Pediatr Radiol
DOI 10.1007/s00247-014-3232-5
ORIGINAL ARTICLE
The challenging ultrasound diagnosis of perforated appendicitis
in children: constellations of sonographic findings improve
specificity
Sheryl Tulin-Silver & James Babb & Lynne Pinkney & Naomi Strubel &
Shailee Lala & Sarah S. Milla & Sandra Tomita & Nancy R. Fefferman
Received: 2 May 2014 / Revised: 22 August 2014 / Accepted: 4 November 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Background Rapid and accurate diagnosis of appendicitis,
particularly with respect to the presence or absence of perfo-
ration, is essential in guiding appropriate management. Al-
though many studies have explored sonographic findings
associated with acute appendicitis, few investigations discuss
specific signs that can reliably differentiate perforated appen-
dicitis from acute appendicitis prior to abscess formation.
Objective The purpose of our study was to identify sono-
graphic findings that improve the specificity of US in the
diagnosis of perforated appendicitis. Our assessment of hepat-
ic periportal echogenicity, detailed analysis of intraperitoneal
fluid, and formulation of select constellations of sonographic
findings expands upon the literature addressing this important
diagnostic challenge.
Materials and methods We retrospectively reviewed 116 ab-
dominal US examinations for evaluation of abdominal pain in
children ages 2 to 18 years from January 2008 to September
2011 at a university hospital pediatric radiology department.
The study group consisted of surgical and pathology proven
acute appendicitis (n=51) and perforated appendicitis (n=22)
US exams. US exams without a sonographic diagnosis of
appendicitis (n=43) confirmed by follow-up verbal commu-
nication were included in the study population as the control
S. Tulin-Silver : J. Babb : L. Pinkney : N. Strubel : S. Lala :
N. R. Fefferman (*)
Department of Radiology, New York University School of Medicine,
660 1st Ave., New York, NY 10016, USA
e-mail: nancy.fefferman@nyumc.org
S. S. Milla
Children’s Healthcare of Atlanta, Emory University,
Atlanta, GA, USA
S. Tomita
Pediatric Surgery, New York University School of Medicine, 560 1st
Ave., New York, NY 10016, USA
group. After de-identification, the US exams were indepen-
dently reviewed on a PACS workstation by four pediatric
radiologists blinded to diagnosis and all clinical information.
We recorded the presence of normal or abnormal appendix,
appendicolith, appendiceal wall vascularity, thick-walled
bowel, dilated bowel, right lower quadrant (RLQ) echogenic
fat, increased hepatic periportal echogenicity, bladder debris
and abscess or loculated fluid. We also recorded the charac-
teristics of intraperitoneal fluid, indicating the relative quantity
(number of abdominal regions) and quality of the fluid (simple
fluid or complex fluid). We used logistic regression for corre-
lated data to evaluate the association of diagnosis with the
presence versus absence of each US finding. We conducted
multivariable analysis to identify constellations of sonograph-
ic findings that were predictive of perforated appendicitis.
Results The individual US findings of abscess/loculated fluid,
appendicolith, dilated bowel and increased hepatic periportal
echogenicity were significantly associated with perforated ap-
pendicitis when compared with acute appendicitis (P<0.01).
The sonographic observation of increased hepatic periportal
echogenicity demonstrated a statistically significant association
with perforated appendicitis compared with acute appendicitis
(P<0.01). The presence of complex fluid yielded a specificity
of 87.7% for perforated appendicitis compared with the acute
appendicitis group. The US findings of ≥2 regions or ≥3
regions with fluid had specificity of 87.3% and 99.0%, respec-
tively, for perforated appendicitis compared with the acute
appendicitis group. Select combinations of sonographic find-
ings yielded high specificity in the diagnosis of perforated
appendicitis compared with acute appendicitis. These constel-
lations yielded higher specificity than that of each individual
finding in isolation. The constellation of dilated bowel, RLQ
echogenic fat, and complex fluid had the highest specificity
(99.5%) for perforated appendicitis (P<0.01).
Conclusion Our study demonstrates that identification of se-
lect constellations of findings using abdominal sonography, in

