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Voi. ui8, No.

USE OF BARIUM IN THE DIAGNOSIS OF


APPENDICITIS IN CHILDREN*
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By WILLIAM L. SCHEY, M.D.t


CHICAGO, ILLINOIS

PPENDICITIS is one of the most Michael Reese Hospital for the past 2
frequent intnaperi toneal inflammatory years (1970 and 1971) with questionable
processes involving the pediatric popula- findings of in tnapeni toneal inflammatory
tion. Although in many instances the diag- disease were reviewed. The patients had
nosis of appendicitis in children is obvious had at least supine and upright noentgeno-
by simple clinical and laboratory investiga- grams of the abdomen and a barium enema
tion, many cases present with unusual examination in the course of their evalua-
findings and make the diagnosis dificult. flon. The noentgenognams were reviewed
A small proportion of patients are tin- and specific plain film and barium enema
necessarily operated upon because of the findings were documented. The specific
clinical signs; others are operated upon and findings on each patient are listed in
pathologic findings other than appendicitis Table I. The criteria used for the diag-
are uncovered. nosis of appendicitis were derived from
Roentgenognams of the abdomen may past experience with barium enema in
suggest an i ntnapeni toneal abnonmali tv, patients with appendicitis and from the
but most do not specifically demonstrate literature. The criteria used to make the
unequivocal findings of appendicitis. diagnosis of appendicitis were: (i) non-
The barium enema examination may be filling of the appendix with a local impnes-
diagnostic of appendicitis, highly sugges- sion on the cecum; (2) partial filling of the
tive, on diagnostic of other disease processes appendix with a local impression on the
which simulate appendicitis. The study cecum on juxtaposed small bowel; () non-
may also definitely exclude the presence filling of the appendix with other evidence
of appendicitis. of a mass in the pelvis (hazy clouding in the
The purpose of this paper is to: (i) es- right lower quadrant on displaced small
tablish criteria useful in making the diag- bowel loops); and (.) irregular mucosal
nosis of appendicitis b a barium enema pattern of the appendix on a cut-off sign
study; (2) apply those criteria to a number indicating a non-tapered abrupt halt to the
of cases in which a barium enema examina- flow of barium in the appendix. The diag-
tion was used to include on exclude the nosis made by barium enema examination
diagnosis of appendicitis; (,) evaluate was compared to the surgical findings or
some plain film noentgenognaphic findings clinical course.
to test their value relative to the barium Plain film roentgenographic findings were
enema study findings; (4) evaluate the analyzed (as noted in Table i) in an at-

significance of non-filling of the appen- tempt to evaluate the usefulness of the


dix; and () in general, determine whether plain film findings alone and relative to the
barium enema is harmful on useful in cases barium enema findings.
of possible acute appendicitis. The second group of patients (controls)
with non-inflammatory disease receiving
MATERIAL AND METHOD
barium enemas for a variety of reasons

The available records of children re- (abdominal distention, obstipation, occa-


ferred to the X-Ray Department at sional diarrhea, bellyache, etc.) were

* Presented at the Fifteenth Annual Meeting of the Society for Pediatric Radiology, Washington, D.C., October u-I, 1972.

tDirector, Pediatric Radiology, Michael Reese Hospital, Chicago, Illinois; Assistant Professor, Pritzker 5chool of Medicine, Uni-
versity of Chicago, Chicago, Illinois.

95
96 William L. Schev MAY, u97

TABLE I
CASES i-6

Case I 2 3 4 S 6
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Age 8 yr. 3 yr. 5 yr. 8 yr. 8 yr. u yr.


Sex F F F M F F
Admitting Diagnosis! Belly pain, Abdominal pain, Fever, abdomi- Possible appendi- Possible appendi- Appendicitis
Comment ? appendicitis bleeding perannun nal pain, ? pal- citis citis
pable mass

Plain Film Reenigeno-


graphic Findings
Ascending Colon Fluid Levels - + + + + - + + -

Adynamic Ileus + + + + +
5coliosis - - - - + -

Calcifications - - + - - -

Mass - - - - - -

Barium Enema Sludy


Appendix Filled + + + + + +
IrregularMucosa ++ - -

Regular Mucosa - + + +
Mas, + ++ + -

Cut-OffSign - ++ -

Didnt Fill + +
Buttock Sign + -

Mass Large - -

Mass Small -

Ileum
Filled + + + + + +
DidntFill - - - - - -

Pressure Upon It? - - + - + -

Disposition Not operated: Operated: normal Operated:twisted Xot operated: Operated: appen- Not operated:
antibiotics for 3 appendix; later ovarian cyst-der- appendicitis; dicitis with gan- probable corpus
days; discharged diagnosis ulcer- moid home without grenous base luteum cyst
ative colitis antibiotics

CASES 7-12

Case 7 8 9 so ii 12

Age 9 yr. 3 yr. 4 yr. 2 yr. 53 yr. 57 yr.


