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Radiología. 2012;54(2):137---148

www.elsevier.es/rx

UPDATE IN RADIOLOGY

Usefulness of ultrasonography in children with right iliac fossa

pain夽
L. Raposo Rodríguez a,∗ , G. Anes González a , J.B. García Hernández a ,
S. Torga Sánchez b

a
Servicio de Radiodiagnóstico, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
b
Servicio de Radiodiagnóstico, Hospital El Bierzo, Ponferrada, León, Spain

Received 14 February 2011; accepted 23 May 2011

KEYWORDS Abstract Acute pain in the right iliac fossa (RIF) is common in children. It can arise from a wide
Abdominal variety of gastrointestinal and genitourinary processes that make up the differential diagnosis
ultrasonography; with acute appendicitis (AA). In this article, we describe the most representative findings of
Right iliac fossa; these processes on ultrasonography (US). We emphasize the characteristics that enable these
Pediatrics; processes to be differentiated from AA.
Acute abdomen; © 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.
Appendicitis;
Crohn’s disease

PALABRAS CLAVE Utilidad de la ecografía en niños con dolor en la fosa ilíaca derecha
Ecografía abdominal;
Fosa ilíaca derecha; Resumen El dolor agudo en la fosa ilíaca derecha es un cuadro frecuente en la infancia. Su
Pediatría; origen puede ser secundario a un amplio abanico de procesos gastrointestinales y genitourinarios
Abdomen agudo; que constituyen el diagnóstico diferencial de la apendicitis aguda. En el presente artículo se
Apendicitis; describen los hallazgos ecográficos más representativos de tales procesos, insistiendo en las
Enfermedad de Crohn características que permiten diferenciarlos de la apendicitis aguda.
© 2011 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados.

Introduction

Acute pain in the RIF is common in pediatric patients.

Although AA and intestinal intussusception are the typical
夽 Please cite this article as: Raposo Rodríguez L, et al. Utilidad de
causes, RIF pain can also be caused by multiple gastrointesti-
nal and genitourinary disorders that should be considered in
la ecografía en niños con dolor en la fosa ilíaca derecha. Radiología.
2012;54:137---48. the differential diagnosis of AA.
∗ Corresponding author. US represents the ideal diagnostic modality in children
E-mail address: luciaraposo81@hotmail.com with abdominal pain. Its excellent anatomic resolution in
(L. Raposo Rodríguez). the pediatric population has helped reduce the negative

