When Appendicitis Is

Suspected in
Children

Oleh :
Dynna Akmal
 Introduction
Acute appendicitis is the most common
condition requiring emergency abdominal
surgery in the pediatric population, with 60,000
80,000 cases annually in the United States.
It is one of the major causes of hospitalization
in children. The condition typically develops in
older children and young adults. It is rare under
the age of 2 years. The lifetime risk of acute
appendicitis ranges from 7% to 9%.
 In this article, we review current practice
with respect to the assessment of suspected
acute appendicitis in children, including the
role of imaging in patient assessment, the
diagnostic efficacy of graded-compression
ultrasonography (US) and helical computed
tomography (CT) for diagnosis, the
characteristic imaging appearance of acute
appendicitis at US and CT, and the effect of
cross-sectional imaging on patient outcomes.
 Clinical Assessment
of Acute Appendicitis

Clinical signs and symptoms associated

with acute appendicitis include crampy,
periumbilical or right lower quadrant pain;
nausea; vomiting point tenderness in the right
lower quadrant; rebound tenderness; and
leukocytosis with a left shift.
 Various objective clinical scoring systems
havebeen devised to stratify patient risk of
appendicitis. The most widely used clinical
scoring system is the MANTRELS score (Table).
It incorporates eight clinical and laboratory
factors that were found to be useful in making
the diagnosis of acute appendicitis.
The MANTRELS score has been shown to
be useful in discriminating between children
with acute appendicitis and those without the
disease.
 The MANTRELS Score
Characteristic Points
M igration of pain to 1
right lower quadrant
A norexia 1
N ausea and vomiting 1
T enderness in 2
right lower quadrant
R ebound pain 1
E levated temperature 1
L eukocytosis 2
S hift of white blood cell 1
count to left
Total 10
 Complications

Reported complications include

perforation, abscess formation, peritonitis,
wound infection, sepsis, infertility, adhesions,
bowel obstruction, and death.
 Imaging Assessment
of Acute Appendicitis
Routine use of abdominal radiography in
these children has little value unless bowel
obstruction or perforation is suspected.
Therefore, conventional radiography is not
discussed here, and we focus on the cross-
sectional imaging assessment of acute
appendicitis with graded-compression US and
helical CT.
 The goals of imaging in this condition are to
(a) facilitate an earlier diagnosis of acute
appendicitis or other conditions that it may
mimic,
(b) reduce negative laparotomy and perforation
rates, and
(c) reduce the intensity and cost of care.
 ultrasonography (US)
At the start of the examination, the patient is asked
to point to the site of maximal tenderness. This is useful
to expedite the examination and to aid in locating a
retrocecal appendix. On longitudinal images, the
inflamed, nonperforated appendix appears as a fluid-
filled, noncompressible,blind-ending tubular structure
(Fig 1).
The maximal appendiceal diameter, from outside
wall to outside wall, is greater than 6 mm. In early
nonperforated appendicitis, an inner echogenic lining
representing submucosa can be identified (Fig 1).
 Figure 1. Acute appendicitis. Longitudinal (a) and transverse
(b) US scans through an inflamed appendix
(between electronic calipers) show that it is enlarged. Note the
central echogenic mucosal lining.
Figure 2. Acute appendicitis with target sign. Transverse
US scan through an inflamed appendix shows an intact
echogenic submucosal layer and a fluid-filled lumen
(F), resulting in a target appearance.
Other findings of appendicitis include an appendicolith,
which appears as an echogenic foci withacoustic
shadowing (Fig 3)

Figure 3. Acute appendicitis with an appendicolith. Longitudinal (a) and

transverse (b) US scans through an inflamed appendix show an echogenic
appendicolith with acoustic shadowing.
 pericecal or periappendiceal fluid; increased
periappendiceal echogenicity representing fat infiltration (Fig 4);
and enlarged mesenteric lymph nodes. The only US sign that is
specific for appendicitis is an enlarged, noncompressible
appendix measuring greater than 6 mm in maximal diameter.

Figure 4. Acute appendicitis

with increased periappendiceal
echogenicity. Longitudinal US
scan through the righ lower
quadrant shows an area of
increased echogenicity (arrows)
representing infiltration of
mesenteric fat surroundingan
enlarged appendix (between
electronic calipers).
Figure 5. Acute appendicitis with loss of the echogenic
submucosal layer. Longitudinal (a) and transverse (b) US
scans through an inflamed appendix show a diffuse hypoechoic
and enlarged appendix (between electronic calipers),
with loss of the normally echogenic submucosal layer. At surgery,
appendiceal perforation was noted.
The use of color Doppler US provides a useful adjunct in the evaluation of
suspected acute appendicitis. Although color Doppler US does not increase
the sensitivity of the examination, it makes interpretation of the gray-scale US
findings easier and can increase observer confidence in the diagnosis of acute
appendicitis. Color Doppler US of nonperforated appendicitis typically
demonstrates peripheral wall hyperemia, reflecting inflammatory
hyperperfusion (Fig 8)

