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Appendicitis Mimics, Thompson et al.

Mimickers of Acute Appendicitis

Joel P. Thompson, M.D., MPH, Dhana Selvaraj, M.D., Refky Nicola, D.O.
Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY

Introduction of patients.2,3 The presence of intravenous and enteric


contrast aids in identification of the appendix.3
Acute abdominal pain is the most common reason
The appendix arises from the cecum inferior to the
for an emergency department visit among patients age
ileocecal junction (Fig. 1). MDCT signs of acute
15 and older, a large portion of them will complain of
appendicitis include appendiceal diameter > 7 mm
pain localizing to the right lower quadrant.1 While
with peri-appendiceal stranding of the mesenteric fat
appendicitis is the most common cause of the surgical
(Fig. 2A).4 Both findings are present in up to 93% of
abdomen, a wide variety of acute gastrointestinal,
appendicitis cases identified on MDCT.5 The diagnosis
genitourinary, and gynecological pathologic processes
of appendicitis should not be made using appendiceal
can present in similar fashion (Table 1). Acute
diameter alone; wall thickening and increased
gastrointestinal diseases, such as Crohns disease,
enhancement should also be present.6 Additional
infectious enterocolitis, mesenteric adenitis, cecal
findings include the presence of an appendicolith,
diverticulitis, Meckels diverticulitis, epiploic
cecal apical thickening (arrowhead sign), mesenteric
appendagitis, and omental infarcts can present with
adenopathy, fluid in the paracolic gutter, and the
right lower quadrant. In addition, acute genitourinary
presence of phlegmon.5 A focal wall defect,
diseases, such as pyelonephritis and ureterolithiasis,
extraluminal air, or presence of an abscess are signs of
can present with similar symptoms. In a young
perforation.5 While MDCT is currently the preferred
woman, acute gynecological disease processes, such as
imaging modality, in the pediatric and pregnant
ovarian torsion, hemorrhagic ovarian cyst, pelvic
patient ultrasound as well as MRI has been shown to
inflammatory disease, and ectopic pregnancy, should
perform comparable to CT.7
also be considered within the differential diagnosis.
Ultrasound has a sensitivity and specificity of 78%
Imaging modalities utilized in the emergency setting
and 83%, respectively.8 The most common findings in
to evaluate right lower quadrant pain include
appendicitis are diameter > 6 mm, lack of
computed tomography (CT), ultrasound (US), and
compressibility, hyperemia of the appendiceal wall on
magnetic resonance imaging (MRI). These modalities
Doppler imaging, peri-appendiceal inflammatory
may be value-added for patients with nonspecific
changes, and the presence of peritoneal fluid (Fig.
symptoms, thus it is useful to triage surgical and non-
2B). Occasionally, a calcified appendicolith may be
surgical patients. It is important for the practicing
seen with posterior shadowing (Fig. 2C). However,
radiologist to be familiar with the various acute
ruling out appendiceal pathology is often difficult with
disease entities which can cause right lower quadrant
US if the appendix cannot be visualized. One study
pain in order to determine the best approach or
reported positive ultrasound findings for appendicitis
modality to make an accurate diagnosis.
in about 20% of cases, but equivocal findings in almost
50% of cases (i.e. inability to identify the appendix).7
Imaging of the appendix Evaluation of the right lower quadrant is particularly
difficult in pregnant women due to distorted
The most common imaging modality for the abdominal and pelvic anatomy (particularly in the third
evaluation of the right lower quadrant pain is MDCT. trimester). MRI has been shown to be superior at
MDCT has a sensitivity of 97%, specificity of 98%, and localizing the appendix in comparison to ultrasound,
accuracy of 98% in diagnosing acute appendicitis, with with a sensitivity and specificity of up to 89% and
the additional benefit of suggesting an alternative 99%.8,9
diagnosis for acute abdominal pain in up to two-thirds

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Appendicitis Mimics, Thompson et al.

Pathology Imaging Appearance Treatment


Gastrointestinal
Crohns Disease Bowel wall thickening and mural stratification, most commonly involving Initially medical. Indications for surgery
the terminal ileum. Chronic inflammation may result in fibrofatty include obstruction due to fibrotic stricture,
proliferation along the mesenteric side of the bowel wall. Fistulas and perforation, abscess formation, and fistulas
abscesses may form. not able to be managed medically.