2173-5107/$ – see front matter © 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.
Document downloaded from http://zl.elsevier.es, day 14/08/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
138
appendectomy rate.1 Technological advances in US allow
examination of the layers of the intestinal wall and
surrounding mesentery with high spatial resolution. This
provides new clinical applications such as the assessment
of acute inflammatory activity, response to treatment and
complications of Crohn’s disease, US evaluation of acute
recurrent appendicitis, follow-up of intestinal involvement
in Schönlein---Henoch purpura (SHP), preoperative assess-
ment of the viability in cases of ovarian torsion, or
support for the decision of performing a biopsy in celiac
disease.
The objective of this study is to describe the US findings
and the key diagnostic findings of those conditions that may
present with acute RIF pain in children, with an emphasis on
AA, since this is the most common disease in children requir-
ing surgery2,3 and the most common source of diagnostic
errors.
Technique
The graded compression technique described by Puylaert in
1986 is based on the fact that gradual compression on the
anterior abdominal wall eliminates bowel gas and intralumi-
nal fluid from the bowel loops, reduces the distance between
transducer and appendix, and displaces bowel loops out of
the RIF.4 This compression allows visualization of iliac ves-
sels and psoas muscle, since the appendix is anterior to these
structures (Fig. 1A). In addition to be ineffective and painful,
fast compression may result in rupture of an appendix at risk
for perforation.2
The exam is performed in the longitudinal and transverse
planes. The ascending colon appears as a nonperistaltic
structure containing fluid and gas. Inferiorly, the terminal
ileum, compressible and peristaltic, can be identified. The
cecal base, where the appendix arises, is 2---3 cm below the
terminal ileum. While the base of the appendix is at a fairly
constant location, its end may move freely, and its location
is therefore very variable; however, this does not trans-
late into a statistically significant difference in the rate of
appendicitis.5,6
The topology of the superior mesenteric vessels and their
relationship with the aorta and inferior vena cava should be
systematically identified.
Normal right iliac fossa
The digestive tract comprises four concentric layers that
can be differentiated histologically. The layers from deep
to superficial are the mucosa----consisting of an epithelium
with underlying lamina propria and the muscularis mucosa----,
the submucosa, the muscularis propria and the adventitia.
US shows a penta-stratified pattern where the first (superfi-
cial mucosa), third (submucosa) and fifth (adventitia) layers
are hyperechogenic, and the second (muscularis mucosa)
and fourth (muscularis propria) layers are hypoechoic6---8
(Fig. 1B).
In adults, the thickness in any segment of the digestive
tract is ≤3 mm. In children, it ranges between 1.5 and 3 mm
in the terminal ileum and <2---3 mm in the colon, depending
on the age.8 Valvulae conniventes are <2 mm in width and
2---5 mm in length, being more numerous in the jejunum (two
L. Raposo Rodríguez et al.
or three per cm) than in the ileum (two per cm). Given its
intestinal origin, the appendix exhibits similar characteris-
tics to the digestive tract, therefore, its maximum diameter
should not exceed 6 mm in the transverse plane and its
wall should not exceed 3 mm.3,4,6,9 Nonetheless, histologi-
cally normal appendixes > 6 mm can also be found in cases
of accumulation of secretions in the lumen, hyperplasia or
fecal impaction.10
The normal appendix is oval-shaped in the transverse
plane and easily compressible. Conversely, in appendicitis,
the appendix walls are inflamed, rigid and noncompressible.
Its lumen may contain air or fluid, or be collapsed with adhe-
sion of the mucosal layers, giving rise to a central echogenic
line.
Lastly, the mesentery appears slightly echogenic.
Acute appendicitis
AA is the most common condition requiring surgery in
children and the one leading to more diagnostic errors.
Traditionally, AA has been described to occur when fecal
matter or appendicoliths obstruct the appendiceal lumen,
which is usually followed by infection. However, we know
now that AA is not always secondary to obstruction and that
several causes may lead to AA: lymphoid follicular hyper-
plasia obstructing the cecal---appendiceal junction, inflamed
follicles in infectious processes, foreign bodies, or trauma.
These factors lead to inflammation and an increase in
intraluminal pressure. As a result, the appendix enlarges
and induces inflammatory changes in the surrounding tis-
sues, such as the pericecal fat and peritoneum.2 Ultimately,
ischemia occurs and the inflamed appendix, eventually, per-
forates.
Sensitivity and specificity of sonography for the diagno-
sis of AA vary greatly between studies (up to 100 and 98%,
respectively).2---12 The appendiceal diameter is considered
the most relevant morphologic criteria (sensitivity > 98%)
and, traditionally, the threshold diameter > 6 mm has been
used for diagnosis of appendicitis. On transverse images,
the appendix appears fixed, round and noncompressible.
Hyperechogenicity of the pericecal fat is common. This
fat may increase in volume and surround the appendix,
which represents the inflamed omentum that migrates to the
appendiceal area in case perforation occurs (Fig. 2A). Free
fluid and mesenteric lymph nodes are frequent but unspe-
cific. In up to 30% of cases, appendicoliths are seen in the
appendiceal lumen.2
Doppler signal varies depending on the stage of the dis-
ease. Although it might increase in the acute phase (Fig. 2B),
it may diminish in case of appendiceal perforation.2---4,9
Therefore, Doppler examination alone cannot reliably
distinguish between normal and abnormal appendix. Per-
foration can be suspected in the presence of an irregular
contour of the appendix, fluid or collections, and dilated
bowel loops with thickened walls2---4,7,10,13 (Fig. 1E). After
perforation occurs, the appendix is usually decompressed
and it is visible only in 30---60% of cases.4,9,13
Acute pain, gas and severe obesity may complicate visu-
alization of the appendix. Therefore, the nonvisualization of
the appendix does not allow us to rule out AA despite the fact
that the first studies considered the nonvisualization on US
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Usefulness of ultrasonography in children with right iliac fossa pain 139

