Commentary

Radiology of Acute Appendicitis

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Although no longer a hot topic in the medical litena- although Hatten et al. [10] found an incidence of only 7%
tune, the diagnosis of acute appendicitis still presents a in a review of 300 cases.
challenge. Several modern series indicate that a preop- At least half of acute appendicitis patients with appen-
enative clinical diagnosis of acute appendicitis will be dicoliths have gangrene or perforation of the appendix
incorrect in 15% of cases and that a significant postop- [4, 6]. This potential for advanced disease has prompted
erative complication rate can be expected as a result of surgical zealots to advocate elective appendectomy for
appendectomy performed for such a mistaken impres- asymptomatic patients who have accidental discovery of
sion [1-3]. In many instances the surgeons palpating an appendicolith [11].
fingers require d iagnostic reinforcement.
Despite numerous publications on the subject, the Gas in Appendix
inconsistent use of radiography by many clinicians mdi- The radiologic discovery of gas in the appendix is
cates that its role in the diagnosis of appendicitis is still noted in less than 2% of patients with acute appendicitis
poorly appreciated. My own views are formed by expeni- [6-8]. It occurs when the appendix is completely ob-
ence with 291 histologically proven cases oven the past 8 structed and infected with gas-forming bacteria, or when
years at Bridgeport Hospital. the lumen of an inflamed atonic appendix communicates
with the cecum. Gas in the appendix with acute appen-
Plain Film Findings dicitis has been associated with gangrene and perfora-
tion in about 50% of published cases [12].
Appendicoliths
The lumen of a gas-filled inflamed appendix often
An appendicolith originates from a fecal lump inspis- appears dilated throughout its entire length, with a
sated in the appendiceal lumen. The irritating fecal nidus poorly defined air-mucosa interface due to mucosal
provokes secretion and precipitation of mucous rich in edema. There may be a gas-fluid level in the appendix
calcium phosphate. Appendiceal calculi are also known and a surrounding soft tissue mass. All seven Bridgeport
as fecaliths on coproliths, designations corrupted by Hospital cases had accompanying radiographic signs of
frequent application to small nadiolucent fecal lumps acute appendicitis
discovered by barium filling the appendix. An uncalcified For many physicians, gas in the appendix implies the
fecal lump does not have the same potential for lumen diagnosis of acute appendicitis [12]. Samuel [13] first
obstruction and production of acute appendicitis. recognized that air may normally be seen throughout
Radiographi#{231}ally, the typical appendiceal calculus is most of the length of an ascending netnocecal appendix.
0.5-2.0 cm in diameter. In 70% of cases they are solitary Gas filling of appendices occupying other positions in
and in 20%, two are present. The majority are oval and the abdomen has not been so well established as a
laminated [4]. A laminated right lower quadrant appen- normal radiographic finding. Conventional wisdom con-
diceal calculus may be mistaken for an ectopic gallstone, tends that, although gas air enters a normal non retroce-
especially if the patient has dilated small intestinal loops cal appendix, it is not sufficient or constant enough to
suggesting a gallstone ileus. The common differential be identified with certainty on plain abdominal films [12,
diagnosis of a nonlaminated appendicolith includes ure- 13]. Dissenting, Lim [14] presented three cases with
teral calculus, bone island of the ilium, or calcified abdominal complaints and normal gas-filled appendices
mesentenic lymph node [5]. occupying the right lower quadrant of the abdomen. In
Radiographic discovery of an appendicolith in a pa- two cases the cecum was not simultaneously distended
tient with abdominal pain is a highly reliable indicator of with gas.
acute appendicitis. Fagenberg [4] noted that 12 of 100 I analyzed three groups of patients without append ici-
consecutive cases of acute appendicitis had append icol- tis to determine the frequency of air filling of normal
iths demonstrable by plain abdominal films, whereas appendices.
