Acute appendicitis in children: Diagnostic imaging
- George A Taylor, MD
George A Taylor, MD
- John A Kirkpatrick Professor of Radiology (Pediatrics)
- Harvard Medical School
- David E Wesson, MD
David E Wesson, MD
- Professor of Surgery
- Baylor College of Medicine
- Section Editor
- Jonathan I Singer, MD
Jonathan I Singer, MD
- Section Editor — Pediatric Surgical Emergencies
- Professor of Emergency Medicine and Pediatrics
- Wright State University Boonshoft School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Appendicitis is the most common condition in children requiring emergency abdominal surgery . The key to a successful outcome has always been early diagnosis followed by appendectomy before gangrene or perforation develops. Nevertheless, confirming the diagnosis of appendicitis and avoiding the risks of unnecessary surgery continue to be a challenge, particularly in young children .
Imaging plays an important role in the evaluation of patients who do not present with the classic signs and symptoms of appendicitis but in whom the diagnosis is being considered. Ultrasonography (US) and computed tomography (CT), separately or in combination, are the modalities used most frequently. In addition, there are data that suggest that using an imaging protocol improves diagnostic accuracy.
This topic will review diagnostic imaging for acute appendicitis in children. The epidemiology, clinical features, diagnosis, and treatment of appendicitis in children are discussed separately. (See "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute appendicitis in children: Management".)
The decision to perform imaging in the diagnostic evaluation of children with abdominal pain is determined by clinical findings and the setting as follows (algorithm 1):
●Low clinical likelihood of appendicitis – Imaging is not warranted in most children who are unlikely to have appendicitis based upon the clinical examination and laboratory studies. (See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical suspicion'.)
- Sivit CJ. Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Pediatr Radiol 2004; 34:447.
- Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002; 137:799.
- Surgical Advisory Panel, American Academy of Pediatrics, Klein MD. Referral to pediatric surgical specialists. Pediatrics 2014; 133:350.
- Right lower quadrant pain - suspected appendictis. Variant 4: Fever, leukocytosis, possible appendicitis, atypical presentation in children (younger than age 14). ACR Appropriateness Criteria. American College of Radiology (ACR), 2013. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightLowerQuadrantPainSuspectedAppendicitis.pdf (Accessed on April 15, 2014).
- Schuh S, Chan K, Langer JC, et al. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med 2015; 22:406.
- Sulowski C, Doria AS, Langer JC, et al. Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis. Acad Emerg Med 2011; 18:167.
- Paulson EK, Harris JP, Jaffe TA, et al. Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT. Radiology 2005; 235:879.
- Bachur RG, Hennelly K, Callahan MJ, Monuteaux MC. Advanced radiologic imaging for pediatric appendicitis, 2005-2009: trends and outcomes. J Pediatr 2012; 160:1034.
- Bachur RG, Levy JA, Callahan MJ, et al. Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis. JAMA Pediatr 2015; 169:755.
- Richards MK, Kotagal M, Goldin AB. Campaigns Against Ionizing Radiation and Changed Practice Patterns for Imaging Use in Pediatric Appendicitis. JAMA Pediatr 2015; 169:720.
- Vainrib M, Buklan G, Gutermacher M, et al. The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis. Pediatr Surg Int 2011; 27:981.
- Dilley A, Wesson D, Munden M, et al. The impact of ultrasound examinations on the management of children with suspected appendicitis: a 3-year analysis. J Pediatr Surg 2001; 36:303.
- Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Acad Emerg Med 2013; 20:697.
- Garcia Peña BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 1999; 282:1041.
- Baldisserotto M, Marchiori E. Accuracy of noncompressive sonography of children with appendicitis according to the potential positions of the appendix. AJR Am J Roentgenol 2000; 175:1387.
- Goldin AB, Khanna P, Thapa M, et al. Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Pediatr Radiol 2011; 41:993.
- Scammell S, Lansdale N, Sprigg A, et al. Ultrasonography aids decision-making in children with abdominal pain. Ann R Coll Surg Engl 2011; 93:405.
- Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology 2006; 241:83.
- Binkovitz LA, Unsdorfer KM, Thapa P, et al. Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 2015; 45:1934.
- Fallon SC, Orth RC, Guillerman RP, et al. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol 2015; 45:1945.
- Bachur RG, Dayan PS, Bajaj L, et al. The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis. Ann Emerg Med 2012; 60:582.
- Anandalwar SP, Callahan MJ, Bachur RG, et al. Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. J Am Coll Surg 2015; 220:1010.
- Cohen B, Bowling J, Midulla P, et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg 2015; 50:923.
- Schuh S, Man C, Cheng A, et al. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. J Pediatr 2011; 158:112.
- Sivitz AB, Cohen SG, Tejani C. Evaluation of acute appendicitis by pediatric emergency physician sonography. Ann Emerg Med 2014; 64:358.
- Lee JH, Jeong YK, Hwang JC, et al. Graded compression sonography with adjuvant use of a posterior manual compression technique in the sonographic diagnosis of acute appendicitis. AJR Am J Roentgenol 2002; 178:863.
- Menten R, Lebecque P, Saint-Martin C, Clapuyt P. Outer diameter of the vermiform appendix: not a valid sonographic criterion for acute appendicitis in patients with cystic fibrosis. AJR Am J Roentgenol 2005; 184:1901.
- Mullins ME, Kircher MF, Ryan DP, et al. Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. AJR Am J Roentgenol 2001; 176:37.
