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CT of Appendicitis in Children¹

¹ From the Department of Radiology, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. Received June 5, 2001; revision requested June 27; revision received September 10; accepted October 16. Address correspondence to G.A.T. (e-mail: george.taylor@tch.harvard.edu).

View larger version (126K): [in a new window]   Figure 1a. (a) Transverse helical CT image obtained with rectal contrast material alone in a 9-year-old girl was interpreted as indeterminate for appendicitis. The inflamed appendix (arrow) was misinterpreted as a fluid-filled loop of small bowel. (b) Transverse helical CT image obtained after administration of IV contrast material shows an enlarged appendix with abnormal wall enhancement and a fluid-filled lumen (arrow).

View larger version (134K): [in a new window]   Figure 1b. (a) Transverse helical CT image obtained with rectal contrast material alone in a 9-year-old girl was interpreted as indeterminate for appendicitis. The inflamed appendix (arrow) was misinterpreted as a fluid-filled loop of small bowel. (b) Transverse helical CT image obtained after administration of IV contrast material shows an enlarged appendix with abnormal wall enhancement and a fluid-filled lumen (arrow).

View larger version (139K): [in a new window]   Figure 2. Equipment for rectal contrast material administration. IV tubing is connected with a 1,000-mL bag of saline that contains diluted contrast material. A small rectal catheter tip is cut and connected with the IV tubing. The flow of contrast material into the rectum is controlled with the compression flow regulator on the IV tubing.

View larger version (155K): [in a new window]   Figure 3a. (a) Transverse helical CT image of the pelvis, obtained with the 14-year-old female patient supine and without IV contrast material, fails to demonstrate the appendix. (b) Transverse helical CT image obtained with the patient in a left lateral decubitus position and without IV contrast material shows a normal appendix filled with enteric contrast material (arrow).

View larger version (152K): [in a new window]   Figure 3b. (a) Transverse helical CT image of the pelvis, obtained with the 14-year-old female patient supine and without IV contrast material, fails to demonstrate the appendix. (b) Transverse helical CT image obtained with the patient in a left lateral decubitus position and without IV contrast material shows a normal appendix filled with enteric contrast material (arrow).

View larger version (148K): [in a new window]   Figure 4. Sagittal reconstruction of right lower quadrant CT image shows a normal, thin-walled, and tortuous appendix (arrow) in a 7-year-old boy.

View larger version (159K): [in a new window]   Figure 5a. (a) Primary and secondary CT signs of appendicitis. Transverse helical CT image obtained through the lower pelvis in a 6-year-old girl shows an enlarged fluid-filled appendix with abnormal wall enhancement (thin arrows) and asymmetric focal cecal apical thickening (thick arrow). (b) Transverse helical CT image obtained in a 4-year-old boy shows a gas-containing calcified appendicolith separated from the cecum by a thickened appendiceal wall (cecal bar, arrows). (c) Transverse helical CT image obtained in the lower abdomen in a 7-year-old girl with necrosis and perforation of the appendix shows an indistinct appendix wall, with irregular contrast material enhancement (black arrow) and punctate gas collection (white arrow) in an area of marked mesenteric inflammation.

View larger version (120K): [in a new window]   Figure 5b. (a) Primary and secondary CT signs of appendicitis. Transverse helical CT image obtained through the lower pelvis in a 6-year-old girl shows an enlarged fluid-filled appendix with abnormal wall enhancement (thin arrows) and asymmetric focal cecal apical thickening (thick arrow). (b) Transverse helical CT image obtained in a 4-year-old boy shows a gas-containing calcified appendicolith separated from the cecum by a thickened appendiceal wall (cecal bar, arrows). (c) Transverse helical CT image obtained in the lower abdomen in a 7-year-old girl with necrosis and perforation of the appendix shows an indistinct appendix wall, with irregular contrast material enhancement (black arrow) and punctate gas collection (white arrow) in an area of marked mesenteric inflammation.

View larger version (136K): [in a new window]   Figure 5c. (a) Primary and secondary CT signs of appendicitis. Transverse helical CT image obtained through the lower pelvis in a 6-year-old girl shows an enlarged fluid-filled appendix with abnormal wall enhancement (thin arrows) and asymmetric focal cecal apical thickening (thick arrow). (b) Transverse helical CT image obtained in a 4-year-old boy shows a gas-containing calcified appendicolith separated from the cecum by a thickened appendiceal wall (cecal bar, arrows). (c) Transverse helical CT image obtained in the lower abdomen in a 7-year-old girl with necrosis and perforation of the appendix shows an indistinct appendix wall, with irregular contrast material enhancement (black arrow) and punctate gas collection (white arrow) in an area of marked mesenteric inflammation.

View larger version (134K): [in a new window]   Figure 6. Sagittal reconstruction of right lower quadrant CT image obtained in an 8-year-old boy shows mild inflammatory changes confined to the distal portion of the appendix (arrow). Acute focal appendicitis was confirmed at laparotomy.