Sex M M M F F M
Admitting Diagnosis/ Nephrotic with Possible appendi- Probable adenitis Pneumonia with ? Appendicitis Diabetic in keto-
Comment fever and abdom- citis with pharyngitis abdominal pain acidosis with ab-
inal pain dominal pain

Plain Film Roenigeno-


graphic Findings
Ascending Colon Fluid Levels + + + + + - + +
Adynainicileus + - + ++ + ++
Scoliosis - - - - - -

Calcifications - - - ? appendicolith - -

Mass - - - - - -

Barium Enema Study


Appendix Filled +
Irregular Mucosa -

Regular Mucosa + +
Mass -

Cut-Off Sign -

Didnt Fill ++ ++ ++ + ++
ButtockSign - - - -

MassLarge ? +++ -

Mass Small + - +++


Ileum
Filled + + + + + +
DidntFill - - - - -

PressureUponlt? - + - + - -

Disposition Not operated: Operated: appen- Operated: ap- Operated: ovar- Not operated: Operated: inter-
antibiotics for diceal abscess pendicitis Ian dermoid home in 3 days val appendec-
peritonitis; home, tomy; localized
well appendiceal ab-
scess
VoL. uu8, No. u Diagnosis of Appendicitis in Children 97

TABLE I-(Continued)

CASES 13-18

Case 53 14 15 i6 17 u8
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Age 4 yr. 57 yr. 14 yr. 53 yr. z6 yr. 2 yr.


5ex F M F M F F
Admitting Diagnosis! Hyperthyroidism Hemophiliac with Appendicitis Probable appen- Probable appen- Fever; rectal
Comment with crampy ab- abdominal pain dicitis dicitis mass by palpa-
dominal pain tion

Plain Film Roenigeno-


graphic Findings
Ascending Colon Fluid Levels + + + + - - -
Adynamic Ileus + + + + +
Scoliosis - - + - - -

Calcifications - - - - - -

Mass - ? ?+ - - +!-?

Batium Enema Study


Appendix Filled + + +
Irregular Mucosa + - -

Regular Mucosa - - +
Mass + - -

Cut-Off5ign + + -

Didnt Fill + + - -

Buttock Sign - - + -

Mass Large - - - +
MassSmall ++ - - -

Ileum
Filled + + + + + +
Didnt Fill - - - - - -

Pressure Upon It? - + (and abnormal - - + +


mucosa)

Disposition Operated: acute Operated: ileitis Operated: acute Observed 24 Operated: twisted Operated: acute
and subacute ap- and appendicitis appendicitis hours. home ovarian cyst appendix with
pendicitis abscess

CASES 19-25

Case xc 20 21 22 23 24 25

Age 52 yr. 12 yr. 8 mo. 8 yr. g yr. 8 yr. 4 yr.


Sex F F F F M F M
Admitting Diagnosis! Appendicitis Gastroenteri- Rectal bleed- Likely appen- Sickle cell dis- Possible early Abdominal
Comment vs. gastroen- tis with pos- ing, abdom- dicitis ease with appendicitis pain
teritis sible pelvic in- inal pain ? appendicitis
flammatory
disease

Plain Film Roentgeno-


graphic Findings
Ascending Colon Fluid Levels - - - - - + +
Adynamic Ileus + + + - - + - + +
Scoliosis + - - + + + -

Calcifications - - - - - - +
Mass - ? pelvic mass - - - - 1 -

Barium Enema Study


Appendix Filled + + + + +
Irregular Mucosa + + - +1 (? stool) + - (? stool) -

RegularMucosa - + - - +
Mass - - - - -

Cut-Off Sign -

Didnt Fill + +
Buttock Sign - -

Mass Large - +
MassSmall - -

fleum
Filled + + + + +
Didnt Fill - - + + - - -

Pressure Upon It? - - - - - - -


Disposition Not operated: Operated: Home in 24 Home in 24 No antibiot- Home in 24 Operated: ap.
placed on an- acute appen- hours; no di- hours; no ics; home in hours pendiceal ab-
tibiotics for 3 diCitis agnosis; no treatment 3 days areas
days; home treatment
98 \\illiarn L. Sciev \l.v, i7

1ABLE II pression on tile cecum, hut the appendix


NON-AIIENDICITIS GROUP filled. The diagnosis of inflammatory mass,
otilen tilan ;tppelldici tis or appendiceal
Age lilled Not lilled al)scess was made. The suggested diagnosis
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was twisted ovarian cyst. Ibis diagnosis


Newhorn-3 mu. 7 o
was confirmed by surgical exploration.