- Lowe LH, Penney MW, Stein SM, et al. Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. AJR Am J Roentgenol 2001; 176:31.
- Sivit CJ, Applegate KE, Stallion A, et al. Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT. AJR Am J Roentgenol 2000; 175:977.
- Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001; 176:289.
- Klig JE. Issues of computerized tomography scans in children and implications for emergency care. Curr Opin Pediatr 2006; 18:231.
- Brody AS, Frush DP, Huda W, et al. Radiation risk to children from computed tomography. Pediatrics 2007; 120:677.
- Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
- Grayson DE, Wettlaufer JR, Dalrymple NC, Keesling CA. Appendiceal CT in pediatric patients: relationship of visualization to amount of peritoneal fat. AJR Am J Roentgenol 2001; 176:497.
- Martin AE, Vollman D, Adler B, Caniano DA. CT scans may not reduce the negative appendectomy rate in children. J Pediatr Surg 2004; 39:886.
- Partrick DA, Janik JE, Janik JS, et al. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediatr Surg 2003; 38:659.
- Kosloske AM, Love CL, Rohrer JE, et al. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics 2004; 113:29.
- York D, Smith A, Phillips JD, von Allmen D. The influence of advanced radiographic imaging on the treatment of pediatric appendicitis. J Pediatr Surg 2005; 40:1908.
- Aspelund G, Fingeret A, Gross E, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics 2014; 133:586.
- Antevil JL, Rivera L, Langenberg BJ, et al. Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation. J Am Coll Surg 2006; 203:849.
- Hernandez JA, Swischuk LE, Angel CA, et al. Imaging of acute appendicitis: US as the primary imaging modality. Pediatr Radiol 2005; 35:392.
- Bachur RG, Hennelly K, Callahan MJ, et al. Diagnostic imaging and negative appendectomy rates in children: effects of age and gender. Pediatrics 2012; 129:877.
- Kaiser S, Finnbogason T, Jorulf HK, et al. Suspected appendicitis in children: diagnosis with contrast-enhanced versus nonenhanced Helical CT. Radiology 2004; 231:427.
- Callahan MJ, Rodriguez DP, Taylor GA. CT of appendicitis in children. Radiology 2002; 224:325.
- Kharbanda AB, Taylor GA, Bachur RG. Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology 2007; 243:520.
- Laituri CA, Fraser JD, Aguayo P, et al. The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography. J Surg Res 2011; 170:100.
- Servaes S, Srinivasan A, Pena A, et al. CT diagnosis of appendicitis in children: comparison of orthogonal planes and assessment of contrast opacification of the appendix. Pediatr Emerg Care 2015; 31:161.
- Taylor GA. Suspected appendicitis in children: in search of the single best diagnostic test. Radiology 2004; 231:293.
- Fefferman NR, Roche KJ, Pinkney LP, et al. Suspected appendicitis in children: focused CT technique for evaluation. Radiology 2001; 220:691.
- Donnelly LF, Emery KH, Brody AS, et al. Minimizing radiation dose for pediatric body applications of single-detector helical CT: strategies at a large Children's Hospital. AJR Am J Roentgenol 2001; 176:303.
- Verdun FR, Lepori D, Monnin P, et al. Management of patient dose and image noise in routine pediatric CT abdominal examinations. Eur Radiol 2004; 14:835.
- Singh S, Kalra MK, Moore MA, et al. Dose reduction and compliance with pediatric CT protocols adapted to patient size, clinical indication, and number of prior studies. Radiology 2009; 252:200.
- Kleinman PL, Strauss KJ, Zurakowski D, et al. Patient size measured on CT images as a function of age at a tertiary care children's hospital. AJR Am J Roentgenol 2010; 194:1611.
- Frush DP. Radiation, CT, and children: the simple answer is ... it's complicated. Radiology 2009; 252:4.
- Didier RA, Vajtai PL, Hopkins KL. Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatr Radiol 2015; 45:181.
- Paterson A, Frush DP, Donnelly LF. Helical CT of the body: are settings adjusted for pediatric patients? AJR Am J Roentgenol 2001; 176:297.
- http://spr.affiniscape.com/associations/5364/ig/ (Accessed on March 21, 2012).
- Duke E, Kalb B, Arif-Tiwari H, et al. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol 2016; 206:508.
- Moore MM, Kulaylat AN, Hollenbeak CS, et al. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatr Radiol 2016; 46:928.
- Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatr Radiol 2012; 42:1056.
- Koning JL, Naheedy JH, Kruk PG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. Pediatr Radiol 2014; 44:948.
- Johnson AK, Filippi CG, Andrews T, et al. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol 2012; 198:1424.
- Campbell JP, Gunn AA. Plain abdominal radiographs and acute abdominal pain. Br J Surg 1988; 75:554.
- Peña BM, Taylor GA, Fishman SJ, Mandl KD. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics 2002; 110:1088.
- Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011; 259:231.
- Russell WS, Schuh AM, Hill JG, et al. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care 2013; 29:568.
- IMAGING DECISION
- IMAGING APPROACH
- ULTRASONOGRAPHY (US)
- Test performance
- Pitfalls and limitations of US
- Sonographic findings
- COMPUTED TOMOGRAPHY (CT)
- Test performance
- - Contrast
- - Focused CT
- - CT scanning parameters
- Pitfalls and limitations of CT
- CT findings
- MAGNETIC RESONANCE IMAGING (MRI)
- PLAIN RADIOGRAPHS
- CLINICAL PROTOCOLS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS