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Pictorial Essay

.:... S.
... rT;
Diagnosis of Appendicitis: Imaging Findings in Patients
with Atypical Clinical Features
Carol H. Wong,1 Thanh-Mai Trinh,1 Andrew N. Robbins,1 Scott J. Rowen,2 and Allen J. Cohen1

Acute appendicitis is usually diagnosed on the basis of Abnormal Appendiceal Position

signs, symptoms, and results of simple laboratory tests. How-
ever, in patients with atypical clinical features, imaging studies The position of the appendix can vary considerably, both
play a significant role in preoperative diagnosis and determina- in relation to the cecum and because of the inconsistent
tion of proper treatment. In this pictorial essay, we present a
position of the cecum itself. Approximately one third of
spectrum of imaging findings in patients whose clinical fea-
patients with appendicitis have localized pain outside of the
tures were unusual because of the abnormal position of the
right lower quadrant [1]. It is important to identify the cecum
appendix, the presence of other Illnesses, or the presence of
complications in children. Appendicitis was not initially consid- on CT so that an abnormal appendiceal location will be rec-
ered on clinical presentation in any of our cases. In most ognized (Fig. 1).
cases, the correct diagnosis of appendicitis was made or, at The relationship of the base of the appendix to the cecum
least in retrospect, could have been made on the basis of imag- is essentially constant, but the free end of the appendix can
ing findings. occupy any position: directed medially, caudally, laterally, or

Fig. 1 .-Malrotation of cecum with abnormal

position of appendix in left upper quadrant. A
42-year-old man had several attacks of pain In
midepigastric area and left upper quadrant for
2 years. At surgery, appendiceal perforation
was found.
A, Initial CT scan shows inflammatory
changes (arrows) in mesentery of left upper
quadrant of abdomen. Cecum was not opaci-
fled, and malrotation was not recognized.
B, CT scan 1 year later at a similar level
shows an opacified cecum and ileocecal valve
(arrow) in left upper quadrant, indicating mal-
rotation. (Courtesy of Lee Mitchel, Dallas, TX.)

Aeceived June 28, 1993; accepted after revision August 4, 1993.

I Department of Radiological Sciences, University of California, Irvine Medical Center, lOi City Dr., Orange, CA 92668-3298. Address correspondence to A. J.
Cohen.
2Department of Aadiology, St. Joseph Hospital/Childrens Hospital of Orange County, 1100 W. Stewart Dr., Orange, CA 92668.
AJR i993;i61 :1199-1203 0361-803X/93/i6i6-i 199 American Aoentgen Aay Society
 1200 WONG ET AL. AJA:i6i, December 1993

retrocecally [2]. The appendix can extend across the midline Appendicitis In the Presence of Other Illnesses
and mimic diverticulitis of the sigmoid colon (Fig. 2). It may In patients who have preexisting chronic medical ill-
be difficult to determine the cause of extrinsic inflammation nesses, appendicitis may be overlooked (Fig. 4). Sometimes
involving bowel loops of the left lower quadrant with contrast
more than one illness may be present. Diagnosis of appendi-
enema or small-bowel series. Careful examination of inflam- citis can be particularly difficult in patients with a history of
matory changes of the cecum and appendix on CT can chronic gastrointestinal disorder, such as Crohns disease
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assist in making the correct diagnosis. (Fig. 5).

Although appendicitis is known to mimic right-sided adnexal
inflammation in women of reproductive age, the appendix
may also extend across the midline, mimicking disease of the Appendicitis with Atypical Features In Children
adnexa uteri on the left side. CT may clarify sonographic find- Appendiceal perforation may result in either diffuse perito-
ings in these patients (Fig. 3). nitis or localized abscesses. Appendiceal abscesses with

A B C
Fig. 2.-Abnormal position of appendix In left lower quadrant, mimicking diverticulitis of sigmoid colon. A 43-year-old woman had a 7-day history of
progressive diffuse abdominal pain radiating to left lower quadrant, associated with nausea, vomiting, and marked leukocytosls but no fever. Appendi-
citis was prospectively diagnosed with CT. At surgery, a periappendiceal abscess was found.
A, Small-bowel serIes shows angulation and spiculation of small bowel at level of distal part of jejunum in left lower quadrant (arrows), suggesting
an extrinsic Inflammatory lesion, possibly diverticulitis.
B, CT scan of pelvis shows a midpelvlc abscess (arrow).
C, CT scan 2 cm higher shows inflammatory mass compressing cecum (soildarrow), indicating appendiceal origin of midpelvic abscess (open arrow).

