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Original article

Accuracy of MRI compared with ultrasound imaging and


selective use of CT to discriminate simple from perforated
appendicitis
M. M. N. Leeuwenburgh1,2 , M. J. Wiezer5 , B. M. Wiarda6 , W. H. Bouma7 , S. S. K. S. Phoa2 ,
H. B. A. C. Stockmann8 , S. Jensch4 , P. M. M. Bossuyt3 , M. A. Boermeester1 and J. Stoker2 on behalf
of the OPTIMAP study group
Departments of 1 Surgery, 2 Radiology and 3 Clinical Epidemiology, Academic Medical Centre, University of Amsterdam, and 4 Department of Radiology,
St Lucas Andreas Hospital, Amsterdam, 5 Department of Surgery, St Antonius Hospital, Nieuwegein, 6 Department of Radiology, Alkmaar Medical
Centre, Alkmaar, 7 Department of Surgery, Gelre Hospitals, Apeldoorn, and 8 Department of Surgery, Kennemer Gasthuis, Haarlem, The Netherlands
Correspondence to: Ms M. M. N. Leeuwenburgh, Department of Radiology, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam,
The Netherlands (e-mail: m.m.leeuwenburgh@amc.uva.nl)

Background: Discrimination between simple and perforated appendicitis in patients with suspected

appendicitis may help to determine the therapy, timing of surgery and risk of complications. The aim of
this study was to estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between
simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected
additional (conditional) use of computed tomography (CT).
Methods: Patients with clinically suspected appendicitis were identified prospectively at the emergency
department of six hospitals. Consenting patients underwent MRI, but were managed based on findings at
ultrasonography and conditional CT. Radiologists who evaluated the MRI were blinded to the results of
ultrasound imaging and CT. The presence of perforated appendicitis was recorded after each evaluation.
The final diagnosis was assigned by an expert panel based on perioperative data, histopathology and
clinical follow-up after 3 months.
Results: MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis
in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified
17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73)
per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65)
per cent) (P = 0517). All missed diagnoses of perforated appendicitis were identified as simple acute
appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a
positive predictive value higher than 53 per cent.
Conclusion: MRI is comparable to ultrasonography with conditional use of CT in identifying perforated
appendicitis. However, both strategies incorrectly classify up to half of all patients with perforated
appendicitis as having simple appendicitis. Triage of appendicitis based on imaging for conservative
treatment is inaccurate and may be considered unsafe for decision-making.
Presented to a scientic meeting of the Association of Surgeons of the Netherlands, Veldhoven, The Netherlands,
May 2012; published in abstract form as Br J Surg 2012; 99(Suppl 7): S6
Paper accepted 24 September 2013
Published online 22 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9350

Introduction

Appendicectomy for acute appendicitis has been questioned recently as being the only correct treatment for
appendicitis. Antibiotic treatment has been shown to be
effective in the management of selected patients with acute
non-perforated (simple) appendicitis in randomized clinical
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trials1 5 . There is also some evidence for the spontaneous


resolution of untreated, non-perforated appendicitis6 . The
complication rates for conservative management increase
with perforation, and conservative treatment is more likely
to fail in those with a perforated appendix. In addition,
previous studies6,7 have revealed a 3510-fold increase in
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M. M. N. Leeuwenburgh, M. J. Wiezer, B. M. Wiarda, W. H. Bouma, S. S. K. S. Phoa, H. B. A. C. Stockmann et al.