Cecum
Terminal ileum

Appendix
Lumen m mm sb mc a
Iliac
vessels

Psoas

Figure 1 (A) US image of the normal right iliac fossa showing the psoas muscle and iliac vessels. (B) Axial US of the appendix
shows the correlation between the normal pentastratified pattern and the corresponding histological layers. Hyperechogenic layers
correspond to the superficial mucosa (m), submucosa (sb) and adventitia (a), while hypoechoic layers correspond to the mucosa
and (mm) and muscularis propria (mc).

an exclusion criterion.5 For an experienced ultrasonologist,
nonvisualization has a negative predictive value of 90%.2,10
Since some appendicitis are limited to the appendiceal
tip, only the detection of a normal appendix throughout
its entire length safely rules out AA.2,4,5 The detection
range of a normal appendix varies between 40 and 82% of
examinations, and this depends on the operator experience
and the physical characteristics of the patient.5,6,10
Recurrent acute appendicitis
In 10% of patients with AA, the symptoms and signs sub-
side spontaneously 12---48 after the onset but they reappear
later on.10,14 This phenomenon, known as ‘‘spontaneously
resolving appendicitis’’, is thought to be due to the relief
of obstruction. In these cases, US follow-up images show
a gradual decrease in the appendiceal diameter.10,14 US
follow-up in patients with AA, performed 6---36 h after the
initial examination, represents a useful diagnostic tool that
complements clinical follow-up and helps reduce the num-
ber of CT studies done on children.
Recurrence rate relates to the presence or absence of
enlarged mesenteric lymph nodes. A study carried out by
Cobben et al. on 60 patients showed that the subgroup of
male patients with no enlarged mesenteric lymph nodes had
a recurrence rate of 60%, which seems a clear indication
for surgery. Conversely, the presence of enlarged mesen-
teric lymph nodes was associated to a lower recurrence
rate.14

Figure 2 Appendicitis: (A) Transversal US image shows inflamed appendix with enlarged diameter and wall thickening, and
hyperechogenicity of periappendiceal fat. (B) Longitudinal color Doppler US image shows inflamed appendix with hyperemic wall.
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140 L. Raposo Rodríguez et al.

The term used to name this entity is also controver-

sial. Some authors use the term ‘‘appendiceal disease’’ in
patients with long-standing symptoms; however, to date this
entity has not been satisfactorily described.

Cystic fibrosis

Patients with cystic fibrosis (CF) usually show markedly dis-

tended appendixes secondary to the presence of inspissated
secretions with associated pain.15 These cases are not to
be confused with AA since in CF the appendix is distended
but not inflamed. Additionally, there is no wall thicken-
ing and the concentric layer structure is intact, with no
inflammation of the mesenteric fat16,17 (Fig. 2E). It has been
postulated as a possible protective role of these secre-
tions against AA considering the lower rate of occurrence
in patients with CF (1---2%) compared with the normal popu-
lation (7---8%).14,16 Nonetheless, the rate of perforations and
abscess formation is higher, probably due to a delay in diag-
nosis because symptoms are often masked by the use of
antibiotics.16,17