Fig. 3.-Abnormal position of appendix In left lower quadrant, mimicking disease of adnexa uteri on left side. A 32-year-old woman had a 10-day his-
tory of pain in lower part of abdomen and left adnexal tenderness. Sonography showed a normal uterus and adnexa but a complex mass In left upper
part of pelvis. Diverticulitis and a perforating sigmoid colon carcinoma were then considered clinically. Appendicitis was prospectively diagnosed with
CT. At surgery, a ruptured leftward-directed appendix with matted cecum, ileum, and slgmoid colon was resected.
A, CT scan of upper part of pelvis shows an inhomogeneous solid mass to left of midline with an appendicolith (arrow), Indicating appendicitis with
localized perforation.
B, CT scan of pelvis 1 cm inferior to A shows thickened sigmoid colon (arrow).
C, Water-soluble contrast enema showed benign stricture of sigmoid colon (arrow), ruling out a perforating carcinoma.
 AJA:i61,Decemberl993 IMAGING OF APPENDICITIS 1201

atypical signs and symptoms in children may be confused Liver abscess (Fig. 8) and pylephlebitis in children with
with congenital or other childhood disorders, such as complicated appendicitis were previously reported by Slovis
infected mesenteric or urachal cysts [3] (Fig. 6). Appendicitis et al. [4]. Venous drainage of the appendix is via the superior
can also mimic a malignant pelvic tumor (Fig. 7). Knowledge mesenteric vein into the portal vein. The inflamed portal vein
of the patients clinical history can be misleading instead of may act as a conduit to the liver for bacteria or it may become
helpful in interpreting imaging studies. thrombosed and cause portal hypertension, cavernous trans-
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A
Fig. 4.-Delayed diagnosis of appendicitis in presence of uncontrolled diabetes mellitus. A 48-year-old woman with diabetes had intermittent, sharp
periumbilical abdominal pain associated with fever, chills, anorexia, nausea, and vomiting. Uncontrolled diabetes was diagnosed, and her abdominal
symptoms were thought to be related. However, unresolved abdominal symptoms led to imaging studies 3 weeks later. At laparotomy, a perforated ret-
rocecal appendix with chronic pericolic inflammation was found.
A, Barium enema shows confined perforation (straight solid arrows) of a retrocecal appendix (curved arrow) and a pericecal mass (open arrows).
B, Confirmatory CT scan shows inflammatory changes in cecal region and a fluid-filled, dilated retrocecal appendix (arrow).

Fig. 5.-Appendicitis overlooked in presence of Crohns disease. A 49-year-old woman with a 7-year history of Crohns disease had pain in lower
part of abdomen, severe diarrhea, and a 16-lb (7 kg) weight loss In 1 month. Barium enema shows a persistently narrowed segment of distal part of
ileum (arrows), approximately 10 cm proximal to iieocecal valve, thought to be compatible with Crohns entenitis. The significance of a normal terminal
ileum and nonfilling of appendix was not recognized prospectively. Patient ultimately underwent a right hemicolectomy. Pathologic examination
revealed chronic appendicitis with no evidence of Crohns entenltis.

Fig. 6.-Appendiceal perforation with localized abscess, mimicking mesenteric or duplication cyst. An 11-year-old boy had a 4-day history of pen-
umbilical abdominal pain associated with tactile fever, vomiting, and dysunia. CT scan of pelvis shows a mass of soft-tissue density (white box) with a
cystic center about 2 cm above dome of bladder. Mass was thought to be too far posterior to be a urachal cyst, but an Infected on noninfected mesen-
tenic on duplication cyst was considered because of Its central location. The radiologists inclusion of appendicitis in the differential diagnosis was
rejected clinically. At surgery, a ruptured appendix and a walled-off abscess were found.
 1202 WONG ET AL. AJA:i6i, December 1993
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Fig. 7.-Appendiceal perforation with localized pelvic abscess, mimicking pelvic sarcoma. A 2-year-old girl had a 3-week history of midline pain in
lower part of abdomen associated with intermittent fever and difficulty urinating and defecating. Congenital urinary abnormalities or possible pelvic
sarcoma were suspected clinically. Significance of cystic nature of mass on CT, more compatible with an abscess, was not recognized preoperatively.
A transrectal needle biopsy yielded benign reactive cells only. At surgery, a perforated appendix with its tip In pelvic abscess was found.
A, Cystogram with rectal contrast material shows a large mass (arrows) between bladder and rectum.
B, Sonogram shows a 7.0 x7.0 x 4.5 cm complex mass (arrows) in pelvis associated with right-sided hydronephrosis.
C, CT scan of pelvis shows a large, predominantly cystic pelvic mass (arrows).