Diverticulitis Thick-walled diverticulum with adjacent infiltrative changes; short or long Medical. Surgical intervention may be
-segment bowel wall thickening. Abscesses may form. necessary for medically refractory cases,
large abscesses, and fistula formation.

Infectious Long-segment circumferential wall thickening, usually without Medical.


Enterocolitis mesenteric fat stranding.

Mesenteric Adenitis Cluster of 3 or more right lower quadrant lymph nodes >5 mm in shortest Medical.
diameter, without identifiable cause.

Neutropenic Colitis Distended and thick-walled cecum, infiltrative changes, pericolic fluid. Medical. High risk of bowel perforation; CT
(Typhlitis) may be used to monitor treatment response.

Meckels Blind-ending tubular structure in the right lower quadrant arising from Surgical resection.
Diverticulitis the distal ileum; infiltrative changes, wall thickening, and
hyperenhancement may be seen.

Epiploic Appendagitis Pericolic fatty mass with surrounding inflammatory changes, most Medical.
commonly in the transverse and descending colon. A central thrombosed
vein may be identified.

Omental Infarct Pericolic fatty mass with surrounding inflammatory changes, most Medical.
commonly in the right hemiabdomen between the colon and the anterior
abdominal wall.

Genitourinary/Gynecological
Urolithiasis Obstructing calculus with hydronephrosis +/- hydroureter. Medical, unless calculus large.

Pyelonephritis Imaging most often normal. May see striated nephrogram or delayed Medical.
contrast excretion on CT. US may show loss of corticomedullary
differentiation.

Ovarian Torsion US: Enlarged and heterogeneous ovary; may be midline. May see Surgical detorsion.
reduced or absent venous flow.

Hemorrhagic Ovarian US: Finely septated fishnet pattern of fibrin bands; retractile clot or None.
Cyst avascular peripheral nodule non-acutely.

Pelvic Inflammatory Dilated tubular structures representing Fallopian tubes with wall Medical.
Disease thickening. Ipsilateral ovary may be enlarged.

Ectopic Pregnancy Non-visualization of an intrauterine pregnancy with positive beta-hCG. Medical but may require surgical
US: May see yolk sac, detect fetal heartbeat, or see ring of fire sign of intervention.
peripheral hypervascularity around adnexal mass.

Mittelschmerz Normal. May see physiologic fluid in the pelvis. None.

Table 1. Overview of gastrointestinal and genitourinary causes of right lower quadrant pain.

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Appendicitis Mimics, Thompson et al.

Figure 1. Normal appendix.


Coronal MDCT with IV and enteric contrast (A)
demonstrates a normal appendix (white arrow) arising
from the cecum inferior to the ileocecal junction
(yellow arrow). Longitudinal ultrasound image (B)
shows a normal appearance of a blind-ending
appendix, which measures 4 mm in diameter (caliper
2).

A B

A B C
Figure 2. Acute Appendicitis.
Axial MDCT image with oral contrast (A) demonstrates an enlarged appendix, measuring up to 14 mm in diameter (white arrow), wall
thickening, and adjacent inflammatory changes with phlegmon formation (yellow arrow). Surgical pathology demonstrated appendicitis.
Longitudinal ultrasound images in a different patient (B) demonstrate an enlarged appendix, measuring up to 10 mm, that is
noncompressible, consistent with appendicitis. Ultrasound image at a different level in the same patient demonstrates a hyperechoic focus
with posterior shadowing, consistent with an appendicolith (C).