mortality rate following perforation. An accurate preoperative diagnosis of perforation is therefore clinically relevant
in determining treatment and timing of surgery, and in
evaluating the risk of complications.
Diagnostic imaging with ultrasonography or computed
tomography (CT) has been proven accurately to detect
acute appendicitis8 . However, these imaging modalities do
not seem to be as effective in differentiating simple from
perforated appendicitis. For ultrasonography, the reported
sensitivities vary from 29 per cent9 to 84 per cent10 . More
recent studies11 13 evaluating the accuracy of CT in detecting perforated appendicitis have documented sensitivities
between 28 and 62 per cent, and specicities between 81
and 91 per cent. In a recent randomized trial1 the investigators selected patients with simple acute appendicitis by
systematic CT assessment before randomization to conservative or operative treatment. Despite the use of CT, complicated appendicitis with peritonitis was found at surgery
in 18 per cent of patients in the appendicectomy group.
Magnetic resonance imaging (MRI) is a promising
modality in the evaluation of suspected acute appendicitis
owing to its high diagnostic accuracy14,15 , and avoidance
of ionizing radiation and intravenous contrast medium.
Newer MRI techniques such as diffusion-weighted imaging
may further increase its accuracy16,17 . Because the use of
MRI in the evaluation of acute appendicitis is relatively
new, data on accuracy for perforated versus simple
appendicitis are not yet available in the literature.
The present study was designed to estimate the accuracy
of MRI for diagnosing perforated appendicitis in patients
with suspected acute appendicitis. The primary aim was
to compare the accuracy of MRI with the currently used
imaging strategy for evaluation of suspected appendicitis:
initial use of ultrasound imaging followed by CT if the
ultrasound results are negative or inconclusive18,19 . The
secondary aim was to identify MRI features associated with
perforated appendicitis.
Methods

Between March 2010 and September 2010 all adult patients


(aged at least 18 years) with clinically suspected acute
appendicitis presenting to the emergency department of
six hospitals were included in this prospective multicentre
diagnostic accuracy study14 . All participating patients gave
written informed consent; each hospitals medical ethics
committee approved the protocol before the start of the
study20 .
Treating physicians in the emergency department
recruited patients with clinically suspected appendicitis
based on medical history, and physical and laboratory
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examination before imaging. Pregnant women, patients


with any contraindication to MRI and critically ill patients
who needed intensive vital organ function monitoring for
life support were excluded. Consenting patients underwent
MRI within 2 h for research purposes, but were managed
based on ultrasound and CT ndings, according to Dutch
guidelines (ultrasound imaging with conditional CT)19 .
Initially a staff radiologist or radiological resident
performed an ultrasound examination of the complete
abdomen. A curved 3550-MHz array and a linear
10-MHz array were used (Aplio XL, Toshiba Medical
Systems, Tokyo, Japan; HDI 5000 and IU 22, Philips
Medical Systems, Best, The Netherlands; Acuson
and Antares, Siemens Medical Systems, Forchheim,
Germany). CT was subsequently carried out if the
ultrasound results were negative or inconclusive18,19 . All
CT images were acquired using a multidetector row four-,
16- or 64-slice scanner (4-slice SOMATOM Volume
Zoom, 16-slice SOMATOM Sensation, Siemens
Medical Systems; 16-slice MX 8000, 64-slice Brilliance,
Philips Medical Systems; 64-slice Aquilion, Toshiba
Medical Systems) and intravenous contrast medium, and
were read by a staff radiologist or supervised radiological
resident. Any diagnosis of perforated appendicitis at
ultrasonography and CT was recorded during this study
(Appendix S1, supporting information).

MRI protocol
Included patients underwent MRI in a 15-T scanner
(MAGNETOM Avanto 15 T MRI, Siemens Medical
Systems; Intera 15 T MRI, Philips Medical Systems)
within 2 h of admission to the emergency department.
The MRI examination comprised breath-hold axial and
coronal T2-weighted sequences (half-Fourier-acquisition
single-shot turbo spin-echo (HASTE): repetition time
(TR) 1500 ms, echo time (TE) 90 ms, ip angle 170 , slice
thickness 6 mm, eld of view (FOV) 400 mm, 256 256
matrix; spectral selection attenuated inversion recovery
HASTE: TR 1400 ms, TE 93 ms, ip angle 160 , slice
thickness 6 mm, FOV 400 mm, 256 256 matrix), and freebreathing axial and coronal diffusion-weighted sequences
(diffusion-weighted imaging: TR 3900 ms, TE 75 ms, slice
thickness 6 mm, FOV 400 mm, 192 192 matrix, B-values
50400800 s/mm2 , 192 192 matrix). No intravenous or
oral contrast medium was administered.

