CT and Sonographic Evaluation of Acute Right Lower Quadrant Abdominal Pain

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Review CT and Quadrant Bernard

Sonographic Abdominal

A. Birnbaum1

and R. Brooke

cute right abdominal

lower quadrant (RLQ) pain is a common chief

complaint

in clinical

A

term “acute abdomen” onset of pain is sudden the pain is present ciated with other The

differential

includes

from benign

to 30%

of cases,

ever

made

ously

without

cult

on

self-limited high

basis

and

history

to

who

separate

require

nostic

is

the

is

to

who

and

physical

difficult

to

patients

women

from

surgery.

erly.

present lap-

able direct

examination.

Un-

dix,

features of in nature. Diagin the 20-33%

of

preschool

the surgical

appendix increases women of reproductive

removal

to

children,

old, and

the eld-

of a normal

means

primary

of

present with what “surgical abdomen.”

examining

acute

RLQ

patients

was formerly This article

the indications for, technique findings in CT and sonography

as the who

rates

of, and imaging of patients with

acute

RLQ

pain.

most

An accurate

Received July 10, 1997; accepted

common diagnosis

cause

Hospital of the University

2Department

of Radiology,

H-1307, Stanford University

AJR 1998;1 70:361-371 0361-803X/98/1702-361

February

of unnecessary

1998

atypical

accepted

higher

appendectomies

imaging

cost-effective

have

health

led to a resurgence

directed

100

to justify care environ-

of clinical innoninvasive imaging

toward

studies

appendicitis.

the during

performance the

past

the role of sonography

of decade

and CT in

extrinsic

examination

CT,

complex

with

role

and

may

colonic

be

abnor-

cross-sectional

imaging

of cecal

diverticuli-

neoplasm). Sonography

cases

sonography

value

ofacute

and

in clinically

appendicitis

CT

ques-

[7-27].

The

between sonography and CT depends on institutional preference and available

largely

are difficult

approach

on

complementary

and

Graded-compression have proven diagnostic

sequences

ofthis

with

enema

presentation

Graded-Compression

choice

to avoid

diagnosed

of inflammation

appendix

Barium

a secondary,

detected

(e.g..

expertise.

more than to evaluate

of the

appen-

examination,

rapid,

Graded-compression noninvasive, the

inflamed

nique

requires

trast

material

associated

and

sonography inexpensive

appendix

no patient

[7].

with

ionizing

radiation.

enabling

with

patient

correlation symptoms

is

Because

not the

can be peris most ten-

of imaging [16].

of tech-

or con-

and

examination is interactive, scanning formed at the site where the patient der,

The

preparation

administration

is a

means

Evaluation

findings of the

after revision August 27, 1997.

of Radiology,

AJR:170,

of

can be

Department

1

traditionally

ofpatients with suspected The result has been is the

assumed

the increased morbidity of appendiceal perforation. However, the medical and economic con-

ment and vestigation

Appendicitis

has

tionable have

in the current

pain.

Appendicitis

[4].

Surgeons

known as a will review

nonfilling

cecal mass effect).

tis or perforated

35-45% in young age, in whom the dis-

difficult

effec-

laparotomy

of cx-

inflamed

is typically

malities

in

means

enema

evidence

establish

have

techniques

of indirect

in evaluating

noninvasive

exploratory

appendicitis

helpful

tinction from pelvic inflammatory disease and acute gynecologic disorders may be extremely

imaging

in which

the basis (i.e.,

ofthe

to barium

of sonography

of patients pain. These

replaced

visualization

in contrast

to that

clinical examination and treatment who present with acute abdominal tively

as the primary

negative laparotomy rate of ap20% [2-5]. The diagnosis is most 20 to 40 years

In fact,

examination

immediate

presenting is greatest

ema

161. Sonography replaced barium en-

pain

amining patients with suspected appendicitis. These cross-sectional imaging techniques en-

who present with atypical clinical [2. 3]. This difficulty has resulted in

these

use of CT and changed the

goal

patients

be protean

difficulty

an average proximately

diffi-

Lower

patients with acute RLQ and CT have effectively

of his-

labora-

perforation

undergo

radiologic

may

patients findings

surgical

appendiceal

findings

without

basis

and simple

develop,

typical

fortunately,

to

on the

the

before

peritonitis

arotomy

spontane-

immediate

The increased availability and sonography have dramatically

Because early

with

In up

diagnosis

resolve

tests.

