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Original Report
Jaime L. Checkoff 1
Richard J. Wechsler
Chronic Inflammatory Appendiceal
Levon N. Nazarian Conditions That Mimic Acute
Appendicitis on Helical CT
OBJECTIVE. Acute appendicitis is commonly diagnosed on CT, but chronic appendiceal
processes can mimic acute appendicitis. The purpose of this study was to identify the fre-
quency of these alternative conditions and their findings on helical CT.
CONCLUSION. Chronic inflammatory conditions other than acute appendicitis were
found in 9% of patients who underwent surgery after CT findings were interpreted as suspi-
cious for appendicitis. These inflammatory conditions were indistinguishable from acute ap-
pendicitis when we used either primary or secondary CT signs.

Received January 7, 2002; accepted after revision
February 22, 2002.
1 Department of Radiology database at our institu-
All authors: Department of Radiology, Suite 3390, Thomas
Jefferson University Hospital, 111 S. 11th St., Philadelphia,
PA 19107. Address correspondence to R. J. Wechsler.
AJR 2002;179:731–734
0361–803X/02/1793–731
© American Roentgen Ray Society
H
elical CT has become a primary
imaging modality in patients with
suspected appendicitis because of
its high accuracy [1]. Many CT signs are
useful for the diagnosis such as appendiceal
enlargement, periappendiceal inflammatory
changes, abscess formation, appendicolith,
adenopathy, and secondary cecal changes [1,
2]. However, chronic appendiceal processes
show many of the same CT signs as acute ap-
pendicitis [3]. The purpose of this study was
to identify the frequency of these alternative
chronic conditions and to characterize their
CT appearance.
Materials and Methods
A retrospective study at a large city university
hospital included potential subjects who under-
went appendectomy after diagnostic CT. The re-
view period was January 1, 1998 to January 15,
2000. Subjects were identified by searching the
tion for official reports that had matching surgical
pathology specimens within 7 days of the scan-
ning. All CT was performed on a single-detector
helical CT scanner (HiSpeed Advantage; General
Electric Medical Systems, Milwaukee, WI) using
5- or 7-mm collimation. All patients received oral
contrast material, barium suspension (Readi-Cat 2;
E-Z-EM, Westbury, NY), or a diatrizoate meglu-
mine–diatrizoate sodium solution (MD-Gastro-
view; Mallinckrodt Medical, St. Louis, MO); and
83 of 106 patients received 150 mL of IV iodi-
nated contrast material ([iothalamate meglumine
or ioversol] Conray or Optiray; Mallinckrodt Med-
ical). All studies were interpreted by one of 10
dedicated body imaging radiologists using a
SPARC teleradiology workstation (Sun Microsys-
tems, Mountain View, CA). The images were re-
viewed in standard soft-tissue window settings
that could be manipulated. Primary signs that were
used to make the diagnosis of appendicitis in-
cluded those that were direct CT evidence of ap-
pendiceal inflammation, such as a distended
appendix (>6 mm) and periappendiceal fat infiltra-
tion. Presence of an appendicolith was also con-
sidered a primary sign because, although not very
sensitive, it has been shown to be up to 100% spe-
cific [2]. Secondary signs indicating inflammation
adjacent to the appendix included abscess, lym-
phadenopathy (enlarged [>5 mm in short dimen-
sion] and clustered [three or more] right lower
quadrant lymph nodes) [4], and cecal changes
(thickening, mass effect, arrowhead sign [5], and
pericecal fat stranding). When the imaging report
described probable or suggestive findings of ap-
pendicitis, the report was coded as positive for ap-
pendicitis. The data were stratified into acute
appendicitis, chronic appendiceal conditions, peri-

AJR:179, September 2002 731

 Checkoff et al.