Image interpretation
Two experienced radiologists (over 500 MRI readings of
the abdomen) read the MRI in a research setting on a
picture archiving and communication system workstation.
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Discriminating between simple and perforated appendicitis

They received clinical information on each included


patient, but were blinded to the results of ultrasonography
and CT, and outcome. The radiologists evaluated the
images separately and differences were resolved by
consensus. The presence of perforated appendicitis and of
the following imaging ndings were recorded: complete
visualization of the appendix, appendiceal diameter,
periappendiceal fat inltration, periappendiceal uid,
absence of intraluminal air, presence of an appendicolith,
destruction of the appendiceal wall, presence of an
abscess and extraluminal free air. Restricted diffusion of
the appendiceal wall, lumen and focal uid collections
on diffusion-weighted imaging were also noted. The
radiologists recorded the imaging ndings, and the nal
judgement on the presence of appendicitis and appendiceal
perforation on a structured case record form (Appendix
S1, supporting information). The diagnosis of appendiceal
perforation was left to the discretion of the reader who
evaluated the images.

Reference standard
All cases were assigned to one of two expert panels,
each consisting of two surgeons and one radiologist. The
panel assigned a nal diagnosis based on peroperative
observations, histopathological ndings and outcome at
3-month follow-up. If the patient had not returned to
the hospital within this period, their general practitioner
was contacted for information. The diagnosis was
classied as no appendicitis (any other diagnosis), simple
appendicitis or perforated appendicitis. Criteria for
perforated appendicitis were perioperative observation of
a perforation in the appendix, pus in the abdomen or
perforation at histopathological examination. Conicting
ndings at perioperative observation, histopathological
or clinical examination were resolved during consensus
meetings of the two expert panels.

Definitions
The diagnostic accuracy for perforated appendicitis was
evaluated for MRI and for ultrasound imaging with
conditional CT. Estimates of sensitivity, specicity and
predictive values were calculated with corresponding 95
per cent condence intervals (c.i.), by comparing the imaging results with the nal diagnosis assigned by the expert
panel. For these calculations only imaging results positive
for perforated or simple appendicitis were used. Cases
of perforated appendicitis in which imaging identied
perforated appendicitis were considered as true positives,
whereas cases of perforated appendicitis identied as simple appendicitis were false negatives. Cases of simple or no
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appendicitis were considered as false positives if imaging


identied perforated appendicitis, and true negatives if
imaging identied them as simple appendicitis.

Statistical analysis
With an MRI sensitivity in detecting perforated appendicitis of around 60 per cent, and about one in seven patients
with suspected appendicitis having a nal diagnosis of perforated appendicitis, the inclusion of 230 patients would
produce a 95 per cent c.i. that extends 15 per cent from the
estimated sensitivity21 .
Differences in sensitivity, specicity and predictive values were tested for statistical signicance using the 2 test.
P < 0050 was considered to indicate statistical signicance.
The presence of individual MRI features, as specied
above, was compared between patients with perforated
and simple appendicitis as nal diagnosis using the 2 test.
Estimates of positive (PPV) and negative (NPV) predictive
values for perforated appendicitis were calculated per
MRI feature, with corresponding 95 per cent c.i. This
was also calculated for the combination of any two MRI
features. The association between each imaging feature
and a nal diagnosis of perforated acute appendicitis was
expressed as a diagnostic odds ratio with corresponding
95 per cent c.i. All statistical analyses were performed with
SPSS software version 18.0 (IBM, Armonk, New York,
USA).
Results

A total of 230 patients with clinically suspected appendicitis


were included. Their median age was 35 (i.q.r. 2449)
years and 92 were men. After completion of the imaging
protocol, 128 patients underwent surgery within a few
hours, and histopathology ndings were available for 123.
Two patients with perforated appendicitis were treated
with percutaneous drainage. The expert panel assigned
acute appendicitis as the nal diagnosis in 118 patients, of
whom 31 had a perforated appendix (perforation rate 263
per cent).