appendicitis

disorders

[I]. It is often

of

alone

those

tory

pain

Right

Jr.2

operate

entities

morbidity.

no pathologic symptoms

intervention

the

The

RLQ

of Acute

established in most patients tory, physical examination,

if the and if

of clinical

with

and

examination

from

of acute

spectrum

associated

practice.

may be applied and unexpected

diagnosis

illnesses

Jeffrey,

for less than 24 hr and assogastrointestinal symptoms.

a broad

that range

Evaluation Pain

of Pennsylvania, Medical

© American

3400 Spruce St., Philadelphia,

Center, 300 Pasteur Dr., Stanford,

PA 19104. Address

correspondence

to B. A. Birnbaum.

CA 94305.

Roentgen Ray Society

361

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Birnbaum

and Jeffrey

Fig. 1.-Typical sonographic appearance of appendicitis in 42-year-old man. Note dilated, noncompressible appendix (arrow) with echogenic intraluminal debris. Surgical exploration revealed nonperforated appendicitis. Numeric scale indicates depth (in sonometers) from transducer.

Fig. 2.-Acute appendicitis in 22year-old woman with right lower quadrant pain. Sonogram shows multiple appendicoliths (arrows) within dilated appendix that were confirmed at surgery.

bowel

is facilitated

ml anatomy

and

If the bowel abdomen

the

tablish

The formed

MHz initiated

by the to show

ability

mu-

in real time.

is unremarkable, the remainder of and pelvis can be surveyed to es-

an alternative

technique

with

probes

high-frequency

linear

array

by

asking

the

in locating

patient

pain, is

is

is often

used

apto

loops

disto

facilitate visualization of the inflamed appendix, which does not compress. Real-time scanfling is initiated in the transverse plane and is directed

toward

origin of the

imaging appendix.

the cecal The

normal

less

in

Though

Rioux

anteroposterior [14] was able

that a normal

positioned

bowel

appears as a blind-ending tuthat generally measures 5 mm

to 7.5-

to the

which

or

visualized, structure

mal appendix in 102 without appendicitis.

study

to point

an aberrantly

pendix. Graded compression place normal gas-containing

(5-

The

transducers).

when bular

is per-

diagnosis.

graded-compression

site of his or her maximum helpful

to define

peristalsis

tip and the appendix,

minority pendix

(82%)

most

appendix

ofcases is not

the

tip and iliac vessels

of

[7,

125

patients

report

in only 1 1 , 24].

landmarks

must

[28]. a nor-

observers

is seen

(0-4%) seen,

dimension to identify

a small If the

of the

be clearly

ap-

cecal

visualized

ing

increased

Doppler

appendiceal

examination

appendicolith study (Fig.

to that

segment

Echogenic

flammation

of adjacent

mesenteric

based

with

mass

on sonography is made if a noncompressible appendix measuring 7 mm or greater in antero-

flow

on color

posterior

diameter

diagnosis

in these

[11,28] (Fig. 1). 5 and 7 mm Appendicitis may be di-

is identified

Appendixes measuring are borderline in size. agnosed

of appendicitis

between

indeterminate

cases

by show-

surrounding

Prospective sonography

color

shadowing

effect

Doppler

the

abscess

is absent.

studies have

in-

or omental typically

ap-

fluid collections Often increased

sonography (Fig.

subflow

indicates

abscesses

hypoechoic (Fig. 3A).

is noted

3B).

of graded-compression

demonstrated

specificities of 87-96%, positive 75-90%,

appendix tissue

as localized

A confident

of the

periappendiceal

Periappendiceal

negative.

with A

be suggested when loss of the echogenic mucosal layer occurs and color Doppler

pear

such cases

29].

generally indicates a positive 2). Gangrenous appendicitis may

fat.

to consider

perfusion [15,

of 86-100%, predictive

sensitivities

of

accuracies values

of 91-

Fig. 3.-Surgically proven retrocecal appendiceal abscess in 64-year-old man. A. Sonogram reveals hypoechoic mass (arrow) posterior to cecum (C). B, Color Doppler sonogram shows marked hyperemia surrounding abscess (arrow).