addition to focused US examination of the right lower quad-
rant, can improve sonographic diagnosis of perforated appen-
dicitis in the pediatric population.
Keywords Perforated appendicitis . Acute appendicitis .
Appendix . Ultrasound . Children
Introduction
Appendicitis is the most common reason for abdominal sur-
gery in children [1]. Rapid and accurate diagnosis of appen-
dicitis, particularly with respect to the presence or absence of
perforation, is essential in guiding appropriate management.
Acute appendicitis is typically treated by appendectomy,
whereas perforated appendicitis can be managed conserva-
tively with antibiotic therapy followed by delayed appendec-
tomy. Children younger than 5 years are known to have a
higher risk of perforated appendicitis [2]. Because the clinical
distinction between perforated and non-perforated appendici-
tis is often difficult, especially in the youngest children, im-
aging plays an integral role in diagnosis.
With concerns regarding childhood radiation expo-
sure, US is frequently the diagnostic imaging modality
of choice for the initial evaluation of suspected appen-
dicitis [3]. Ramarajan et al. [4] demonstrated that a
multidisciplinary approach with the staged use of US
supplemented by CT imaging, if necessary, can decrease
radiation exposure while maintaining diagnostic accura-
cy. Perforated appendicitis, however, has repeatedly
been recognized as a potential pitfall in the sonographic
diagnosis of appendicitis [3, 5–7]. The perforated ap-
pendix can decompress and lose its integrity such that it
cannot be reliably identified. US visualization of the
normal appendix can also be difficult, with reported
rates ranging from 2.4% to 86.2% [8–13]. The diagnosis
of perforated appendicitis can be particularly challeng-
ing when the appendix is not visualized, which can
occur in the setting of both perforated appendicitis and
a normal appendix. Although many studies have ex-
plored sonographic findings associated with acute ap-
pendicitis, few investigations discuss specific signs that
can reliably differentiate perforated appendicitis from
acute appendicitis prior to abscess formation. The find-
ings of a loculated fluid collection and absence of the
echogenic appendiceal submucosal layer have been
shown to be predictive of perforated appendicitis in
children [14] and adults [15, 16]. The secondary sono-
graphic findings of echogenic mesenteric fat, fluid col-
lections and dilated bowel were found to be helpful in
the diagnosis of acute appendicitis in children when the
appendix was not visualized [17]. More recently
Blumfield et al. [18] demonstrated that the presence of
Pediatr Radiol
abscess or appendicolith and the loss of the echogenic
appendiceal submucosal layer were associated with per-
forated appendicitis.
Several of these earlier studies evaluating the sono-
graphic diagnosis of perforated and non-perforated ap-
pendicitis in the pediatric population were performed
more than a decade ago. Recent advances in US tech-
nology have allowed for acquisition of more detailed
and higher-resolution images. Although previous studies
have discussed the association of lower abdominal sono-
graphic findings with perforated appendicitis, no study
has explored the utility of sonographic evaluation of the
abdomen focusing on liver echotexture, intraperitoneal
fluid and the value of combinations of specific sono-
graphic findings in the diagnosis of perforated appendi-
citis. The purpose of our study was to identify sono-
graphic findings that improve the specificity of US in
the diagnosis of perforated appendicitis and demonstrate
the value of abdominal sonography in the setting of
perforated appendicitis. Our assessment of hepatic
periportal echogenicity, detailed analysis of the quantity
and quality of intraperitoneal fluid, and formulation of
select constellations of sonographic findings expands
upon the literature addressing this important diagnostic
challenge.
Materials and methods
Our institutional review board approved this study,
which was compliant with the Health Insurance Porta-
bility and Accountability Act. Patient informed consent
was waived for this retrospective investigation.
Pediatric Surgery departmental databases were uti-
lized to retrospectively identify all pediatric patients
ages 2–18 years who presented to our university hos-
pital pediatric radiology department between January
2008 and September 2011 with a chief complaint of
abdominal pain and suspected diagnosis of appendici-
tis. Database A was generated by extracting all pediat-
ric appendectomy patients evaluated pre-operatively
with abdominal sonography from the Pediatric Surgery
clinical database. Database A (n = 194) was used to
create the two experimental groups of acute appendici-
tis and perforated appendicitis. Using a second Pediat-
ric Surgery database, database B was generated by
extracting all patients evaluated by abdominal US for
suspected appendicitis who were subsequently
discharged without undergoing appendectomy. This
second database was compiled from the hospital infor-
mation system and included all children presenting
with abdominal pain and suspected appendicitis. Data-
base B (n = 68) was utilized to create the control group
Pediatr Radiol