Fig. 8.-Complicated appendicitis in children: hepatic abscesses. An il-year-old boy had pain in right upper quadrant and fever. Sonograms
showed two hepatic lesions and splenomegaly, clinically suggesting lymphoma or leukemia. Abnormal appearance of appendix on CT was not recog-
nized prospectively. At laparotomy, perforating appendicitis was found. Masses in liver were hepatic abscesses.
A, CT scan of liver shows two low-density masses (arrows) that were thought to be metastases.
B, CT scan at a lower level shows a thick-walled appendix (solid arrow) with a peniappendiceal abscess and extraluminal gas bubble (open arrow)
compatible with perforated appendix. (Courtesy of Royce Chrys, Oakland, CA.)

formation, and hypersplenism. With the advent of modern the influence of gravity. When the inflammation involves the
antibiotics, these complications are rare but they do occur. In rectosigmoid colon, marked cramps in the lower part of the
children, the presence of low-density areas in the liver should abdomen and severe diarrhea can occur.
suggest the possibility of hepatic abscesses, and inflamma- Early appendiceal perforation in children may occasionally
tory disease of the appendix needs to be considered. produce a dilated transverse colon sign (Fig. 1 0) on ab-
An unusual manifestation of diffuse peritonitis due to dominal radiographs, as previously described by Swischuk
appendiceal perforation in children is severe diarrhea (Fig. and Hayden [6]. The transverse colon is dilated, the cecum
9). Picus and Shackelford [5] previously reported nine chil- and ascending colon are empty, and an abrupt zone of
dren with perforated appendices who had severe diarrhea. demarcation is present between the two areas. This is most
All nine patients had spasm and irregularity of the rectosig- often seen on a plain film obtained with the patient supine
moid colon shown by barium enema. The explanation is that, and is believed to result from a combination of paralytic ileus
after rupture of the appendix, inflammatory exudate flows of the transverse colon and spasm of the ascending colon
along peritoneal reflections and settles in the pelvis under due to appendiceal perforation.
 AJA:i6i, December 1993 IMAGING OF APPENDICITIS 1203
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Fig. 9.-Complicated appendicitis in children: Fig. 10.-Early appendiceal perforation with dilated transverse colon sign seen on plain film.
severe diarrhea. An 18-month-old girl had a 3- A 2-year-old boy had a 2-day history of pain in epigastnic area and right upper quadrant associated
day history of fever, vomiting, and diarrhea. with bilious vomiting and fever. Appendicitis was suggested on review of abdominal radiograph
Occult blood was found in stool. Barium enema and confirmed on barium enema. At surgery, acute nonperforating appendicitis was found.
showed mucosal irregularity of proximal part of A, Abdominal radiograph of supine patient shows a dilated transverse colon sign, which is
ascending colon and rectosigmoid colon most commonly seen with pancreatitis but may be seen with early appendiceal perforation.
(arrows), thought to be compatible with clinical B, Barium enema shows a defect of medial cecum and nonfilling of appendix.
diagnosis of infectious colitis. Significance of
sparing of transverse colon was not recognized.
Patient remained febnile 2 days later and had
increasing abdominal distension with impend-
ing respiratory failure. At exploratory laparot-
omy, a perforated appendix with multiple intra-
abdominal abscesses was found.

REFERENCES urachal cyst (letter). N V State J Med i992;92:365

4. Slovis TL, HaIler JO, Cohen HL, Berdon WE, Watts FB Jr. Complicated
1. Aamsden WH, Mannion AAJ, Simpkins KC, deDombal FT. Is the appen- appendiceal inflammatory disease in children: pylephlebitis and liver
dix where you think it is-and if not, does it matter? Clin Radio! 1992;47: abscess. Radiology 1989;171 :823-825
100-103 5. Picus D, Shackelford GD. Perforated appendix presenting with severe
2. Schwartz SI, Shires GT, Spencer FC. Principles of surgery, 5th ed. New diarrhea. Radiology 1983;149:i41-143
York: McGraw-Hill, 1989:1315 6. Swischuk LE, Hayden CK Jr. Appendicitis with perforation: the dilated
3. Sawczuk IS, Brown W. Appendiceal abscess presenting as an infected transverse colon sign. AJR 1980;i35:687-689