362

AJR:170, February 1998

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CT

and Sonography

of Acute

Abdominal

Pain

Fig. 4.-Mild appendicitis in 25-yearold woman. Contrast-enhanced CT scan shows mildly distended, fluidfilled appendix in longitudinal section with subtle penappendiceal inflammatory changes (arrow). Appendiceal wall appears hyperemic and minimally thickened. No perforation was seen at surgery.

Fig. 5.-Calcified appendicolith in 45year-old woman with surgically proven acute appendicitis. Contrast-enhanced CT scan reveals calcified appendicolith (straight arrow) obstructing lumen of mildly distended inflamed appendix. Thickened appendiceal wall shows homogeneous enhancement Penappendiceal inflammatory stranding is evident (curvedanow).

94%, 97%

and

negative

for acute

experienced

predictive

appendicitis

hands,

sonography

most entities requiring tervention that mimic An important

suffers

can also show

is that

tion may be difficult

with retrocecal

tis or in overweight

patients,

may result

ing prevent

appendici-

31]. Sonographic

RLQ

result ifa gas-filled or markedly pendix is mistaken for small bowel, also

of early

appendicitis

confined

in which

to the distal

pendix

appears

dilated

ap-

or in cases

inflammation

is

tip and the proximal

ap-

normal. CT

diagnosing emerging

easy,

and rapid

and staging acute appendicitis. usefulness of CT in this clinical

ting has paralleled

advances

20]. Subsequent

reports

documented

tivity mixed

only

when

The set-

thickening

or periappendiceal

[34].

ability

structing appendicoliths. appear otherwise normal

in ad[18-

findings of appendiceal almost universally present obstructing

a deliberate

effort

the appendix. Visualization of the appendix

on contrast-enhanced ble-halo or target

The with

mild

mon and abscess

nodes

occur

in only a minority

with

acute

appendicitis.

mimic

tion

abdominal

CT stud-

a pericecal

abscess

The

benefits

in this

clinical

The

23%),

and

(94%

versus

but

cases

to frank

with associated

gations

or phlegmon

vessels

seen

on end can

of adenopathy.

of improved

z-axis

setting

demonstrated

were

resolu-

has

[23]

permitting

is identified is seen

findings

further

in phlegile-

This

or if in as-

detection

of

were

recently acute

versus

of

appendicitis

with prior

investi-

has

by

data

sets

misregistration.

translated

into

calcified

appendicoliths,

reported

in 43-46% [25,

was CT

imaging

of volumetric

by respiratory

using have

versus

(28%

appendiceal

appendicitis

performed

visual-

(75%

10-mm slice collimation use of thin-section helical

enhanced

technology

specificities

typical

compared

acquisition

unencumbered

ranges

improved

appendixes

79%)

in which

may

enabled

appendicoliths

1211. The

used

niques

fat, and

mesenteric the appearance

dense

made

of mesenteric

mci-

lymph nodes may be overstated CT examinations because un-

calcified

of the CT cx-

of ileocecal bowel opacification. appendix is identified in approxi-

patients

reported

18%),

circum-

response

appendix

of adult

The

imaging

with

abnormal

sign

Optimized imaging of the appendix depends on the prospective acquisition of high-resolution (5-mm slice collimation) images of the

ocecal thickening in cases of perforation. A definitive CT diagnosis of appendicitis can be ifan

appen-

of this

of abnormal

of the mesoappendix

formation

Identification

[351.

ization

present

appendicitis

to fun-

thin-section

incipient

inflammatory

media

that usually

thickened.

