval is typically 36
hours. Lee and Ho [40] retrospectively com-
pared appendectomy cases of children and
adults and found that emergency department
physicians were able to diagnose perforated
appendicitis, on average, 3 hours earlier in
children than in adults, at a mean evaluation
time of 3.3 ± 1.7 hours (SD).
In experienced hands, ultrasound should
be the imaging modality of choice in chil-
dren with suspected appendicitis because it
spares the child exposure to ionizing radia-
tion. Ultrasound may depict the abnormally
dilated (> 6 mm), noncompressible appendix
arising from the cecum as well as second-
ary signs such as inflammatory changes of
the fat, hyperemia, and free fluid. The find-
ing of an appendicolith, as in the presented
case, is typical of appendicitis and may help
to exclude other entities such as Meckel di-
verticulum, infected duplication cyst, and in-
flammatory bowel disease from the differen-
tial diagnosis. Complications of appendicitis,
such as abscess from perforation, can be eas-
ily identified, as in our case. CT should be
reserved for cases in which ultrasound is un-
successful for evaluating the RLQ (Fig. 11)
or at clinical discretion, particularly when
symptoms have persisted for more than 72
hours or when perforation and abscess for-
mation are suspected.
Stump appendicitis is an uncommon clini-
cal entity that results from inflammation of
the appendiceal remnant after appendec-
tomy. Imaging findings are nonspecific and
include inflammatory changes in a perice-
cal location that may be accompanied by ab-
scess formation [41].
Primary mesenteric adenitis (Fig. 12) is a
relatively common clinical entity with symp-
toms that can mimic acute appendicitis. Pri-
mary mesenteric adenitis is usually the result
of a viral illness. Classically, imaging shows
enlargement of mesenteric lymph nodes, typ-
ically centered in the RLQ. There may be as-
sociated mild (< 5 mm) wall thickening of the
terminal ileum [42, 43]. Primary mesenteric
adenitis is a self-limited inflammatory pro-
cess that responds to conservative therapy.
Conclusion
We present six of the many entities that
cause RLQ pain in children. Numerous other
diseases, including obstructing distal ureter-
al calculus, pyelonephritis, ectopic pregnancy,
epiploic appendagitis, and omental infarction,
although not discussed, may present with simi-
lar clinical symptoms. Knowledge of the wide
spectrum of disease processes that cause RLQ
in children may facilitate accurate and timely
diagnosis in this challenging population.
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