275

Sonographic Diagnosis of
Downloaded from www.ajronline.org by 103.105.30.84 on 08/01/21 from IP address 103.105.30.84. Copyright ARRS. For personal use only; all rights reserved

Perforation in Patients with Acute

Appendicitis

Karen F. Borushok1 The sonographic diagnosis of appendicitis can be challenging in patients with perle-
R. Brooke Jeffrey, Jr.2 ration. In order to detect the accuracy of specific sonographic features of appendiceal
Faye C. Laing1 perforation, graded compression sonograms in 100 patients with surgically confirmed
acute appendicitis were reviewed retrospectively. Twenty-two of these patients had
Ronald R. Townsend1
perforation. A statistically significant association was found between three sonographic
findings and perforation: loculated pericecal fluid, prominent pencecal fat, and circum-
ferential loss of the submucosal layer of the appendix. No single finding had a specificity
greater than 59% By using a combination of one or more findings, the overall sensitivity
of sonography for the diagnosis of perforation was 86%. The specificity, however, was
only 60%.
Our results suggest that in patients without a sonographically visible appendix,
recognition of loculated pencecal fluid and prominent pencecal fat may be a useful
indirect clue to the diagnosis of perforating appendicitis.

AJR 154:275-278, February 1990

Graded compression sonography has been proved to be of value in the diagnosis

of acute appendicitis, with sensitivities ranging from 75% to 89% [1 -5]. The
sonographic diagnosis of appendicitis may be difficult, however, in patients with
perforation. Puylaert et al. [4] reported a sensitivity of only 29% in patients with
perforating appendicitis in a recent prospective study. In addition, there are no
reports of specific criteria that can be used to diagnose a perforated appendix
sonographically.
On the basis of our prior clinical experience with graded compression sonography
in suspected acute appendicitis, we noted several sonographic features that
appeared to be of value in differentiating perforating from nonperforating appendi-
citis. In this report, we attempt to analyze the sonographic findings associated with
appendiceal perforation.

Materials and Methods

From February 1986 to May 1989, 100 patients who had both graded compression
Received August 21 , 1 989; accepted after revi- sonography that showed acute appendicitis and surgical confirmation were selected for a
sion September 22, 1989.
retrospective review of the sonographic and pathologic findings. Overall, there were 69 males
1 Department of Radiology (1X55), University of
and 31 females, ranging in age from 1 to 71 years (mean, 29 years). Among the 22 patients
Califomia, San Francisco, San Francisco General
with perforating appendicitis, there were 1 6 males and 6 females, ranging in age from 1 to
Hospital, 1001 Potrero Ave., San Francisco, CA
94110. 68 years (mean, 27 years). All sonographic studies were obtained with a 5-MHz electronically
2 Department of Diagnostic Radiology (Hi 307), focused linear-array transducer (Acuson, Sunnyvale, CA) by using the real-time graded
Stanford University Schcol of Medicine, Stanford, compression technique described by Puylaert [1]. The sonographic criteria established by
CA 94305. Address reprint requests to R. B. Jef- Jeffrey et al. [3] were used to diagnose acute appendicitis in this series. Patients with a
frey, Jr. noncompressible appendix 7 mm or more in maximal outer diameter were considered to have
0361 -803X/90/i 542-0275 acute appendicitis. The only exception to the size criterion was in patients with a sonograph-
© American Roentgen Ray Society ically visible appendicolith. If an appendicolith was present, the patient was considered to
 276 BORUSHOK ET AL. AJR:154, February 1990

TABLE 1: Sonographic Findings in Appendiceal Perforation

Sonographic Finding True-Positive True-Negative False-Positive False-Negative p Value Sensitivity (%) Specificity (%)
Statistically significant for
perforation
Loculated pericecal 9 78 0 13 <.001 40.9 100.0
fluid
Downloaded from www.ajronline.org by 103.105.30.84 on 08/01/21 from IP address 103.105.30.84. Copyright ARRS. For personal use only; all rights reserved

Prominent pericecal fat 11 63 15 11 <.01 0 50.0 80.8

>10 mm
Circumferential loss of 13 53 25 9 <.050 59.1 67.9
submucosal layer of
appendix