1110.-I yr. 6 0
One patient was diagnosed as non_ap-
pendiceal inflammatory disease, most likely
I vr.-2 yr. 6 1 pelvi c i llfl am m atorv di sease. Roen tgeno-
grams demonstrated 11011-filling of tile ap-
2 vr.-5 yr. 7 0
pendix, 1)Ut l1() masses, impressions, or
5 yr-b yr. 11 2 otller evidence of appendicitis. An i 8
cm. long appendix witFi :111 illflamed tip
10 yr. 9 I was found surgically.
lilerefore, of 25 cases, 2 1 (84 per cent)
Total 46
4 were diagnosed correct1 as either ap-
pendicitis or 110 appendicitis. Of tile re-
also evaluated. Special efforts to fill the maining 4, 2 may llave been appendicitis,
appendix in these children were made. Tile but were managed by antibiotics, I had
ages of the patients are indicated in Table definite surgical disease (a mass) proven
ii, as are tile results. by barium enema study and ill only i case
was the barium enema examination not
RESU LIS
llelpful in adding more information.
PATIENTS IN WHOM A BARIUM ENEMA Of tile control group 50 cases were
EXAMINATION WAS PERFORMED
evaluated. Non-filling of the appendix oc-
Of 24 children with undiagnosed but curred 8 per cent of tile time. Age did not
suspected intrapenitoneal inflammatory dis- seem to be a collSideratioll relative to the
ease the correct diagnosis of appendicitis ease with wilich the appelldix filled.
was made preopenativelv, by virtue of the
PLAIN FlINt ROENTGENOGRAIHIC FINDINGS
barium enema examination, in 9.
The incorrect diagnosis of appendicitis Of the 9 patients with proven appendici-
was made in I patient who had a twisted
ovarian dermoid, which was inflamed. The
appendix did not fill and a lange mass
impression on the cecum was evident.
In ii cases the barium enema examina-
tion demonstrated filling of the appendix,
no mass, no unusual impressions or sep-
aration of small bowel juxtaposed to the
cecum and appendix. These patients were
followed as non-appendicitis patients, were
treated conservatively, and did well.
Two patients were believed to have ap-
pendicitis by barium enema study findings.
Surgical consultants disagreed and they
were treated with antibiotics. Their symp-
toms disappeared in 3 to 4 days and they
were discharged. 11G. I. A cecal tip impression (arrow) and non-filling
One patient demonstrated a mass im- of the appendix.
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100 William L. Schey MA\, 1973

bowel loops), make the diagnosis likely


(Fig. 3).
Partial filling with and without a mass.
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Partial filling may be suspected if a very


short appendix is found. .Any distortion in
shape or caliber of the partiall filled ap-
pendix, with or without a cecal impression,
should be considered abnormal (Fig. 4).
li-regular ft//ing or cut-off sign. Irregular
filling of the appendix suggests mucosal
edema, and acute on chronic appendicitis34
(Fig. 5). A normal appendix should fill
and have a smooth mucosa (Fig. 6).
Marked distortions are obviously patho-
H
logic, but minor changes cannot establish
conclusively the diagnosis of appendicitis.
11G. . Non-filling of the appendix with the associa-
An abrupt obstruction to the flow of
tiotl of a mass impression on the distal ileum
(arrows). barium in the appendix (especially if the
viscus appears short) is strong suggestive
dicitis (Fig. i). This has been noted by evidence of appendicitis.
others,26 who have suggested that edema Although others have called attention to
from inflammation creates the impression. the position of the appendix as a guide to
\Ve were misled once by this combination possible inflammatory disease, we do not
of findings in a patient with an inflamed consider position important.
ovarian denmoid. A schematic representation of the possi-
1Von-fihling of the appendix with and with-
out associatedfindings. In the series of pa-
tients with no clinical evidence of appen-
dicitis (controls) the appendix failed to
visualize on 4 occasions (8 pen cent). There-
fore, one may expect the appendix not to
fill on occasion in a normal patient. This
is especially true if the appendix is netro-
cecal. In patients with a netrocecal ap-