On MRI, the appearance of acute appendicitis Differential Diagnosis


includes an appendiceal diameter > 7 mm and
adjacent fat stranding that is often best appreciated Crohn's Disease
on T2 fat saturated sequences.10 An inflamed Crohn's disease can involve any segment of the
appendix demonstrates restricted diffusion.10 The gastrointestinal tract, but the most common location is
appendix may be filled with high T2 fluid or edema, within the terminal ileum. Patients often present with
which decreases in signal intensity if the fluid is abdominal cramps localized within right lower
purulent (higher debris and protein quadrant and bloody stools. The initial presentation
content). Appendicoliths are low in T1 and T2 signal typically occurs between 15 and 30 years of age.
intensity, with blooming artifact on GRE images. A The imaging features of Crohn's disease consist of
periappendiceal abscess is identified as a walled-off bowel wall thickening (greater than 4 mm), mural
high T2 fluid collection with restricted diffusion. An stratification ("target" or stratified appearance of the
appendix filled with high T2 fluid and diameter of 6-7 bowel wall due to submucosal edema), and abnormal
mm is indeterminate (if no adjacent fat stranding of enhancement (Fig. 3).11 Active inflammation leads to
fluid) and should be closely followed up.10 engorgement of vasa recta (the "comb sign"). Chronic
inflammation results in fibrofatty proliferation along
the mesenteric side of the bowel wall, creating the
"creeping fat" sign.12 Over time, the chronic

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Appendicitis Mimics, Thompson et al.

Figure 3. Crohns disease.


11-year-old boy with acute
abdominal pain and history
of Crohn's disease. Oblique
axial MDCT enterography
image (A) demonstrates
signs of active
inflammation in the
terminal ileum (white
arrow), including mucosal
hyperenhancement, wall
thickening, and adjacent
inflammatory changes. The
appendix is normal (yellow A B
arrow). MR enterography
in the same patient 2 years later (B) demonstrates wall thickening and fibrosis without adjacent inflammatory changes, consistent with
sequela of multiple prior Crohn's flares.

inflammatory process of Crohn's disease can result Mesenteric Adenitis


intramural or interloop abscesses. Fistulous Mesenteric adenitis, or right lower quadrant
anastomosis with the bowel, bladder, skin, and vagina lymphadenopathy, is defined as a cluster of 3 or more
can occur. This is best evaluated by MDCT or MRI lymph nodes greater than 5 mm in shortest diameter
enterography, which utilize IV contrast during the late in the right lower quadrant mesentery (Fig. 4).15
arterial phase and low density oral contrast to Primary mesenteric adenitis is thought to be due to an
facilitate evaluation of the small bowel mucosa.13 underlying ileitis. Secondary mesenteric adenitis has
Bowel wall thickening (>3mm) and stratification, an identifiable cause on MDCT, such as appendicitis or
mucosal hyperenhancement, inflammatory changes in Crohn's disease. Patients present with abdominal
adjacent mesenteric fat, and engorged vasa recta pain, fever, and leukocytosis. This is an uncommon
("comb sign") are all findings on enterography diagnosis, but may be considered in patients whose
consistent with active inflammation.13 The initial only imaging abnormality is focal mesenteric
management of Crohns disease is non-surgical. lymphadenopathy.
However, surgery may be necessary if fistulas or
stricture formation develop.

Infectious Enterocolitis
Infectious enterocolitis can present clinically similar
to appendicitis, particularly if caused by pathogens
such as Yersinia, Campylobacter, or Salmonella, which
may cause ileocecitis.12,14 The imaging findings on
MDCT involve a long-segment circumferential wall
thickening with homogenous enhancement, usually
without stranding of the adjacent fat. In addition,
mesenteric adenopathy and surrounding free fluid
may be present.

Figure 4. Mesenteric adenitis.


Coronal MDCT with oral contrast shows a cluster of right
lower quadrant mesenteric lymph nodes greater than 5 mm
in shortest diameter without identifiable cause (circled),
consistent with mesenteric adenitis. The appendix was
normal (white arrow).

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Appendicitis Mimics, Thompson et al.