consisting of children without a sonographic diagnosis greater than 2 mm [19, 20], dilated bowel measuring
of appendicitis. The study population inclusion criteria greater than 2.5 cm [21], echogenic RLQ fat defined as
consisted of children presenting with abdominal pain an area of increased echogenicity greater than 1 cm in
and no known co-morbid conditions who had under- diameter [15], increased hepatic periportal echogenicity
gone abdominal US including dedicated images of the defined as the qualitative increased echogenicity of the
right lower quadrant (RLQ), right upper quadrant in- portal venule walls relative to the adjacent liver parenchy-
cluding at least one image of the liver, and at least one ma and referred to as the “starry sky” liver [22–24]
image of two additional abdominopelvic regions. The (Fig. 1), and bladder debris (mobile or layering echogenic
four abdominal quadrants and the pelvis composed the material within the bladder). The vascularity of the ap-
five abdominopelvic regions for our investigation. The pendix was also evaluated by presence or absence of
US studies were performed by radiology residents, US hyperemia. Appendiceal hyperemia is defined as
technicians, attending radiologists or a combination of hypervascularity in the wall of the appendix when com-
the three operators, using the Acuson Antares, S2000 pared with normal soft tissues showing absence or rare
and Sequoia US equipment (Siemens Medical Solu- scattered foci of color Doppler signal [25, 26]. The radi-
tions, Malvern, PA). All US examinations were ologists recorded specific characteristics of the intraperi-
interpreted by an attending pediatric radiologist. toneal fluid including quality (simple or complex) and
The patient age, gender, presence of co-morbid con- relative quantity as a function of the distribution of fluid
ditions and date of abdominal US were recorded from
the electronic medical record. We reviewed both the
operative and pathology reports for children who
underwent appendectomy following the abdominal US
for all children in database A. The diagnosis of acute or
perforated appendicitis in the study group was based on
review of the operative and pathology reports. In a
small number of children the operative and pathology
reports differed with respect to the presence or absence
of perforation (n=9); in these cases if either the surgical
report (n=7) or pathology report (n=2) included evi-
dence of perforation, the diagnosis was considered to
be perforated appendicitis. In the seven cases where the
surgical note reported perforation and the pathology
report did not mention perforation, it was presumed that
the site of perforation was not included in the patho-
logical specimen. The absence of appendicitis in the
control group was confirmed by follow-up verbal com-
munication with families and children by the surgical
service. The follow-up interval ranged from 3 months to
3 years after the US examination.
The US exams were randomized and assigned study
numbers. De-identification of the patient data was
achieved by exporting the anonymized US exam images
as secure jpeg files from the PACS workstation to a
password-protected institutional server for review. Each
US exam was independently reviewed on a PACS work-
station (Color Coronis 6MP monitor, Barco Inc., Duluth,
GA) by four pediatric radiologists with Certificates of
Added Qualification and experience ranging 2–12 years
(S.L., S.M., N.S., L.P.). The radiologists were blinded to
diagnosis and all clinical information, including prior and
subsequent imaging studies. The following data were Fig. 1 Normal liver vs. increased periportal echogenicity. a Longitudinal
US image of the normal liver in a 5-year-old boy with acute appendicitis.
recorded: presence of a normal appendix defined by a b Longitudinal US image of the liver in a 7-year-old boy with perforated
diameter measuring less than 6 mm [11], abnormal ap- appendicitis demonstrates the “starry sky appearance” of increased
pendix [6], appendicolith, thick-walled bowel measuring periportal echogenicity

(Fig. 2). The relative quantity of fluid was designated on a
scale of 0–5 based on presence or absence of fluid in the four
abdominal quadrants and pelvis, reflecting a sum total of the
five regions. The presence of abscess or loculated fluid was
also recorded.
To further investigate the potential subjectivity of the sono-
graphic finding of increased hepatic periportal echogenicity
and potential bias related to the presence of additional ultra-
sound findings, the US images of the liver were subsequently
separated from each of the original US examinations. At least
6 months after the initial review, this subset of liver images
was presented to the reviewers in a blinded fashion for reas-
sessment of the presence of increased hepatic periportal
echogenicity.
Statistical analysis
The data for each child consisted of sonographic findings from
each of four independent readers. The results were summed
over readers to generate overall estimates of diagnostic
Fig. 2 Fluid in perforated appendicitis. Transverse US images of the
right (a) and left (b) lower quadrants demonstrate complex peritoneal
fluid in a 4-year-old girl with perforated appendicitis
Pediatr Radiol
accuracy such that numerators and denominators represented
counts of evaluations rather than individual children. Varia-
tions in US protocols resulted in a small number of missing
data points, which resulted in variations in the denominators
used for some of the sonographic findings.
Logistic regression for correlated data was used to
evaluate the association of diagnosis (control, acute
appendicitis or perforated appendicitis) with the pres-
ence or absence of each individual sonographic finding.
For each individual sonographic finding, sensitivity and
specificity were calculated for the discrimination of
appendicitis (acute and perforated) from the control
group and discrimination of perforated appendicitis from
acute appendicitis. Exact Mann–Whitney tests were used
for pair-wise comparison of diagnostic groups in terms
of ordinal imaging measures represented for each sub-
ject as an average over the four readers.
Based on the statistical analysis of the individual findings
in isolation, a multivariable analysis was conducted to identify
constellations of sonographic findings that were predictive of
perforated appendicitis. To minimize the false discovery rate,
the constellations tested were limited to those consisting of
findings individually showing a significant association with
perforated appendicitis. These findings included dilated bow-
el, echogenic RLQ fat, complex fluid, ≥2 regions of fluid,
increased periportal echogenicity and appendicolith. The
same logistic regression and exact Mann–Whitney tests were
used to analyze the constellations of findings and their asso-
ciation with the diagnosis.
Intra- and inter-reader agreement were assessed for the
evaluation of hepatic periportal echogenicity using simple
kappa coefficients. Kappa (K) was interpreted as an indication
of poor agreement when less than 0.2, as fair agreement when
0.2<K≤0.4, as moderate agreement when 0.4<K≤0.6 and as
substantial agreement when K>0.6 [27]. Inter-observer vari-
ability was assessed for all sonographic findings in our inves-
tigation by calculating the percentage concordance and kappa
coefficient. Results were pooled over the six distinct reader
pairs and the Fleiss multi-reader kappa was reported. All tests
were conducted at the two-sided 5% significance level using
SAS 9.3 (SAS Institute, Cary, NC).
Results
Of the total 194 children who underwent appendectomy (da-
tabase A), 49 were excluded because they did not undergo US
examination and 1 was excluded because the US images were
not retrievable in PACS. Of the remaining 144 children in
database A who underwent US examination, 61 were exclud-
ed because they did not fulfill the imaging inclusion criteria such
that the US exam did not include images beyond the RLQ (n=
Pediatr Radiol