appendiceal disorders mimicking appendicitis, and
negative findings at appendectomy. The study pa-
tients included those in whom chronic appendiceal
conditions were diagnosed at surgical pathology.
These cases were retrospectively reviewed for
signs of appendicitis by two experienced CT radi-
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appendiceal inflammation was seen in five
patients. An appendicolith was seen in only
one patient. At least one primary sign of
acute appendicitis was seen in eight (80%) of
10 patients, and five (50%) of 10 patients had
two primary signs of acute appendicitis.
pendicitis [3]. Four of our five patients with
chronic inflammation or fibrosis of the ap-
pendix had at least one primary and one sec-
ondary sign of acute appendicitis (Figs. 1
and 2). Patients with this condition usually
benefit from surgery and have relief of symp-

ologists in consensus.
Results
One hundred six patients (53 females and
53 males; age range, 4–91 years) underwent
surgery within 7 days of CT. Eighty-three
patients (78%) had acute appendicitis. Six
patients (6%) had periappendiceal disorders
mimicking acute appendicitis. These condi-
tions included diverticulitis, salpingitis, peri-
appendicitis, adenocarcinoma of the cecum
and ileocecal valve, and nonspecific inflam-
mation of the terminal ileum and right colon.
Seven patients (7%) had a normal appendix
at surgery.
Ten patients (9%) had chronic appendiceal
inflammatory conditions and composed the
study group (Table 1). Their conditions in-
cluded chronic appendicitis (n = 2) (Fig. 1),
appendiceal fibrosis (n = 3) (Fig. 2), granulo-
matous appendicitis (n = 2) (Fig. 3), and
lymphoid hyperplasia (n = 3) (Fig. 4). CT re-
vealed increased appendiceal diameter
(range, 8–13 mm) in seven of these patients
and normal diameter in two patients. In one
patient the appendix was not visualized, but
the diagnosis of appendicitis was suspected
because of the presence of five secondary
signs, including a low-density collection in
the expected location of the appendix. Peri-
Secondary CT signs of acute appendicitis
included lymphadenopathy (n = 5), cecal
mass effect (n = 4), and focal cecal thicken-
ing (n = 2). Appendiceal abscess was present
in one patient. At least one secondary sign of
acute appendicitis was present in nine (90%)
of 10 patients, and more than one secondary
sign was present in three (30%) of 10 patients.
Discussion
Several chronic appendiceal conditions
mimic acute appendicitis both clinically [6]
and radiographically, and the CT appearance
of some of these conditions has been de-
scribed [3]. These alternative conditions have
in common a relatively slow progression of
inflammation, which is of longer duration
than the inflammation typically seen in acute
appendicitis. Our results support the fact that
many of these conditions are not distinguish-
able from acute appendicitis using primary
or secondary CT signs. Patients with chronic
appendicitis may present with symptoms that
are not acute, but many of these patients be-
come acutely symptomatic [3]. The cause of
chronic appendicitis may be prolonged par-
tial obstruction of the appendiceal lumen [3].
The CT findings in patients with chronic ap-
pendicitis are the same as those in acute ap-
toms after appendectomy [7].
Similarly, patients with granulomatous ap-
pendicitis usually have a clinical presentation
similar to that of acute appendicitis [8]. One
of our patients with granulomatous appendi-
citis showed two primary CT signs and one
secondary sign of acute appendicitis (Fig. 3).
The appendix was not well seen on CT in the
other patient, but five secondary signs were
present, including an abscess that probably
indicated a superimposed acute inflammatory
process. Idiopathic granulomatous appendici-
tis has been described as distinct from granu-
lomatous ileocolitis (Crohn’s disease) [8].
However, Crohn’s disease can develop later
in as many as 21% of cases [8].
Lymphoid hyperplasia can occur anywhere
in the bowel but is often seen in the terminal
ileum and appendix [9]. Its acute form can be
indistinguishable clinically from acute appen-
dicitis, and it is thought that upper respiratory
infection may play a causative role [9]. Lym-
phoid hyperplasia may cause partial obstruc-
tion of the appendiceal lumen [3], resulting in
chronic or recurrent inflammation. Lymphoid
hyperplasia has also been described in associ-
ation with infectious mononucleosis [10].
Two of our patients with appendiceal lym-
phoid hyperplasia showed two primary CT
signs of acute appendicitis (Fig. 4), and the