Neutropenic Colitis (Typhlitis) and sigmoid colon, diverticula may also form along the
Neutropenic colitis has a similar presentation of ascending colon and present with right-sided
acute appendicitis, but occurs particularly in abdominal pain. Diverticulitis is thought to be caused
immunosuppressed patients with leukemia, post- by microperforation of a diverticulum.
transplantation status, or acquired immunodeficiency.
Mucosal damage secondary to both infection and
ischemia is typically confined to the cecum and
ascending colon.16 A prompt diagnosis is necessary
due to the high risk of perforation. MDCT findings
includes a distended cecum with circumferential wall
thickening, peri-colonic infiltration, and peri-colic fluid
(Fig. 5).6,16,17 Pneumatosis can also be present.6
Treatment includes bowel rest and antibiotics. MDCT
is used to follow the progression of therapy, as
evidenced by the improvement in the thickening of
cecal wall.6 The extent of cecal wall thickening into
the ascending colon as well as the patients history
helps to differentiate neutropenic colitis from cecal Figure 6. Diverticulitis.
wall thickening associated with appendicitis. 83-year-old woman with acute leukocytosis and right lower
quadrant abdominal pain. Axial MDCT image with oral
contrast shows diverticular wall thickening with infiltration
of the adjacent fat (white arrow) in the ascending colon just
above the cecum, consistent with acute diverticulitis.

On MDCT, diverticulitis is associated with wall


thickening of the colon with infiltration of the adjacent
mesenteric fat (Fig. 6).6 The vasa recta is engorged
due to inflammation. Complications of acute
diverticulitis include colonic perforation and abscess
formation. Long-standing diverticulitis can result in
colovesical or colovaginal fistula formation. Treatment
of acute diverticulitis includes bowel rest and
antibiotics; complicated diverticulitis requires drain
placement or partial colectomy. It can be difficult to
Figure 5. Neutropenic colitis/Typhlitis. exclude an underlying neoplasm in the setting of acute
57-year-old man with acute myeloid leukemia, neutropenia, diverticulitis. However, signs concerning for
right lower quadrant pain, and persistent fever. Axial MDCT malignancy include a short-segment of involved colon
image with oral contrast demonstrates cecal wall thickening (< 10 cm), colonic mass with overhanging shoulders,
(white arrow) with surrounding inflammatory changes,
consistent with typhlitis. The appendix was normal (yellow and peri-colic lymphadenopathy.6,18 Colonoscopy is
arrow). recommended as a follow-up examination once the
patient's symptoms subside to exclude an underlying
Diverticulitis neoplasm.6 CT colonoscopy can be performed;
Diverticulitis is a common cause of abdominal pain, however, the discussion of CT colonoscopy is beyond
particularly in patients over 40 years of age. the scope of this review article.
Diverticula form in the weakest portion of the colonic
wall where vasa recta, the nutrient arteries, penetrate
and extend into the submucosal layer. While
diverticulitis most commonly involves the descending

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Figure 7. Meckels diverticulitis.


16-year-old girl with right lower quadrant
abdominal pain and small amount of free
fluid on pelvic ultrasound. Axial MDCT
image with IV contrast (A) demonstrates a
blind-ending tubular structure arising from
the distal ileum with adjacent inflammatory
changes (white arrow). Superiorly (B), the
appendix (white arrow) was mildly dilated
to 8 mm with wall thickening, but with
minimal adjacent inflammatory changes.
Surgical pathology demonstrated an
inflamed Meckels diverticulum and a
normal appendix (apparent wall thickening
A B may have been due to reactive changes
from the Meckels diverticulitis).

Meckels Diverticulitis epiploic appendages increase from the cecum to the


Meckel's diverticulum is a congenital anomaly due sigmoid colon, epiploic appendagitis usually results in
to the persistence of the omphalomesenteric left-sided abdominal pain. However, epiploic
(vitelline) duct, which connects the yolk sac to the appendagitis can occur in the ascending colon and
midgut lumen in the developing fetus. Meckel's even the cecum. On ultrasound, epiploic appendagitis
diverticula are located 60-100 cm from the ileocecal is seen as a hyperechoic mass with a hypoechoic rim
valve, typically in the right lower quadrant or lower deep to the abdominal wall.22 The MDCT findings
central abdomen.19 Inflammation occurs due to include a peri-colic fatty mass with surrounding
mucosal ulceration from ectopic gastric mucosa or due infiltrative changes; a high-attenuation central dot may
to luminal obstruction by an enterolith.12 Meckel's be seen, which represents a thrombosed vein (Fig.
diverticulum may also act as a lead point for 8).14 Treatment is usually supportive with anti-
intussusception. Meckel's diverticulum are identified inflammatory agents.
on MDCT as a blind-ending tubular structure arising
from the anti-mesenteric side of the distal ileum.20
Wall thickening, hyperenhancement, and adjacent
mesenteric fat stranding suggest active inflammation
(Fig. 7). A Meckel's diverticulum can also be identified
using radionuclide scanning with 99mTc-pertechnetate;
however, sensitivity and specificity are lower in adults
patients when compared to children due to the
decreased prevalence of ectopic gastric mucosa.21
Management is surgical resection.