Appendiceal mucocele
Appendiceal mucocele is characterized by distension of the
appendix secondary to intraluminal accumulation of mucus.
To date, four pathological processes leading to appendiceal
mucocele have been described: obstruction at the cecal
appendiceal junction; mucosal hyperplasia; mucinous cys-
tadenoma and mucinous cystadenocarcinoma. US shows a
distended appendix with no wall thickening and no regional
inflammatory signs, with abundant echogenic content in
the interior and the ‘‘onion skin’’ structure,18---20 a sign
considered to be characteristic of mucoid material that
allows differential diagnosis with appendiceal abscesses21
(Fig. 3).
Lymphoid hyperplasia related to viral
infections
Follicular lymphoid hyperplasia is a histopathologic finding
based on the enlargement of the lymphoid follicles in the
lamina propria of the appendiceal mucosa, without infil-
tration of polymorphonuclear leukocytes. It is common in
childhood, and according to some authors, it may be the
cause of acute RIF pain in children.7 It also relates to intesti-
nal intussusception.
Only on rare occasions does US allow for the diagnosis
of this condition. In such cases, US findings include dilated
appendix and thickening of the appendiceal mucosa and
ileocecal valve, secondary to the presence of hypoechogenic
nodules. Mesenteric lymph nodes are a constant. Cecum,
mesenteric echogenicity and mobility of the distal ileum are
normal.7
Mesenteric lymphadenitis
Mesenteric lymphadenitis (ML) is a controversial entity, and
we frequently resort to this diagnosis in patients in whom
normal appendices have been removed. The term is used to
Figure 3 Mucocele. Hypoechoic mass arising from the cecum,
with ‘‘skin onion’’ structure (*), thin walls and no associated
inflammatory changes.
refer to enlargement of some mesenteric lymph nodes, with
or without ileitis.9,10 However, some papers describe the
presence of enlarged (>10 mm in the short axis) mesenteric
nodes in asymptomatic children.22 Increased color Doppler
signal in the mesenteric vessels and minimal amount of free
fluid may be seen (Fig. 3E). The nonvisualization of the
inflamed appendix is more indicative of ML than AA.9
Acute gastroenteritis
Acute gastroenteritis (AGE) is the most common inflamma-
tory disease in children. It usually has a viral origin and the
iliocecal region is the most frequently affected. The classic
presentation of AGE does not require imaging studies. US
shows dilated, hyperperistaltic fluid-filled small bowel loops
with thin walls, where it is not uncommon to see transient
intussusception9 (Fig. 4E).
Infectious ileitis or iliocecitis
Some bacteria----such as Salmonella, Campylobacter
jejuni, Yersinia and, more rarely, Mycobacterium
tuberculosis----have a strong affinity for the lymphoid
tissue of the terminal ileum and give rise to enteritis whose
symptoms may simulate those of AA. US findings include
intestinal wall thickening and hypogenicity----usually with
intact wall layers----, transmural or mucosal hypervascularity
and enlargement of mesenteric lymph nodes.9,10 In contrast
to AA, the mesentery is normal and the thickened bowel
loops do not form a conglomerate around the appendix.
Tuberculous ileitis is rare in developed countries. It
appears as asymmetrical, non-stratified thickening of the
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Usefulness of ultrasonography in children with right iliac fossa pain 141

Figure 4 (A and B) Patient with tuberculosis and pain in right iliac fossa. (A) Chest radiograph shows patchy lesions of alveolar
characteristics with bilateral distributions and diffuse secondary to tuberculous bronchopneumonia. (B) US images of the right flank
show diffuse hypoechoic thickening, with loss of normal stratification, secondary to tuberculous ileitis. Note the similarity to the
characteristic thickening of Crohn’s disease (see Fig. 5A and B).

