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Right Lower Quadrant Pain and Suspected Appendicitis: Nonfocused Appendiceal CT-Review of 100 Cases¹

¹ From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. From the 1999 RSNA scientific assembly. Received September 2, 1999; revision requested October 14; final revision received January 20, 2000; accepted February 1. Address correspondence to S.N.G. (e-mail: sgoldber@caregroup.harvard.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To determine the value of standard, nonfocused computed tomography (CT) in examining patients with right lower quadrant (RLQ) pain and suspected appendicitis.

MATERIALS AND METHODS: The CT scans and medical records of 100 consecutive patients who presented to the emergency department with RLQ pain and were clinically suspected of having appendicitis were retrospectively reviewed. Helical CT of both the abdomen and pelvis was performed at 7-mm increments after oral and intravenous contrast material administration. CT scans were evaluated for the presence of appendiceal or other disease. Results were correlated with surgical and pathologic findings in 34 patients or with 3-month clinical follow-up in 66 patients.

RESULTS: CT depicted abnormalities in 66 patients (66%). In 59 (59%) patients, the abnormality was located in the pelvis; 23 (39%) of these patients had appendicitis. Seven (7%) patients had abnormalities outside of the pelvis, a region not typically scanned during focused appendiceal imaging. Four of these seven patients required surgery. Thus, if only pelvic focused RLQ CT had been performed, overall sensitivity would have decreased from 99% to 88% (P < .05) and sensitivity for cases necessitating surgery would have decreased from 96% to 82% (P < .05).

CONCLUSION: Both abdominal and pelvic CT examinations are necessary to increase sensitivity and identify the many possible causes of RLQ pain in patients with clinically suspected appendicitis.

Index terms: Abdomen, acute conditions, 751.291 • Abdomen, CT, 78.12112, 78.12114, 78.12115, 78.12118 • Appendicitis, 751.291 • Pelvis, CT, 88.12112, 88.12114, 88.12115, 88.12118 • Uterine neoplasms, 85.3117, 85.313, 85.315

	INTRODUCTION

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Patients who present to the emergency department with right lower quadrant (RLQ) pain may have a range of underlying conditions, including appendicitis, diverticulitis, pelvic inflammatory disease, and renal calculi. Appendicitis is the most common cause of acute RLQ pain, but many conditions, some of which do not necessitate surgery, may mimic appendicitis (1,2). The value of computed tomography (CT) in the diagnosis of acute appendicitis has been well documented in the literature (3–8), with a reported accuracy between 93% and 98%. Various CT techniques have been described, including conventional and helical scanning. Scanning of the entire abdomen and pelvis after the administration of oral and intravenous contrast material has been recommended by some authors (3,9). Others have recommended dedicated CT scanning without the use of any contrast material (4,8). Helical CT limited to the RLQ with contrast material administered through only the colon has had a reported accuracy of 98% (10). However, this technique is not always used because its success is dependent on an emergency department setting with a dedicated radiologist who is actively involved in screening patients prior to radiologic investigation. The purpose of this retrospective study was to evaluate whether routine oral and intravenous contrast material–enhanced 7-mm helical CT is sufficient for adequate diagnosis of the potential causes of acute RLQ pain, including appendicitis.

	MATERIALS AND METHODS

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A computer database search of emergency department admissions between January and September 1998 was performed, and 100 consecutive patients (37 men, 63 women; mean age, 43 years; age range, 19–77 years) with RLQ pain who were suspected of having appendicitis and underwent CT were identified. These patients had a clinical presentation that was considered to be atypical or nonspecific for appendicitis. However, appendicitis remained the leading diagnosis suggested by the clinician, and imaging was requested to verify the clinical suspicion. In 94 patients, CT was the only imaging modality requested. For six female patients, the clinician ordered pelvic ultrasonography (US) to be performed within 24 hours after the CT study. The number of patients who underwent surgery without CT or other imaging in the study period is not known.

All patients were scanned by using a HiSpeed Advantage unit (GE Medical Systems, Milwaukee, Wis) after the oral administration of 900 mL of a 2.1% barium sulfate suspension (READI-CAT 2; E-Z-EM, Westbury, NY) at least 45 minutes before scanning. No rectal contrast material was administered. All patients received 150 mL of 43% iodinated contrast material (Conray; Mallinckrodt Medical, St Louis, Mo) intravenously at a rate of 2 mL/sec. Single-breath-hold scans were obtained through the entire abdomen and pelvis with 7-mm collimation and a pitch of 1.5 after a 50-second delay. In 14 patients, additional thin-section images were obtained through only the pelvis with 5-mm collimation after a 15-minute to 2-hour delay.