Epiploic Appendagitis
Epiploic appendages are small fat protrusions
arising from the serosal surface of the colon; these are
not usually identifiable on cross sectional imaging. Figure 8. Epiploic appendagitis.
Torsion of an epiploic appendix causes vascular 63-year-old man with a history of diverticulitis presents with
occlusion, ischemia, and acute onset abdominal pain. right-sided abdominal pain that is worse with movement
and deep breathing; no leukocytosis. Axial MDCT image
An inflammatory process within the abdomen can also demonstrates a focus of inflammatory changes just superior
extend to the epiploic appendages, causing secondary to the transverse colon with a high attenuation central dot
epiploic appendagitis. Since the number and size of (white arrow), consistent with epiploic appendagitis.

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Appendicitis Mimics, Thompson et al.

Omental Infarction Acute Genitourinary Diseases


In contrast to epiploic appendagitis, omental
Urolithiasis
infarction is most commonly a right-sided entity,
perhaps due to longer length and mobility of the Urolithiasis may present with right lower quadrant
omentum in the right hemiabdomen compared to the pain, particularly if an obstructing calculus is present in
left.17,23 Omental infarction is caused by torsion or the right ureterovesicular junction. Ultrasound
vascular thrombosis secondary to postoperative evaluation of the abdomen may demonstrate
omental adhesions, trauma, or increased intra- hydroureter, which can be differentiated from bowel
abdominal pressure (coughing, obesity, strenuous due to the lack of bowel signature (alternating
exercise).23 The most common presenting symptom is hyperechoic and hypoechoic tissue layers) (Fig. 10). If
acute-onset abdominal pain. MDCT imaging findings the bladder is distended, the obstructing calculus may
vary from an ill-defined, heterogeneous fat- be visualized as an echogenic focus in the region of the
attenuation lesion to a well-defined heterogeneous ureterovesicular junction. Identification is improved by
fatty mass, classically located between the anterior creation of the twinkle artifact on Doppler images,
abdominal wall and ascending or transverse colon (Fig. which is rapidly changing red and blue colors behind
9).12,23 Omental infarction may be differentiated from the calcification due to "phase jitter" within the
epiploic appendagitis by location (between the colon machine.24
and anterior abdominal wall), larger size (often greater CT images demonstrate a high attenuation calculus
than 5 cm in diameter), absence of a peripheral rim, within the ureter, with or without proximal ureteral
and absence of a central dot sign.17,23 Management is dilatation. Ureteral wall thickening and adjacent fat
typically supportive; complications are rare. stranding may be present. Pelvic phleboliths may
simulate distal ureteral calculi. If the ureter cannot be
followed in its entirety and the calcification is
indeterminate, the presence of a soft tissue rim ("rim
sign" due to inflamed ureteral walls) and the absence
of a soft tissue tail ("tail sign" due to thrombosed vein
leading into the calcification) may help characterize
urolithiasis.25,26 Treatment for ureteral calculi less
than 4 mm in diameter is supportive.

Pyelonephritis
Pyelonephritis is most commonly associated with an
ascending genitourinary tract infection and is a clinical
diagnosis; often times, the sonographic and MDCT
findings are normal.27 However, imaging is useful in
excluding complications, such as abscess formation,
emphysematous pyelonephritis (typically in diabetics
and immunocompromised patients), or
Figure 9. Omental infarct. xanthogranulomatous pyelonephritis. Findings of
72-year-old man presents with 3 days of right lower
pyelonephritis on CT include nephromegaly due to
quadrant pain. Axial MDCT demonstrates infiltrative
changes with central fat density between the cecum and the edema, a striated or delayed nephrogram, perinephric
anterior abdominal wall (white arrow), consistent with the fat stranding, and wall-thickening and enhancement of
appearance of omental infarct. The appendix was normal. the renal collecting system (Fig. 11).28 Delayed
appearance of the calices may also be seen; however,
since pyelonephritis is often bilateral, comparison
between the two kidneys may not be helpful.

