Post on 06-Jul-2018
8/18/2019 Imaging Appendicitis
1/75
Plain film from www.learningradiology.com
Diagnosing Appendicitis
Heather Burns Gunn, HMS IIIGillian Lieberman, MD
Radiology Core
BIDMCNovember 2007
CT, US, MRI all PACS BIDMC
with Imaging
in the Emergency Department
8/18/2019 Imaging Appendicitis
2/75
Let’s meet our patient in the emergency room
8/18/2019 Imaging Appendicitis
3/75
Patient CH: History
24 yo woman presents to ED with 2 days of abdominal pain initially diffuse, crampy pain in epigastric area
pain migrated to RLQ 12 hours ago and becamesharper several episodes of N/V in last 12 hours
denies diarrhea, constipation, melena, BRBPR endorses reduced appetite
8/18/2019 Imaging Appendicitis
4/75
Patient CH: Physical Exam & Labs
Physical exam normal except abdominal
exam Soft, non-distended, tender RLQ
No rebound tenderness
+ Rovsing’s sign (pain in RLQ duringpalpation of LLQ)
Labs of note: WBC: 16.6 with 83% Neutrophils Creatinine: 0.9
8/18/2019 Imaging Appendicitis
5/75
DDx
of RLQ pain
•
GI–
Appendicitis–
Crohn’s
–
Right sided diverticulitis–
Mesenteric adenitis–
Epiploic
appendagitis–
Bowel ischemia–
Right colonic neoplasia–
Infectious ileocolitis–
Mucocele
of the appendix–
Typhilitis–
Sigmoid diverticulitis–
Intussusception–
Pseudomembraneous
or
cytomegalovirus colitis–
Perforated peptic ulcer–
Perforated cholecystitis–
Pancreatitis
•
Renal–
Acute pyelonephritis–
Renal and urinary tract obstruction
•
Gynecological–
Pelvic inflammatory disease–
Hemorrhagic ovarian cyst–
Ovarian vein thrombosis–
Ovarian dermoid
–
Necrotic uterine leiomyoma–
Ovarian torsion–
Endometriosis–
Ruptured ectopic pregnancy
Yu J et al. Helical CT evaluation of acute right lowerquadrant pain. AJR 2005.
8/18/2019 Imaging Appendicitis
6/75
DDx
of RLQ pain
•
GI–
Appendicitis–
Crohn’s
–
Right sided diverticulitis–
Mesenteric adenitis–
Epiploic
appendagitis–
Bowel ischemia–
Right colonic neoplasia–
Infectious ileocolitis–
Mucocele
of the appendix–
Typhilitis–
Sigmoid diverticulitis–
Intussusception–
Pseudomembraneous
or
cytomegalovirus colitis–
Perforated peptic ulcer–
Perforated cholecystitis–
Pancreatitis
•
Renal–
Acute pyelonephritis–
Renal and urinary tract obstruction
•
Gynecological–
Pelvic inflammatory disease–
Hemorrhagic ovarian cyst–
Ovarian vein thrombosis–
Ovarian dermoid
–
Necrotic uterine leiomyoma–
Ovarian torsion–
Endometriosis–
Ruptured ectopic pregnancy
Yu J et al. Helical CT evaluation of acute right lowerquadrant pain. AJR 2005.
8/18/2019 Imaging Appendicitis
7/75
•
COMMON Appendicitis is the most
common cause of acuteabdomen.1
•
EXPENSIVE:In 2004, 300,000 cases
in US alone, totalhealthcare cost of 5.8 billion.2
•
DANGEROUS:Before universal
acceptance ofappendectomy asstandard of care,mortality for appendicitis was more than 50%.3
http://history1900s.about.com/library/photos/blywwiip251.htm
1Davies G et al. The burden of appendicitis relatedhospitalizations in the United States in 1997. Surg
Infect2004.
2 Otero H et al. Imaging utilization in the management of
appendicitis and its impacton
hospital charges. Emerg
Radiol
2007.
3 Weyant MJ et al. Is imaging necessary for the diagnosisof acute appendicitis? Adv Surg 2003.
8/18/2019 Imaging Appendicitis
8/75
Before 1997, because of appendicitis’high mortality rate, surgeons agreed
that a 20% negative appendectomyrate was acceptable.
That is no longer the case . . .
8/18/2019 Imaging Appendicitis
9/75
. . . because of advances in imaging in
emergency departments.
Colson M et al. High negative appendectomy rates are no longer acceptable. Am J Surg
1997.