Not statistically significant

for perforation
Appendicohiths 8 65 13 14 >050 36.4 83.3
Focal loss of submu- 7 38 40 15 >.1 00 31 .8 48.7
cosal layer of appen-
dix
Retrocecal location of 8 61 17 14 >250 36.4 78.2
appendix
Free pericecal fluid 6 56 22 16 >750 27.3 71.8
Maximal outer wall di- 16 22 56 6 >750 72.7 28.2
ameter of appendix
1O mm

Percentage of All Find- 19 47 31 3 86.4 60.3

ings

have acute appendicitis regardless of the size of the appendix. tions, and appendicoliths. The following specific sonographic features
Surgery was performed within 48 hr of sonography in all patients. were analyzed: (1 ) lack of visualization of the echogenic submucosal
Pathologic reports of the appendiceal specimens were reviewed layer (either focal or circumferential) (Figs. 1 and 2), (2) presence or
retrospectively, noting the presence of perforation, appendiceal size, absence of appendicoliths, (3) pericecal free fluid, (4) pericecal locu-
appendicoliths, and final pathologic diagnosis. Final pathologic diag- lated fluid (Fig. 3), (5) pericecal echogenic fat more than 10 mm thick
noses were either uncomplicated acute suppurative appendicitis or (Fig. 1), and (6) marked enlargement of the appendix with maximal
appendicitis with perforation. Surgical reports also were used to outer appendiceal diameters of greater than or equal to 10 mm.
confirm these pathologic diagnoses. There were 22 patients with
perforating and 78 patients with nonperforating appendicitis. Chi-
square analysis with Yates correction, or Student’s t test, was used Results
to evaluate each of the sonographic features for perforation (see
Only three sonographic findings were statistically significant
Table 1).
The sonographic studies were reviewed retrospectively in a blinded for the diagnosis of perforating appendicitis: loculated pence-
fashion without knowledge of whether there was appendiceal perfo- cal fluid (p < .001), circumferential loss of the echogenic
ration. Transverse and longitudinal sonographic images of the appen- submucosal layer of the appendix (p < .05), and prominent
dix and pericecal area were analyzed for evidence of transmural adjacent penicecal fat more than 1 0 mm thick (p < .01). The
appendiceal inflammation, periappendiceal inflammatory reaction, remaining sonographic findings were not statistically signifi-
marked enlargement of the appendix, free or loculated fluid collec- cant in discriminating between perforating and nonperforating

Fig. 1.-Perforating appendicitis with CT cor-

relation.
A, Sagittal sonogram shows a noncompres-
sible appendix with an appendicolith (curved ar-
row). Note linear echogenic appearance of pre-
served submucosal layer (large straight arrow)
and focal areas of interruption of submucosa
(small straight arrows). Note prominent fat (ar-
rowheads) surrounding perforated appendix.
B, CT scan of same patient shows calcified
appendicolith (black arrow) and surrounding
edematous periappendiceal fat (white arrows).
 AJR:154, February 1990 SONOGRAPHY OF ACUTE APPENDICITIS 277

Fig. 2.-Perforated appendix (A) with circum-

ferential loss of echogenic submucosa on sag-
ittal sonogram. Note prominent periappendiceal
fat (arrows). C = cecum.
Downloaded from www.ajronline.org by 103.105.30.84 on 08/01/21 from IP address 103.105.30.84. Copyright ARRS. For personal use only; all rights reserved

Fig. 3.-Perforated appendix with loculated

fluid (abscess). Sonogram shows rounded col-
lection of complex fluid containing low-level
echoes. Note surrounding echogenic fat (ar-
rows) “walling off” abscess.

