T he British Journal of Radiology, 71 (1998), 9498 1998 The British Institute of Radiology

Pictorial review
Diseases that simulate acute appendicitis
on ultrasound
T RIPOLLE

S, M J MARTINEZ-PEREZ, V MOROTE and J SOLAZ

Department of Radiology, Dr Peset Hospital, 90 Gaspar Aguilar Av., 46017 Valencia, Spain
Abstract. Ultrasound is useful in the assessment of patients with possible appendicitis. A diagnosis
of appendicitis can be made in patients with persistent right lower quadrant pain when a non-
compressible appendix greater than 6 mm in diameter is shown. When a normal appendix is
aected by an adjacent lesion, reactive inammation can cause secondary enlargement of the
appendix. This article reviews ultrasound ndings in conditions which can clinically mimic acute
appendicitis. Examples of Crohns disease, tuboovarian abscess, typhilitis, sigmoid diverticulitis,
perforated sigmoid neoplasm, perforated peptic ulcer, perforated acute cholecystitis, caecal carci-
noma and appendiceal tumours are included.
Introduction only moderate mural thickening of the appendix
(Figure 2), whereas marked wall thickening of the
Acute appendicitis is the commonest cause of
appendix and mild involvement of the caecum
right lower quadrant pain. Ultrasound with graded
and terminal ileum are features of acute appendi-
compression plays an important role in the diag-
citis. Intraabdominal abscesses may be found on
nosis of patients with right lower quadrant pain
ultrasound in both conditions.
and suspected acute appendicitis. The diagnosis of
The appendix may ll with barium in Crohns
acute appendicitis is made on ultrasound when a
disease (Figure 3), because there is no obstruction
non-compressible, abnormally thickened (>6 mm)
and the appendiceal lumen remains patent [4, 6].
appendix is seen [1]. However, many conditions
In acute appendicitis, the barium will not usually
with a clinical presentation similar to appendicitis
ll the appendix.
can produce periappendiceal inammatory
changes with secondary thickening of the appendix
Tuboovarian abscesses
(periappendicitis), causing a potential pitfall on
ultrasound [2, 3]. The purpose of this article is to
Ultrasound is able to dierentiate accurately
review those diseases which mimic acute appendi-
between pelvic inammatory disease and acute
citis on clinical grounds and on ultrasound, with
appendicitis. The extrinsic inammation from
a description of the ultrasound features that help
tuboovarian abscesses located adjacent to the
to establish a correct diagnosis.
appendix may cause serosal oedema and mural
thickening of the appendix, causing diagnostic
diculties on ultrasound (Figure 4). When there
Crohns disease
is an inammatory mass or abscess near an
Although most patients with Crohns disease
enlarged appendix, an adjacent inammatory con-
only have involvement of the terminal ileum
dition is the probable cause [3] if the echogenic
(Figure 1), the appendix is aected in a minority
submucosal ring of the appendix is intact and no
of cases. It is uncertain if thickening of the
appendicolith is seen.
appendix wall is caused directly by Crohns
disease or is secondary to the surrounding
Typhlitis
inammatory condition. A combination of thick-
Typhlitis occurs in neutropenic patients and ening of the ileum, caecum and appendix can be
results in necrotizing injury to the caecum and
seen in both acute appendicitis and Crohns
ascending colon. Prompt diagnosis is essential to disease [25]. However, it is usually possible to
prevent transmural necrosis and perforation. distinguish these entities on ultrasound. In
Ultrasound shows severe thickening of the right
Crohns disease ultrasound shows severe mural
colonic wall (Figure 5). There is sometimes thickening of the terminal ileum and caecum and
involvement of the appendix, in which visualization
of marked wall thickening of the right colon is the Received 13 June 1997 and accepted 28 August 1997.
T he British Journal of Radiology, January 1998 94
Pictorial review: Diseases simulating appendicitis on US
clue for dierentiating typhilitis from the mild Caecal carcinoma
secondary mural thickening of the caecum which
Caecal carcinoma can clinically mimic acute
is seen in acute appendicitis.
appendicitis, either by presenting as a painful mass
or secondary to perforation. Ultrasound is able to
Sigmoid diverticulitis
distinguish between caecal carcinoma and appendi-
citis. A caecal carcinoma is seen on ultrasound as
Sigmoid diverticulitis is the commonest cause
a solid, hypoechoic, non-compressible mass in the
of acute pain in the left lower abdomen. Normally,
caecal pole. When the tumour invades the base of
the clinical picture is typical and very dierent to
the appendix and causes obstruction of the
acute appendicitis. However, appendicitis may be
appendiceal lumen, either a sterile accumulation
clinically suspected when the diverticular inam-
of mucinous material in the lumen or acute appen-
mation is localized to a right-sided loop of sigmoid
dicitis may develop. The ultrasound features of
or there is complicated extensive sigmoid diverticu-
appendicitis or dilatation of the appendiceal lumen
litis with large abscesses. The appendix may be
with mucus (Figure 10), may then be shown in