48) and US exam was limited by technique or patient body Table 1 Mean and standard deviation (SD) of patient age and the number
(percentage) of boys within each diagnosis group (controls, acute appen-
habitus (n=13). Children with co-morbid conditions were also
dicitis or perforated appendicitis)
excluded (n=10), including Wilms tumor (n=1), parasitic infec-
tion with Enterobius vermicularis (n=2), sickle cell disease (n= Diagnosis Control Acute Perforated
1), leukemia (n = 2), lymphoid hyperplasia (n = 3) and
Total subjects 43 51 22
appendiceal mass (n=1). Of these 61 children excluded from
Male 14 (32.6%) 33 (64.7%) 9 (40.9%)
database A with localized RLQ US exams or technically limited
Age±SD (yrs) 9.5±4.6 11.3±3.7 9.4±3.6
US exams, 45 had acute appendicitis and 13 had perforated
appendicitis and 3 did not have appendicitis. Among children yrs years
with appendicitis, the percentage with perforated appendicitis
was 30.1% (22/73) for those included in the study and 22.4% (Fig. 3). The mean age of the study patients was 9.5, 11.3
(13/58) for those excluded from the study. According to a Fisher and 9.4 years, respectively. Children with perforated appendi-
exact test, the included and excluded patients were not signifi- citis were significantly younger (P=0.04) than those with
cantly different (P=0.43) in terms of the percentage with perfo- acute appendicitis but did not have significantly different
rated appendicitis. There were no negative appendectomies in age than the control subjects (P=0.97). There was a trend
our study cohort and there were two negative appendectomies in for children with acute appendicitis to be older than the control
the subset of children excluded on the basis of co-morbid patients (P=0.09). The total study population consisted of 60
conditions. girls and 56 boys (Table 1).
Of the 68 children discharged without undergoing appen- The percentage and number of children with each individ-
dectomy (database B), 1 was excluded because the US images ual US finding are summarized in Table 2. With the exception
were not retrievable in PACS. Of the remaining cases, 24 were of appendiceal hyperemia, all individual sonographic findings
excluded because they did not fulfill the inclusion criteria; US were most commonly seen in children with perforated appen-
exam did not include images beyond the RLQ (n=16) and US dicitis. The individual US findings and select constellations of
exam was limited because of technique (n=6), suspected lym- findings had specificity for the diagnosis of appendicitis
phoid hyperplasia (n=1), and age younger than 2 years (n=1). (acute and perforated combined) ranging from 59.9% to
The final study population consisted of 116 children in 100%, the majority of which were greater than 95% compared
three diagnostic categories: control group (n=43), acute ap- with the control group. These results are summarized in
pendicitis (n = 51), and perforated appendicitis (n = 22) Table 3.

