1265

Acute Appendicitis in Children:

Value of Sonography in Detecting
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Perforation

. : : ‘ :

Shawn P. QuiIIin1 OBJECTIVE. We determined the sonographic features of perforating appendicitis in

Marilyn J. Siegel1 children in order to determine the best criteria for establishing the diagnosis.
Cheryl M. Coffin2 MATERIALS AND METHODS. Sonograms of the right lower quadrants of 71 children
with proved appendicitis were reviewed to determine the value of sonography in
distinguishing between nonperforating and perforating appendicitis. The sonographic
signs evaluated included the presence or absence of an appendix, an echogenic
submucosal layer, increased periappendiceal echogenicity, free or loculated periappen-
diceal or pelvic fluid collections, and appendicoliths. The sonographic findings were
correlated with the surgical and pathologic findings.
RESULTS. Forty-five patients had nonperforating appendicitis, and 26 had perforating
appendicitis. A sonographically visible appendix was present in all patients with non-
perforating appendicitis and in 10 (38%) of 26 patients with perforation. An echogenic
submucosa was noted in 27 (60%) of 45 patients with uncomplicated appendicitis but
in only three (30%) of 10 patients with a visible appendix and perforating appendicitis
(p < .05). In 19 of 26 patients with perforating appendicitis, sonography showed Ioculated
periappendiceal or pelvic fluid collections; no patient with nonperforating appendicitis
had a loculated fluid collection (p < .05). No statistically significant association was
found between the presence or absence of perforation and free pelvic fluid, prominent
periappendiceal fat, or an appendicolith.
CONCLUSION. Our results indicate that sonography can be helpful in the diagnosis of
perforating appendicitis. The best predictors of perforation are absence of the echogenic
submucosal layer and the presence of a loculated fluid collection.

AJR i59:i265-i268, December 1992

Graded-compression sonography of the right lower quadrant using a high-

resolution, linear-array transducer has been shown to be a useful technique for
diagnosing appendicitis, with a sensitivity between 80% and 95% [1 -8]. Recently,
attempts have been made to differentiate between nonperforating and perforating
appendicitis by using sonography [6, 9]. Puylaert et al. [6] reported a sensitivity of
29% for sonography in diagnosing perforating appendicitis. A more recent investi-
gation by Borushok et al. [9] showed that no single sonographic finding was
Received June 1 , 1 992: accepted after revision sensitive in diagnosing perforation, but that when a combination of findings was
JuIy7, 1992.
used, the sensitivity of sonography for diagnosing appendiceal perforation in-
Presented in part at the annual meeting of the creased to 86%. Both these studies evaluated mainly adult patients. In a small
American Institute of Ultrasound in Medicine, San
Diego, CA, March 1992. series, Vignault et al. [8] described one sonographic finding (diffuse hypoecho-
1 The Mallinckrodt Institute of Radiology. Wash- genicity) that appeared to be highly suggestive of perforation in children. To better
ington University School of Medicine, 510 5. Kings- determine the value of sonography in distinguishing between nonperforating and
highway Blvd., St. Louis, MO 631 10. Address re- perforating appendicitis in children, we reviewed the sonographic findings in 71
print requests to M. J. Siegel.
2 Department of Pathology, Washington Univer- children with appendicitis, 26 of whom had appendiceal perforation.
sity School ofMedicine, 5i0 5. Kingshighway Blvd.,
St. Louis, MO 63i 10.
Materials and Methods
0361 -803X/92/i 596-i 265
0 American Roentgen Ray Society We retrospectively reviewed the sonograms of 79 children with surgically proved appen-
 1266 QUILLIN ET AL. AJR:159, December 1992
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Fig. 1.-Nonperforating appendicitis.

A, Longitudinal sonogram shows a noncom-
pressible, tubular appendix with an echogenic
submucosal layer (arrows) and a hypoechoic
center.
B, Transverse sonogram in another patient
shows a target appearance with a hypoechoic
lumen containing scattered debris, a more echo-
genic submucosa (arrows), and hypoechoic wall.

dicitis who were examined between January 1988 and December test was done to evaluate the usefulness of individual sonographic
1 991 . All sonograms were obtained with a 5-MHz linear-array trans- features in diagnosing perforation.
ducer by using the graded-compression technique described by
Puylaert [5]. Images of the right lower quadrant were obtained in
Results
longitudinal and transverse planes. Surgery was performed within 36
hr of the sonographic examination in all but two patients. The sonographic findings are summarized in Table i Forty- .

