Appendicitis:

Atypical and Challenging

CT Appearances

Christopher M. Chin, MD
Kheng L. Lim, MD

Both authors have disclosed no relevant relationships.

Address correspondence to C.M.C., Department of Radiology, Pennsylvania

Hospital, University of Pennsylvania Health System, 800 Spruce St, Philadelphia, PA
19107 (e-mail: christopher.chin@uphs.upenn.edu).
 Introduction
• Appendicitis is commonly seen in medical practice, and its
preoperative diagnosis is increasingly reliant on imaging, particularly
computed tomography (CT), with clinical manifestations and
laboratory test results playing a less important role.
• The imaging-based diagnosis of appendicitis is not always
straightforward. To achieve an accurate diagnosis, radiologists must
be familiar with atypical as well as characteristic CT appearances of
appendicitis.
• This online presentation reviews:
– The pathophysiology and etiology of appendicitis, including various
causes of secondary/reactive appendicitis and mimics
– Atypical and complicated cases of appendicitis
– Advantages and potential pitfalls of using appendiceal caliber and/or
appendiceal filling by oral contrast material as diagnostic criteria at CT
– The importance of comparing current imaging studies with previous
studies when evaluating early, chronic, and resolving appendicitis
 Teaching Points
• An increase in appendiceal caliber between serial CT examinations,
even in the absence of adjacent fat stranding, may signal early-
stage appendicitis.
• However, increased appendiceal caliber alone is not a reliable
indicator of appendicitis and must be considered alongside the
patient’s clinical history and other imaging findings to avoid
misdiagnosis.
• The presence of oral contrast material within the appendix conflicts
with a diagnosis of acute appendicitis and can be used as
supporting evidence for a nonobstructed appendix in equivocal
cases, such as when appendiceal mural thickening is seen without
substantial periappendiceal fat stranding.
• Primary appendicitis should be distinguished from secondary or
reactive appendicitis, which can be caused by cecal and/or terminal
ileal diverticulitis, terminal ileitis, active Crohn disease, colitis, or an
acute gynecologic disease process.
• Clinical mimics of appendicitis include appendiceal mucoceles and
neoplasms.
 Learning Objectives
After viewing this presentation, participants should be able to:
• Discuss the advantages and potential pitfalls of using appen-
diceal caliber and/or appendiceal filling by oral contrast material
at CT to determine whether acute appendicitis is present.
• Recognize the broad spectrum of CT appearances of atypical,
complicated, and secondary or reactive appendicitis.
• List potential mimics of acute appendicitis.
 CT Protocol
• Controversy surrounds the optimal CT protocol for evaluating patients with
signs and symptoms of acute appendicitis, and the value of intravenous,
oral, and rectal contrast agents is debated.
• At our institution, we routinely administer both oral and intravenous contrast
material and acquire 5-mm-thick axial sections with 3-mm coronal and
sagittal reconstructions. The targeted interval between the administration of
oral contrast material and scanning is 60 minutes.
• Alternatives include the use of intravenous contrast material alone, oral
contrast material alone, rectal contrast material alone, or no contrast
material at all.
• In many centers, patients with right lower quadrant pain who are evaluated
in the emergency department undergo CT without contrast material.
• The chosen protocol should satisfy the needs of referring clinicians and be
appropriate for the particular patient, although that ideal may be difficult to
achieve in emergent settings.
• Dose reduction strategies should be used to minimize the patient’s
exposure to radiation while maintaining the image quality needed to achieve
a high level of diagnostic accuracy.
 Advantages and Disadvantages of
Using Oral Contrast Material
Advantages
• Allows improved diagnostic
accuracy in patients with a paucity
of intra-abdominal fat and
resultant susceptibility to volume
averaging of bowel, vessels, and
other viscera
• Allows a decreased number of
false-negative findings in certain
settings
• In equivocal cases, appendiceal
filling can provide supportive
evidence for a nonobstructed
appendix
Disadvantages
• Increases scanning time, which
may delay patient care
• May mask appendicoliths
• Leads to decreased patient
satisfaction with the imaging
examination (due to unpleasant
taste and potential side effects
such as nausea, vomiting, and
diarrhea)
• Increases the cost of the imaging
examination
 Pathophysiology of Acute
Appendicitis
• Appendiceal inflammation leads
to appendiceal wall thickening
and distention.
• Possible complications of acute
appendicitis include
– Abscess
– Gangrene
– Perforation
– Peritonitis
• In the case shown here, the
underlying cause of appendicitis
was uncertain, but obstruction of
Figure 1. Coronal CT image shows a dilated fluid-
the appendiceal lumen by the filled appendix with a calcified appendicolith
appendicolith or by lymphoid (arrow) and extensive extraluminal fluid and fat
stranding (arrowheads) in the right lower quadrant,
hyperplasia was suspected to findings suggestive of perforated appendicitis.
play a role.
 Atypical Location: Normal Variation
versus Herniation
Normal variation
• Normal appendix is relatively
mobile and may be found in a
retrocecal, subcecal, retroileal,
preileal, or pelvic site
Amyand hernia
• Herniation of the appendix into an
inguinal hernia
• Occurs in <1% of inguinal hernias
(appendicitis is found in 0.13% of
inguinal hernias)
• Most common in male patients
De Garengeot hernia Figures 2–9. Amyand hernia. Coronal CT image
series shows a fluid-filled and mildly dilated
• Herniation of the appendix into the (maximal diameter, 9 mm) appendix (arrow) in an
femoral canal atypical location in the right inguinal canal. These
findings could be due to compression at the hernia
• Even rarer than Amyand hernia ring or to a mild mucocele, but no pathology report
• Most common in female patients or follow-up CT study was available.
 Atypical Location:
Congenital Rotation Anomalies
• Left-sided appendicitis is
associated with two congenital
anomalies: intestinal malrota-
tion and situs inversus.
• CT findings of left-sided
appendicitis are similar to those
of right-sided appendicitis, ex-
cept for the difference in the
location of the appendix.