is usually

contrast

of the occluded

in diameter

dis-

studies; however, a dousign may be seen. Periappen-

clouding

orifice

enhanced

are of an

homogeneously

most

sug-

et al. [23], who used conventional dynamic CT and showed that 5-mm

appears

symmetrically

Another

by Balthazar incremental

structure wall

allows

the origin

dence of these on unenhanced

show

as a slightly

15 mm

cecum

toward

is determined

the amount

1998

and

subtle

the degree The normal

AJR:170, February

appears

wall is usually

4).

amination,

of routine

ferentially

from

the type

44-51%

proximal

RLQ.

appendiceal

(Fig.

by its size,

mately

The

[21-25].

to

to

appendicitis reflect the In mild appendicitis,

5 and

inflammation be absent in the

is made

in-

inflammation in the setting

tubular

between

diceal

visualize

and quality

appendix

fluid-filled

measures

patients

CT

clinical appen-

appendicolith.

CT findings of acute severity of inflammation.

incipient

confirmed that the sensiofCT diagnosis are maxi-

of

for appendicitis.

gestive finding is the arrowhead sign, which resuits when focal symmetric thickening of the

may improve diagnostic confidence in cases of subtle appendicitis. Small regional lymph

The appendix will in such cases. In con-

trast,

[21-23].

appendi-

air has no associated with

The

me-

foci of calcification will occasionin detection of incidental nonob-

thickened

the ability

of CT to show milder and more forms of appendiceal inflammation investigations and specificity

of

in CT technology.

described the CT findings of perforated appendicitis

Initial reports vanced cases

These

means

of the normal

of a calcified

appendiceal unless

wall

tended

CT is an accurate,

fat density

The presence

the inflamed High-Resolution

the

but not specific

diceal

even small ally result

pain and guard-

within

It most

or ringRLQ. It is

the homogeneous

flammation

compression [8, 28, false-negative diagnoses may

adequate

structure

33].

tubular

nd

diceal

and nondiagnostic

if abdominal

pericecal

[32,

as a small

usually collapsed or slightly filled with fluid or air, has a pencil-thin wall, and is surrounded by

colith or significance

examina-

adults

appears

sentety.

it is an operator-

of perforation,

in asymptomatic

commonly like

technique that requires considerable and expertise. Diagnostic specificity in the presence

studies

ies

In

of graded-compression

however,

dependent experience

of 89-

medical or surgical inacute appendicitis [30].

limitation

sonography,

values

[7-1 1, 13, 15].

shown sensitivities of 83-97%, accuracies

which of patients

27].

high-resolution

improved

CT

scanning

studies

tech-

of 90-100%, of 93-98%,

sociation with an appendicolith (Fig. 5). The simple presence

[23, 24, 34] of pericecal in-

positive predictive values of 94-97%, and negative predictive values of 93-98% for acute ap-

flammation

is suggestive

pendicitis

or an RLQ

abscess

of

[23-25,

27].

363

Birnbaum

and Jeffrey

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Fig. 6.-Perforated appendix in 25year-old man. A, Unenhanced CT scan shows nonspecific pencecal inflammation (arrow). B, Contrast-enhanced CT scan shows abnormal enhancing appendix (arrow)

centered in inflammation. Surgical exploration confirmed remains of perforated appendix within retrocecal inflammation.

When

compared

trast-enhanced

with

CT is more

sonography, accurate

periappendiceal inflammation and more likely to provide an alternative in patients without

appendicitis.

for revealing

sitive This

latter

exclusion

point

is critical,

media this

is now

from

ensuring optimized of the many gastrointestinal,

because

definitive

ization

visualiza-

nary,

Adfacts

by patient

controversial.

Sup-

porters of contrast-enhanced CT maintain that IV contrast material is essential for diagnosing mild

appendicitis

in patients

mesenteric fat; differentiating

with

a paucity

appendicitis

of with

malignant

causes

of

gynecologic

bowel

disorders

with

abnormal

appendix

misdiagnosing loops

ology ever,

recognition and

specifically

collapsed

as the

is not because

appendix.