Seventy-one patients had abnormal sonographic findings and were five patients had nonperforating appendicitis, and 26 had
shown to have appendicitis at surgery. There were 43 boys and 28 perforating appendicitis. A visible appendix with a diameter
girls, ranging from 1 9 months to 18 years old (mean age, 1 1 years).
of greater than 6 mm was seen in all 45 patients with
Of the 26 patients with appendiceal perforations, 15 were boys and
nonperforating appendicitis and in 1 0 (38%) of 26 patients
1 1 were girls, ranging in age from 19 months to 17 years (mean, 10
with perforation. An echogenic submucosa was visualized in
years). In eight patients, the results of sonography were falsely
negative, and these patients were excluded from the study. None of 27 (60%) of 45 patients with uncomplicated appendicitis (Fig.
these patients had perforating appendicitis. Obesity accounted for 1) and in three of 1 0 patients with perforating appendicitis
the difficulty in identifying appendicitis by sonography in one of the and a sonographically recognizable appendix (p < .05). The
eight patients. Adequate graded compression could not be achieved presence of the echogenic submucosa produced a target sign
because of severe pain in two patients. The other false-negative on transverse sonograms, characterized by a hypoechoic
studies had no obvious explanation. center representing intraluminal fluid or pus, a hyperechoic
The sonograms were reviewed blindly without knowledge of the submucosal layer, and a hypoechoic muscular rim. A diffusely
surgical or pathologic findings. Images were evaluated with specific
hypoechoic appendix with or without scattered internal
attention to the presence or absence of an appendix, an echogenic
echoes but without an echogenic submucosa was seen in 18
submucosal layer, increased periappendiceal echogenicity, free or
of 45 patients with nonperforating appendicitis (Fig. 2) and in
loculated periappendiceal or other pelvic fluid collections, and
appendicoliths.
seven of 1 0 patients with perforating appendicitis and a
Surgical and pathologic reports of each patient were retrospec- sonographically identifiable appendix.
tively reviewed for the presence or absence of perforation, abscess, Loculated periappendiceal or pelvic fluid collections were
and appendicoliths, and those results were compared with the son- seen in 1 9 (73%) of 26 patients with perforation (Figs. 3 and
ographic findings. Statistical analysis with a Fisher exact two-tailed 4) and in none of the 45 patients without perforation (p <
.05). Free fluid in the right lower quadrant or pelvis was seen
in 1 4 (31 %) of 45 patients with nonperforating appendicitis
TABLE 1: Sonographic Findings in Perforating and and in 1 3 (50%) of 26 patients with perforation. Prominent
Nonperforating Appendicitis
periappendiceal echogenicity (Fig. 5) and appendicoliths were
No. (%) of Patients noted in six (1 3%) and eight (1 8%) patients without perfora-
Sonographic Findings
tion, respectively. In patients with perforation, prominent peri-
Nonperforating Perforating
appendiceal echogenicity and appendicoliths were noted in
(n=45) (n=26)
eight patients (31 %) each. These differences were not statis-
Visible appendix 45 (100) 10 (38)
tically significant.
Echogenic submucosa 27 (60) 3 (30)
Hypoechoic appendix 18 (40) 7 (70)
On gross examination, the nonperforated appendix usually
Loculated pericecal fluid 0 (0) 1 9 (73) was characterized by congestion and serosal hyperemia.
Free intraperitoneal fluid 14 (31) 1 3 (50) After perforation, the appendix was distorted and covered by
Increased periappendiceal echo- 6 (1 3) 8 (31) a purulent exudate. Microscopically, the changes ranged from
genicity
minimal inflammation of the mucosa and submucosa to ne-
Appendicolith 8 (1 8) 8 (31)
crosis and destruction of these layers and the wall. Appendi-
 AJR:159, December 1992 SONOGRAPHY OF ACUTE APPENDICITIS IN CHILDREN 1267