Diagnostic accuracy of ultrasound imaging


with conditional CT for appendiceal perforation
The imaging protocol was violated in eight patients: one in
whom CT was carried out without initial ultrasonography,
and seven in whom no CT was performed after a negative
or inconclusive ultrasound examination. The ndings of
ultrasonography with conditional CT are summarized in
Fig. 1a. The initial ultrasound examination identied 17
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Clinically suspected appendicitis


n = 230
No ultrasonography
n=1

Ultrasonography
n = 229

No appendicitis

Appendicitis

CT
n = 115

Perforated appendicitis n = 22
Final diagnosis
Perforated appendicitis n = 15
Simple appendicitis n = 6
Other n = 1

Simple appendicitis n = 103


Final diagnosis
Perforated appendicitis n = 16
Simple appendicitis n = 78
Other n = 9

No appendicitis n = 105
Final diagnosis
Perforated appendicitis n = 0
Simple appendicitis n = 3
Other n = 102

Ultrasonography and CT
Clinically suspected appendicitis
n = 230
MRI
n = 223

Appendicitis

Perforated appendicitis n = 30
Final diagnosis
Perforated appendicitis n = 17
Simple appendicitis n = 12
Other n = 1

No appendicitis

Simple appendicitis n = 90
Final diagnosis
Perforated appendicitis n = 13
Simple appendicitis n = 71
Other n = 6

No appendicitis n = 103
Final diagnosis
Perforated appendicitis n = 0
Simple appendicitis n = 4
Other n = 99

MRI

Fig. 1 Flow chart showing imaging results: a ultrasound imaging with conditional computed tomography (CT) and b magnetic
resonance imaging (MRI)

patients with perforated appendicitis. In this group the


nal diagnosis was perforated appendicitis in ten patients
(10 true positives), simple appendicitis in six, and one
patient was diagnosed with an adenocarcinoma of the
caecum (7 false positives). Perforated appendicitis was not
identied by ultrasonography in 11 patients. The sensitivity
of ultrasonography alone for perforated appendicitis was
48 (95 per cent c.i. 28 to 68) per cent (10 of 21 patients).
After inconclusive or negative ultrasound ndings for
acute appendicitis, CT was performed in 115 patients
and another ve patients were correctly identied with
perforated appendicitis (5 true positives). CT did not
generate any additional false positives.
In 208 patients appendiceal perforation was excluded
by ultrasound examination with conditional CT; 103 of

these patients were diagnosed with simple appendicitis.


In this group 16 patients were diagnosed with perforated
appendicitis by the expert panel (16 false negatives, 87
true negatives). Simple appendicitis was also excluded in
the other 105 patients; three had simple appendicitis and
none of these patients had perforated appendicitis as nal
diagnosis (Table 1).
Ultrasound imaging with conditional CT discriminated
perforated appendicitis from simple appendicitis or no
appendicitis with a PPV of 68 (47 to 84) per cent (15
of 22 patients) and a NPV of 84 (76 to 90) per cent (87
of 103 patients). The sensitivity of ultrasonography with
conditional CT in detecting perforation of the appendix
was estimated at 48 (32 to 65) per cent (15 of 31 patients)
(Table 2).