Important: Localize the cecum before
evaluating the appendix on CT
images. Do not assume that the
appendix is normal if it is not seen in
the right lower quadrant.
Figures 10–19. Coronal CT image series shows
acute appendicitis due to bowel malrotation in the
left mid abdomen (arrow). The cecum is near the
midline in the left hemiabdomen, and the duodeno-
jejunal junction is in the right upper quadrant, with
inversion of the normal relationship between the
superior mesenteric artery and vein (not shown).
 Utility of Increased Appendiceal
Caliber for Diagnosing Appendicitis

a. b. c.
Figure 20. Interval increase in appendiceal caliber in serially acquired axial CT studies is suggestive of
early acute appendicitis. (a, b) Axial CT scans obtained in an asymptomatic patient for ovarian cancer
follow-up show a slight increase in appendiceal diameter from 6 mm at baseline (arrow in a) to 9 mm 3
months later (arrow in b), without substantial adjacent stranding. Viewed in isolation, the appendiceal
appearance in b would be equivocal; however, the subtle increase in appendiceal caliber between a and
b raises the possibility of very early acute appendicitis. (c) Repeat CT scan obtained because the
patient reported abdominal pain 1 week after b shows the appendix (arrow) with an enlarged diameter
of 15 mm and adjacent fat stranding, findings that helped confirm the diagnosis of appendicitis.

Important: An interval increase in appendiceal caliber over serial CT examina-

tions is suggestive of early-stage acute appendicitis even in the absence of
adjacent fat stranding.
 Limitations of Appendiceal Caliber
for Diagnosing Appendicitis

a. b.
Figure 21. Variability of appendiceal caliber in two patients with pathology-proved acute appendicitis.
(a) Axial CT image obtained in a 23-year-old woman with nausea and vomiting depicts a normal-
caliber 6-mm appendix with indistinct wall (arrow). Minimal anterior pelvic fat stranding also is seen.
(b) Cor-onal CT image obtained in a 40-year-old woman with right lower quadrant abdominal pain
shows an unusually large appendix measuring up to 2.1 cm in diameter, with adjacent fat stranding.