ileocecal walls23---25 (Fig. 4A and B). Its clinical course is
similar to that of chronic diseases with US findings similar
to those of Crohn’s disease, but always with considerable
involvement of the cecum.9 The microorganism induces
an inflammatory process that eventually leads to ulcer
formation with subsequent healing, as well as extensive
infiltration of peritoneum, omentum and mesentery associ-
ated with centrally hypodense lymph nodes.24---26 There are
no pathognomonic findings. Biopsy during colonoscopy and
culture of lesions is the diagnostic technique of choice, while
negative histologic results do not preclude tuberculosis.26
Crohn’s disease
In 25% of cases, Crohn’s disease (CD) begins in child-
hood, with involvement of the iliocecal region in 55% of
patients.8 Acute abdominal symptoms simulating AA are not
unusual. CD causes transmural inflammation that extends
to the surrounding mesentery. On US this translates into
circumferential wall thickening that may be segmental or
multifocal, and finally, loss of wall stratification.8---10,27,28
The wall appears hypoechoic with an echogenic cen-
tral line that represents the superficial mucosa (Fig. 5A
and B). The mesentery is hyperechogenic and there is
no motion of bowel loops with transducer pressure.10
Enlarged lymph nodes are found in approximately 15% of CD
patients.29
CD is associated with intestinal neovascularization. In
contrast with what happens in areas of fibrotic scarring,
in active disease there is mesenteric hypervascularity and
‘‘comb sign’’, indicative of increased blood flow in the vasa
recta (Fig. 5B). This finding may help differentiate CD from
infectious or eosinophilic ileitis or ileitis associated with
SHP, where vascular proliferation is less conspicuous. Ves-
sel density, assessed by Doppler US in affected bowel loops,
correlates with disease activity and is used as a non-invasive
technique for monitoring the course of the disease and the
response to treatment.8,28,30 Vessel density is classified as
low, moderate and high if there are 0---2, 3---5, or more than
5 Doppler signals per cm,2 respectively.30
Appendiceal involvement appears in 23% of patients with
CD, manifesting as appendiceal hyperemia similar to that of
AA. However, thickening > 5 mm and hyperemia of the termi-
nal ileum support the diagnosis of CD. US findings in cecum
and appendix are similar in both entities and therefore can-
not be used for differentiation.28
Schönlein---Henoch purpura
SHP is a small-vessel vasculitis that may affect the intestinal
tract. In some patients (10---30%), the intestinal involvement
may precede skin lesions, simulating AA. The episodes of
paroxysmal pain are secondary to edema in the subserosa
and submucosa and hemorrhagic infiltration.8,31
Characteristic US findings include diffuse, circumferen-
tial thickening of the bowel wall, with focal intramural
hematomas that appear as hyperechogenic areas, giving an
irregular appearance to the thickened wall.2,8,31 Associated
mesenteric adenopathy and free fluid are common. The duo-
denum and jejunum are the initially involved sites but, with
recurrent episodes, the disease extends to the ileum.
Celiac disease
Up to 25% of children with celiac disease initially
present with acute abdomen. US may help make an
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142 L. Raposo Rodríguez et al.

Figure 5 Crohn’s disease. (A) Color Doppler US shows marked wall thickening of the terminal ileum mainly due to a hyperechogenic
submucosa, a finding characteristic of Crohn’s disease, and mural hypervascularity. (B) Presence of multiple enlarged lymph nodes
of inflammatory appearance (*) and mesenteric hyperechogenicity and hypervascularity.

initial diagnosis and institute an early treatment. Char-
acteristic findings include abnormally dilated fluid-filled
bowel loops and reversal of the jejuno-ileal fold pattern.
There is hyperperistalsis and minimal ascites in 82% of
cases.32,33
Intestinal intussusception is a common complication and
the presence of underlying celiac disease should be inves-
tigated in case of recurrent intussusception. Ulcerative
jejuno-ileitis should be suspected in adult patients with
celiac disease and acute abdomen.34
US findings may confirm the need for biopsy.35
Typhlitis
combined with the fact that pediatric patients are not good
candidates for surgery, makes the surgical management of
these children, who present with appendiceal thickening
and RIF pain, controversial.39
Intussusception
Intussusception involves invagination of a segment of
intestine into the lumen of an immediately distal seg-
ment. Intussusception is usually idiopathic, associated with
lymphoid hyperplasia, secondary to viral infections. Approx-
imately 90% of patients with intussusception are younger
than two years.3 Findings on abdominal radiograph may be