This

universally recent

scanning

agreed studies

or ileal

method-

upon, howhave shown

excellent CT [26,

diagnostic results with unenhanced 27]. Proponents of unenhanced CT

contend

that

this technique

allows

patients

that

of the

[27].

unenhanced imaging Adequate

oral contrast patients

bene-

to the potential risk and that the lower

examination

makes

alternative

it a

to sonogra-

opacification

of

RLQ

bowel loops typically requires 45-60 mm. As an alternative, Rao et al. [25] have promoted a

to avoid

nonopacified

because

administered,

fit from not being exposed of a contrast agent reaction,

phy

which

of the normal

immediately is not

cost-effective

patients can present with acute lower abdominal pain [6, 21-24, 34, 36] (Fig. 6). These investigators also advocate the use of oral water-soluble iodinated contrast material (diatrizoate megluto improve

material

cost

charactergenitouri-

and

and

be scanned

from

the mural enhanceof differentiating be-

thickening;

requires

phleg-

vessels

nign

mine)

somewhat

pericecal

enhanced

sen-

most investigators stress the imof administering IV and oral contrast to patients with suspected appendicitis,

topic

distinguishing

[24].

Although portance

nonspecific

lymph nodes; evaluating ment pattern as a means

appendix

is not limited

from

abscesses, diagnosis

tion ofthe normal appendix in its entirety. ditional advantages of CT include the that this technique is operator-independent and that examination body habitus.

perforation mon;

and more

the normal

of appendicitis

conin staging

to

focused limited

appendiceal helical CT

formed colonic

after rapid administration of oral and contrast material but without IV con-

media. These cellent diagnostic specificity (95%) trast

showed normal without further identifying

CT technique in which a study of the RLQ is per-

investigators sensitivity with this

achieved (

100%)

technique

cxand and

partial or complete opacification of the appendix in 29 (71%) of 41 patients appendicitis. investigation, a normal

These given appendix

results the

warrant

importance in patients

of with

Fig. 1.-Surgically proven cecal diverticulitis in 37-year-old woman. A, Contrast-enhanced CT scan reveals asymmetric thickening of lateral wall of cecum and adjacent pericecal inflammatory stranding (arrows). B, Caudal CT scan shows normal barium-fllled appendix (arrow).

364

AJR:170, February

1998

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CT

and

Sonography

of Acute

Fig. 8.-Perforated cecal carcinoma in 63-year-old woman with acute right lower quadrant pain and palpa-

accuracy

and

of enhanced

patients

with

vestigation

acute

reduction

unenhanced

pain.

RLQ

This

because

is needed

potential

unenhanced

CT in type of in-

it may expose

a

accuracy

in diagnostic

CT for establishing

of

alternative

di-

be higher right-sided poechoic mation

of cecal

where diverticulosis findings

ofthe

41].

The

of segmental

hyinflam-

in an echogenic

inflamed

diverticulum

mass

can

Typhlitis

Typhlitis,

of

39].

and adjacent

fat, resulting

The

[27,

consist

may

incidence

exists

thickening

mural

diverticulitis

a greater

in Japan,

sonographic

[40,

bowel wall enhancement, and pneumatosis coli (arrow). Diagnosis was established on basis of characteristic imaging features and typical clinical presentation.

The frequency

tries.

Pain

Fig. 9.-Typhlitis in 42-year-old female neutropenic patient who experienced acute right lower quadrant pain after undergoing bone marrow transplantation for multiple myeloma. Contrast-enhanced CT scan shows circumferential cecal wall thickening, heterogeneous

ble mass. Contrast-enhanced CT scan shows heterogeneously enhancing, asymmetrically thickened cecum (C). Note direct extension of tumor toward abdominal wall (arrow) and inflammatory stranding of omentum (arrowhead). Perforated adenocarcinoma of cecum and proximal ascending colon was identified at surgery.

suspected appendicitis. To date, no prospective studies have been performed comparing the

Abdominal

often

also

terocolitis, tizing

known

is an acute process

of

characteristically minal ileum and in terminally

as neutropenic

inflammatory multifactorial

also seen in adult patients after chemotherapy for

accuracy,

The diverticulum

may cast an acoustic

nancy

CT also serves as an accurate “road map” for determining the proper approach for surgical

and may contain findings usually

a fecalith or gas. The CT consist of mild asymmetric

or percutaneous

thickening

In addition

to its high

diagnostic

abscess

drainage

[37].