appendicitis. The best single sonographic feature for diagnos- appendectomy also can be performed with low morbidity [16,
ing appendiceal perforation was detecting a loculated perice- 1 7]. Thus, the failure to diagnose perforating appendicitis by
cal fluid collection indicating an abscess. However, this find- sonography may lead to inappropriate early surgery when
ing was visualized in only nine of 22 perforated appendices conservative management or percutaneous drainage would
(sensitivity, 4i%) but was not visualized in any of the 78 have been preferable.
nonperforated cases (specificity, 100%). To date, little analysis of specific sonographic features of
By using a combination of one or more of the statistically appendiceal perforation has been done. Puylaert noted that
significant findings, the overall sensitivity for the sonographic atonic bowel loops, intenloop fluid pockets, thickened bowel
diagnosis of perforation was 86%, with a specificity of 60%. walls, moderate amounts of free fluid, and no tenderness
when pressure is applied to the right lower quadrant may be
identified in various degrees in patients with perforating ap-
Discussion
pendicitis [1]. The ultimate usefulness of these findings is
limited by the lack of statistical analysis and documentation
Graded compression sonography is of value in the clinical of their occurrence in patients with appendicitis without per-
diagnosis of acute appendicitis. However, the recently re- foration.
ported low sensitivity of 29% for diagnosing appendicitis in Three sonographic findings (loculated fluid, prominent pen-
patients with perforation suggests a relative limitation of this cecal fat, and circumferential loss of the echogenic layer of
technique [4]. It is likely that focal peritonitis associated with appendiceal submucosa) were all statistically associated with
perforation may lead to inadequate compression or that ex- appendiceal perforation. No single finding had a sensitivity for
tensive necrosis of the appendix renders it difficult to visualize. perforation greater than 59%. With a combination of one or
In reports of large numbers of cases, the rate of appendiceal more findings, however, the sensitivity increased to 84%, but
perforation ranges from 1 3% to 31 %, with rates as high as the specificity was only 60%.
65% accuracy in the elderly [6-i 1]. In a review of 1000 Recent anatomic studies correlating the sonographic ap-
patients from our institution who underwent appendectomy pearance of layers of the bowel wall show that the submu-
before graded compression sonography, the overall perfora- cosal layer can readily be identified sonographically and that
tion rate was 21 %, virtually identical to the 22% rate noted in it is echogenic [1 8]. Although not specifically proved by our
this series [6]. data, the lack of sonognaphic visualization of the echogenic
Puylaert et al. [4] have suggested that failure to diagnose submucosal layer is likely to represent extensive submucosal
appendiceal perforation by sonography rarely affects treat- ulceration and necrosis that can be correlated statistically
ment of patients. This is certainly true in patients with small with a greater likelihood of perforation.
perforations, because prompt appendectomy is warranted. A No statistically significant correlation was seen between
review of the surgical literature, however, suggests that the sonographic edema of free fluid and the presence of perfo-
need for immediate surgery is controversial in patients with ration. Neither the presence of an appendicohith or marked
perforating appendicitis and large peniappendiceal inflamma- enlargement of the appendix (>1 0 mm) was associated with
tory masses. Early surgery in some patients may be associ- perforation.
ated with higher morbidity than conservative management In adults, appendiceal perforation is often contained and
[1 2-i 5]. In patients with large peniappendiceal phlegmons, “walled off” by adjacent omental and mesenteric fat, thus
antibiotic therapy followed by interval appendectomy is an preventing generalized peritonitis [1 6] (Fig. 3). With contrast-
acceptable alternative to immediate surgery [1 6]. In patients enhanced CT, peniappendiceal inflammatory masses are often
with well-defined and well-localized periappendiceal ab- composed primarily of inflamed omental and mesenteric fat
scesses, percutaneous catheter drainage followed by interval [1 6] (Fig. i). Thus, prominent penicecal fat may be indirect
 278 BORUSHOK ET AL. AJR:154, February 1990

evidence of appendiceal perforation with evolution of a per- taneous drainage. Sonography may then help in the selection
iappendiceal phlegmon. This sonographic finding will be of of patients for further evaluation with CT.
limited use in patients with little omental or mesenteric fat.
We also have observed, anecdotally, prominent omental fat REFERENCES
in patients with other diseases causing transmural inflamma-
1 . Puylaert JCBM. Acute appendicitis: US evaluation using graded compres-
tion of the bowel such as cecal diverticuhitis. Thus, this finding
sion. Radiology 1986;i58:355-360
Downloaded from www.ajronline.org by 103.105.30.84 on 08/01/21 from IP address 103.105.30.84. Copyright ARRS. For personal use only; all rights reserved