All of the CT scans were retrospectively reviewed and interpreted by means of consensus between two radiologists (S.N.G., I.R.K.) who were blinded to the original CT reports and surgical or pathologic findings. The readers evaluated the images to determine whether the appendix could be visualized, whether the appendix was abnormal, and/or whether other abnormalities that could explain the patient’s symptoms could be identified. The anatomic location of the abnormalities was classified as abdominal—that is, above the iliac crest—or pelvic—that is, below the iliac crest. CT findings of an abnormal appendix included a dilated (diameter >6 mm), nonopacified appendix with an adjacent inflammatory change, such as fat stranding, and the presence of an appendicolith (6). The presence of other indirect signs of appendicitis, including abscess, adenopathy, fluid collection, or extraluminal gas, also was assessed. However, these findings are nonspecific for appendicitis and can be noted in other conditions. When the appendix was not visualized at CT, appendicitis was excluded if the other signs of appendicitis were absent. In the 14 cases in which delayed thin-section imaging was performed, separate analysis was performed to determine whether improved visualization resulted in a change in diagnosis.

The surgical and pathologic findings in the 34 patients who underwent appendectomy or other surgery were reviewed by a single author (I.R.K.). The results of clinical follow-up evaluation at 3 months and the diagnosis at discharge were available in the remaining 66 patients. No cases were lost to follow-up.

	RESULTS

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Of the 100 patients who presented with RLQ pain, 34 had normal CT scans and 66 had abnormal CT findings (Fig 1). The abnormality was in the pelvis in 59 (59%) cases and confined to the abdomen, a region not typically scanned at focused appendiceal CT, in seven (7%) cases. Twenty-three (39%) of the 59 patients with pelvic abnormalities had appendicitis that was diagnosed at CT (Fig 2, Table 1), and the remaining 36 (61%) patients had abnormalities that did not necessitate surgery (Table 2). Four of the seven patients with an abdominal pathologic entity at CT required surgery. These conditions included perforated duodenal ulcer (Fig 3), superior mesenteric venous thrombosis (Fig 4), small-bowel ischemia, and abdominal wall hernia. The remaining three cases had abnormalities that did not necessitate surgery, including middle ureteric stone (Fig 5), pyelonephritis (Fig 6), and epiploic appendagitis. Twenty-two (96%) of the 23 patients with appendicitis had primary CT signs of appendicitis, including the presence of a dilated appendix with surrounding fat stranding, with or without an appendicolith. In one patient, the only finding of perforated appendicitis was an RLQ abscess abutting the medial cecum.

View larger version (21K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Classification of 100 patients, based on location of abnormality at CT.

View larger version (198K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Transverse pelvic CT scan positive for appendicitis obtained in a 26-year-old man shows a thickened appendiceal wall surrounding a distended appendix (large arrow) and periappendiceal fat stranding (small arrow). These findings are consistent with acute appendicitis, which was confirmed at surgery and pathologic analysis.

View larger version (167K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Perforated duodenal ulcer. Transverse CT scan obtained in a 70-year-old man who presented with RLQ pain shows thickening of the duodenal wall (large arrow) with surrounding fat stranding (small arrow). The patient was found to have a perforated duodenal ulcer at surgery.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Superior mesenteric venous thrombosis. (a) Transverse CT scan obtained in a 57-year-old man who presented with RLQ pain shows nonspecific small-bowel wall thickening (arrow). (b) Transverse CT scan through the abdomen in the same patient shows the cause of the small-bowel wall thickening to be superior mesenteric venous thrombosis (arrow).

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Superior mesenteric venous thrombosis. (a) Transverse CT scan obtained in a 57-year-old man who presented with RLQ pain shows nonspecific small-bowel wall thickening (arrow). (b) Transverse CT scan through the abdomen in the same patient shows the cause of the small-bowel wall thickening to be superior mesenteric venous thrombosis (arrow).

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Right ureteral calculus. Transverse abdominal CT scan obtained in a 73-year-old woman who presented with RLQ pain and had a negative pelvic CT scan shows a middle ureteric stone (arrow), which resulted in hydronephrosis and hydroureter.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 6. Acute right pyelonephritis. Transverse CT scan through the level of the kidneys in a 29-year-old woman who presented with RLQ pain shows a striated right nephrogram (arrow) indicating acute pyelonephritis. Transverse CT scans through the pelvis (not shown) showed no pelvic disease.

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 7. Classification of 100 patients, based on diagnosis at CT, pathologic findings, and clinical follow-up results.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 8. False-negative appendicitis. Transverse pelvic CT scan obtained in a 57-year-old woman shows a normal-appearing appendix (arrow). The study was reported as negative for appendicitis. Twenty-four hours after CT, the patient underwent an appendectomy that revealed acute appendicitis.

Of the six patients who underwent pelvic US, four had adnexal cysts and two each had negative studies. None of these patients had appendicitis at either imaging examination.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
CT has been shown to be an excellent diagnostic technique for patients with acute abdominal pain and may have a major effect on the treatment of these patients (11). This is particularly true in cases of RLQ pain in which the clinician suspects appendicitis.