only one of 100 normal cases had such a finding. He 1 . In 100 consecutive ambulatory patients with back
concluded that discovery of an appendicolith in a patient pain, no appendiceal air was observed on a single supine
with abdominal pain indicates at least 90% chance of abdominal film. The study agrees with the series of 200
acute appendicitis. Appendicoliths have been noted in normal subjects studied by Graham and Johnson [7];
7%-12% of cases in large series [6-9]; a 14% incidence none had gas in the appendix.
has been noted in the Bridgeport Hospital review of 291 2. Ninety consecutive hospital cases with abdominal
cases. The frequency of appendicoliths has been ne- complaints, numerous supine abdominal films, and bar-
ported as high as 50% in children with appendicitis, ium studies for confirmation of the shape and position of
1001
 1002 COMMENTARY

the appendix were then reviewed. Appendiceal air was may not be present in a few normal patients. Steinert et
visualized in six cases. Of the two with complete al. [9] noted blurring of the right propenitoneal fat in six
filling, one was a netnocecal appendix, the other was in of 104 cases.
the pelvis. In four cases air filling of the appendix
occurred on only one of many films and only in a short Separation of Cecal Contents from Right Properitoneal
proximal segment. Fat
3. In 100 consecutive hospital patients with either This indicates edema of the cecal wall and/on fluid in
excretory urogram or supine abdominal films, four had the night flank. Casper [15] attempted to quantify this
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unquestionable air filling of the appendix. Three of these observation to increase its diagnostic usefulness. On the
were located in the night lower quadrant. basis of 100 randomly selected supine films, he found
Air extending for even a long segment of a nondilated that the soft tissue between the night propenitoneal fat
appendix occupying any position of the abdomen may and the night colonic contents usually measures 2-3 mm.
be normal. I cannot offer any criteria to judge early He considered that a measurement of greater than 5 mm
degrees of dilatation. In my own experience there has anywhere along the night flank (with the colon empty on
been no significant difference in the frequency of visual- distended) indicated an abnormal amount of soft tissue.
ization of air in the appendix in cases with acute appen- Of 28 of his cases with acute appendicitis, 15 had a
dicitis and those with other abdominal complaints. cecal-fat distance greaten than 5 mm.
I reviewed films on 172 presumably normal supine
Appendiceal Ileus
abdomens to substantiate the normal distance. The dis-
Acute appendicitis may induce atony of the neighbor- tance could not be ascertained in nine cases; in six
ing cecum and terminal ileum causing dilated air- and cases a gasless night colon prevented identification of
fluid-filled bowel loops confined to the night lower quad- the colonic contents; and in three instances the night
rant, so-called appendiceal ileus. This sentinel ileus is propenitoneal fat line could not be identified. The mean
seldom dramatic; the bowel loops are only moderately distance for the 162 remaining cases was 4 mm (SD =
dilated, and fluid levels, if present, are short. 2.9 mm). Hence, a distance of 10 mm or greaten may be
Many authors dispute the reliability of appendiceal regarded as abnormal at the 95% level of confidence,
ileus in the diagnosis of appendicitis [8]. If the term is whereas Caspers suggestion [15] of 5 mm does not
restricted only to those cases with air-fluid levels in seem valid. In 221 cases of appendicitis in which a
dilated right lower quadrant bowel loops, then appendi- measurement was obtainable, 37 had a cecal-fat dis-
ceal ileus should prove a useful radiographic finding. tance of 10 mm on more.