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Table 1

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Imaging results compared with reference standard


Reference standard
No. of patients

Ultrasound imaging with conditional CT*


Perforated appendicitis
Simple appendicitis
No appendicitis
Magnetic resonance imaging
Perforated appendicitis
Simple appendicitis
No appendicitis
Missing

Perforated appendicitis (n = 31)

Simple appendicitis (n = 87)

No appendicitis ( n =112)

15
16
0

6
78
3

1
9
102

17
13
0
1

12
71
4
0

1
6
99
6

230

223

*All patients underwent initial ultrasonography, then computed tomography (CT) if the ultrasound results were negative or inconclusive.
Table 2

Accuracy of MRI and ultrasonography with conditional CT for perforated appendicitis


No. of patients

Ultrasound imaging with conditional CT*

125

MRI

120

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

48 (32, 65)
15 of 31
57 (39, 73)
17 of 30

93 (85, 96)
87 of 94
86 (77, 91)
77 of 90

68 (47, 84)
15 of 22
57 (39, 73)
17 of 30

84 (76, 90)
87 of 103
86 (77, 91)
77 of 90

0517

0127

0399

0833

Values in parentheses are 95 per cent condence intervals; proportions used to calculate diagnostic indices are also shown. Only imaging results positive
for perforated or simple appendicitis were used for these calculations. *All patients underwent initial ultrasonography, then computed tomography (CT) if
the ultrasound results were negative or inconclusive. PPV, positive predictive value; NPV, negative predictive value; MRI, magnetic resonance imaging.
2 test.

Diagnostic accuracy of MRI for appendiceal


perforation
MRI could not be performed in seven of the 230 included
patients owing to claustrophobia or unexpected technical
failure. The nal diagnoses in these seven patients were
perforated appendicitis (1), acute diverticulitis (1), acute
cholecystitis (1), benign adnexal cyst (2), simple urinary
tract infection (1) and non-specic abdominal pain (1).
The ndings of MRI are summarized in Fig. 1b.
Radiologists classied 30 patients as having perforated
acute appendicitis on MRI; this was conrmed at surgery
in 17 patients (17 true positives). Simple appendicitis was
the nal diagnosis in 12 of these 30 patients; in one
patient laparotomy showed an inltrate with involvement
of the appendix and adnexa in the right lower abdomen
owing to endometriosis (13 false positives). Radiologists
classied 90 patients as having simple acute appendicitis
with MRI; 13 of these 90 patients had a perforated
appendix at surgery (13 false negatives, 77 true negatives).
The remaining 103 patients were not diagnosed with
appendicitis; none had perforated appendicitis as the nal
diagnosis.
MRI discriminated perforated appendicitis from simple
appendicitis or no appendicitis with a PPV of 57 (39 to
73) per cent (17 of 30 patients) and a NPV of 86 (77 to
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91) per cent (77 of 90 patients). The sensitivity of MRI in


detecting perforated appendicitis was 57 (39 to 73) per cent
(17 of 30 patients) (Table 2).

Comparison of protocols for diagnosis


of appendiceal perforation
There were no signicant differences in sensitivity,
specicity, PPV and NPV for perforated appendicitis
between MRI and ultrasonography with conditional CT
(Table 2). All missed cases of perforated appendicitis were
identied as simple appendicitis in both imaging protocols.
Both strategies had a low PPV for perforated appendicitis;
more than 30 per cent of positive ndings were falsely
positive.

Diagnostic accuracy for acute appendicitis


(simple or perforated)
Ultrasound imaging with conditional CT had a PPV for
simple or perforated appendicitis of 92 (86 to 96) per cent
(115 of 125 patients) and a NPV of 97 (92 to 99) per cent
(102 of 105 patients). MRI performed equally well, with
an estimated PPV of 94 (88 to 97) per cent (113 of 120
patients) (P = 0505) and a NPV of 96 (90 to 98) per cent
(99 of 103 patients) (P = 0682).
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Table 3

M. M. N. Leeuwenburgh, M. J. Wiezer, B. M. Wiarda, W. H. Bouma, S. S. K. S. Phoa, H. B. A. C. Stockmann et al.

Prevalence and predictive values for perforated appendicitis according to features on MRI
Appendicitis group

