Clinical Imaging 36 (2012) 29 – 34

Diagnostic power of various computed tomography signs in diagnosing

acute appendicitis
Vincent Lai⁎, Wan Chi Chan, Hin Yue Lau, Tsz Wai Yeung,
Yiu Chung Wong, Ming Keung Yuen
Department of Radiology, Tuen Mun Hospital, Tuen Mun, Hong Kong, PR China
Received 2 February 2011; accepted 11 March 2011

Abstract

Objective: To review the diagnostic power of various computed tomography (CT) signs in acute appendicitis, in particular those initially
classified as inconclusive. Materials and methods: Retrospective review of 100 CT abdomen and pelvis studies with assessment of maximal
luminal diameter, wall thickness and cross-sectional diameter of the appendix, periappendiceal inflammatory changes, and presence of
appendicolith. Results: All CT signs show statistically significant occurrences in acute appendicitis. Their respective cut-off values with best
sensitivity and specificity were calculated. Those from the inconclusive cases were also reviewed. Conclusion: Maximal cross-sectional
diameter of the appendix is the most powerful parameter. Rest of the CT signs is supportive, especially in cases with inconclusive results.
© 2012 Elsevier Inc. All rights reserved.

Keywords: Acute appendicitis; Computed tomography; Diagnostic signs; Maximal diameter; Periappendiceal inflammation

1. Introduction
Acute appendicitis is one of the commonest causes of acute
abdomen, and prompt diagnosis is essential to minimize
morbidity. Traditionally, diagnosis relied on history and
physical examination, but it had been difficult to find the
balance between decreasing false-negative appendectomy
rates (10–30%) and making a diagnosis before perforation
occurs [1–5]. With advances in imaging technology, com-
puted tomography (CT) has now become part of the standard
of care in managing patients with suspected acute appendicitis
[6–9]. Well-documented CT findings include direct signs
such as thickened appendiceal diameter, thickened appendi-
ceal wall, and distended appendiceal luminal diameter, and
indirect signs such as presence of periappendiceal inflamma-
tory changes (fat stranding, fluid collection, phlegmon, or
abscess formation), appendicolith, extraluminal air, adjacent
adenopathy, and adjacent bowel wall thickening [10–19].
⁎ Corresponding author. Department of Radiology, Li Ka Shing Faculty
of Medicine, The University of Hong Kong, Hong Kong. Tel.: +852
61224478; fax: +852 24663569.
E-mail address: vincentlai@hkcr.org (V. Lai).
However, not all of the above features are always useful
in diagnosing appendicitis. The incidences of appendicolith,
adjacent bowel wall thickening, and adenopathy may be too
low for clinical use [16,20]. Extraluminal air occurs in cases
with perforation only [21,22]. The occurrence of periappen-
diceal inflammatory changes is usually of variable degree
[16]. We tend to rely on direct signs by measuring the
maximal cross-sectional appendiceal diameter or wall
thickness. Yet discrepancies exist amongst the recommended
data or measurement from various past literatures, causing
diagnostic confusion occasionally in cases with intermediate
findings [23].
Hence, in this study, we aimed to review the diagnostic
power and measurement of various CT signs in diagnosing
acute appendicitis. We also reviewed the CT findings for
patients classified as inconclusive from the initial CT studies.
2. Materials and method
We retrospectively reviewed all urgent CT studies of
the abdomen and pelvis performed for either (1) acute abdo-
men of uncertain cause initially but subsequently diagnosed

0899-7071/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.clinimag.2011.04.003
30 V. Lai et al. / Clinical Imaging 36 (2012) 29–34