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Figure 10. Nephrolithiasis.


43-year-old man with right groin
pain and history of renal calculi.
Axial unenhanced MDCT image (A)
demonstrates a 4 mm calculus at
the right ureterovesicle junction
(white arrow). Axial CT image above
the level of the bladder (B)
demonstrates a normal appendix
(yellow arrow).

A B

Figure 12. Ovarian torsion.


22-year-old woman with right lower quadrant pain.
Figure 11. Pyelonephritis.
Transabdominal ultrasound image with power Doppler
35-year-old woman with right flank and abdominal pain.
shows an enlarged right ovary with a large simple cyst (long
Axial MDCT with IV contrast demonstrates a striated
white arrow), echogenic stroma (long black arrow), a few
appearance of the right kidney, an appearance consistent
peripherally displaced follicles (short white arrows), and
with pyelonephritis or glomerulonephritis. Patient history
decreased blood flow within the ovary. Diagnosis of ovarian
was indicative of pyelonephritis and she was treated with
torsion was made based on the above findings and
antibiotics.
confirmed at surgery; the patient underwent right salpingo-
oophorectomy.
Ultrasound may show nephromegaly and loss of renal
sinus fat due to inflammation, as well as loss of the pathologies include ovarian torsion, hemorrhagic
corticomedullary junction. The kidneys may be ovarian cyst, pelvic inflammatory disease, ectopic
abnormally hyperechoic or hypoechoic. In the pregnancy, and Mittelschmerz. Ultrasound, preferably
absence of complications, treatment includes transvaginal, is the preferred initial imaging evaluation
antibiotics and supportive measures. in these cases.

Gynecologic Diseases Ovarian Torsion


Gynecologic emergencies, especially those affecting Ovarian torsion results from twisting of the ovary on
the right adnexa, are important in the differential its supporting ligaments. Patients are usually in the
diagnosis of acute appendicitis in young women. reproductive age group and present with acute onset
Screening the right ovary is routinely performed along lower abdominal pain on the side of the ovary
with ultrasound evaluation of the appendix in involved. Torsion usually occurs in the presence of
pediatric patients. Commonly encountered underlying pathology, such as enlarged ovaries from

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Appendicitis Mimics, Thompson et al.

A B C
Figure 13. Hemorrhagic cyst.
28-year-old woman with acute right lower quadrant and pelvic pain. Transvaginal ultrasound with Doppler of the right ovary (A) shows a
complex cyst (arrow) with fine reticular pattern and echogenic areas; no internal vascularity is seen. Transvaginal ultrasound image of the
same patient superior to the uterus (B) demonstrates hemoperitoneum with debris (arrow) from rupture of the hemorrhagic cyst.
Pregnancy test was negative, excluding the possibility of ectopic pregnancy. Follow up transvaginal ultrasound at a 2 week interval (C)
shows decrease in the size of the cyst with changes in the internal architecture from retraction of the clot (arrow).