Rhea J et al. The status of appendiceal
CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 2005.
8/18/2019 Imaging Appendicitis
10/75
. . . because of advances in imaging in
emergency departments.
Colson M et al. High negative appendectomy rates are no longer acceptable. Am J Surg
1997.
Rhea J et al. The status of appendiceal
CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 2005.
PACS BIDMC
Plain film from www.learningradiology.com
8/18/2019 Imaging Appendicitis
11/75
Before we consider our menu of imaging tests
to narrow our diagnosis . . . . What additional lab test should we order forour patient CH?
A pregnancy test!
+ A positive pregnancy test will change our imagingoptions.
-
A negative pregnancy test will remove ectopic pregnancyfrom our differential.
8/18/2019 Imaging Appendicitis
12/75
ACR appropriateness criteria for RLQ Painfever, leukocytosis, and classic presentation for appendicitis in adults
Radiologic Procedure
Rating(1 = least appropriate,
9 = most appropriate)Relative Radiation Level
CT abdomen and pelvis with contrast 8 HighUS abdomen RLQ graded compression 6 None
CT abdomen and pelvis without contrast 6 High
X-ray chest 5 Min
US pelvis transabdominal
and transvaginal 5 NoneX-ray abdomen supine and upright 5 Low
X-ray colon barium enema double-contrast 4 Med
X-ray colon barium enema single-contrast 4 Med
MRI abdomen and pelvis 4 NoneX-ray small bowel series with barium 3 Low
NUC gallium scan abdomen 3 High
NUC WBC scan abdomen pelvis 3 Med
X-ray small bowel enteroclysis 2 Med
www.acr.org
8/18/2019 Imaging Appendicitis
13/75
ACR appropriateness criteria for RLQ Painfever, leukocytosis, pregnant woman
Radiologic Procedure
Rating(1 = least appropriate,
9 = most appropriate)Relative Radiation Level
US abdomen RLQ graded compression 8 NoneMRI abdomen and pelvis 7 None
US pelvis transabdominal
and transvaginal 6 None
CT abdomen and pelvis with contrast X-ray chest 6 High
CT abdomen and pelvis without contrast 5 HighX-ray chest 4 Min
X-ray abdomen supine and upright 2 Low
X-ray colon barium enema double-contrast 2 Med
X-ray small bowel enteroclysis 2 MedX-ray colon barium enema single-contrast 2 Med
NUC WBC scan abdomen pelvis 2 Med
X-ray small bowel series with barium 2 Low
NUC gallium scan abdomen 2 High
www.acr.org
8/18/2019 Imaging Appendicitis
14/75
Not pregnant
1.
CT C+ abd/pelv 2.
US abd
RLQ gradedcompression
3.
CT C-
abd/pelv
4.
X-ray chest
5.
US pelvis transabd
&transvag
Pregnant
1.
US abd
RLQ gradedcompression
2.
MRI abd
and pelvis
3.
US pelvis transabd
&transvag
4.
CT C+ abd/pelv 5.
CT C-
abd/pelv
Comparison of Appropriate Tests
8/18/2019 Imaging Appendicitis
15/75
Pregnant Woman and Appendicitis
•
COMMON: Acute appendicitis is mostcommon surgical emergency
during pregnancy.
1
•
TRICKY:Clinical diagnosis can be difficult2
–
Appendix may have moved due togravid uterus –
pain may notlocalize to RLQ
–
Leukocytosis
can be physiologicalduring pregnancy
–
Nausea and vomiting common in both pregnancy and appendicitis
•
DANGEROUS:
In appendicitis, fetal loss is morethan 30% with ruptured appendixand 2% with unruptured
appendix.3
1 Cobben L et al. MRI for clinically suspected appendicitis during pregnancy. AJR 2004.2,3 Birchard K et al. MRI of acute abdominal and pelvic pain in pregnant patients. AJR 2005.
MR Abdomen –
Sagittal: PACS BIDMC
8/18/2019 Imaging Appendicitis
16/75
Consideration in imaging the appendix
(besides whether or not patient ispregnant or a child):
Where is the appendix?
8/18/2019 Imaging Appendicitis
17/75
Anterior view Posterior view
Tamburrini S et al. CT appearance of the normal appendixin adults. Eur Radiol 2005.
Variability in the location of the appendix
8/18/2019 Imaging Appendicitis
18/75
Anterior view Posterior view
Tamburrini S et al. CT appearance of the normal appendixin adults. Eur Radiol 2005.