Important: Appendiceal caliber alone is not a reliable indicator of appendicitis

and must be interpreted within the context of the patient’s clinical history and
other CT findings to avoid misdiagnosis.
Utility of Oral Contrast Material Filling for
Diagnosing Acute Appendicitis
The presence of oral contrast material
within the appendix conflicts with a
diagnosis of acute appendicitis and
can be used as supporting evidence
for a nonobstructed appendix in
equivocal cases, such as when the
appendix is mildly dilated and there is
no substantial adjacent fat stranding.

Important: Dense oral contrast

material can be hard to distinguish
from an appendicolith on standard CT
images obtained with soft-tissue
window and level settings. Use of a
bone window will show an
appendicolith to be much denser than
oral contrast material.
Figure 22. Mildly dilated, oral contrast mate-
rial-filled appendix. Axial CT image shows ap-
pendiceal caliber of 7–8 mm and mild mural
thickening. Appendiceal filling by oral contrast
material (arrow) and the absence of
substantial periappendiceal stranding militate
against a di-agnosis of acute appendicitis. The
pathology report confirmed that the appendix
was non-obstructed.
 Signs of Early-Stage Appendicitis
• Appendiceal caliber >6 mm
• Abnormal appendiceal wall
enhancement
• Periappendiceal stranding
• Appendicolith may be present
• “Arrowhead” sign
– Focal symmetric thickening of
the upper cecal wall where it
approaches the obstructed
appendiceal orifice, with an
arrowhead-shaped collection of
oral and/or rectal contrast
material Figure 23. Arrowhead sign in early-stage appen-
dicitis. Coronal CT image shows focal symmetric
– Observation of this sign allows thickening of the wall of the upper cecum where it
diagnostic sensitivity of 30% approaches the orifice of the obstructed appendix.
Note the arrowhead-shaped collection of oral
and specificity of 100%, contrast material (arrow) within the appendix.
according to Rao et al
 Atypical Appendicitis with Normal
White Blood Cell Count
Important: Although leuko-
cytosis is often associated with
acute appendicitis, a normal
white blood cell (WBC) count
alone does not allow the ex-
clusion of appendicitis. When
the WBC count is normal or
borderline high, concomitant
elevation of the absolute a. b.
neutrophil count (ANC) or Figure 24. Atypical acute appendicitis without leuko-
percentage of neutrophils cytosis. (a) Coronal CT image shows a dilated 1.4-cm
supports a diagnosis of acute appendix (arrow) with only minimal periappendiceal fat
stranding in a 59-year-old immunocompetent man with 2
appendicitis. days of right lower quadrant abdominal pain and normal
WBC count, ANC, and percentage of neutrophils. (b) Axial
CT image shows a mildly dilated 1-cm appendix (arrow)
without substantial periappendiceal fat stranding in a 22-
year-old immunocompetent man with a normal WBC count
and normal percentage of neutrophils but marginally
elevated ANC. Pathology reports indicated acute
appendicitis in both patients.
 Atypical Appearances:
Tip Appendicitis

a. b. c.
Figure 25. Tip appendicitis. Evaluation of the appendix on coronal CT images reveals a normal-
appearing proximal portion filled with oral contrast material (arrow in a), a nondilated middle portion
(arrow in b), and a markedly thickened distal portion (arrow in c) with associated periappendiceal
stranding, findings suggestive of tip appendicitis. The diagnosis was confirmed at pathologic analysis.

Important: Close inspection of the entirety of the appendix, from its origin to its
most distal portion, is essential at imaging in order to avoid missing the diagnosis
of tip appendicitis. Note that the normal appendiceal tip is bulbous in configura-
tion and is expected to be wider in diameter than the rest of the appendix.
 Atypical Appearances:
Stump Appendicitis
• Inflammation of residual appendix after
appendectomy is known as stump appendi-
citis. Surgical resection of the inflamed
appendiceal stump with or without invagin-
ation, referred to as repeat or completion
appendectomy, is usually recommended.
• A recent literature review performed by
Kanona et al showed that 37% of cases of
stump appendicitis occurred after initial
laparoscopic appendectomy and 63%
occurred after initial open appendectomy,
contrary to earlier reports that suggested Figure 26. Stump appendicitis. Axial CT
an increased incidence rate after appen- image obtained approximately 2 years after
dectomy with a laparoscopic approach. The laparoscopic appendectomy shows a long
interval between initial appendectomy and appendiceal remnant (arrow) with adjacent fat
stranding, findings suggestive of stump
repeat appendectomy varied from 9 weeks appendicitis.
to 50 years.
• Rarely, an inflamed epiploic appendage
may calcify and mimic stump appendicitis.
 Atypical Appearances:
Focal Inflammation of Appendix