Fig. 3 Control and study groups. a Database A includes all children who underwent appendectomy to create the two experimental groups. b Database B
includes all children who were discharged after abdominal US without undergoing appendectomy to create the control group
 Pediatr Radiol

Table 2 The percentage (%) and

number (#) of positive evaluations Control Acute Perforated
and the total number (n) of evalu-
ations for each US finding among US finding % # n % # n % # n
children in each diagnostic group
Abscess/loculated fluid 0.6% 1 166 0.5% 1 186 23.1% 18 78
Appendicolith 0.0% 0 29 20.6% 33 160 45.2% 28 62
Bladder debris 7.5% 12 161 8.6% 16 186 16.9% 14 83
Complex fluid 1.2% 2 172 12.3% 25 204 42.1% 37 88
Dilated bowel 2.4% 4 170 6.0% 12 201 28.7% 25 87
Echogenic fat 4.1% 7 171 65.3% 132 202 75.0% 63 84
Fluid regions ≥1 40.1% 69 172 53.9% 110 204 86.4% 76 88
Fluid regions ≥2 10.5% 18 172 12.7% 26 204 47.7% 42 88
Fluid regions ≥3 2.3% 4 172 1.0% 2 204 21.6% 19 88
↑ Periportal echoes 22.1% 38 172 19.7% 40 203 51.8% 44 85
Thickened bowel 10.5% 18 171 12.9% 26 201 29.1% 25 86
Appendiceal hyperemia 25.0% 3 12 66.0% 103 156 34.4% 21 61

The individual US findings of abscess/loculated fluid,
appendicolith, dilated bowel and increased hepatic
periportal echogenicity were significantly associated
with perforated appendicitis when compared with acute
appendicitis (P<0.01). The presence of complex fluid
yielded a specificity of 87.7% for perforated appendici-
tis compared with the acute appendicitis group. The US
finding of ≥2 regions or ≥3 regions with fluid had
specificity of 87.3% and 99.0%, respectively, for perfo-
rated appendicitis compared with the acute appendicitis
group. Echogenic RLQ fat did not distinguish between
perforated appendicitis and acute appendicitis. Select
constellations of US findings in the diagnosis of perfo-
rated appendicitis compared with acute appendicitis
yielded higher specificity than that of each individual
finding in isolation (Table 4). The constellation of di-
lated bowel, RLQ echogenic fat, and complex fluid had
the highest specificity of 99.5% for perforated appendi-
citis (P<0.01) (Fig. 4).
Abscess or loculated fluid was identified in only 23.1% of
US examinations in the perforated appendicitis group. There
was a systematic increase in both the number of
abdominopelvic regions containing intraperitoneal fluid and
the complexity of the fluid when comparing the three

Table 3 The sensitivity and

specificity of US findings for the US finding Specificity Sensitivity P-value
detection of appendicitis (dis-
crimination of controls from the Abscess/loculated fluid 99.4% (165/166) 7.2% (19/264) 0.01
combined group of acute and Appendicolith 100% (29/29) 27.5% (61/222) <0.01
perforated appendicitis) Complex fluid 98.8% (170/172) 21.2% (62/292) <0.01
Dilated bowel 97.6% (166/170) 12.8% (37/288) <0.01
Echogenic fat 95.9% (164/171) 68.2% (195/286) <0.01
Fluid regions ≥1 59.9% (103/172) 63.7% (186/292) 0.01
Fluid regions ≥2 89.5% (154/172) 23.3% (68/292) 0.04
Fluid regions ≥3 97.7% (168/172) 7.2% (21/292) 0.27
↑ Periportal echoes 77.9% (134/172) 29.2% (84/288) 0.10
Fluid regions ≥2, complex fluid 99.4% (171/172) 9.6% (28/292) 0.01
Dilated bowel, echogenic fat, complex fluid 100% (169/169) 3.5% (10/283) 0.02
↑ Periportal echoes, fluid regions ≥2 98.3% (169/172) 10.4% (30/288) 0.01
↑ Periportal echoes, complex fluid 100% (172/172) 12.8% (37/288) <0.01
↑ Periportal echoes, dilated bowel 98.8% (168/170) 5.6% (16/284) 0.04
↑ Periportal echoes, echogenic fat 100% (171/171) 21.6% (61/282) <0.01
↑ Periportal echoes, echogenic fat, appendicolith 100% (29/29) 6.9% (15/217) 0.23
↑ Periportal echoes, echogenic fat, complex fluid 100% (171/171) 11.0% (31/282) <0.01
Fluid regions ≥2, echogenic fat 99.4% (170/171) 16.8% (48/286) 0.01
Complex fluid, echogenic fat 99.4% (170/171) 17.8% (51/286) <0.01
Pediatr Radiol