Variability in the location of the appendix
18%
26%
MostMost
commoncommon
locationslocations
8/18/2019 Imaging Appendicitis
19/75
Exploring the Menu of Tests
•
Plain films
•
Ultrasound•
MRI
•
CT
8/18/2019 Imaging Appendicitis
20/75
Exploring the Menu of Tests
••
Plain filmsPlain films
•
Ultrasound•
MRI
•
CT
8/18/2019 Imaging Appendicitis
21/75
AbdominalPlain Films
•
Abdominal plain films areneither sensitive nor specificfor acute appendicitis.1
•
X-ray of chest often ordered
in acute abdomen–
to check for free air underdiaphragm
–
because chest disease cansimulate abdominal
conditions.2•
Some radiographic signs ofacute appendicitis:3
–
Appendicolith
–
Scoliosis–
RLQ fluid levels–
Ileus–
Bowel wall edema
1Rao P et al. Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT. American Journalof Emergency Medicine 1999.2Greene C. Indications for plain abdominal radiography in the emergency department. Annals of Emergency Medicine 1986.3Olutola PS. Plain film radiographic diagnosis of acute appendicitis: an evaluation of the signs. Can Assoc Radiol J. 1988.
Abdominal plain film of appendicoliths
from www.learningradiology.com
Companion Patient 1: Abdominal Plain Film of Appendicitis
8/18/2019 Imaging Appendicitis
22/75
Supine abdominal plain filmUpright abdominal plain film
Altering position of this pediatricpatient revealed two different
radiographic signs of appendicitis.
Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html
AbdominalPlain Films
of Appendicitis
Companion
patient 2
8/18/2019 Imaging Appendicitis
23/75
Supine abdominal plain filmUpright abdominal plain film
Altering position of this pediatricpatient revealed two different
radiographic signs of appendicitis.
Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html
Scoliosis dueto RLQsplinting
Appendicolith
AbdominalPlain Films
of Appendicitis
Companion
patient 2
8/18/2019 Imaging Appendicitis
24/75
Supine abdominal plain filmUpright abdominal plain film
Altering position of this pediatricpatient revealed two different
radiographic signs of appendicitis.
Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html
AbdominalPlain Films
of Appendicitis
Scoliosis dueto RLQsplinting
Appendicolith
Companion
patient 2
8/18/2019 Imaging Appendicitis
25/75
Exploring the Menu of Tests
•
Plain films √
••
UltrasoundUltrasound•
MRI
•
CT
8/18/2019 Imaging Appendicitis
26/75
Ultrasound
•
No radiation exposure –
good for pregnant women and children•
Patient need not be cooperative –
good for children•
Sensitivity for diagnosing appendicitis = 0.861
•
Specificity for diagnosing appendicitis = 0.812
•
Findings on ultrasound:3
–
Appendiceal
Findings•
Diameter of appendix ≥ 6 mm MOST SENSITIVE AND SPECIFIC FINDING•
Lack of compressibility of appendix 2ND MOST SENSITIVE AND SPECIFIC•
Intraluminal
fluid•
Doppler flow in wall
–
Periappendiceal
Findings•
Inflammatory fat changes•
Cecal
wall thickening
•
Periileal
lymph nodes•
Peritoneal fluid
1,2 Terasawa
T et al. Systematic review: computed tomography and ultrasonography
to detect acute appendicitis in adults andadolescents. Ann Inten Med 2004.3 Kessler N et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratoryfindings. Radiology 2004.
8/18/2019 Imaging Appendicitis
27/75
Ultrasound of Appendicitis
Appendix diameteris larger than 6 mm
PACS BIDMC
Note how roundappendix is despite
compression withultrasoundtransducernon-compressibleappendix
Companion Patient 3
8/18/2019 Imaging Appendicitis
28/75
PACS BIDMC
Intraluminal
fluid Doppler flow in wall
Ultrasounds of Appendicitis
Companion Patient 4 Companion Patient 5
8/18/2019 Imaging Appendicitis
29/75
Why would you ever use anything else
to diagnose appendicitis in pregnant women?
•
The Drawbacks to US:– Graded compression US is sometimes not
feasible because of enlarged uterus1
– Negative predictive value of nonvisualized
appendix is .902
1Pedrosa I et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology 2006.2Kessler N et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 2004.