a. b.
Figure 27. Appendix with rarely seen focal inflammation. Axial (a) and coronal (b) CT images show a
1.5-cm appendix (arrow) containing fluid and gas from the middle to the distal portion. These findings
are suggestive of an intraluminal abscess in the setting of acute appendicitis. Pathologic analysis
showed focal inflammation with a bulging appendiceal luminal wall containing fecal matter.

Important: The presence of gas in the appendiceal lumen does not permit the
exclusion of appendicitis, and when seen with other features of acute
appendicitis, it is suggestive of complicated appendicitis.
 Complicated Appendicitis:
Perforation
• Classic CT findings of
perforated appendicitis are
– Abscess
– Extraluminal air
– Extraluminal appendicolith
• Visualization of one or more
appendicoliths increases the
probability of appendiceal
perforation
– Appendicoliths may accelerate
the rate at which perforation Figure 28. Perforated appendicitis. Axial CT
occurs image shows an appendicolith (arrow) with
an atypical, extraluminal location in the
anterior pelvis, a finding indicative of
appendiceal perforation.
 Complicated Appendicitis:
Perforation (continued)
• Horrow et al identified five
CT findings that collectively
yielded 95% sensitivity and
specificity for a diagnosis of
perforated appendicitis:
– Extraluminal air
– Extraluminal appendicolith
– Abscess
– Phlegmon
– Defect in mural enhancement
(individual feature with the
highest sensitivity, at 64%)
Figure 29. Perforated appendicitis. Coronal
CT image shows disruption of the appen-
diceal wall by extraluminal air (arrow), a
finding indicative of perforation.
 Complicated Appendicitis:
Perforation (continued)

a. b.
Figure 30. Perforated appendicitis with free intraperitoneal and right retroperitoneal air in
an 82-year-old woman. Axial (a) and coronal (b) CT images show air collections anterior to
the liver, tracking into the retroperitoneal space, along the right paracolic gutter, and into the
region of the cecum. Such extensive pneumoperitoneum is infrequently seen in cases of
appendicitis.
Complicated Appendicitis: Abscess
• Abscess is the most
frequent complication of
perforated appendicitis.
• A localized abscess occurs
if periappendiceal fibrinous
adhesions develop before
the appendix ruptures.
• Infection may spread to
a. b.
adjacent structures and
Figure 31. Perforated appendicitis with a
spaces, such as the complex multicompartmental abscess
iliopsoas muscles and extending into the retroperitoneal tissues, right
retroperitoneal tissues, if psoas muscle, right iliacus muscle (arrow in
the abscess is not promptly a), and posterior subcutaneous tissues of the
right flank (arrow in b). Culture of fluid from
diagnosed. the abscess showed Klebsiella infection.
 Complicated Appendicitis:
Peritonitis
• When appendiceal rupture
occurs before inflammatory
adhesions form in early acute
appendicitis, peritonitis may
result.
• Peritonitis secondary to
perforated appendicitis is more
common in children than in
adults because progression
from inflammation to
perforation is more rapid in
children.
Figure 32. Perforated appendicitis with resultant
• Contrast-enhanced CT is peritonitis in a 59-year-old woman. Coronal CT
helpful for distinguishing image obtained after appendectomy shows
enhancing, thickened peritoneum (white arrow)
peritonitis from ascites. and mild to moderate ascites (black arrow) in the
patient’s abdomen and pelvis.
 Complicated Appendicitis:
Other Associated Findings
Pylephlebitis and pylethrombosis
• Caused by ascending infection
along the draining mesenteric-
portal venous system
Genitourinary involvement
• May result in reactive hydroureter
or hydronephrosis
Gangrenous appendicitis
• Pneumatosis, shaggy appendiceal
wall, and patchy areas of mural
nonperfusion
Figure 33. Pylephlebitis secondary to
appendicitis. Axial CT image obtained in a
patient with appendicitis shows a focal linear
region of hypoattenuation in the right hepatic
lobe (arrow), a finding that likely represents
thrombosis of the distal end of an anterior
branch of the right portal vein.
 Complicated Appendicitis:
Bowel Obstruction
Bowel obstruction may occur due to
• Narrowing of the distal ileum because of periappendiceal inflammation
• Adhesions from appendectomy