is not specific for perforating appendicitis. 2. Jeffrey RB, Laing FC, Lewis FR. Acute appendicitis: high resolution real-
The most specific sonographic feature of appendiceal per- time US findings. Radiology 1987;163: 11-14
foration in this series was the presence of loculated pericecal 3. Jeffrey RB, Laing FC, Townsend RR. Acute appendicitis: sonographic
fluid, indicating an abscess. Loculated fluid collections often criteria based on 250 cases. Radiology 1988;167:327-329
4. Puylaert JCBM, Rutgers PH, Lalisang RI, et al. A prospective study of
appeared rounded in configuration and cause a mass effect
ultrasonography in the diagnosis of appendicitis. N EngI J Med 1987;
on adjacent bowel loops (Fig. 3). Free fluid in the right lower 317:666-669
quadrant, on the other hand, is nonspecific and may be seen 5. Abu-Yousef MM, BleicherJJ, MaherJW, Urdaneta LF, Franken EA, Metcalf
in patients without appendicitis. It is often triangular in config- AM. High-resolution sonography of acute appendicitis. AJR 1987;149:
53-58
uration as it passively conforms to the paracolic gutter. In
6. Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis: a critical review
patients with sonographic findings suggestive of appendicitis, of diagnosis and treatment in 1 000 cases. Arch Surg 1975;1 10:677-684
the visualization of a loculated penicecal fluid collection was 7. Detmer DE, Nevers LE, Sikes ED. Regional results of acute appendicitis
1 00% specific for perforation in our series. The sensitivity, care. JAMA 1981;246:1318-1320
however, was only 41%. 8. Ricci MA, Cuasay RS, Beck WC. Appendicitis: the perforation rate when
reviewed by decades in a general hospital. Am Surg 1988;54:273-275
Recognition of the sonographic findings associated with 9. McCallion J, Canning GP, Knight PV, McCallion JS. Acute appendicitis in
appendiceal perforation is important for two reasons. First, in the elderly: a 5-year retrospective study. Age and Ageing 1987;1 6:
patients without an initially visible, noncompressible appendix, 256-260
identification of prominent penicecal fat and/or loculated per- 10. Berry J, Malt RA. Appendicitis nears its centenary. Ann Surg 1984;200:
567-575
icecal fluid may be an important indirect clue to the diagnosis
1 1 . Peltokallio P. Tykka H. Evolution in the age distribution and mortality of
of underlying appendicitis. Thus, further efforts to show the acute appendicitis. Arch Surg 1981;1 16: 153-1 56
appendix are warranted. When specific attention is directed 12. Skoubo-Kristensen E, Hvid I. The appendiceal mass: conservative man-
toward imaging of the prominent penicecal fat, remnants of a agement. Ann Surg 1982;196:584-587
13. Hoffman J, Lindhard A, Jensen HE. Appendix mass: results of conservative
perforated appendix can be recognized surrounded by the
management without interval appendectomy. Am J Surg 1984;148:
echogenic fatty mass. The ultimate specificity of prominent 379-382
pericecal fat and loculated fluid alone, without a sonographi- 14. Bagi P. Dueholm S. Nonoperative management of the ultrasonically eval-
cally visible appendix, must await a prospective study. uated appendiceal mass. Surgery 1987:101:602-605
Second, patients with appendiceal perforation and a large 15. Paull DL, Bloom GP. Appendiceal abscess. Arch Surg 1982;1 17:
101 7-1 019
abscess or phlegmon may be managed with antibiotics and/
16. Jeffrey RB, Tolentino CS, Federle MP, Laing FC. Percutaneous drainage
or with percutaneous drainage. Contrast-enhanced CT is the of periappendiceal abscesses: review of 20 patients. AJR 1987;149:
imaging method of choice to characterize peniappendiceal 59-62
inflammatory masses [1 6]. CT can be used readily to distin- 1 7. Jeffrey RB, Federle MP, Tolentino CS. Periappendiceal inflammatory
guish areas of hiquified abscess from phlegmon and to guide masses: CT-directed management and clinical outcome in 70 patients.
Radiology 1988;167: 13-16
percutaneous catheter drainage [16]. On the basis of the CT 18. Kimmey MB, Martin RW, Hagitt RC, Wang KY, Franklin DW, Silverstein
findings, the surgeon can make an informed decision regard- FE. Histologic correlates of gastrointestinal ultrasound images. Gastroen-
ing either early surgery, primary antibiotic therapy, or percu- terology 1989;96:433-441