Analyzing a series of 200 normal patients, Graham and
Johnson [7] found that sentinel right lower quadrant ileal Abscess
loops occurred without air-fluid levels in 19%, a right An appendiceal abscess occurs most frequently and
colon air-fluid level occurred in 9%, and sentinel night characteristically in the right lower quadrant or in the
lower quadrant air-fluid levels occurred in 2.5%. In com- right panacolonic gutter. However, it may be found al-
panison, analyzing a series of 104 appendicitis cases, most anywhere in the abdomen because of the extreme
Steinert et al. [9] noted cecal air-fluid levels in 40 cases variability in the position of the appendix and the numen-
(38.5%) and sentinel ileal air fluid levels in 19 cases ous potential routes for intra- or retnopenitoneal dissem-
(18.3%). ination. Appendiceal abscesses have been noted in such
unusual sites as the night thigh on the left subphrenic
Right Lower Quadrant Soft Tissue Mass
area. Abscess formation is noted surgically in about 15%
A soft tissue mass may be caused by an abscess, by of large series of appendicitis [1 , 2]. An abscess will
edema of the mesoappendix, on by aggregation of fluid- occasionally contain gas, most unmistakably in a soap
filled small bowel loops. All may be reflected only as a bubble appearance.
localized increased density oven the night sacroiliac joint
with blurring of the joint margins. A soft tissue mass is a Other Signs
frequent and reliable radiographic finding with appendi- Such findings as splinting of the night side of the
citis, being noted in 12%-33% of large series [6-9]. abdomen and loss of the night psoas margin occur in a
large number of normal individuals and are of value only
Deformity of Cecal Outline
as supportive signs [7]. Other findings, such as diffuse
Edema deforms the air-filled cecum by causing thick- dilatation of the small on large bowel, are nonspecific
ening of mucosal folds, straightening of normally curved and serve only to confuse the diagnosis.
margins, and/on narrowing of the lumen by lobulated
submucosal fluid collections (thumb prints). Most series Discussion: Plain Films

note this finding in less than 5% of appendicitis cases. The original large radiographic series of Steinert et al.
in 1943 [9] first evaluated the usefulness of the plain
Blurring or Loss of Right Properitoneal Fat Stripe
abdominal film in acute appendicitis and developed
This sign occurs when the inflammatory process infil- three categories: (1) normal; (2) possibly abnormal, such
trates and causes edema of the well defined fat stripe. as cases with scoliosis, absence of the night psoas mar-
Even when a left fat stripe is present, a night fat stripe gin, and air in a nondilated appendix; and (3) probable
 COMMENTARY 1003

appendicitis or suggestive of appendicitis. Demonstra- origin of the appendix. The surface of this defect may be
tion of an appendicolith on night lower quadrant abscess smooth on irregular.
gas justifies the specific diagnosis. 3. A bibbed cecal filling defect in the expected posi-
Steinert et al. [9] classified 24 of 104 cases (23%) as tion of the appendix. The indentation between these two
normal and 28 as possibly abnormal. There were 52 lobes is caused by filling of the most proximal portion of
cases (50%) with findings characteristic on suggestive of the appendix, which then tapers down to a point of
appendicitis. In a continuation of this same series, Fnei- obstruction [18].
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man-DahI [16] noted that these percentages have ne- Lange cecal filling defects usually indicate abscess
mained largely unchanged after examination of oven formation, as does terminal ileal displacement. An ab-
2,000 patients. Of 291 Bridgeport Hospital cases, 121 scess from a netnocecal appendix characteristically
(42%) were negative, 32 (11%) had possibly abnormal causes a pressure effect on the ascending colon, while a
findings, and 138 (47%) had a positive examination. pelvic abscess impinges on the netnosigmoid region. An
Most often several signs will be present in cases with abscess may also displace other structures, such as the
positive abdominal films. A combination of findings more bladder on night ureter, on spread to remote sites. If an
strongly suggests a right lower quandrant inflammatory abscess does not impinge upon the right colon on termi-
process than any one alone. Of the 138 positive Bridge- nal ileum, its appendiceal origin usually remains unsus-
port Hospital cases, 99 (72%) had two or more radio- pected preoperatively.
graphic signs of appendicitis.