secondarily aected if it is located within this large
addition to the tumour [2, 8]. The appearances
inammatory mass. While it is often possible to
on barium examination may be compatible
visualize an enlarged appendix on ultrasound in
with either periappendiceal abscess or caecal
these cases, common ndings of advanced sigmoid
malignancy.
diverticulitis such as mural thickening and
inammed diverticula with or without faecoliths
are also seen [2] (Figure 6). In doubtful cases, a
Appendiceal tumours
CT scan will usually conrm the diagnosis and
Appendiceal neoplasms, such as cystoadenoma
will also demonstrate interloop abscesses. It is
and carcinoid, may cause an enlarged appendix,
theroretically possible for enlargement of the
either by growth of the tumour itself or by obstruc-
appendix to be caused by right-sided diverticulitis.
tion of the appendiceal lumen. Obstruction pro-
duces an accumulation of mucus in the lumen
Perforated sigmoid neoplasm
(mucocele) or a true appendicitis. On ultrasound,
the tumour may be seen as a large hypoechoic Perforated sigmoid carcinoma is clinically indis-
tinguishable from sigmoid diverticulitis. The mech- cystic mass without inammatory signs in the right
lower quadrant [2, 9] ( Figure 11). anism of involvement of the appendix is similar to
that in advanced sigmoid diverticulitis. The appen-
dix may be localized within the large inammatory
mass and show secondary thickening (Figure 7).
These ndings are consistent with either diverticu-
litis or carcinoma [7]. Barium studies or colon-
oscopy and biopsy are necessary to conrm the
diagnosis.
Perforated peptic ulcer
In some patients with perforated peptic ulcer,
the clinical symptoms are similar to appendicitis.
This is because the gastric contents may descend
along the paracolic gutter towards the right lower
quadrant and cause chemical periappendicitis with
thickening of the appendix wall. In these patients,
ultrasound shows a large collection of free uid in
the abdominal cavity and intraperitoneal free air
(accumulated between the liver and the lateral
abdominal wall when the patient is in a left
posterior oblique position) [2] (Figure 8).
Perforated acute cholecystitis
The leaked bile can descend along the paracolic
gutter, causing local peritonitis with reactive thick-
ening of the appendix. Ultrasound features of
Figure 1. Long-axis scan through the inamed ileum
cholecystitis and free uid in the abdominal cavity
shows diuse wall thickening of the terminal ileum (IT)
and caecum (C). suggest this diagnosis (Figure 9).
T he British Journal of Radiology, January 1998 95
T Ripolles, M J Martinez-Perez, V Morote and J Solaz
Figure 2. Cross-sectional scan of the right lower quad-
rant shows a markedly thickened terminal ileum (IT)
and caecal wall (C). The appendix (APP) is visible
behind the caecum.
Figure 3. Small bowel barium examination shows typi-
cal changes of Crohns disease of the terminal ileum (IT).
Appendix (APP) is adjacent to the ileum. Barium lls
an irregular appendiceal lumen.
Figure 4. Periappendicitis from tuboovarian abscess.
Transverse scan of the right lower quadrant shows a
large abscess (ABS) causing secondary thickening of the
appendix (APP) (diameter of 14.4 mm).
(a) (b)
Figure 5. Typhlitis in neutropenic patient with leukemia. (a) A sagittal scan shows a thick-walled caecum (C) and
ascending colon. The appendix (APP) is also aected (diameter of 7.1 mm). ( b) Corresponding CT scan. There is
marked mural thickening of the caecum.
T he British Journal of Radiology, January 1998 96
Pictorial review: Diseases simulating appendicitis on US
(a)
(c)
(b)
Figure 6. Complicated sigmoid diverticulitis with per-
iappendicitis. (a) Cross-sectional scan shows a right-
sided sigmoid (S) with symmetrical wall thickening.
There is secondary enlargement of the appendix (APP)
with a diameter of 11.5 mm. ( b) Transverse scan caudal
to (a) shows hypoechoic mural thickening of the
sigmoid (S) with hyperechoic diverticulum (D) casting
acoustic shadowing. (c) Corresponding CT scan demon-
strates the thickened intestinal loop (S) and extensive
inammation of the mesenteric fat with multiple extralu-
minal gas bubbles. Appendix (APP).
Figure 7. Perforated sigmoid carcinoma. Transverse
scan shows eccentric mural thickening of the sigmoid (S)
with inammatory changes in the pericolic fat. The
Figure 8. Perforated ulcer peptic. Intercostal ultrasound
appendix (APP and arrowhead) is clearly enlarged.
demonstrates free intraperitoneal uid (*) and
Barium study demonstrated an annular lesion with
air (arrows) between the lateral abdominal wall and the
overhanging margins. Surgical specimen showed scir-
liver (L). Air from the lung can be dierentiated by its
rhous carcinoma and periappendicitis.
cranial continuation and change during respiration.
T he British Journal of Radiology, January 1998 97
T Ripolles, M J Martinez-Perez, V Morote and J Solaz
Figure 10. Caecal carcinoma. Sagittal scan depicts a
Figure 9. Cross-sectional scan of the thickened
markedly thickened appendix (APP) contiguous with a
appendix (APP) with a large amount of free uid (*) in
hypoechoic mass representing the caecal carcinoma (C).
a patient that also showed cholecystitis sonographic
ndings.
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