Figure 8. Acute appendicitis at color Doppler US. Longitudinal (a) and transverse (b) US
images through an inflamed appendix demonstrate marked hyperemia along the
periphery.
 Helical CT
Helical CT has been shown to be a highly
sensitive and specific modality for the
diagnosis of acute appendicitis in children and
adults.
The normal appendix can be identified at
CT in over three-fourths of children . The
appendix arises from the posteromedial
aspect of the cecum, approximately 12 cm
below the ileocecal junction (fig 11).
 Figure 11. Normal appendix. (a) Axial CT scan obtained through the
lower abdomen with thin collimation following the intravenous and rectal
administration of contrast material demonstrates the normal terminal ileum
(arrows). (b) Axial CT scan obtained 2 cm below a demonstrates the normal
proximal appendix (arrow) originating from the cecal apex. (c) Axial CT scan
obtained 2 cm below b demonstrates the normal distal appendix (arrow).
Note that the appendix does not fill with
contrast material.
a. b.
c. The relationship of the base of
the appendix to the cecum is
constant, but the free end of
the appendix is mobile and
can be directed medially,
caudally, laterally, or
retrocecally. The appendix is
usually curved and may be
tortuous. A segment of the
appendix is commonly noted
at a level higher than the
ileocecal valve. The maximal
normal appendiceal diameter
is quite variable; although it
usually is 7 mm or less, it may
occasionally be larger
 The only CT findings specific for
appendicitis are an enlarged appendix and
cecal apical changes, which represent
contiguous spread of the inflammatory
process to the cecum. The identification of
cecal apical changes is particularly useful in
allowing a confident diagnosis of acute
appendicitis if there is difficulty in identifying
an enlarged appendix (Fig 21).
Figure 21. Acute appendicitis with cecal apical thickening. (a) Axial CT scan obtained through
the upper pelvis
with thin collimation following the intravenous and rectal administration of contrast material
demonstrates focal cecal apical thickening (arrow). (b) Axial CT scan obtained 1 cm below a
demonstrates an enlarged curvilinear appendix (arrow). Note that there is not a good plane of
separation between the appendix and adjacent unopacified small bowel loops. The cecal apical
thickening was helpful in calling attention to the abnormal appendix.

a b
 Alternative
Diagnoses in Children
with Suspected Acute Appendicitis

Most children referred for US or CT evaluation

of suspected acute appendicitis will not have the
condition.
In a study of 178 patients, Siegel et al found
that only 22% of children referred fo US for
suspected acute appendicitis actually had
appendicitis; 29% had other specific diagnoses,
usually gastrointestinal and gynecologic
abnormalities.
 In a study of 178 patients, Siegel et al found that
only 22% of children referred for US for suspected
acute appendicitis actually had appendicitis; 29% had
other specific diagnoses, usually gastrointestinal and
gynecologic abnormalities. US aided in the diagnosis of
other conditions in approximately 60% of these
patients.
Sivit et al found appendicitis in 29% of 180 patients
referred for US because of suspected acute
appendicitis. Alternative diagnoses were established at
US in 25% of patients in that series who did not have
appendicitis. Therefore, a survey of the pelvis and
upper abdomen should be performed in patients who
have normal results from US examination of the right
lower quadrant.
 This is also a relevant issue for CT
evaluation, since controversy exists on
whether to perform a focused or targeted CT
examination of the right lower quadrant and
pelvis to assess only for appendicitis versus
complete abdominopelvic scanning. Sivit et al
found appendicitis in 38% of patients referred
for CT because of suspected acute
appendicitis. In 37% of patients with a true-
negative diagnosis for appendicitis at CT, an
alternative diagnosis was established on the
basis of CT findings
 Summary
Both graded-compression US and helical CT have been
shown to have potential utility in the evaluation of
suspected acute appendicitis in children. The principal
advantages of US are its lower cost; lack of ionizing
radiation; and its ability to assess vascularity through color
Doppler analysis, provide dynamic information through
graded-compression, and delineate gynecologic disease
which is a common mimic of acute appendicitis. The
principal advantages of CT include less operator
dependency than US, as reflected by a higher diagnostic
accuracy in most published studies, and enhanced
delineation of disease extent in perforated appendicitis. CT
is particularly valuable in obese patients, since they are
typically difficult to evaluate with US.
 A few studies have shown improved patient
outcome measures in children with acute appendicitis.
It should be noted, however, that these studies which
demonstrated improved outcomes in children with this
condition undergoing cross-sectional imaging have
used imaging protocols developed by multidisciplinary
teams of emergency physicians, surgeons, and
radiologists Such protocols go beyond technology
assessment and precisely define which patients underg
a specific diagnostic test. More work is needed to
better define how cross-sectional imaging affects the
cost of care, negative appendectomy rates,
appendiceal perforation, and complication rates. This
information is critical to reduce health care costs and
improve patient outcomes.