8/18/2019 Imaging Appendicitis
30/75
Exploring the Menu of Tests
•
Plain films √
•
Ultrasound √ ••
MRIMRI
•
CT
8/18/2019 Imaging Appendicitis
31/75
MRI
•
No radiation exposure –
good for pregnant women
•
Sensitivity for diagnosing appendicitis = 1.001
•
Specificity for diagnosing appendicitis = 0.942
•
Findings on MRI:3
–
Diameter of appendix ≥ 6 mm
–
Thickening of appendiceal
wall with high intensity on T2 weighted images
–
Dilated lumen filled with high intensity material on T2 weighted
images
–
Increased intensity of periappendiceal
tissue on T2 weightedimages
1,2 Pedrosa
I et al. MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006.3
Nitta N et al. MR imaging of the normal appendix and acute appendicitis. Journal of Magnetic Resonance Imaging 2005.
8/18/2019 Imaging Appendicitis
32/75
MRI of appendicitis
in a pregnant woman
PACS BIDMC
•
Appendixdiameter ≥ 6 mm
• Dilated lumenfilled with high
intensity material
Companion Patient 6: MR T2
SSFSE ( S ingle S hot F ast S pin E cho)
Coronal
8/18/2019 Imaging Appendicitis
33/75
PACS BIDMC
Appendix is dilated
Appendiceal
walls are
thickened and highintensity
Increased intensity ofperiappendiceal
tissue
indicatinginflammatory changes
Companion Patient 7: MR T2
SSFSE ( S ingle S hot F ast S pin E cho)
Coronal
MRI of appendicitis
in a pregnant woman
8/18/2019 Imaging Appendicitis
34/75
Exploring the Menu of Tests
•
Plain films √
•
Ultrasound √ •
MRI √
••
CTCT –
test of choice for non-pregnant adults
} for children and pregnant women
} for pregnant women
8/18/2019 Imaging Appendicitis
35/75
CT•
Test of choice for non-pregnant adults and adolescents•
CT is credited with drop in negative appendectomy rate from 20% to 3%1
•
Since CT provides view of entire abdomen and pelvis (unlike US),
otherdiagnoses may be made.
•
Sensitivity for diagnosing appendicitis = 0.992
•
Specificity for diagnosing appendicitis = 0.953
•
Findings on CT:4
–
Diameter of appendix ≥ 6 mm
–
Periappendiceal
inflammatory changes•
Fat stranding•
Fluid collections•
Phlegmon•
Abscess formation
–
Wall thickness ≥ 3 mm
–
Extraluminal
air–
Adjacent adenopathy –
Adjacent bowel wall thickening–
Focal cecal
wall thickening
1,2,3Rhea J et al. The status of appendiceal
CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 2005.4Moteki T et al. New CT criterion for acute appendicitis: maximum depth of intraluminal appendiceal fluid. AJR 2007.
CT C l R t ti f A di iti
8/18/2019 Imaging Appendicitis
36/75
CT Coronal Reconstruction of Appendicitis:Companion Patient 8
Focal cecal
wall
thickening.
Extensive fatstranding.
Dilated appendix.
PACS BIDMC
8/18/2019 Imaging Appendicitis
37/75
Where’s the appendix?
PACS BIDMC
Axial CT of appendicitis: Companion Patient 9
8/18/2019 Imaging Appendicitis
38/75
PACS BIDMC
Axial CT of appendicitis: Companion Patient 9
Dilated appendix, not filling with contrast
Axial CT of Appendicitis:
8/18/2019 Imaging Appendicitis
39/75
PACS BIDMC
Dilated appendix, not filling with contrast.
Axial CT of Appendicitis:Companion Patient 10
A i l CT f A di iti
8/18/2019 Imaging Appendicitis
40/75
PACS BIDMC
Appendixnot filling
with contrast
Axial CT of Appendicitis:Companion Patient 11
Axial CT of Appendicitis:
8/18/2019 Imaging Appendicitis
41/75
Fatstranding
Dilated appendix
PACS BIDMC
Axial CT of Appendicitis:Companion Patient 12
8/18/2019 Imaging Appendicitis
42/75
PACS BIDMC
Where is thisman’s inflamedappendix?
Look for the fat
stranding.
Axial CT of Appendicitis:Companion Patient 13
8/18/2019 Imaging Appendicitis
43/75
An aside: do younotice any otherabnormality in thisman’s pelvis?
Axial CT of Appendicitis:Companion Patient 13
PACS BIDMC
8/18/2019 Imaging Appendicitis
44/75
A kidneytransplanted
into thepelvis.