Fig. 2.-Nonperforating appendicitis. Longi-

tudinal sonogram shows a dilated appendix (ar-
rows) with a hypoechoic lumen. Note loss of
echogenic submucosa. During surgery, distal tip
was found to be grossly distended and inflamed
without evidence of perforation.
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Fig. 3.-Perforated appendix with periappen-

diceal fluid. Longitudinal sonogram shows an
irregular, poorly defined appendix (arrows). A
noncompressible fluid collection (F) is noted ad-
jacent to appendiceal tip. Perforated appendix
with a periappendiceal abscess was found dur-
ing surgery.

Fig. 4.-Perforating appendicitis. Longitudi-

nal sonogram shows a rounded, noncompres-
sible fluid collection (arrows) in right lower
quadrant. No appendix was identifiable at so-
nography. Pencecal abscess was found during
surgery.

Fig. 5.-Perforated appendix. Longitudinal

sonogram shows a diffusely hypoechoic ap-
pendix, loss of echogenic submucosa, and
echogenic periappendiceal fat (arrows). Acute
appendicitis with a perforated tip and periappen-
diceal phlegmon were noted during surgery.
Echogenic focus (arrowhead) in appendiceal tip
represented an appendicolith.

coliths were found in eight patients without perforation and in surgical field may be desirable. In patients with large or well-
1 5 patients with perforation. defined appendiceal abscesses, percutaneous catheter drain-
age may be preferred to early surgery [1 2, 13].
Our study confirms the value of sonography in identifying
Discussion
abnormalities in patients with perforation. In our series, an
High-resolution sonography with graded compression has echogenic mucosa was visualized in 60% of patients with
proved to be a reliable technique for establishing the diagnosis uncomplicated appendicitis and in 30% of patients with a
of appendicitis in adults and children. However, the usefulness visible appendix and perforating appendicitis. Conversely,
of sonography in the diagnosis of perforating appendicitis is loss of the echogenic layer of the submucosa was seen in
more controversial, with its relatively low sensitivity of 29% 40% of patients with nonperforating appendicitis and 70% of
reported in a series by Puylaert et al. [6] and its relatively high patients with perforating appendicitis and a visible appendix.
sensitivity of 86% reported by Borushok et al. [9]. It has been postulated that the loss of the sonographic
Appendiceal perforation was seen in 13-30% of children, echogenic submucosa reflects extensive submucosal necro-
with rates as high as 90% in infants [1 0, 1 1 ]. The 38% sis that predisposes to perforation [9]. On the basis of an
frequency of perforation in this series is, therefore, not unex- observed absence of echogenic submucosa, we found the
pected. Identification of appendiceal perforation is important sensitivity of sonography in perforated appendicitis to be
because it can alter clinical management. Prompt appendec- similar to that found by Vignault et al. [8], who reported loss
tomy is the treatment of choice in patients with nonperforating of the submucosa in 25% of children with nonperforating
appendicitis or small perforations. However, in patients with appendicitis and in 75% of children with perforating appendi-
periappendiceal phlegmon (i.e., an indurated soft-tissue mass citis. Our study also confirms the data of Borushok et al. [9],
without drainable pus) or relatively small periappendiceal ab- who reported a 60% sensitivity of sonography in the diagnosis
scesses, conservative management with antibiotic therapy of perforating appendicitis in patients with a visible appendix
followed by appendectomy at a later time through a cleaner without an echogenic lining.
 i 268 QUILLIN ET AL. AJR:159, December 1992

Loculated periappendiceal or pelvic fluid was seen in 73% In our experience, the appendix is visible on sonograms in
of our patients with perforation and was 1 00% specific for 70% of children with appendicitis. The absence of the echo-
the diagnosis. The loculated fluid collections varied in size genic submucosal layer and the presence of a loculated fluid
from 2 to 1 2 cm in diameter, were often round and complex, collection are the most conclusive sonographic findings of
and had mass effect on adjacent structures. Borushok et al. perforating appendicitis.
[9] reported that the finding of loculated pericecal fluid had a
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