CT is

of

the

especially useful in cases of perforation because it can reliably differentiate phlegmon

inflammation,

from abscess. This clinical significance

ening and pericolic be noted in severe

treat

patients

or small

with

fled

drainage

if these

mediate surgical appendectomy extensive Cecal

Cecal

with

phlegmon

an initial

nonsurgical

therapy. Patients with liquemay undergo percutaneous appear

well

exploration if abscess

and poorly

defined

Diverticulitis diverticulitis

mon disorder

has important surgeons may

periappendiceal

abscesses

of antibiotic abscesses

trial

distinction because

or im-

with drainage and formation appears [38].

is a relatively

that is usually

operatively as appendicitis. results from inflammation

localized

misdiagnosed

uncompre-

Cecal diverticulitis and perforation of

acquired right-sided colonic diverticula, which occur in approximately 5% of patients with diverticular disease in developed Western coun-

AJR:170,

February

1998

[42]

(Fig.

cecal

wall,

focal

and the presence 7).

appendicitis

Marked

asymmetric

wall

carcinoma

difficult if the normal appendix a prominent soft-tissue mass present, respectively. Perforated cecal

as hypoechoic mural

vascularity fident CT gan and

may from

may

be

in-

in patients generally

that cause

and have

be

asym-

than inflammatory lesions. A condiagnosis of perforated carcinoma

tumors

in the presence

may

diceal orifice, causing secondary appendicitis.

risk

of contiguous

or-

peritoneal implants, (Fig. 8). Strategically

also

occlude

mucinous

the

Early

diagnosis

dilatation

[44].

and

wall thickening,

low-attenuation

indicative

of edema

matosis

coli,

colon bowel

intramural or necrosis,

fluid,

(Fig.

circum-

segmental

gions

pericolic

to

perforation.

of the right

include

[45-47]

with

essential

reveals

thickening

findings

fomay

treatment are

characteristically

CT

however,

present with known fever, and diarrhea.

necrosis

mural

with or fun-

infiltration

aggressive

transmural

and

repneu-

perienteric

9).

The differential diagnosis ofacute right-sided colonic inflammation includes pseudomembranous

colitis,

prolonged or

and

viral,

role;

neoplastic

antibiotics

Sonography

maligand

by bacterial,

typically pain,

RLQ

is

of immunosup-

a dominant

broad-spectrum

avoid

hematologic

transplantation

and

Patients

pressed

appen-

plays

factors,

stranding

less internal

organ Infection

ischemia

coexist.

thick-

should

diagnosis Neoplasms

masses

invasion, malignant distant metastases

located

[43].

typhlitis

agranulocytosis

as a complication for

AIDS

cal

is not seen or if component is

carcinoma

thickening

can be made

pression

ferential

cluded in the differential more than 50 years old. metric

and

gal agents

pericolic

of diverticula

phlegmon or abscess cases. Differentiation

or perforated

appear

shadow

with

that

or the terdescribed

children,

ill leukemic

be identified as an echogenic outpouching within an area of asymmetric mural thickening.

bowel

origin

affects the cecum appendix. Initially

ischemia)

agnoses (e.g., pyelonephritis, in patients without appendicitis.

en-

and necro-

which

individuals antibiotic

may

occur

in immunosup-

or in patients

who

therapy

complicated

have

had by

Clostridium dfflcile enterotoxin overgrowth [48]. The inflammation is pancolonic in most cases; however, isolated involvement of the