as appendicitis or (2) clinically suspected acute appendici- 3. Results

tis during the period of April 2007 to June 2008 at our
hospital through our radiology information system database. For the 100 cases, 41 (41%) of them were subsequently
A total of 100 patients matching the above criteria were proven to be positive, while 59 (59%) of them were negative
retrieved and recruited in the study. Forty-four patients were for appendicitis. The interobserver agreement showed good
male and 56 were female. The mean age was 38.6 years agreement with the kappa value (κ) of “maximal luminal
(2–88 years old). diameter of the appendix”, “maximal wall thickness of the
Imagings for all cases were performed by our multi- appendix”, “maximal cross-sectional diameter of the appen-
detector CT machine (16-head, Brillance 16, Philips). dix”, “periappendiceal inflammatory changes and free fluid”,
Scanning range was from the level of the diaphragm to the “abscess formation”, and “presence of appendicolith”
pubic symphysis in all patients. Imaging was performed in measured at 0.75, 0.82, 0.81, 0.78, 0.90, and 1.00, respec-
the noncontrast phase initially and subsequently during the tively. The demographic and CT results are summarized in
portovenous phase after a delayed dynamic bolus (2 ml/kg of Table 1.
body weight; maximum dose 100 ml) of nonionic iodinated Amongst the appendicitis group, there were 41 patients
contrast (Omnipaque 300) administered intravenously by a (22 males, 19 females) with a mean age ±S.D. of 37.8±27.2.
mechanical injector at a rate of 3 ml/s. The raw images The mean values±S.D. of the measured parameters were as
acquired were reconstructed into 2 mm thickness with 1-mm follows: maximal luminal diameter of the appendix=5.95±3.62
interspace for interpretation. No oral or rectal contrast was mm; maximal wall thickness of the appendix=3.43±1.52 mm;
given or administrated. maximal cross-sectional diameter of the appendix=12.68±2.99
Images from all cases were reviewed by two indepen- mm; periappendiceal infiltrates=1.71±0.75; periappendiceal
dent radiologists directly from the CT workstation, with the fluid=1.51±1.08. All of them showed statistically significantly
following CT criteria assessed: (1) maximal luminal diam- higher values compared with those in the nonappendicitis
eter of the appendix; (2) maximal wall thickness of the group (Pb.001). Abscess formation was present in 14
appendix; (3) maximal cross-sectional diameter (outer wall- (34%) of 41 patients and appendicolith was also found in
to-outer wall) of the appendix; (4) periappendiceal inflam- 14 (34%) of 41 patients, also showing statistically
matory infiltrates (defined as stranding and infiltration of significantly higher occurrences compared with the non-
the periappendiceal fat) and free fluid; each of which was appendicitis group (Pb.001).
graded as absent (score=0), mild (score=1), moderate For the nonappendicitis group, there were 59 patients
(score=2), or severe (score=3) subjectively; (5) periappen- (22 males, 37 females) with a mean age±S.D. of 41.2±24.7
diceal abscess formation; and (6) presence of appendicolith. years. Twenty-six (44%) of those patients were proven sur-
For Parameters 1 to 3, all measurements were taken at the gically as laparotomy was performed for other depicted
transverse (axial) section at the level of maximal dimension surgical causes in the CT scans: small bowel diverticulitis,
along any elongated segment of the appendix. Sampling at intussusceptions, small bowel perforation, ruptured right
any turning point of the appendix was avoided. In order ovarian cyst, right retroperitoneal hematoma, pseudoaneur-
to standardize the measurement method and to minimize ysm, tubo-ovarian abscess, Crohn's disease with terminal
measurement error, a magnification ratio of 2.0 was used ileitis, caecal perforation, and terminal ileitis. The spectrum
and each parameter was measured three times by each of the diseases is similar to previous published data [24,25].
radiologist with the mean value obtained for each subject. The remainders were assumed to be normal as they were
Discrepancy of measurement, if any, was resolved after treated conservatively and subsequently discharged home
subsequent consensus. on stable condition. The mean values±S.D. of the measured
The histological analytic results from the surgical cases parameters were as follows: maximal luminal diameter of
were evaluated and used as the gold standard to define the
definitive diagnosis. The whole population was then Table 1
divided accordingly into two different groups with age Summarized results of demographic data and different CT signs
and sex matched: appendicitis group (n=41) and non- Appendicitis Nonappendicitis P
appendicitis group (n=59). Interobserver agreement for the group group value
measured data was evaluated and expressed with the κ n 41 59
statistic. Agreement was excellent with κN0.80; good, Male sex (%) 22 (54) 22 (39) .639
κ=0.61–0.80; moderate, κ=0.41–0.60; fair, κ=0.21–0.40; Age (years) 37.8±27.2 41.2±24.7 .439
and poor, κb0.20. Statistical analyses were then performed Maximal luminal diameter (mm) 5.95±3.62 1.92±1.60 b.001
Maximal wall thickness (mm) 3.43±1.52 2.03±0.95 b.001
by SPSS 16.0 for Windows (SPSS Inc.) with the use of the
Maximal cross-sectional 12.68±2.99 5.98±1.55 b.001
t test. Differences with a P value of b.05 were considered diameter (mm)
to be statistically significant. Receiver operating character- Periappendiceal infiltrates (grade) 1.71±0.75 0.20±0.52 b.001
istic (ROC) curves were then generated with the cut-off Periappendiceal fluid (grade) 1.51±1.08 0.41±0.79 b.001
values of the respective parameters determined from the Periappendiceal abscess 14 (34%) 2 (1%) b.001
Appendicolith 14 (34%) 0 (0%) b.001
coordinates along the curves.
 V. Lai et al. / Clinical Imaging 36 (2012) 29–34 31

Fig. 1. Generated ROC curves for various CT signs.