Table 4 The sensitivity and

specificity of US findings for the US finding Specificity Sensitivity P-value
detection of perforated appendi-
citis (discrimination of acute ap- Abscess/loculated fluid 99.5% (185/186) 23.1% (18/78) <0.01
pendicitis from perforated Appendicolith 79.4% (127/160) 45.2% (28/62) <0.01
appendicitis) Complex fluid 87.7% (179/204) 42.1% (37/88) <0.01
Dilated bowel 94.0% (189/201) 28.7% (25/87) <0.01
Echogenic fat 34.7% (70/202) 75.0% (63/84) 0.26
Fluid regions ≥1 46.1% (94/204) 86.6% (76/88) <0.01
Fluid regions ≥2 87.3% (178/204) 47.7% (42/88) <0.01
Fluid regions ≥3 99.0% (202/204) 21.6% (19/88) <0.01
↑ Periportal echoes 81.3% (163/203) 51.8% (44/85) <0.01
Fluid regions ≥2, complex fluid 96.1% (196/204) 22.7% (20/88) <0.01
Dilated bowel, echogenic fat, complex fluid 99.5% (199/200) 10.8% (9/83) <0.01
↑ Periportal echoes, fluid regions ≥2 96.1% (195/203) 25.9% (22/85) <0.01
↑ Periportal echoes, complex fluid 94.6% (192/203) 30.6% (26/85) <0.01
↑ Periportal echoes, dilated bowel 98.0% (196/200) 14.3% (12/84) <0.01
↑ Periportal echoes, echogenic fat 86.6% (174/201) 42.0% (34/81) <0.01
↑ Periportal echoes, echogenic fat, appendicolith 97.5% (154/158) 18.6% (11/59) <0.01
↑ Periportal echoes, echogenic fat, complex fluid 95.0% (191/201) 25.9% (21/81) <0.01
Fluid regions ≥2, echogenic fat 90.1% (182/202) 33.3% (28/84) <0.01
Complex fluid, echogenic fat 90.1% (182/202) 36.9% (31/84) <0.01

diagnostic groups. Specifically, the number of regions con-
taining fluid and the complexity of the fluid both increased
from control to acute appendicitis and from acute appendicitis
to perforated appendicitis, with corresponding increasing
specificity (Table 5). The presence of any fluid, simple or
complex, in any number of quadrants yielded a sensitivity of
86.6% for perforated appendicitis.
Percentage concordance and kappa among the readers for
the specific sonographic findings assessed in our investigation
ranged from 74.9% to 95.3% and 0.42 to 0.66, respectively
(Table 6). There was moderate to high agreement for all of the
findings. In the focused assessment of increased hepatic
periportal echogenicity averaged over reader pairs, the kappa
for inter-reader agreement was 0.54, indicative of moderate
agreement. Intra-reader agreement was fair for reader 1 (kap-
pa=0.28) and moderate-substantial for the other three readers
(kappa=0.54–0.66). Percentage concordance between reader
pairs for increased periportal echoes ranged from 77.2% to
87.8% with an overall percentage concordance of 82.5%.
Discussion
Perforated appendicitis is a well-known diagnostic challenge
in the sonographic assessment of abdominal pain in children.
Reliable US imaging in this setting is fundamental in guiding
patient management and minimizing radiation exposure. Al-
though studies have addressed the sonographic diagnosis of
perforated appendicitis, several of these studies utilized older-
generation US equipment, potentially limiting clinical appli-
cation. Using state-of-the-art US equipment, we investigated
the novel association of increased hepatic periportal
echogenicity with perforated appendicitis in addition to the
previously described sonographic findings of RLQ echogenic
fat, dilated bowel and appendicolith; we also correlated the
quantity and quality of intraperitoneal fluid with respect to the
diagnosis of perforated appendicitis. We subsequently per-
formed a detailed analysis of the association of specific con-
stellations of these sonographic findings in the setting of
perforated appendicitis, with the goal of improving the diag-
nosis of perforated appendicitis.
The sonographic findings that define an abnormal appendix
are well described in the literature. However, these findings
located in the RLQ may not provide adequate information to
distinguish non-perforated from perforated appendicitis, an argu-
ment for the need to improve sonographic distinction between
these pathological entities. Individual sonographic findings
yielded a broad range of specificity for perforated appendicitis
compared with acute appendicitis. Dilated bowel proved to be a
useful individual sonographic finding associated with perforated
appendicitis when compared with acute appendicitis. The finding
of dilated bowel likely reflects the presence of an ileus in response
to the marked RLQ inflammation in the setting of perforation.
Increasing volume of intraperitoneal free fluid and the presence of
complex fluid, as individual findings, were both suggestive of
perforated appendicitis. The increasing volume or complexity of
fluid associated with perforated appendicitis may reflect early
purulent changes even prior to frank abscess formation. Not
 Pediatr Radiol