a. b.
Figure 34. Axial CT images obtained in the lower abdomen show multiple dilated small
bowel loops containing differential air-fluid levels, findings consistent with a small bowel
obstruction (arrows in a) secondary to appendicitis (arrow in b).
 Complicated Appendicitis: Fistula
• A fistula may form from a
perforated appendix to
adjacent bowel, bladder,
vagina, uterus, or skin.
• Fistulation is a rare com-
plication of perforated
appendicitis.

Figure 35. Coronal CT image shows

improving appendicitis with a probable fistula
(arrow) to the adjacent sigmoid colon.
Chronic and Recurrent Appendicitis
Chronic appendicitis
• Symptoms last for weeks,
months, or years
Recurrent appendicitis
• Characterized by repeated
episodes of pain
• Intervals between episodes may a. b.
vary from weeks to years Figure 36. Chronic appendicitis. Axial CT
images obtained 5 months apart in the same
• Clinical manifestations may be the patient show a persistently dilated, fluid-filled
same as those of acute or chronic appendix (arrow) without substantial adja-
appendicitis cent fat stranding. Even when conservative
management of appendicitis fails, the result
is not invariably a ruptured appendix.
 Resolving Appendicitis

a. b. c. d.
Figure 37. Resolving appendicitis without surgical intervention. Axial CT scans obtained in
the same patient at diagnosis (a) and 1 month (b), 4 months (c), and 8 months (d) later
demonstrate a gradual decrease in caliber of the appendix (arrow) and periappendiceal
stranding. No antibiotics were administered for the apparent “cecal mass” found in a, which
was no longer seen when the patient presented for CT-guided biopsy (b). The mild dilata-
tion of the appendix seen in b may be an equivocal finding in isolation, but when compared
with the findings in previous studies, is suggestive of resolving appendicitis.

Important: CT evaluation for appendicitis should include a comparison of

current images with any available previous studies and with available clinical
information to allow accurate differentiation between a normal appendiceal
variant, early-stage appendicitis, and resolving appendicitis.
 Appendectomy Mimics
Important: Do not
mistake retained oral
contrast material in the
appendix for
appendicoliths or
changes due to
appendectomy.

a. b.
Figure 38. Retained barium mimicking changes after
appendectomy. (a) Coronal contrast-enhanced CT
image shows high-attenuation collections (arrow) with
streak artifact adjacent to the cecum, findings initially
thought to represent a surgical staple line from a
possible appendectomy. (b) Coronal unenhanced CT
image obtained approximately 1½ years later shows
an intact appendix (arrow). Decreased hyperatten-
uation of the previously seen collections is consistent
with residual barium.
 Necrotizing Appendicitis Mimicking
Normal Bowel

a. b. c.
Figure 39. Necrotizing appendicitis mimicking bowel. (a) Axial CT image shows a 2-cm
dilated, thickened appendix (arrow) containing feces-like material without substantial
adjacent stranding, findings that mimic normal small bowel. (b) Coronal CT image more
clearly shows the appendix (arrow) arising from the cecum inferior to the expected location
of the ileocecal valve. (c) Coronal CT image helps confirm that the blind-ended tubular
structure in b represents the appendix, which tapers distally and contains high-attenuation
material at its tip, presumably an appendicolith (arrow).