Appendiceal diameter > 7 mm


Periappendiceal fat infiltration
Periappendiceal fluid
Absence of intraluminal air
Appendicolith
Destruction of appendiceal wall
Abscess
Extraluminal free air
Restricted diffusion of appendiceal wall
Restricted diffusion of appendiceal lumen
Restricted diffusion of focal collections

Predictive values

No. of patients
(n = 223)

Perforated
(n = 30)

Simple
(n = 87)

No
(n = 106)

PPV (%)

NPV (%)

Diagnostic
odds ratio

210
210
210
210
210
210
223
223
207
207
207

30 of 30
29 of 30
27 of 30
26 of 30
16 of 30
14 of 30
10 of 30
1 of 30
27 of 29
24 of 29
15 of 29

84 of 86
81 of 86
61 of 86
80 of 86
36 of 86
13 of 86
8 of 87
0 of 87
72 of 85
62 of 85
12 of 85

13 of 94
8 of 94
13 of 94
29 of 94
4 of 94
2 of 94
1 of 106
1 of 106
5 of 93
8 of 93
4 of 93

24 (17, 32)
25 (18, 33)
27 (19, 36)
19 (14, 27)
29 (18, 41)
48 (31, 66)
53 (32, 73)
50 (9, 91)
26 (19, 35)
26 (18, 35)
48 (32, 65)

100 (96, 100)


99 (94, 100)
97 (92, 99)
95 (87, 98)
91 (85, 95)
91 (86, 94)
90 (85, 94)
87 (82, 91)
98 (93, 99)
96 (90, 98)
92 (87, 95)

(5, )
30 (4, 222)
13 (4, 44)
4 (1, 13)
4 (2, 9)
10 (4, 23)
10 (4, 28)
7 (0, 109)
18 (4, 77)
7 (3, 20)
11 (4, 26)

Values in parentheses are 95 per cent condence intervals. Data were missing for some features. MRI, magnetic resonance imaging; PPV, positive
predictive value; NPV, negative predictive value.

MRI features associated with perforated acute


appendicitis
Imaging features were available for 210 patients; appendix
features from the diffusion-weighted series were available
for 207 patients (Table 3).
Most of the MRI features known to be associated
with acute appendicitis were recorded in the majority
of patients with perforated and simple appendicitis: an
enlarged appendix (30 of 30 versus 84 of 86; P = 0399),
periappendiceal fat inltration (29 of 30 versus 81 of 86;
P = 0597) and absence of intraluminal air (26 of 30 versus
80 of 86; P = 0285). Findings of periappendiceal uid
(27 of 30 versus 61 of 86; P = 0036), destruction of the
appendiceal wall (14 of 30 versus 13 of 86; P < 0001),
presence of an abscess (10 of 30 versus 8 of 87; P < 0001)
and restricted diffusion of focal uid collections (15 of
29 versus 12 of 85; P < 0001) were more common among
patients with perforated appendicitis than those with simple
appendicitis. Extraluminal air was found in one patient with
perforated appendicitis and in one with acute diverticulitis
with a covered perforation (1 of 30 versus 0 of 87 with
simple appendicitis; P = 0089).
None of the investigated MRI features had a PPV higher
than 53 per cent, although the NPV was high (at least
87 per cent). The combination of an appendicolith and
destruction of the appendiceal wall had the highest PPV:
78 (45 to 94) per cent. The second best combination
was an appendicolith and restricted diffusion of focal uid
collections, with a PPV of 75 (41 to 93) per cent. The
combination of an appendicolith and destruction of the
appendiceal wall was found in only seven of 30 patients
with perforated appendicitis, and both appendicolith
and restricted diffusion of focal uid collections in six
of 29.
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Discussion