Table 6 The percentage (fraction) of times that results from two readers
were concordant and the kappa to assess reader agreement in terms of
each finding

US finding Concordance Kappa

Appendicolith 83.4% (267/320) 0.58

Bladder debris 93.8% (570/608) 0.66
Complex fluid 92.0% (640/696) 0.69
Dilated bowel 90.4% (613/678) 0.42
Echogenic fat 80.6% (544/675) 0.61
Fluid regions ≥1 74.9% (521/696) 0.49
Fluid regions ≥2 86.5% (602/696) 0.55
Fluid regions ≥3 95.3% (663/696) 0.54
↑ Periportal echoes 82.5% (567/687) 0.54
Thickened bowel 87.8% (595/678) 0.53
Wall hyperemia 75.4% (233/309) 0.55

association with perforated appendicitis as compared with

acute appendicitis. This finding provided modest specificity
(77.9–81.3%) for perforated appendicitis as an individual
finding (Fig. 5). Multiple etiologies have been hypothesized
for the presence of increased periportal echogenicity. These
include hepatic congestion in the setting of cardiac disease,
edema in the setting of acute hepatitis or septic shock, infil-
trative processes and excessive intravenous fluid administra-
tion [22, 28]. Children with known co-morbidities were ex-
cluded to minimize confounding factors in sonographic as-
sessment of the liver. We postulate that the increased hepatic
periportal echogenicity observed in our study may reflect the
edematous response of the liver to peritonitis, because this
finding was more commonly seen in the setting of perforated
appendicitis. Our blinded re-assessment of increased
Fig. 4 Constellation of findings shows high specificity for perforated
appendicitis. a Transverse US image of the right lower quadrant in a 9- periportal echogenicity addressed the potential subjectivity
year-old girl demonstrates an abnormal appendix, increased echogenicity of associated with this sonographic finding, demonstrating mod-
the adjacent fat and dilated fluid-filled bowel. b Transverse US image of the erate inter-reader agreement and predominantly moderate-to-
lower abdomen demonstrates complex peritoneal fluid in the same girl substantial intra-reader agreement for three of the four readers,
with 82.5% overall concordance between reader pairs. These
surprisingly, echogenic RLQ fat did not distinguish between acute results reflect the natural subjectivity that exists in clinical
appendicitis and perforated appendicitis, likely because of the practice for imaging findings lacking specific defined criteria.
varying degrees of localized inflammation present in both The moderate agreement and high percentage of concordance
conditions. in concert with the statistically significant association of in-
The sonographic observation of increased hepatic creased periportal echogenicity with perforated appendicitis in
periportal echogenicity demonstrated a statistically significant our study suggests that this finding has validity in discrimi-
nating perforated appendicitis. Further prospective assessment
Table 5 Intraperitoneal fluid characteristics for each diagnostic category
(controls, acute appendicitis, perforated appendicitis)
of this sonographic finding may be beneficial to clarify its role
in evaluation of pediatric patients with abdominal pain.
Fluid Control Acute Perforated The initial evaluation of individual sonographic findings
served as the basis for formulating select constellations and as
Quantity a 0.53±0.63 0.68±0.55 1.60±0.92
a reference standard for their diagnostic utility. Findings that
Quality b 0.41±0.40 0.67±0.51 1.28±0.55
demonstrated a significant association with perforated appen-
a
Quantity is defined as the sum total 0–5 of regions containing fluid in dicitis included appendicolith, echogenic RLQ fat, dilated
the abdomen and pelvis bowel, increased hepatic periportal echogenicity, complex
b
Quality is defined as no fluid=0, simple fluid=1, complex fluid=2 fluid and presence of intraperitoneal fluid in ≥2 regions; these
Pediatr Radiol
Fig. 5 US imaging in a 14-year-old boy with perforated appendicitis. a
Longitudinal image of the liver demonstrates increased periportal
echogenicity. b Oblique image of the right lower quadrant shows an
abnormal appendix with adjacent increased echogenicity
findings were combined in the select constellations. Although
the absence of appendiceal wall hyperemia was significantly
associated with perforated appendicitis compared with acute
appendicitis, variations in US protocols limited the number of
data points. Therefore, this finding was not included in the
constellations. Of the significant individual findings, bowel
wall thickening showed the weakest association with perfo-
rated appendicitis and therefore was also not included in the
constellations. We performed a detailed analysis of the select
constellations of sonographic findings in association with
perforated appendicitis, focusing on several representative
constellations to assess their diagnostic utility with respect to
specificity.
The results comparing controls with the combined cohort of
acute and perforated appendicitis help establish that the indi-
vidual US findings and constellations of US findings investi-
gated in our study are infrequently seen in patients without
appendicitis. This is particularly relevant in the subset of pa-
tients in whom no normal or abnormal appendix is identified. In
the absence of a normal or abnormal appendix, presence of any
of the constellations of US findings described in our study
should raise suspicion of perforated appendicitis.
Our results demonstrate that the specificity of select con-
stellations of findings is consistently higher than that of each
individual sonographic finding in isolation when comparing
perforated appendicitis to acute appendicitis. Distinguishing
acute appendicitis from perforated appendicitis has important
implications from the patient management perspective. Iden-
tification of highly specific sonographic findings enables reli-
able identification of children with perforated appendicitis and
adds value to the imaging method. Additionally, the high
specificity of these constellations lends credence to the impor-
tance of imaging regions of the abdomen beyond the RLQ in
the US evaluation for suspected appendicitis.
There are several limitations to our study, many of which
relate to the retrospective design. Perhaps most important is
the lack of a standardized US protocol for the evaluation of
suspected appendicitis in the study cohort. This resulted in the
exclusion of 61 patients from database A who had localized
RLQ US exams or technically limited exams. Statistical anal-
ysis confirmed that the included and excluded patients were
not significantly different in terms of the percentage of pa-
tients with perforated appendicitis suggesting that the exclud-
ed patients were not fundamentally different from the study
population and therefore not likely to introduce selection bias.
Additionally, multiple operators with variable levels of expe-
rience performed the examinations. This led to a variation in
the number of images acquired of the abdominopelvic regions
and viscera, resulting in incomplete data points for a small
number of the sonographic findings. A further limitation is
that our study groups were not well balanced with respect to
gender composition, which may have confounded our group
comparisons based on the greater prevalence of boys in the
acute appendicitis group (64.7%) compared with the perforat-
ed appendicitis group (40.9%). However, it is unlikely that
these substantial gender differences would impact our assess-
ment of the utility of the sonographic findings because the
individual findings are not gender-specific.
Our study population is relatively small because the strict
criteria excluded focused RLQ US examinations and studies
performed prior to 2008. Given the retrospective nature of the
investigation and the relatively small study population, we
included US examinations containing images of at least three
of the five abdominopelvic regions. Loss of diagnostic infor-
mation in those regions not imaged might have led to an
underestimation of the power of the results.