Typhlitis occurs more typically in patients with hemato-

logic malignancies who are neutropenic as a result of
chemotherapy. In the pediatric population, typhlitis is
more frequently seen in pre-adolescent children with acute
myeloid leukemia. The most commonly affected portions
are the ascending colon and the cecum----hence the term
typhlitis----although any segment of the intestinal tract may
be involved. For this reason, the term ‘‘neutropenic ente-
rocolitis’’ seems more appropriate. Histologic examination
reveals bowel wall necrosis and hemorrhage, without inflam-
matory or tumoral infiltration. Imaging features include
asymmetrical thickening of the cecal wall (>3 mm) that is
usually hyperechogenic and heterogeneous with areas of dif-
ferent echogenicity secondary to necrosis or hemorrhage,
and redundant mucosa (Fig. 6). In most cases, Doppler
US shows hypervascularity and surrounding inflammatory
changes, as well as free fluid.36---38 Figure 6 Typhlitis in an 8-year-old child treated for leukemia,
In same patients, in addition to the findings compati- with RIF pain and fever. Axial US image of the RIF shows abnor-
ble with typhlitis, there might also be thickening of the mal thickening of the wall of the cecum (thick arrows), with loss
appendix, possibly due to the same causative factors of of stratification, and of the terminal ileum to a lesser extent (i).
typhlitis, and surgery may therefore not be indicated. This, Appendiceal caliber appears normal (arrow).
Document downloaded from http://zl.elsevier.es, day 14/08/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Usefulness of ultrasonography in children with right iliac fossa pain
Figure 7 Axial US image of an ileocolic intussusception shows
three layers of loops and the mesentery. The outer layer is
the receptor loop or intussuscipiens, which contains the cen-
tral entering limb of the intussusceptum (i), located at the
center of the intussusception next to the mesentery (M) drag-
ging some lymph nodes (*). The receptor loop also contains
the everted returning limb of the intussusceptum, which is
thicker, constituting the outer hypoechoic ring of the doughnut
(arrows).
non-specific and the use of conventional enema to make
the diagnosis is no longer justified.3 US is the test of choice
because it provides a diagnostic accuracy of 97---100%, allows
for the detection of the causes and predictive factors of
irreducibility, and can be used for follow-up and assessment
of response to treatment.40
Approximately 90% of intussusceptions are ileocolic.
The diagnostic image of intussusception is located at
the receptor bowel loop, which would explain why the
lesion is not detected in the RIF, but in the subhepatic
region (Fig. 5E). The ‘‘doughnut’’ sign refers to the
transverse section of the intussusception that shows a
thick hypoechoic ring and an echogenic center.9,41 The
target sign consists of concentric hypo- and hyperechogenic
rings, whose number varies depending on the extension
of the edema (Fig. 7). The pseudokidney sing refers to
the kidney-like appearance of the loop inside the recep-
tor loop, in the longitudinal section (Fig. 5E), usually
exceeding 5 cm in length.42 The main prognostic indicators
for irreducibility and ischemia on US include presence of
liquid trapped inside the intussusception,43 absence of
flow on Doppler US, enlarged lymph nodes, thickening of
the outer ring of the doughnut and presence of gas in the
intussusceptum.3,44
Meckel diverticulum
Meckel diverticulum, related to a persistent omphalome-
senteric duct, occurs on the antimesenteric border of the
ileum. Meckel diverticulum is a true diverticulum com-
posed of all layers of the intestinal wall. It should be
143
Figure 8 Ileal duplication cyst. Transversal view of the RIF
shows hypoechoic mass with an inner echogenic layer corre-
sponding to the mucosa, surrounded by an outer hypoechoic
layer corresponding to the muscle wall.
suspected in children with inflammatory signs of RIF in
whom a normal appendix and a lesion connected to the
terminal ileum with similar appearance to that of AA are
visualized.2,5,10,45
Right-sided diverticulitis
Right-sided diverticulitis is an unusual inflammatory condi-
tion that can mimic AA. It should be considered in young
patients with RIF pain and normal appendix. Right-side
diverticula are true diverticula, composed of all intestinal
layers, and are usually congenital and solitary. US findings of
right-sided diverticulitis include direct visualization of the
diverticulum in the right wall of the colon, focal thickening
of the colonic wall at the diverticulum site and inflamma-
tion of the adjacent fat.10,25,11,46 This condition is usually
self-limited and does not require surgery.47
Enteric duplication cysts
Enteric duplication cysts are congenital abnormalities that
result in duplication of a normal bowel loop. They normally
occur on the mesenteric border of the bowel, usually on
the ileum. The walls are composed of all intestinal layers
and most lesions do not communicate with the lumen of the
digestive tract. They may contain ectopic gastric mucosa or