MRI was unable to discriminate accurately between simple


and perforated appendicitis. In this respect, it performed
as poorly as ultrasound imaging with conditional CT.
MRI would miss 43 per cent of patients with perforated appendicitis, whereas ultrasonography with conditional CT would miss 52 per cent of such patients.
Although the investigated imaging strategies can adequately detect appendicitis (all missed cases of perforated appendicitis were identied as acute appendicitis
in both imaging protocols), the accuracy of discrimination between simple and perforated appendicitis seems
unacceptably low.
With the prospect of triaging patients with suspected
appendicitis for antibiotic treatment, one would want to
select a group with simple appendicitis1 . In this study,
ultrasound imaging with conditional CT selected a group
of 103 patients with simple appendicitis, of whom 16
had a perforated appendix (NPV 84 per cent). MRI
selected a group of 90 patients with simple appendicitis,
of whom 13 had a perforated appendix (NPV 86
per cent). In the authors opinion, too many patients
with perforated appendicitis were misclassied as having
simple appendicitis. These patients would probably benet
from immediate operation instead of antibiotic treatment
alone. Triage of appendicitis based on imaging for
conservative treatment is inaccurate and may be unsafe.
On the other hand, the high percentage of false-positive
cases of perforated appendicitis (68 per cent PPV for
ultrasound imaging with conditional CT, 57 per cent
PPV for MRI) would also lead to inaccurate treatment
decisions.
Several limitations need to be addressed. The present
study was powered primarily to estimate the sensitivity and
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specicity for acute appendicitis. Because only 31 patients


were diagnosed with perforated appendicitis, differences in
sensitivity could not be estimated with high precision,
which is reected in the relatively wide condence
intervals. Furthermore, no direct comparison could be
made between MRI and CT, because of the selective
use of CT after inconclusive or negative ultrasonography.
However, a similar conditional strategy with CT seemed
more sensitive than single use of CT in patients with
acute abdominal pain18 . In addition, studies11 13 that
reported on sensitivity for perforated appendicitis in a
single CT strategy showed equally poor results for the
discrimination between simple and perforated appendicitis.
The reference standard of appendiceal perforation was
subject to the completeness of observation during surgery,
as well as to the thoroughness of pathological evaluation
of the appendiceal specimens. To achieve the optimal
nal diagnosis regarding perforated acute appendicitis,
the expert panel was provided with all relevant clinical
information, laboratory evaluations, results of ultrasound
imaging and CT, perioperative ndings, histopathology
and follow-up data. A disadvantage of this design is that
imaging results of ultrasonography and CT comprised
part of the information provided to the expert panel; this
may have caused an incorporation bias for the accuracy
of this imaging protocol. In practice, the decision of
the expert panel was based on perioperative ndings and
histopathology in most instances.
The MRI protocol used in the present study did not
comprise a gradient echo sequence. In-phase and opposedphase gradient echo images may help demonstrate perforated appendicitis owing to the characteristic blooming
susceptibility effect that occurs on in-phase images compared with opposed-phase images in the presence of air22 .
However, images from patients with perforated appendicitis rarely demonstrate extraluminal gas. A relative
limitation of the MRI protocol was the lack of intravenous
or oral contrast material; a focal defect in the enhancement
of the appendiceal wall has been associated with perforated appendicitis in CT in previous studies23 . Most of the
MRI features investigated in this study were signicantly
associated with perforated appendicitis, but none had a
sufciently high PPV to be discriminative. Because there
were only 31 patients with appendiceal perforation, the
statistical power was not high enough for development
of a solid multivariable model to predict perforation on
the basis of imaging features. A predictive model based
on a combination of clinical and imaging features may
improve the diagnostic accuracy of imaging in detecting
perforated acute appendicitis. Studies with a larger sample
size than used here are needed for such a model to be

developed. There are none currently available in literature.