Several authors have emphasized the value of focused appendiceal imaging. With the technique described herein, contiguous thin-section helical scanning limited to the RLQ, with (10) or without (4) rectal contrast material, is used. The use of this technique in a select population reportedly results in an extremely high rate (up to 100%) of visualization of the appendix and is 98% accurate for the diagnosis of acute appendicitis, which is somewhat better than the accuracy rates of nonfocused appendiceal imaging techniques reported in the literature. In a study by Rhea et al (12), the authors claim that the use of focused appendiceal CT can lower the variable and total costs of caring for patients with clinically suspected appendicitis. Nevertheless, limitation of the diagnostic study to the RLQ and visualization of the appendix may not always facilitate a diagnosis.

In our study, we reviewed the role of 7-mm section thickness helical abdominal and pelvic CT in examining patients with RLQ pain who were suspected of having appendicitis. We demonstrated the value of obtaining a CT scan of the abdomen and pelvis compared with obtaining a CT scan limited to the RLQ. The observed sensitivity in identifying patients in need of immediate surgery was 96% and would have decreased to 82% if scanning had been limited to only the RLQ.

Our patient population was different from that of Rao and colleagues (10) in several important ways. The majority (n = 63) of patients in our study were adult female patients compared with 27% (27 of 100) pediatric patients in the Rao et al study. Rao and colleagues (10) performed pelvic US in several hundred female patients, and those with gynecologic abnormalities were excluded from their study. In contrast, only six female patients in our study underwent pelvic US within 24 hours after undergoing abdominal CT. More important, in our study, US was not routinely performed in young female patients with RLQ pain to exclude adnexal lesions. Excluding those patients with gynecologic disease established by using US may have resulted in a high pre-examination probability for diagnosing appendicitis at CT in the study by Rao et al (10). This may also explain the 53% (53 of 100) of cases positive for appendicitis in their study compared with the 24% of positive cases in our study. Although US may be diagnostic for appendicitis and other conditions (6,13) and thus obviate CT, the optimal choice between either of these modalities has been debated and in this study was left to the clinician’s preference.

In our patient population, there was a range of gastrointestinal and genitourinary pathologic entities that resulted in RLQ pain simulating appendicitis. Of the 77 cases that were interpreted as negative for appendicitis at CT, 43 (56%) were those of other diseases, and seven of these abnormalities would have been missed at focused CT because of their location alone. The four cases that were not appendicitis but necessitated immediate surgery were perforated duodenal ulcer, small-bowel ischemia, superior mesenteric venous thrombosis, and incarcerated abdominal wall hernia.

In addition to the diverse clinical presentations in our patient group, which increased the range of potential diagnoses, many of the scans were obtained after hours when radiologists with variable CT experience, who often were residents, were involved in the initial interpretation of these studies. This setting is compared with a prior study (10) in which the scans were reviewed and interpreted by a single emergency department radiologist. Our study results suggest that a standardized CT protocol for patients who present with RLQ pain that includes imaging of the abdomen and pelvis with routine oral and intravenous contrast material provides an accurate diagnostic study, even without the preselection of patients who are more likely to have appendicitis. Routine scanning also may improve throughput, because dedicated staff often are not available for tailoring every study.

In studies in which rectal contrast material was administered, better visualization of the appendix (94%) was reported compared with that in the current study without rectal contrast material (72%) (6,10). However, we did not encounter a case in which nonvisualization of the appendix impaired the ability to assess for possible appendicitis. In fact, the false-negative case occurred in a case in which the appendix was well visualized and appeared to be normal. Rectal contrast material may be useful in cases in which clinical suspicion strongly points to appendicitis despite the presence of a normal-appearing appendix at routine scanning. Using a targeted strategy after a more general study has been performed is a common practice in other imaging situations, such as in the evaluation of suspected pancreatic head malignancy, in which additional oral contrast material may be administered to better delineate the bowel (14).

In our retrospective study, we evaluated CT scans that were obtained when patients presented with RLQ pain and the clinical impression was equivocal for appendicitis, although appendicitis was still considered the primary diagnosis. Thus, our patient population represented a selected group with atypical clinical features that warranted further imaging. Our study findings suggest that in patients who present to the emergency department with acute RLQ pain, in whom underlying conditions other than appendicitis may be present, 7-mm contrast-enhanced CT of the abdomen and pelvis is more appropriate than a focused imaging approach of scanning only the RLQ.

	FOOTNOTES

 
Abbreviation: RLQ = right lower quadrant

Author contributions: Guarantors of integrity of entire study, I.R.K., S.N.G.; study concepts, I.R.K., S.N.G., V.R.; study design, I.R.K., S.N.G.; definition of intellectual content, all authors; literature research, I.R.K.; clinical studies, I.R.K., S.N.G.; data acquisition, I.R.K., S.N.G.; data analysis, I.R.K., S.N.G., M.P.R.; statistical analysis, I.R.K., M.P.R.; manuscript preparation, I.R.K., S.N.G., M.T.K.; manuscript editing and review, all authors.

	REFERENCES

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This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kamel, I. R. Articles by Raptopoulos, V. Search for Related Content PubMed PubMed Citation Articles by Kamel, I. R. Articles by Raptopoulos, V.