the appendix=1.92±1.60 mm; maximal wall thickness of
the appendix=2.03±0.95 mm; maximal cross-sectional diam-
eter of the appendix=5.98±1.55 mm; periappendiceal in-
filtrates=0.20±0.52; periappendiceal fluid=0.41±0.79.
Abscess formation was present in only 2 (1%) of 59 patients
only and appendicolith was absent (0%) in all patients. They
were of statistically significantly lower values and occur-
rences compared with the appendicitis group.
ROC curves were generated to further evaluate the sen-
sitivity, specificity, and strength of different CT signs and
their diagnostic powers for acute appendicitis (Fig. 1 and
Table 2). All the significant continuous variables were intro-
duced onto the ROC curves, and results demonstrated that
the maximal cross-sectional diameter of the appendix was
the most powerful predictor for acute appendicitis with a
cut-off value of 8.5 mm, leading to a sensitivity of 90.2% and
a specificity of 91.5%. Maximal luminal diameter and
maximal wall thickness of the appendix were also good
predictive CT signs, showing good specificities with cut-off
values of 4.5 mm (91.5%) and 3.5 mm (93.2%), respectively,
but with much lower sensitivities (63.4% and 48.8%,
respectively). Similarly, periappendiceal inflammatory in-
filtrates and fluid were also of good predictors for acute
appendicitis, but with much lower sensitivities (53.7% and
22.0%, respectively). The cut-off values for different CT
signs together with their best respective specificities and
corresponding sensitivities are summarized in Table 3.
Eleven patients (four males, seven females) with a mean
age of 33.8±25.6 years were initially classified as inconclu-
sive result on CT study due to intermediate results, satisfying
only one or two CT criteria (see Table 4). Nine of them
underwent surgery subsequently with four (36%) of nine
patients turning out to be positive and the other five (64%) of
nine patients were negative for appendicitis. The remaining
two patients were treated conservatively and symptoms
gradually resolved, hence assumed to be negative for appen-
dicitis as well. For the 4 of 11 patients who were positive
for appendicitis, the maximal cross-sectional diameters of
the appendix were 7, 8 (in two patients), and 9. All of them
were associated with a mild to moderate degree of peri-
appendiceal inflammatory changes. For the 7 of 11 patients
who did not suffer from appendicitis, the measured

Table 2
Summarized results of diagnostic powers according to ROC curves for different CT signs
Test result variable(s) Area under Standard error a Asymptotic Asymptotic 95% CI
the curve significance b
Lower bound Upper bound
Maximal luminal diameter 0.811 0.050 b.001 0.714 0.909
Maximal wall thickness 0.771 0.049 b.001 0.675 0.866
Maximal cross-sectional diameter 0.986 0.008 b.001 0.971 1.002
Periappendiceal infiltrates 0.944 0.022 b.001 0.899 0.988
Periappendiceal fluid 0.784 0.048 b.001 0.690 0.878
CI=Confidence interval.
a
Under the nonparametric assumption.
b
Null hypothesis: true area = 0.5.
32 V. Lai et al. / Clinical Imaging 36 (2012) 29–34

Table 3 necessarily present and substantial discrepancy in their

Cut-off values for different CT signs with their respective best specificities
and corresponding sensitivities
Cut-off Sensitivity
value (%)
Maximal luminal diameter (mm) 4.5 63.4
Maximal wall thickness (mm) 3.5 48.8
Maximal cross-sectional diameter 8.5 90.2
Periappendiceal infiltrates (grade) 1.5 53.7
Periappendiceal fluid (grade) 2.5 22
maximal cross-sectional diameters of the appendix were
within the range of 6–8 mm. Variable degrees of peri-
appendiceal inflammatory changes were present in four
(57%) of them (Patients 5, 8, 9, and 11), although these four
patients were subsequently operated on and found to be
suffering from other diseases. Nevertheless, there seemed to
be overlapping results demonstrated for patients with
appendixes showing maximal cross-sectional diameters of
7–8 mm, leading to potential diagnostic confusion.
4. Discussion
Appendicitis is a common clinical entity with substantial
morbidity and mortality, if untreated. CT has become im-
portant and popular as it has the ability to diagnose appen-
dicitis rapidly and effectively, clearly depicting the typical
findings with sensitivity and specificity ranging from 91%
to 100% and 91% to 99%, respectively [3,5,26–31]. We
generally rely on a typical constellation of CT findings to
diagnose appendicitis, including appendiceal diameter of
more than 6 mm, appendiceal wall thickness of more than
3 mm, periappendiceal inflammatory changes (fat stranding,
fluid collection, phlegmon, or abscess formation), presence
of appendicolith, extraluminal air, adjacent adenopathy, and
adjacent bowel wall thickening [26,32]. However, missed/
incorrect diagnoses still occur as not all of these signs are
frequencies [16] as well as recommended values had been
found. Besides, some symptomatic patients may only show
Specificity one of the above findings on CT scan (e.g., isolated appen-
(%)
diceal enlargement or right lower quadrant stranding den-
91.5 sities), causing diagnostic dilemma.
93.2
Results from our study demonstrated that all the CT signs
91.5
94.9 were useful in predicting appendicitis, showing statistically
100 significant occurrences (Pb.001). From the analysis of the
ROC curve, the maximal cross-sectional diameter of the
appendix was the most powerful CT sign in diagnosing acute
appendicitis, with a cut-off value of 8.5 mm (sensitivity of
90.2% and specificity of 91.5%). This value is higher than
the 6 mm stated from various past literatures [14,15,19,31],
but is in line with findings from more recent studies by Ives
et al. [33] and Daly et al. [23]. Maximal wall thickness of
the appendix, maximal luminal diameter of the appendix,
periappendiceal inflammatory changes, and presence of
appendicolith were also good predictive signs for appendi-
citis but with lower and variable sensitivities (22.0–63.4%)
when maintaining at a high specificity (N90%).
Retrospective review of the CT findings for patients
initially reported as inconclusive revealed mixed results for
appendix showing a maximal cross-sectional diameter of
7–8 mm. This appeared incoherent with previous studies by
Bursali et al. [34], Johnson et al. [35], Benjaminov et al. [36],
and Webb et al. [37], showing that the mean diameter of
a normal appendix ranged from 3.4 to 5.1, 5 to 7, 3.6 to 6.6,
and 6 to 10 mm, respectively. Such findings signified a
potential grey zone requiring further ancillary findings or
secondary/indirect signs, in particular the presence of peri-
appendiceal inflammatory changes and exclusion of other
pathological processes, to conclude a definitive diagnosis
[23]. Nevertheless, such postulation would require further
dedicated study for clarification of such relationship. Non-
visualization of the appendix is another major challenge with
a reported rate of 15% [38], causing difficulty in interpre-
tation. Although this may be of lesser concern with the use