TABLE 1 Diagnoses and Findings in Chronic Appendiceal Inflammatory Processes Revealed by Helical CT in 10 Patients

Primary Sign Secondary Sign

Patient Age Cecal
Sex Pathologic Diagnosis Distended Fat Cecal Arrowhead Pericecal
No. (yr) Appendicolith Abscess Adenopathy Mass
Appendix Infiltration Thickening Sign Stranding
Effect
1 41 Male Granulomatous appendicitis + + – – + – – – –
2 45 Female Mild chronic inflammation + + – – + – – – +
3 61 Male Lymphoid hyperplasia + + – – – – – – +
4 36 Female Fibrosis of appendiceal tip + + – – – + + – +
5 29 Male Lymphoid hyperplasia + – + – + – – – –
6 23 Female Mild chronic inflammation + – – – – – + – –
7 91 Female Appendiceal fibrosis – – – – + – – – –
8 26 Female Chronic fibrosis + – – – – – + – –
9 26 Female Lymphoid hyperplasia – + – – – – – – –
10 28 Male Granulomatous appendicitis – – – + + + + – +
Note.— Plus sign (+) indicates present, minus sign (–) indicates absent.

732 AJR:179, September 2002

 CT of Conditions That Mimic Appendicitis

third patient showed one primary sign—
namely, periappendiceal fat infiltration. Most
patients with lymphoid hyperplasia have res-
olution of symptoms after surgery [9].
In these patients with chronic inflammatory
appendiceal conditions, the most commonly
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seen primary sign of acute appendicitis was
distention of the appendix. Although other re-
searchers [2] report 100% specificity for the
finding of an enlarged (>6 mm) appendix in
acute appendicitis, a more recent sonographic
study [11] has shown a lower specificity. In
fact, sonography has revealed a specificity of
only 68% for an outer appendiceal diameter of
6 mm or larger, and a specificity of 88% for a
diameter of 7 mm or larger [12].
Limitations of this study include its retro-
spective design. The official CT reports from

Fig. 1.—45-year-old woman with right flank pain. Single-detector
helical CT scan shows appendix (arrows) to be distended (11 mm).
Note periappendiceal and pericecal fat infiltration. Pathology
specimen showed mild chronic inflammation.
Fig. 2.—36-year-old woman with right lower quadrant pain and
tenderness. Single-detector helical CT scan shows appendix
(arrow ) to be distended (9 mm) and mass effect on cecum.
Note periappendiceal and pericecal fat infiltration. Pathology
specimen showed fibrous obliteration of tip of appendix.

Fig. 3.—41-year-old man with right lower quadrant pain.
Single-detector helical CT scan shows appendiceal wall
(arrow ) to be markedly thickened (outer diameter, 13 mm).
Note surrounding fat infiltration. Right lower quadrant ade-
nopathy was also present (not shown). Pathology specimen
showed granulomatous appendicitis.
Fig. 4.—61-year-old man with right lower quadrant pain. Single-
detector helical CT scan shows thickened (11 mm) appendix
(arrow ). Note mild periappendiceal and pericecal fat infiltration.
Pathology specimen showed lymphoid hyperplasia.

AJR:179, September 2002 733


a 2-year period were used rather than review-
ing all 106 cases. Only the study cases were
then reviewed retrospectively, using a con-
sensus interpretation. Finally, the study sam-
ple size was small because of the relative
rarity of the chronic appendiceal conditions.
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In conclusion, chronic inflammatory condi-
tions were found in 9% of patients taken to
surgery on the basis of CT findings suspicious
for acute appendicitis. On retrospective review
using primary and secondary CT signs, these
conditions appeared similar to acute appendi-
citis. Therefore, performing surgery based on
CT findings of acute appendicitis will inevita-
bly result in some appendixes being removed
for chronic conditions. However, according to
the literature, most of these appendectomies
will still benefit the patient symptomatically.
734
Checkoff et al.
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