365

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Birnbaum

and Jeffrey

Fig. 1O.-Crohn’s disease mimicking acute appendicitis in 29-year-old man. A, Sonogram shows marked thickening of terminal ileum (TI) and loss of normal echogenic indicates

CT scan shows thickening

B, Contrast-enhanced

of terminal ileum (arrow)

cecum and the ascending colon is not rare. The colon may appear near-normal with mild involvement. In severe cases, marked low-attenuation mural intraluminal

thickening contrast

swollen haustral pseudomembranous lonic

munoassay

is seen on CT. with agent trapped between

folds. The CT appearance colitis is nonspecific.

biopsies,

may

submucosal

layer. Marked

stool

cultures,

of stool

be needed

samples

this

or inflammatory

colitides

should

positive

patients

Crohn’s

ing

Adenitis Ileitis

Mesenteric disorder

relate

to benign

self-limited

inflammation

can

terminal

present

with

(Fig.

10), which

may vessels

sonographically

seen

in

the epicenter

both

pro-

manifests as only minimal

usu-

and usually

pose

no diagnostic

ally occurs. The disease commonly affects children and young adults and is most fre-

Characteristic thickening

findings include terminal ileal with or without a target sign en-

the

mation

mesentery.

ileal

Coexistent

of the terminal

quently

caused

by Yersinia

pseudotub(’rc’ulosis,

The

adenitis

mesenteric

associated

when

or CT

je-

of mesenteric

nodes

or ileocecal

moderately

en-

CT

show

can

definitively

exclude

diagnostic

specificity

wall

[49].

Patients

with

teric

lymphadenitis

a normal

AIDS

and

it has greater

this

clinical

setting

may

develop

mesen-

resulting

proliferation adenopathy,

[53].

on contrast-enhanced

CT,

of the ileal mesentery, and perienteric sinus

tracts and mesenteric abscesses vere extramural inflammation.

in cases

of se-

fat (arrows)

from

Mvc’obacte-

confirmed presence

dition

Diverticulitis

that

ofeither or a true

arises

an acquired congenital

The CT findings

as a result

of inflammation

ileal pseudodiverticulum Meckel’s are usually

diverticulum. nonspecific

and

experi-

is usually

A specific

the in-

CT diagno-

diverticulum.

Epiploic

Appendagitis

Epiploic

appendagitis

that of

an

citis if the has

appendage

been

and findings

is

after

colon

regress.

a small,

mass

is af-

however, exer-

Symptoms

spontaneously include

large

strenuous

stretching.

ovoid

the

uncertain;

reported

excessive

noncompressible

of

presents with mimic appendi-

or ascending

cause

of

or inflamma-

The condition pain that can

cecum

clinical

as a result

ischemia,

epiploic

The and

to occur

torsion,

bowel [55-57]. acute abdominal fected.

is an unusual

is thought

spontaneous tion

in our

diverticulitis can be made if enterolith is identified within

inflamed

entity

the inflammatory

diagnosis

the

changes.

sis of Meckel’s an obstructing

graphic

differential diagnosis of ileal inflamincludes ileal diverticulitis, a rare con-

in-

by barium studies that show of ileal diverticula with serosal

self-limited The mation

perienteric

is unusual

and

flammatory

the

within

finding

however,

cise

SmallBowel

with

I 1). A “target” appearon contrast-enhanced

diverticula This

torsion

thickening

appendix

appendicitis, in

pattern

fibrofatty

difficulty

with or without

149-51 1. The appendix is usually not visualized by sonography in these cases 150. 5 1 ]. Because

hancement reactive

graded-compres-

reveals

lymph

ileal

Y.