Only one published study24 has constructed a regression
model that correlated CT features with the histological
severity of appendicitis; in that study 105 patients had an
appendicectomy.
Clinical and imaging features of perforated appendicitis
have frequently been analysed individually in univariable
analysis. Two retrospective studies13,25 assessed clinical
features in patients who had undergone appendicectomy to differentiate simple from perforated appendicitis.
C-reactive protein level and duration of abdominal pain
were identied as strong predictors of perforated acute
appendicitis in both series. Other studies23,26 29 focused
specically on imaging ndings and the diagnosis of perforated appendicitis. One study29 assessed ultrasonographic
ndings in patients with appendicitis, and found that a
visible appendix, abscess, local free uid and presence of
an appendicolith were associated with perforation. The
use of CT to distinguish perforated from simple appendicitis has been assessed by several investigators in small
retrospective studies of patients with surgically proven
appendicitis: the presence of an abscess, extraluminal air
and an enhancement defect of the appendiceal wall were
found to have a low sensitivity but a high specicity for
perforated appendicitis23,26 28,30 . This corresponds to the
present ndings of the following specic MRI signs having only moderate sensitivity in identifying appendiceal
perforation: abscess, extraluminal free air and destruction
of the appendiceal wall. However, the combination of an
appendicolith with either destruction of the appendiceal
wall or restricted diffusion of focal uid collections indicated a probability of perforated appendicitis of at least
75 per cent. In patients with perforated appendicitis, an
enlarged appendix, periappendiceal inltration and uid,
and absence of intraluminal gas were frequently recorded,
but these signs were also observed in a substantial number
of patients with appendicitis without surgical or pathological ndings of perforation.
Although MRI of the abdomen has been demonstrated
to diagnose appendicitis accurately14 and to differentiate appendicitis from other causes of acute abdominal
pain31 , its reliability in differentiating perforated from simple appendicitis is unsatisfactory. Triage of patients with
appendicitis based on imaging, whether with MRI or ultrasonography with conditional CT, is still far from perfect.

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Published by John Wiley & Sons Ltd

www.bjs.co.uk

Collaborators

Other members of the OPTIMAP study group are:


J. W. C. Gratama (Gelre Hospitals, Apeldoorn), A. P.
J. Houdijk, M. Richir (Medical Centre Alkmaar, Alkmaar),
BJS 2014; 101: e147e155

e154

M. M. N. Leeuwenburgh, M. J. Wiezer, B. M. Wiarda, W. H. Bouma, S. S. K. S. Phoa, H. B. A. C. Stockmann et al.

A. Spilt (Kennemer Gasthuis, Haarlem), H. W. van Es, M.


F. Verhagen (St Antonius Hospital, Nieuwegein), B. C.
Vrouenraets (St Lucas Andreas Hospital, Amsterdam),
L. P. J. Cobben (Haaglanden Medical Centre, The Hague).
Members of expert panel 1: M. J. Wiezer, B. C. Vrouenraets
and H. W. van Es; members of expert panel 2: A. P. J.
Houdijk, H. B. A. C. Stockmann and A. Spilt.

Acknowledgements

The authors thank the Departments of Surgery, Radiology


and Emergency Care in the participating hospitals
for their contribution to this study: Alkmaar Medical
Centre, Alkmaar; St Antonius Hospital, Nieuwegein;
St Lucas Andreas Hospital, Amsterdam; Gelre Hospitals,
Apeldoorn; and Kennemer Gasthuis, Haarlem.
The Dutch Organization for Health Research and
Development, Health Care Efciency Research Programme (Zon Mw, grant no. 171001005) funded the
OPTIMAP study, and B.M.W. received nancial support
for research from Siemens (Erlangen, Germany). Neither
organization was involved in designing and conducting
this study, had access to the data, or was involved in data
analysis or preparation of this manuscript.
Disclosure: The authors declare no other conict of interest.

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Supporting information

Additional supporting information may be found in the online version of this article:
Appendix S1 Structured case record form (Word document)

2013 BJS Society Ltd


Published by John Wiley & Sons Ltd

www.bjs.co.uk

BJS 2014; 101: e147e155