PACS BIDMC
CT Coronal
Reconstruction of Appendicitis:Companion Patient 13
8/18/2019 Imaging Appendicitis
45/75
8/18/2019 Imaging Appendicitis
46/75
PACS BIDMC
Appendix is filled with contrast.
Appendix diameter= 5.0 mm (less than
6.0 mm)No periappendicealinflammatorychanges to be seen!
Normal appendix
Coronal Reconstruction CT: Companion Patient 14
8/18/2019 Imaging Appendicitis
47/75
Back to our patient CH . . .
• she wasn’t pregnant
• her renal function was fine (creatinine
was 0.9)
. . . so she was given a CT scan
with contrast.
P i CH A i l CT
8/18/2019 Imaging Appendicitis
48/75
PACS BIDMC
Patient CH: Axial CT
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
49/75
Patient CH: Axial CT
PACS BIDMC
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
50/75
Patient CH: Axial CT
PACS BIDMC
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
51/75
Patient CH: Axial CT
PACS BIDMC
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
52/75
Patient CH: Axial CT
PACS BIDMC
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
53/75
Patient CH: Axial CT
PACS BIDMC
P ti t CH A i l CT
8/18/2019 Imaging Appendicitis
54/75
Patient CH: Axial CT
PACS BIDMC
Patient CH: Axial CT
8/18/2019 Imaging Appendicitis
55/75
Patient CH: Axial CT
PACS BIDMC
Patient CH: Axial CT
8/18/2019 Imaging Appendicitis
56/75
Let’s find the appendix.
Patient CH: Axial CT
PACS BIDMC
8/18/2019 Imaging Appendicitis
57/75
PACS BIDMC
An elongated anddilated appendix.
Considerable fatstranding (as well as air inappendiceal
lumen)
Patient CH:
Axial CTs
8/18/2019 Imaging Appendicitis
58/75
PACS BIDMC
An elongated anddilated appendix.
Considerable fatstranding (as well as air inappendiceal
lumen)
Diagnosis:Diagnosis:acuteacute
appendicitis!appendicitis!
Patient CH:
Axial CTs
8/18/2019 Imaging Appendicitis
59/75
We have our diagnosis butlet’s look at the coronal
reconstructions as well.
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
60/75
PACS BIDMC
Patient CH s CT: Coronal Reconstruction
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
61/75
Patient CH s CT: Coronal Reconstruction
PACS BIDMC
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
62/75
Patient CH s CT: Coronal Reconstruction
PACS BIDMC
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
63/75
PACS BIDMC
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
64/75
PACS BIDMC
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
65/75
PACS BIDMC
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
66/75
Some individual
coronal slices.
PACS BIDMC
8/18/2019 Imaging Appendicitis
67/75
Patient CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
68/75
PACS BIDMC
Air inappendixlumen doesnot rule outappendicitis. Air is presentin lumen of
appendix inover 15% ofcases ofappendicitis
imaged onCT.1
1Rao P et al. Appendiceal and peri-appendiceal air at CT: prevalence,appearance, and clinical significance. Clin Radiol 1997.
Patient CH s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
69/75
•
The patient CH was taken to OR
•
Laparoscopic appendectomy
•
Pathological findings: erythematous
appendix, measuring 9.5 cm in length,average of 1.2 cm in diameter. Dilatedlumen of up to 0.8 cm containing some
fecal material.•
After removing the appendix and
irrigating the abdomen, the surgeonsturned the case over to a different team –
can you guess which kind?
8/18/2019 Imaging Appendicitis
70/75
Take another look at the CT
coronal reconstruction . . . .
CH’s CT: Coronal Reconstruction
8/18/2019 Imaging Appendicitis
71/75
PACS BIDMC
Retrocecal
appendix
Right ovarianRight ovarian dermoiddermoid
cystcyst
8/18/2019 Imaging Appendicitis
72/75
•
Ob/Gyn
service felt it was not prudent to
remove dermoid
at this time.•
Patient was discharged from hospital twodays later with plans for Ob/Gyn
followup.
8/18/2019 Imaging Appendicitis
73/75
Many thanks to . . .
•
Gillian Lieberman, MD
•
Melissa Gerlach, MD
•
Bettina Siewert, MD
•
Anne Catherine Kim, MD
•
Rich Rana, MD
•
Andrew Hines-Peralta, MD
•
Maria Levantakis
8/18/2019 Imaging Appendicitis
74/75
8/18/2019 Imaging Appendicitis
75/75