View larger version (132K): [in a new window]   Figure 7a. (a) Transverse helical CT image of the pelvis, obtained in a 12-year-old girl within 24 hours of the initial onset of symptoms, shows no focal abnormalities. Arrows = position of appendix. (b) Repeat transverse helical CT image obtained 24 hours after a shows enlargement and hyperemia of the appendix and periappendiceal inflammation (arrows). Acute appendicitis was confirmed at surgery.

View larger version (127K): [in a new window]   Figure 7b. (a) Transverse helical CT image of the pelvis, obtained in a 12-year-old girl within 24 hours of the initial onset of symptoms, shows no focal abnormalities. Arrows = position of appendix. (b) Repeat transverse helical CT image obtained 24 hours after a shows enlargement and hyperemia of the appendix and periappendiceal inflammation (arrows). Acute appendicitis was confirmed at surgery.

View larger version (129K): [in a new window]   Figure 8a. Transverse helical CT scans obtained in three patients suspected of having appendicitis in whom alternative diagnoses were made at CT. (a) Image obtained in a 13-year-old boy shows diffuse thickening and abnormal enhancement of anterior mesenteric fat (arrows) as a result of omental torsion. (b) Image obtained in a 10-year-old girl shows a large heterogeneous mass (arrow) anterior to the appendix. A germ cell tumor of the right ovary was identified at surgery. (c) Image obtained in a 12-year-old girl shows a midline retro-uterine mass (arrows) due to torsion of the right ovary. This patient underwent imaging prior to institution of our clinical practice guidelines for appendicitis. According to our current imaging algorithm, this patient would have undergone pelvic US as the initial imaging examination.

View larger version (115K): [in a new window]   Figure 8b. Transverse helical CT scans obtained in three patients suspected of having appendicitis in whom alternative diagnoses were made at CT. (a) Image obtained in a 13-year-old boy shows diffuse thickening and abnormal enhancement of anterior mesenteric fat (arrows) as a result of omental torsion. (b) Image obtained in a 10-year-old girl shows a large heterogeneous mass (arrow) anterior to the appendix. A germ cell tumor of the right ovary was identified at surgery. (c) Image obtained in a 12-year-old girl shows a midline retro-uterine mass (arrows) due to torsion of the right ovary. This patient underwent imaging prior to institution of our clinical practice guidelines for appendicitis. According to our current imaging algorithm, this patient would have undergone pelvic US as the initial imaging examination.

View larger version (85K): [in a new window]   Figure 8c. Transverse helical CT scans obtained in three patients suspected of having appendicitis in whom alternative diagnoses were made at CT. (a) Image obtained in a 13-year-old boy shows diffuse thickening and abnormal enhancement of anterior mesenteric fat (arrows) as a result of omental torsion. (b) Image obtained in a 10-year-old girl shows a large heterogeneous mass (arrow) anterior to the appendix. A germ cell tumor of the right ovary was identified at surgery. (c) Image obtained in a 12-year-old girl shows a midline retro-uterine mass (arrows) due to torsion of the right ovary. This patient underwent imaging prior to institution of our clinical practice guidelines for appendicitis. According to our current imaging algorithm, this patient would have undergone pelvic US as the initial imaging examination.

View larger version (138K): [in a new window]   Figure 9a. Transverse helical CT scans obtained in two patients with conditions that may mimic appendicitis at CT. (a) Image obtained in a 9-year-old boy shows asymmetric thickening of the appendix (arrows) due to infiltration with Burkitt lymphoma. (b) Image of the right lower quadrant in a previously healthy 14-year-old boy shows inflammatory changes of the appendix (arrow) and periappendiceal tissues due to involvement by Crohn disease.

View larger version (139K): [in a new window]   Figure 9b. Transverse helical CT scans obtained in two patients with conditions that may mimic appendicitis at CT. (a) Image obtained in a 9-year-old boy shows asymmetric thickening of the appendix (arrows) due to infiltration with Burkitt lymphoma. (b) Image of the right lower quadrant in a previously healthy 14-year-old boy shows inflammatory changes of the appendix (arrow) and periappendiceal tissues due to involvement by Crohn disease.

View larger version (131K): [in a new window]   Figure 10. Sagittal reformatted CT scan of the right lower quadrant in a 12-year-old girl shows an enlarged (8-mm) fluid-filled appendix (arrows) and was interpreted as positive for appendicitis. A normal appendix was found at laparotomy and histologic evaluation. This examination was performed without IV contrast material administration.

View larger version (130K): [in a new window]   Figure 11a. (a) Transverse helical image from initial pelvic CT in a 4-year-old boy, obtained with rectal contrast material, shows reflux of contrast material into the distal small bowel. (b) Repeat transverse helical CT image obtained without intestinal or IV contrast material 24 hours after a shows an appendicolith (arrow) that had been obscured by intestinal contrast material at initial CT. Note the thickened bowel and abscess anterior to arrow.

View larger version (122K): [in a new window]   Figure 11b. (a) Transverse helical image from initial pelvic CT in a 4-year-old boy, obtained with rectal contrast material, shows reflux of contrast material into the distal small bowel. (b) Repeat transverse helical CT image obtained without intestinal or IV contrast material 24 hours after a shows an appendicolith (arrow) that had been obscured by intestinal contrast material at initial CT. Note the thickened bowel and abscess anterior to arrow.