Patients with more advanced disease (i.e. perforation
,
Nonfilling of Appendix
on gangrene) are more likely to have a positive radio- Lumen obstruction is a prerequisite for development
graphic examination (62% in the Bridgeport Hospital of appendicitis in most patients [19]. However, in the
series), as are children [7]. Most authors have found that absence of cecal deformity, nonfilling of the appendix is
plain film studies are less frequently positive when the not a helpful diagnostic sign of appendicitis for the
appendix is in the retrocecal position. following reasons.
Perhaps to avoid embarrassment, few authors analyze 1 . Barium may not fill a normal appendix. Sakoven and
the frequency of radiographic examinations which incon- Del Fava [20] attempted to fill the appendix by barium in
rectly suggest the diagnosis of appendicitis in patients 525 patients without appendicitis; in 66 (12.5%) there
without significant abdominal disease. I estimate that I was no visualization of the appendix. In suspected ap-
make one such false positive diagnosis for every five or pendicitis cases colonic preparation cannot be used,
six times I prove connect. I have been betrayed most often further hindering appendiceal filling.
by the appendiceal ileus complex of signs and by incor- 2. Barium may fill the proximal portion of the appendix
rectly diagnosing a cecal deformity. that is obstructed and inflamed distally [21].
Even if positive, abdominal radiographs add little to 3. Barium may completely fill an inflamed appendix
the straightforward case of acute appendicitis except [17]. Of cases with acute nongangrenous nonperforative
expense and radiation exposure. Abdominal radiography appendicitis, 20% have no demonstrable lumen obstnuc-
is indicated for the evaluation of a patient with suspected tion [19].
appendicitis only when the existence of a surgical prob-
lem is in doubt, or when appendicitis is only one of many Discussion: Barium Enema
diagnostic possibilities. Perhaps 20% of patients with
Soten [17] presented the first large series of cases of
appendicitis present such problems [2]. About half of
acute appendicitis examined by means of the barium
appendicitis patients over 60 have minimal symptoms,
enema. All 25 had diagnostic findings with pressure
the so called silent appendix. Since the plain film is
changes on the cecum and nonfilling of the appendix.
positive in less than 50% of appendicitis cases, further
Rajogopalan et al. [22] performed 221 barium enemas in
evaluation by barium enema examination may be mdi-
cases suspected of having appendicitis. Of 110 patients
cated.
with a positive barium enema, 107 (97%) had appendici-
Barium Enema Findings tis confirmed at surgery. Of 1 1 1 patients with negative
studies, 96 (86.5%) were merely observed for 48 hr and
Deformity of Distended Cecum and/or Superior Medial
discharged as presumably normal. Fifteen patients with
Displacement of Terminal Ileum
a negative barium enema were surgically explored for
Uncomplicated appendicitis causes cecal deformity by impelling clinical reasons. Appendicitis was found in six,
extension of the inflammation from the base of the an overall false negative frequency of 7%. Of 40 Bridge-
appendix to the cecum (typhlitis) and/or pressure on the port Hospital cases with appendicitis, 30 had positive
cecum by edematous peniappendiceal tissue, most com- barium enemas with nonfilling of the appendix and
monlythe mesoappendix [17, 18]. contour abnormalities of the right colon. Two of the 40
Early contour changes characteristic of appendicitis had extrinsic impressions on the rectum and retrosig-
include the following. moid without cecal or ileal abnormalities.
1 Flattening
. of the cecum between the expected Many physicians hesitate to order a barium enema for
origin of the appendix and ileocecal valve. Normally this problem cases of appendicitis, even though published
segment is convex. evidence indicates its desirability. Two objections are
2. A single filling defect in the region of the expected raised.
 1004 COMMENTARY

1. Barium, especially administered under pressure, 6. Brooks DW, Killen DA: Roentgenographic findings in acute
may perforate an inflamed cecum. This complication is appendicitis. Surgery 57 :377-384, 1965
very rare [17, 22-24]. I am puzzled whythe barium enema 7. Graham AD, Johnson HF: The incidence of radiographic
is an accepted procedure with cases of diverticulitis of findings in acute appendicitis compared to 200 normal
the sigmoid with its known tendency for perforation, but abdomens. Milit Med 131 :272-276, 1966
8. Aulfs DM, Fisher AG; Radiographic findings in acute appen-
not in cases of appendicitis.