lymphoid tissue. US examination shows a well-defined, fluid-
filled mass with tubular or spherical shape and an echogenic
inner mucosal layer48 (Fig. 8). In some cases, the content is
heterogeneous as a result of hemorrhage or thick material
in the interior.
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144
Figure 9 (A---C) Ovarian torsion. (A) Axial US image of the RIF in a newborn shows a cystic structure with fluid---fluid level (arrows),
very suggestive of ovarian torsion secondary to the presence of a complicated cyst. Bladder (V). (B) T2 weighted images of MRI
study, with and without fat suppression, performed the following day cannot identify the right ovary but the cystic lesion is observed
in the left flank. The mobility of the lesion suggests ovarian origin, which was subsequently confirmed at surgery. (C) The left ovary
showed normal morphology and a normal location in the pelvis (arrow).
Burkitt lymphoma
Burkitt lymphoma is the most common intraabdominal tumor
in children aged 5---12. It usually occurs in the terminal
ileum and US demonstrates bowel wall thickening with trans-
mural involvement with loss of stratification and markedly
hypoechogenic.49 Ascites and enlarged mesenteric lymph
nodes are frequent.
Epiploic appendagitis
Epiploic appendagitis (EA) is an unusual cause of acute
abdomen in children. It is a benign and self-limited condition
occurring secondary to torsion or spontaneous venous throm-
bosis of the draining veins of the epiploic appendages. As a
result, ischemic necrosis of the fatty tissue with associated
peritoneal irritation occurs. US images show a noncompress-
ible hyperechoic ovoid mass usually 1.5---5 cm in diameter
that is surrounded by a thin hypoechogenic rim and is adher-
ent to the colon (Fig. 6E).11,50---52 Color Doppler US shows
absence of central blood flow, unlike the increase in blood
flow normally detected in appendicitis.
Omental infarction
Omental infarction is a rare cause of abdominal pain in chil-
dren. It may be primary or secondary to omental torsion,
trauma, vasculitis or hypercoagulability. US findings show
an ovoid noncompressible hyperechogenic mass in the right
flank immediately beneath the rectus abdominis. This mass
is larger than that in AE, not connected to the colon and
without halo.52 Both AE and omental infarctions are self-
limited processes that usually do not require surgery.11,52
Lymphangioma
Lymphangiomas are benign cystic tumors, usually multiloc-
ulated that arise from the endothelium of lymphatic vessels
and are filled with serous or chylous fluid.48,53 Mesenteric
lymphangiomas are rare and usually discovered incidentally.
L. Raposo Rodríguez et al.
Acute abdominal symptoms may occur as a result of rupture,
torsion, infection or hemorrhage (Fig. 7E).
Ovarian torsion
Ovarian torsion is the most frequent alternative diagnosis to
AA in girls with RIF pain.5 It is usually unilateral and with
right-sided preference. Although it may result from exces-
sive mobility of the ovary, it may be associated with ovarian
tumors or cyss (in girls, benign teratomas).53---55
US, CT and MRI show similar non-specific findings that
vary depending on the duration of the torsion and the pres-
ence of an underlying mass (Fig. 9A---C). The most constant
finding is an enlarged ovary that appears heterogeneous due
to edema and hemorrhage.54,56 In 74% of cases, US exami-
nation demonstrates multiple small cysts in the periphery
of the ovary.54,55 This finding alone is not indicative of tor-
sion since it can also be seen in polycystic ovaries and
even in normal ovaries in the fertile woman; but it can
be indicative of torsion in the setting of pain with uni-
lateral ovarian enlargement. The presence of fluid-blood
level has been described as a pathognomonic sign of ovar-
ian torsion.54,55,57 Other findings include thickened fallopian
tube, fluid in the pouch of Douglas, ipsilateral deviation of
the uterus and thickening of the coexisting mass wall, if
present.54,55,58
Sometimes, color Doppler US has a limited diagnostic
utility.55 Although it may show absence of arterial flow, up
to 60% of ovarian torsions show normal arterial waveforms54
because the symptoms of venous thrombosis appear before
the arterial obstruction occurs. Additionally, the arterial
flow persists because of the dual ovarian blood supply from
the ovarian artery and the ovarian branches from the uterine
artery.59 The most common finding is a decreased or absent
venous flow.55 The main use of color Doppler is to the preop-
erative assessment of the viability of the ovary, associated
with the presence of central venous flow, while absence of
flow is associated with non-viability.55,60 The whirlpool sign
is the identification of the twisted vascular pedicle at color
Doppler US. This sign is not always visible, but its presence
suggests that the ovary is still viable.55,61
Document downloaded from http://zl.elsevier.es, day 14/08/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Usefulness of ultrasonography in children with right iliac fossa pain 145