Table 4
Results of various CT signs for patients initially classified as inconclusive result on CT studies of the abdomen and pelvis
Patient Sex Age LD (mm) WT (mm) CSD (mm) Infiltrates (grade) Fluid (grade) Remark
Appendicitis group
1 M 52 0 4 8 2 3
2 F 14 1 3 7 2 2
3 F 17 2 3 8 3 3
4 M 4 1 4 9 1 3

Nonappendicitis group
5 F 30 4 2 7 1 2 Pelvic inflammatory disease
6 F 9 0 2 7 0 0 Mesenteric adenitis
7 M 80 4 1 7 0 0 Not operated on
8 F 49 4 2 8 1 3 Terminal ileitis
9 F 39 0 4 8 1 2 Ruptured right ovarian cyst
10 M 67 4 3 8 0 0 Not operated on
11 F 11 0 3 6 2 2 TB peritonitis
LD=Maximal luminal diameter of the appendix; WT=maximal wall thickness of the appendix; CSD=maximal cross-sectional diameter of the appendix.
Grade: 0=absent; 1=mild; 2=moderate; 3=severe.
 V. Lai et al. / Clinical Imaging 36 (2012) 29–34
of multidetector CT nowadays, paucity of intra-abdominal
fat is still a major contributing factor [10,24,39,40] espe-
cially in children since it is a natural contrast agent allowing
inflammatory changes to be detected easily. We encountered
three appendicitis cases with indistinct appendix, all of
which were associated with moderate to marked periappen-
diceal inflammatory infiltrates, fluid, and abscess formation.
Therefore depiction of secondary signs becomes important
in these encounters. One can conclude that the detective
rate of acute appendicitis would be low in the absence of a
distinctly visualized appendix and any secondary inflamma-
tory changes.
The major limitation of our results is that majority of the
cases in the nonappendicitis group could not be verified by
surgical–pathological proof. Those who recovered sponta-
neously or upon conservative management were assumed to
be normal and did not suffer from acute appendicitis. Yet
some of these patients could be suffering from early acute
appendicitis, chronic inflammatory appendiceal conditions
[14], or chronic appendicitis syndrome, which is a unique
phenomenon in adult as described by Giuliano et al. [41].
However, it would be unethical to perform surgery or ob-
tain histological proof on these patients. The other major
limitation would be the potential measurement errors that
occurred in obtaining the maximal cross-sectional diameter,
maximal wall thickness, and maximal luminal diameter of
the appendix.
In conclusion, the overall accuracy of various CT signs
in diagnosing acute appendicitis is high. The maximal cross-
sectional diameter of the appendix is the most powerful
parameter, with a cut-off value of 8.5 mm for acute appen-
dicitis showing high sensitivity and specificity. Maximal
luminal diameter of the appendix, maximal wall thickness of
the appendix, and periappendiceal inflammatory changes are
also good predictive CT signs showing statistically higher
occurrences and are particularly useful as supportive signs
when the CT findings are seemingly inconclusive.
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