dicitis. Tex Med 67:89-93, 1971
2. The study is not 100% accurate in comparison with
9. Steinert A, Hareide I, Chnistiansen T: Aoentgenolic exami-
surgical exploration. This argument erroneously as-
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nation of acute appendicitis. Acta Radiol 24 : 13-37, 1943

sumes that surgery is innocuous. Kazanian et al. [1] 10. Hatten LE, Miller AC, Hester CL, Moynihan PC: Appendicitis
reported a 14% morbidity rate in patients undergoing and the abdominal roentgenogram in children. South Med
surgery for a mistaken diagnosis of acute appendicitis J 66:803-806, 1973
(the same incidence of morbidity encountered in patients 11 . Copeland EM, Long JM: Elective appendectomy for appen-
with nonperforative appendicitis); others have reported diceal calculus. Surg Gynecol Obstet 130:439-442, 1970

occasional postoperative deaths [2, 3]. 12. Killen DA, Brooks DW: Gas filled appendix: a roentgeno-
The barium enema deserves widen application in the graphic sign of acute appendicitis. Ann Surg 161 :474-478,
1965
diagnosis of appendicitis. It guides the connect mode of
13. Samuel E: The gas filled appendix. Br J Radiol 30:27-30,
therapy when appendicitis is only one of several diagnos-
1957
tic possibilities, such as regional entenitis or perforating 14. Lim MS: Gas-filled appendix: lack of diagnostic specificity.
cancer of the night colon. In cases with a questionable Am J Roentgenol 128:209-210, 1977
acute abdomen, a positive barium enema leads to 15. Casper RB: Fluid in the right flank as a roentgenographic
prompt indicated surgery for appendicitis. A negative sign of acute appendicitis. Am J Roentgenol 110:352-354,
study with good filling of the appendix offers the surgeon 1970
good justification for a policy of watchful waiting. Such 16. Fnimann-Dahl J: Roentgen Examinations in Acute Abdomi-
an approach for questionable appendicitis should ob- nal Diseases. Springfield, Ill., Thomas, 1974
1 7. Soten CS: The use of barium in the diagnosis of acute
viate most negative diagnostic laparotomies with their
appendiceal disease: a new radiological sign. Clin Radiol
attendant expense and morbidity.
19:410-415, 1968
Peter M. Shimkin 18. Figiel LS, Figiel SJ: Barium examination of the cecum in
Bridgeport Hospital appendicitis. Acta Radiol 57 :469-480, 1962
Bridgeport, Connecticut 06602 19. Wangensteen OH, Bowers WF: Significance of the obstruc-
tive factor in the genesis of acute appendicitis. Arch Surg
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20. Sakover AP, Del Fava AL: Frequency of visualization of the
1 . Kazanian KK, Roedor WJ, Mersheimer WL: Decreasing mor- normal appendix with the barium enema examination. Am
tality and increasing morbidity from acute appendicitis. Am J Roentgenol 121 :312-317, 1974
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2. Barnes BA, Behninger GE, Wheelock FC, Wilkens EW: pendix.JAMA 208:1495, 1969
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PostgradMed44:110-114, 1968 23. Mendeloff J: Granulomatous reaction to barium sulfate in
4. Fagenberg D: Fecaliths of the appendix: incidence of sig- and about the appendix.Am J Clin Pathol 26:155-160, 1956
nificance. Am J Roentgenol 89 :752-759, 1963
24. Kay 5: Tissue reaction to barium sulfate contrast medium.
5. Felson B, Bernhard CM: The roentgenologic diagnosis of Histopathologic study. Arch Pathol 57 :279-284, 1954
appendiceal calculi. Radiology 49:178-191 1947 ,