Figure 10 Persistent urachus. Child with abdominal pain, fever and mictional syndrome. Echogenic tubular structure connected
to the umbilicus (*) in contact with the bladder dome (v).

Hemorrhagic ovarian cyst
Ovarian cysts may cause pain due to hemorrhage or
rupture.9 Classically they appear as avascular complex cys-
tic lesions, with a thin reticular pattern, fluid-detritus levels
and/or hyperechogenic areas in relation to coagulated blood
(Fig. 8E).9 The absence of involvement of the adjacent fat
helps differentiate it from an abscess. The presence of free
peritoneal fluid is common.
Ovarian tumors
Most ovarian tumors in girls are benign and painless but,
on occasions, they may cause pain due to compression of

Differential diagnosis of acute pain in the right iliac fossa in children

UROLOGIC PATHOLOGY LOOP PATHOLOGY

Acute right pyelonephritis Schönlein-Henoch
Infected urachal cyst Acute gastroenteritis Celiac disease
Ureterohydronephrosis
Vesicoureteral reflux
Right diverticulitis

ILIOCECAL
LIOCECAL PATHOLOGY MESENTERIC/OMENTAL PATHOLOGY
Crohn's disease Mesenteric lymphadenitis
Infectious ileitis Lymphangioma
Typhlitis Omental infarction
Burkitt lymphoma Appendagitis
Intussusception
Duplication cyst

Meckel diverticulum

APPENDICEAL PATHOLOGY
Acute appendicitis
Mucocele GYNECOLOGIC PATHOLO
PATHOLOGY
Distension related to cystic fibrosis Ovarian torsion
Lymphoid hyperplasia Hemorrhagic cyst
Ovarian tumors

Figure 11 Diagram depicting the anatomy of RIF and the possible disorders arising from its structures.
Document downloaded from http://zl.elsevier.es, day 14/08/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
146
adjacent structures or increase in size. Cystic teratoma
is the most common ovarian tumor. US shows a complex
solid-cystic mass with echogenic or hypoechogenic com-
ponent depending on the amount of fat, fluid or calcium
(Fig. 9E).54,62 The rest of benign ovarian tumors are usually
cystadenomas that usually present as large unilocular cystic
lesions with thin septa that may show solid poles.
Acute pyelonephritis
In most cases of acute pyelonephritis, US findings are
normal, but there might be focal or generalized renal
enlargement, areas of hypo- or hyperechogenicity (Fig. 10E),
loss of corticomedullary differentiation, thickening of the
pelvic and/or ureteral urothelium, and/or perinephric
inflammatory changes.9,63 Color Doppler US shows cortical
hypoperfusion.64
Urachal anomalies
Urachal anomalies are caused by incomplete persistence
of patency of the urachus. Urachal sinus refers to the
persistence of the urachus at the umbilical end. At US,
the persistent urachus and the urachal sinus are small-
caliber tubular structures, which appear as a fluid-filled long
tube or as an echogenic cord (Fig. 10). Diverticulum and
cyst are fluid-filled masses, with or without communication
with the bladder, respectively. Internal echoes result from
infection.65
In addition to acute pyelonephritis and urachal anoma-
lies, other urinary disorders such as ureterohydronephrosis
(Fig. 11E) and vesicoureteral reflux may also cause acute and
intermittent abdominal pain.9 For this reason, the urinary
system must also be assessed during US examination.
Conclusion
US is a useful technique for the evaluation of acute RIF
pain in children. Multiple conditions may cause RIF pain
(Fig. 11). The high spatial resolution of US in children, even
better than that of CT, provides relevant information regard-
ing these disorders and may help confirm or rule out AA,
or establish an alternative diagnosis, without the need of
invasive techniques.
Authorship
1. Responsible for the integrity of the study (original idea
of the study): GAG.
2. Conception of the study: GAG, LRR.
3. Design of the study: LRR.
4. Acquisition of data: GAG, JBGH.
5. Analysis and interpretation of data: LRR, GAG, JBGH.
6. Statistical analysis: N/A.
7. Bibliographic search: LRR.
8. Drafting of the paper: LRR, STS.
9. Critical review with intellectually relevant contribu-
tions: GAG, JBGH and STS.
10. Approval of the final version: LRR, GAG, JBGH, STS.
L. Raposo Rodríguez et al.
Conflict of interest
The authors declare not having any conflict of interest.
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