Important: A dilated appendix may mimic small bowel (terminal ileum) but
should arise from the cecum and be blind-ended.
 Appendiceal Diverticulosis and
Appendiceal Diverticulitis
Appendiceal diverticulosis
• Rare (found in 0.004%–2.7% of
appendiceal specimens at surgery
or autopsy)
• More often acquired than
congenital
• Asymptomatic
Appendiceal diverticulitis
• Frequency of perforation is more
than four times that in appendicitis
• Appendicoliths are not usually
seen
• Figure 40. Axial CT image shows scattered
Associated with older age (>30
appendiceal diverticula (arrowheads) in a
years) and longer duration of 72-year-old woman with no right lower
symptoms (1–13 days) than quadrant pain, findings characteristic of
appendicitis diverticulosis.
 Causes of Secondary or Reactive
Appendicitis: Diverticulitis
Cecal diverticulitis
• Accounts for only 5% of all
diverticulitis cases
• Thickening and inflammation,
usually centered around cecum
• Identifying inflamed diverticulum
increases diagnostic specificity
a. b.
Terminal ileal diverticulitis Figure 41. Reactive appendicitis secondary
• Ileal diverticulosis (incidence, to terminal ileal diverticulitis. Axial CT images
0.001%–1.9%) may lead to rare show inflammatory fat stranding surrounding a
few terminal ileal diverticula (arrowheads) and
acute complications, such as ileal
an appendix measuring up to 1 cm in caliber,
diverticulitis with mild mural thickening (arrow).
• Small bowel diverticula are most
common in male patients and often
coexist with colonic diverticula
 Causes of Secondary or Reactive
Appendicitis: Terminal Ileitis
• Etiology includes bacterial,
mycobacterial, parasitic, and
viral infections
– Yersiniosis
– Tuberculosis
– Cryptosporidiosis
– Cytomegalovirus infection a. b.
Figure 42. Reactive appendicitis secondary
• CT typically shows mild
to terminal ileitis. Axial CT images show an
terminal ileal wall thickening inflamed appendix (arrow in b) just inferior to
(<5 mm) with or without a thickened terminal ileum (arrow in a) in a
associated mesenteric 42-year-old woman with a history of recent
travel abroad. Stool culture was positive for
adenitis Salmonella.
• Correlation of CT features with
clinical manifestations and/or
laboratory findings is essential
 Causes of Secondary or Reactive
Appendicitis: Crohn Disease
• Crohn disease can affect any
part of the gastrointestinal tract
but most commonly affects the
terminal ileum
• Characteristic findings include:
– Bowel wall circumferential
thickening and mural
stratification (“target” sign) in
acute and subacute cases
– Skip lesions
– Mesenteric fat proliferation
– Mesenteric hypervascularity Figure 43. Reactive appendicitis secondary to
(“comb” sign) active Crohn disease. Coronal CT image shows a
dilated, fluid-filled appendix with enhancing wall
– Fistulas, sinus tracts, and
(black arrow) adjacent to an inflamed, thickened
abscesses distal ileum (white arrow) with associated mesen-
teric hypervascularity in a comblike configuration.
 Causes of Secondary or Reactive
Appendicitis: Colitis

a. b.
Figure 44. Reactive appendicitis secondary to pancolitis in 19-year-old woman with a
history of cystic fibrosis. Axial (a) and coronal (b) CT images show extensive mural and fold
thickening involving the cecum and ascending, transverse, and descending colon (white
arrows). There is dilatation and hyperemia of the proximal to mid appendix (black arrow),
which tapers distally to normal caliber (not shown). The cause of colitis was unknown, and
the patient deferred colonoscopy.
 Causes of Secondary or Reactive
Appendicitis: Pyosalpinx
Acute gynecologic
disease processes,
such as pyosalpinx,
tubo-ovarian abscess,
and endometriosis,
may cause reactive
appendicitis.

a. b.
Figure 45. Reactive appendicitis secondary to pyosalpinx.
(a) Axial CT image shows a minimally dilated, air-filled
appendix (arrow) with adjacent stranding. (b) Axial CT
image of the right adnexa shows a dilated, fluid-filled
tubular structure (arrow) with peripheral enhancement,
findings suggestive of pyosalpinx, a diagnosis confirmed
by findings at subsequent ultrasonography. Uterine leio-
myomas (arrowheads) also were incidentally seen.
 Causes of Secondary or Reactive
Appendicitis: Tubo-ovarian Abscess