pendix a smooth double convex contour of


the cecum (buttock sign) ma be evi-
dent (Fig. 2,zl and B).We have found the
appendix more difficult to fill in these in-
stances. Delayed noentgenograms (up to 6
hours after tile initial study) and spot
filming on the postevacuation studies are
essential prior to establishing a no-fill
situation. If the appendix does not fill it
must be considered highly suspicious, but
not diagnostic. Associated findings with
FIG. 4. Partial filling of the appendix. The proximal
non-filling, such as a hazy density in the appendix is dilated and the barium column ends
right lower quadrant on other evidence of abruptly (large arrow). An associated mass effect
a mass (displaced on compressed juxtaposed is noted on the distal ileum (small arrows).
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102 William L. Schev MAY, 197.3

I
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NOPI4AL RETROCECAL APPENDIX - FILLING OF THE


BUTTOCK SIGN APPENDIX WITH LGE. MASS

NON-FILLING PLUS A NON-FILLING PLUS A - NONFILLING WITH


CECAL DEFECT MASS EFFECT ASSOCIATED FINDINGS
_________________________ (HAZY DENSITY , RLQ)
-2-2::- --#{149} ___

NQN-FILLINGWITHOUT -_ - - MAFECT PLUS _

110. T. A schematic representation of the appearance of the appendix, terminal ileum, and cecum in the
normal and abnormal conditions considered. LGE=large; RLQ=right lower quadrant.
Vot. uu8, No. I Diagnosis of Appendicitis in Children 103

nephrosis, diabetes, hypenthvroidism, he- The barium enema examination is a


mophilia and sickle cell disease. The possi- harmless procedure in patients with acute
bility of appendicitis in these patients was appendicitis and its use is urged.
accunatel determined by virtue of the
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Pediatric Radiology
barium enema examination. 1\Iichael Reese Hospital
Although suggestions of possible con- and Medical Center
tnaindications to the use of the barium 29th Street and Ellis Avenue
enema study have been noted,2 we know Chicago, Illinois 6o6i6
of no complications as we applied it.
RE FERENCES
CONCLUSIONS AND SUMMARY
1. BECK, W. S., and WINTER, 1. Acute appendicitis
The use of the barium enema examina- and retained barium. Gut/irie C/in. Ru/i., 1964,
33, I0-I07.
tion to define the presence on absence of
2. lIGIEL, I. S., and 1IGIEL, S. J. Barium examina-
appendiceal disease has proven to be of
tion ofcecum in appendicitis. 4cta radio/., 1962,
significant value. This evaluation in a 57, 469479.
series of patients with appendicitis and in 3. KUZNETSON, A., P0DOINY, 1., and BRATUS, I. I.
a group of patients without appendicitis Roentgen diagnosis of chronic appendicitis.
conclusively demonstrates the excellent Vrach. (/t/O., Kiev., 1971, 12, 54-56.
results obtained. 4. 1,ASSRICH, M. A. Radiological examination in
chronic appendicitis in children. 4nn. radio/.,
Findings in tile barium enema study of
1964, 7, ,95399.
(I) non-filling of the appendix, plus a mass, . RULPS, D. M., and 1ISHER, R. G. Radiographic
(2) non-filling of the appendix with asso- findings in acute appendicitis. Texas Med.,
ciated findings, () partial filling with and 1971, 67, 89-9.
without a mass, and (4) irregular filling on 6. SOTER, C. Use of barium in diagnosis of acute
a cut-off sign are strongly suggestive, if appendiceal disease: new radiological sign.
C/in. Radio/., 1968, i, 410-415.
not diagnostic, of acute appendicitis.
7. SOTER, C., and MALMED, L. A. Contribution of
Non-filling of the appendix occurs about radiologist in diagnosis of acute appendicitis.
8 pen cent of the time and should be consid- Northwest Community Hosp. Med. Ru/i., 1968,
ered suspicious of an appendiceal problem. 5, 35-360.
Plain film noen tgenographic findings, 8. TEGTMEVER, C. J., THISTLETHWAITE, J. R., and
other than an appendicolith or gas within SNEED, T. 1. Roentgen findings in acute appen-
dicitis. Med. ilnn., 1969, 38, 127-130.
the appendix, are inconclusive and cannot
9. \VILKINSON, R. H., BARTLETF, R. H., anti
indicate the nature of the problem in as ERAKLIS, A. J. I)iagnosis of appendicitis in
specific a manner as the barium enema infancy. A.M.A. Am. 7. Dis. Child., 1969, zz8,
examination. 687-690.