The fact that clinical factors were not considered in concert
with US findings may be viewed as a potential limitation.
However, it is common for the clinical presentation of perfo-
rated appendicitis to be atypical. To that end, the clinical
management is based on both the imaging findings and the
clinical presentation, including physical examination, labora-
tory studies and detailed history. Because the purpose of our
investigation was to specifically identify sonographic findings
or constellations of findings that improve the diagnostic utility
of US in making the diagnosis of perforated appendicitis,
readers were blinded to the patients’ clinical information other
than the presenting complaint of abdominal pain in order to
eliminate bias.
It is not surprising that the sensitivity of the select constel-
lations of findings for perforated appendicitis is low, because
the goal of this investigation was to identify markers that
demonstrate a high association with perforated appendicitis.
The presence of abscess has been shown to have high speci-
ficity and low sensitivity for perforated appendicitis [10]. If an
abscess is identified, it is highly suggestive of perforation
because an abscess is unlikely to be present in a control patient
or non-perforated appendicitis. Similarly, identification of our
proposed constellations of findings is intended to help identify
perforated appendicitis with high specificity, because it would
be unlikely for these constellations of findings to be present in
a control patient or non-perforated appendicitis. However the
absence of these constellations does not confidently exclude
appendiceal perforation, reflected by the low sensitivity sim-
ilar to that of abscess. Because abscess formation is a relative-
ly late finding in the histopathological course of perforated
appendicitis, it is useful to have additional findings with a high
specificity for perforated appendicitis prior to abscess
formation.
The classic right lower quadrant US findings described for
the diagnosis of acute appendicitis have limited application in
distinguishing between acute and perforated appendicitis. Our
results suggest the importance of examining the abdomen
beyond the RLQ when evaluating for appendicitis, including
the liver echotexture and presence and quality of intraperito-
neal fluid, because US findings outside the RLQ can contrib-
ute valuable diagnostic information. Furthermore our study
demonstrates that select constellations of sonographic find-
ings improve specificity for perforated appendicitis beyond
that of individual sonographic findings used in isolation,
which may help improve timely and accurate detection of this
challenging diagnosis in the pediatric population.
Conclusion
Our study demonstrates that identification of select constellations
of findings using abdominal sonography, in addition to focused
Pediatr Radiol
US examination of the RLQ, can improve sonographic diagnosis
of perforated appendicitis in the pediatric population.
Conflicts of interest None
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