a. b.
Figure 46. Tubo-ovarian abscess in a 40-year-old woman with a fever and vaginal dis-
charge after unprotected sexual intercourse. Coronal CT images show a multicystic right
adnexal mass involving both the ovary (white arrow in b) and uterine tube (arrowheads in
a), with mild dilatation of the appendix (black arrow in b) representing reactive appendicitis.
 Mimics of Appendicitis: Omental
Infarction and Epiploic Appendagitis
Omental infarction
• Necrosis of a portion of omentum
• Large (3–10-cm-diameter), heterogeneously
hazy and streaky region, typically between
abdominal wall and colon on the right side
• Self-limiting process (duration, 1–4 months)
Figure 47. Omental infarction.
Epiploic appendagitis
• Inflammation, torsion, or ischemia of epiploic
appendage
• Small (1–4-cm-diameter) fat-attenuation mass
with a ringlike region of peripheral
hyperattenuation
• More often located in the left lower quadrant
than in the right
Figure 48. Epiploic appendagitis.
• Self-limiting process (duration, 1–2 weeks)
 Mimics of Appendicitis:
Appendiceal Mucoceles
• Appendix is distended by
intraluminal mucus due to
– Chronic obstruction
– Mucosal hyperplasia
– Benign or malignant neoplasm
• Usually clinically asymptomatic
• Appears as a hypoattenuating
cystic encapsulated mass with
or without mural calcifications
at CT
• Appendiceal wall thickening
and periappendiceal fat
stranding are atypical findings
• Focal nodular wall thickening
suggests the presence of
mucinous cystadenocarcinoma
a. b. c.
Figure 49. (a) Giant appendiceal mucocele.
Coronal CT image shows a low-attenuation,
peripherally calcified tubular structure arising
from the cecum and measuring approximately
13 × 4 cm without substantial fat stranding.
(b) Perforated appendiceal mucinous adeno-
carcinoma. Coronal CT image shows an ap-
pendiceal mucocele (arrow) with atypical wall
thickening, periappendiceal stranding, and a
fluid collection (arrowhead). (c) Appendiceal
mucocele (arrow) with superimposed strand-
ing. Pathologic analysis revealed both
appendiceal adenocarcinoma and acute
appendicitis.
 Mimics of Appendicitis:
Appendiceal Neoplasms
• Are present in 0.5%–1.0% of
appendectomy specimens
• Generally affect adults
• 30%–50% manifest with signs
and symptoms of uncompli-
cated appendicitis
• Appendiceal diameter of >15 a. b.
Figure 50. Appendiceal neoplasms mimic-
mm should arouse suspicion, king appendicitis. (a) Axial CT image shows
especially in older patients, per a 1.3-cm dilated appendix (arrow) with
Pickhardt et al thickened hyperenhancing walls, low-
attenuation intraluminal material, and
• Imaging findings suggestive of
adjacent fat stranding. Pathologic analysis
appendiceal neoplasm are showed mucinous cystadenocarcinoma.
likely to alter surgical planning (b) Axial CT image shows a 1.2-cm dilated
and should be reported appendiceal tip (arrow) with adjacent free
fluid (arrowhead) in the right lower quadrant.
Pathologic findings indicated mucinous
cystadenoma in the tip.
 Mimics of Appendicitis:
Appendiceal Carcinoid
• The most common of
appendiceal neoplasms
• Usually incidentally
discovered, because most
are smaller than 1 cm in
diameter and are located in
the distal third of the
appendix a. b.
Figure 51. Appendiceal carcinoid. Axial CT
images show normal caliber of the midportion of
the appendix (arrowhead) but focal prominence
of the appendiceal tip (arrow), which measures
up to 1 cm in diameter, mimicking tip appendicitis
without adjacent stranding. Pathologic analysis
showed the lesion in the appendix tip to be a
carcinoid tumor.
 Mimics of Appendicitis:
Appendiceal Metastasis

a. b. c.
Figure 52. Metastatic appendiceal mixed goblet cell carcinoid-adenocarcinoma mimicking
appendicitis. Axial CT images show an enlarged appendix with nonuniform mural enhance-
ment (arrow in a), new mild left omental infiltration (arrowhead in b), and new prominence
of the left ovary with a nonuniform, mildly enhancing rim (arrow in c).
 Suggested Readings
Constantine S. Computed tomography appearances of Amyand hernia. J Comput Assist Tomogr
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