Appendicitis essentially means inflammation of the appendix. It is a very common condition in general radiology practive and is a major cause of abdominal surgery in young patients.
Acute appendicitis is typically a disease of children and young adults with peak incidence in the 2nd to 3rd decades of life 1.
Classically presentation consists of periumbilical pain (referred) with a day or so later localizes to McBurney's point and is associated with fever, nausea and vomiting 2. This progression is only seen in a minority of cases, and is especially unhelpful in children who often present with vague and non-specific signs and symptoms. It also relies on the appendix being in a 'normal' position, which is not the case in a large number of cases (see below).
In general signs and symptoms include 1-2 :
- nausea and vomiting
- localized pain and tenderness
- RLQ pain over appendix = McBurney sign
- pelvic pain, diarrhoea and tenesmus (pelvic appendix)
- flank pain (retrocaecal appendix)
- groin pain (appendix within an inguinal hernia)
- atypical location: within pelvis (30%), extra-peritoneal (5%)
Appendicitis is typically caused by obstruction of the appendiceal lumen, with resultant build up of fluid, infection, venous congestion, ischaemia and necrosis. Obstruction may be caused by 1:
- lymphoid hyperplasia : ~ 60%
- appendicolith : ~ 33%
- foreign bodies : ~ 4%
- Crohn's disease
- other rare causes, e.g. stricture, tumour, parasite
One of the biggest challenges of imaging the appendix is finding it. Once confidently identified whether or not it is normal is relatively straight forward in most instances.
The location of the base of the appendix is relatively constant, located roughly between the iliocecal valve and the apex of the caecum. This relationship is maintained even when the caecum is mobile.
The location of the tip of the appendix is much more variable, especially as the length of the appendix has a large range ( 2 - 20cm)8. The distribution of positions has been described as 7-8:
- behind the caecum (ascending retrocaecal) : 65%
- inferior to the caecum (subcaecal) : 31%
- behind the caecum (transverse retrocaecal) : 2%
- anterior to the ileum (ascending paracaecal preileal) : 1%
- posteior to the ileum (ascending paracaecal retroileal) : 0.5%
Plain radiography is infrequently able to give the diagnosis, however is useful in identifying free gas, and may show an appendicolith in 7-15% of cases 1. In the right clinical setting, finding an appendicolith makes the probability of acute appendicitis up to 90%.
If an inflammatory phlegmon is present, displacement of caecal gas with mural thickening may be evident.
Small bowel obstruction pattern with small bowel dilatation and air-fluid levels is seen in approximately 40% of perforations.
Ultrasound with its lack of ionizing radiation should be the investigation of choice in young patients, and is effective in competent hands in identifying abnormal appendixes, especially in thin patients. However, the identification of a normal appendix is more problematic, and in many instances, appendicitis cannot be ruled out.
The technique is known as graded compression, and uses the linear probe over the site of maximal thickness, with gradual increasing pressure exerted to displace normal overlying bowel and bowel gas.
Findings supportive of the diagnosis of appendicitis include 4
- aperistaltic, noncompressible, dilated appendix ( > 6mm outer diameter)
- distinct appendiceal wall layers
- target appearance (axial section)
- periappendiceal fluid collection
- echogenic prominent pericaecal fat
- confirming that the structure visualised is the appendix is clearly essential and requires demonstration of it being blind ending and arising from the base of the caecum
CT is highly sensitive (94 - 98%) and specific (up to 97%) for the diagnosis of acute appendicitis, and allows for alternative causes of abdominal pain to also be diagnosed.
The need for contrast (IV, oral or both) is debatable and varies from institution to institution. Findings include 1-3:
- dilated appendix with distended lumen ( > 6mm diameter) 3
- thickened and enhancing wall
- thickening of the caecal apex (up to 80%): caecal bar sign, arrowhead sign
- periappendiceal inflammation, including stranding of the adjacent fat and thickening of the lateral conal fascia or mesoappendix.
- extraluminal fluid
- inflammatory phlegmon
- abscess formation
- appendicolith may also be identified
Recognised complications include 5
- perforation occurs in up to 13 - 30% of cases
- abscess formation : appendiceal abscess
- generalized peritonitis
- pylephlebitis : infective thrombophlebitis of the portal circulation, which can be
- complicating hepatic abscess
Treatment and prognosis
Treatment is appendicectomy, which can be performed either open or laparoscopically 5. Mortality from simple appendicitis is approximately 0.1%, but is as high as 5% in perforation with generalized peritonitis 5.
In approximately 30% of cases where the appendix has become gangrenous, recovery is complicated by abdominal / pelvic abscess formation. It is in this situation that radiologists have a therapeutic role to play with percutaneous CT or US guided drainages.
The imaging differential includes:
- 1. Weissleder R, Wittenberg J, Harisinghani MG et-al. Primer of diagnostic imaging. Mosby Inc. (2007) ISBN:0323040683. Read it at Google Books - Find it at Amazon
- 2. Callahan MJ, Rodriguez DP, Taylor GA. CT of appendicitis in children. Radiology. 2002;224 (2): 325-32. doi:10.1148/radiol.2242010998 - Pubmed citation
- 3. Pereira JM, Sirlin CB, Pinto PS et-al. Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain. Radiographics. 24 (3): 703-15. doi:10.1148/rg.243035084 - Pubmed citation
- 4. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158 (2): 355-60. Radiology (abstract) - Pubmed citation
- 5. Doherty GM, Way LW. Current surgical diagnosis & treatment. McGraw-Hill Medical. (2006) ISBN:007142315X. Read it at Google Books - Find it at Amazon
- 6. Pinto leite N, Pereira JM, Cunha R et-al. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol. 2005;185 (2): 406-17. AJR Am J Roentgenol (full text) - Pubmed citation
- 7. Fritsch H, Kühnel W. Color atlas of human anatomy, Internal organs. Thieme Medical Publishers. (2008) ISBN:3135334058. Read it at Google Books - Find it at Amazon
- 8. Ghosh BD. Human Anatomy for Students. Jaypee Brothers Medical Publishers (P) Ltd. ISBN:8180618668. Read it at Google Books - Find it at Amazon
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