cysts, tumors, enlarged corpus luteum, or ovulation vascularity. Echogenic fluid can be seen in the cul-de-
induction for infertility. Ultrasound is performed as the sac in cases of ruptured cyst (Fig. 13B). In
first line of imaging, demonstrating increased size (>4 indeterminate cases, MRI may be performed to show
cm in greatest diameter) and volume of the involved the blood products, or a follow-up sonogram can show
ovary, heterogeneous appearance from edema and change in the echo pattern or resolution of the cyst
hemorrhage, and typically an associated cyst or mass (Fig. 13C). Correlation with menstrual history is
(Fig. 12). Multiple small follicles can be seen in the helpful as these typically occur in the luteal phase.
periphery of the enlarged ovary due to displacement Treatment is typically supportive.
from stromal edema, described as string of pearls
sign.29 On Doppler, venous flow is often reduced or
absent, but this is less sensitive than gray-scale Pelvic Inflammatory Disease
findings. The arterial blood flow may be dampened or Acute pelvic inflammatory disease can present with
absent as well, but this finding is variable due to dual fever and lower abdominal pain, similar to that of
blood supply (ovarian artery and uterine branch acute appendicitis. Neisseria gonorrhoeae and
artery). Comparison with the normal unaffected ovary Chlamydia trachomatis are the most commonly
is often helpful. Treatment is surgical detorsion and implicated organisms. Patients may have additional
removal of necrotic tissue. symptoms relating to the urogenital tract, including
dysuria, dyspareunia, and vaginal discharge. On
transvaginal ultrasound, enlarged and heterogeneous
Hemorrhagic Ovarian Cyst appearing ovaries, thickened adnexal structures,
Hemorrhage into an ovarian cyst can cause abrupt dilated fallopian tubes containing simple fluid or
lower abdominal or pelvic pain. Hemorrhagic cysts echogenic contents, and pelvic fluid collections can be
have a thin wall with posterior through transmission. seen (Fig. 14). CT findings include enlarged ovaries
The internal architecture depends on the stage of with abnormal enhancement, dilated and fluid filled
evolution of the hemorrhage, from anechoic fluid in fallopian tubes with enhancing wall from pyosalpinx,
the acute stage to echogenic clot in later stages, giving stranding of the pelvic fat, enhancement of the
rise to varied sonographic appearances.30 The most adjacent peritoneum, and pelvic abscesses in
common appearance is a finely septated fishnet advanced cases (Fig 14C).31 Similar findings can be
pattern resulting from fibrin bands (Fig. 13A). seen involving the endometrium and cervix in
Additional findings include a fluid-debris level, a endometritis and cervicitis. Treatment is supportive,
nodule from retracting clot, or a completely echogenic including antibiotic therapy.
lesion. These typically do not show internal

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Appendicitis Mimics, Thompson et al.

A B
Figure 14. Tubo-ovarian abscess.
26-year-old woman with acute right lower quadrant pain.
Transvaginal ultrasound image with Doppler (A) shows an
enlarged, complex appearing, and hyperemic right ovary (arrows)
from tubo-ovarian abscess. Transvaginal ultrasound with Doppler
(B) reveals thickened and hyperemic left adnexal structures
(arrow) with adjacent fluid collection. Axial post-contrast CT
image of the pelvis (C) shows a heterogeneously enhancing right
ovary (long arrow) and thickened adherent left adnexal
structures with pyosalpinx (short arrow). The patient improved
on antibiotics.

Ectopic Pregnancy from hemoperitoneum can be seen in the pelvis and


Ectopic pregnancy needs to be excluded in all abdomen in cases of rupture. If diagnosed early,
women of reproductive age who present with treatment is medical including methotrexate to
abdominal pain. As with other gynecologic terminate the non-viable preganancy. Surgical
emergencies, transvaginal ultrasound along with treatment may be pursued in the presence of
serum beta-hCG level plays crucial role in diagnosis. hemodynamic instability, ongoing rupture, or
Non-visualization of an intrauterine gestational sac on contraindication to methotrexate.
transvaginal ultrasound with a beta-hCG level greater
than 2000 mIU/ml should raise the suspicion for Mittelschmerz
ectopic pregnancy. Ninety-five percent of ectopic
pregnancies are tubal, and visualization of a complex This is pain associated with rupture of the dominant
mass separate from the ovary helps in differentiating it follicle during ovulation, occurring in the mid
from a complex ovarian cyst (Fig. 15). Presence of yolk menstrual cycle, usually felt in the lower abdomen.
sac or a live embryo with cardiac activity makes the The laterality of pain varies corresponding to the side
diagnosis.32 Other findings include the tubal ring of ovulation. Sometimes, the pain can be severe,
sign, referring to a hyperechoic ring around the associated with nausea, and mimic appendicitis if
adnexal gestational sac. On Doppler, peripheral occurring on the right side. Correlation with menstrual
vascularity with high velocity and low impedance can cycle, spotting, and history of prior such episodes can
be seen around the adnexal mass, separate from the help.
ovary, called the ring of fire sign.33 Echogenic fluid

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Appendicitis Mimics, Thompson et al.

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Figure 15. Ectopic pregnancy. 2011;8:749-55.
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