Campvlobaeter

diagnosis

suggested

sonography

and cecum

enierocolitica,

and

noninvasive is

larged

ileum

inflam-

thickening

[54] (Fig. be noted

of air-filled ence,

inflammation. The CT feadisease are well established

366

of surrounding

examinations, indicative of nonneoplastic bowel wall thickening. The diagnosis can be suggested preoperatively if CT evidence exists

on

periappendiceal tures of Crohn’s

within

of mural

flammation ance may

process.

phlegmon by identi-

of the inflammatory

consist

be

A combination of and appendix can oc-

which in Crohn’s disease severe ileocecal thickening with

nodes

thickenstriking

most

of mural

color Doppler imaging. thickened ileum, cecum,

mesenteric

mural

is the

hyperemia

be

with

marked

cess,

symptoms

of lymph

in HIV

pain and cavi-

RLQ

ileum

feature

associated

fying is an appendicitis-mim-

whose

who have

Crohn’s disease and appendiceal [52]. These entities are distinguished

and Acute

adenitis

icking

sion

echogenicity

disease.

This

be considered

however,

of the

casionally Mesenteric Terminal

infection.

always

disease

sonographic

[48].

to be Crohn’s

adenopathy.

taly

im-

A or B entity from

on endoscopy

avium-intracellulare

rium

adenopathy;

for toxin

proven

diagnosis

of Co-

enzyme

and

to differentiate

other infectious

jufli.

increased

inflammation.

are Sono-

echogenic,

that is usually

lo-

cated directly under the abdominal wall at the site of maximum tenderness [57]. The inflamed

mass

echoic

line

features

is often or

consist

ring.

delineated The

of a small

by a hypo-

CT

corresponding

pedunculated

fat-at-

AJR:17O, February

1998

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CT

and

Sonography

of Acute

mass

a hyperattenuating

with

that approximates the serosal lon (Fig. 12). A small linear tenuating

focus

be seen

may

rim

surface of the coor round hyperatin the

center

the lesion, thought to represent either rhagic necrosis or vascular thrombosis.

OmentaJ

are present

primary

differential

appendagitis

is a rare

Right-sided

entity

that

can

tis [58,

59].

portion

of the omentum

mimic

fragile

that

a solid,

moderately

ovoid

caused

lower

stranding,

nostic,

seen

CT

and

appears

scribed

region

of

inflamed

spersed

with

on

inflammatory

colon

the approximate The abnormality

as a well-circumomental

hyperattenuating stranding.

terminal ileum, fected (Fig. 13).

and

AJR:170, February

1998

level of is well fat

streaks

The underlying appendix

remain

and colon, unaf-

a specificity Associated dilatation,

system

distal

is particularly calculi

ureteral

usethat are

[65].

most

of 96%, secondary

perinephric

Conditions

common with

acute

gynecologic pelvic

pain

disorders are ovarian

pelvic inflammatory disease, adnexal and ectopic pregnancy. Because of the

cysts,

disease

dilatation,

Gynecologic

The

torsion, broad

overlap

tions

of these

between diseases

the clinical and

acute

presentaappendicitis

asym-

renal enlargement, and periureteral [61, 62] (Fig. 14). Periureteral edema as a circumferential

in distinguishing

from meddlesome an unenhanced helical may

reveal

renal

or pyelonephritis

pain and unenhanced

in patients

with

CT

studies

findings.

A confident

sonographic

obstruction

is present

ureteral

CT can follow, infarction, renal vein

acute

negative

of

phleboliths [61]. If CT study is nondiag-

thrombosis, flank

rim

obstructing

contrast-enhanced

which

proximal

diagnosis

is made

when

to a shadowing

of acute hydroureter stone.

With

distal calculi, the dilated ureter may be seen as it courses over the pelvic brim adjacent to the iliac

inter-

unenhanced stone

Acute

that present

attenuation that surrounds the ohstone. This tissue-rim sign has proved

with conservative findings consist of

and the ascending

above, [59].

collecting

this

presents

urinary

the peritoneum

shown

of97%,

and

urography as in many cen-

ureteral

ful in detecting

side

on the symptomatic

scanning

effective

soft-tissue structing

lateral

at, or slightly the umbilicus

and

[64]. Transvaginal

not seen transabdominally

typically

with

tween

et al. [60] have

may is Unen-

calculi,

excretory of choice

of97%. ureteral

useful

be-

ureteral

and an accuracy findings include

calculi

interposed

calculus.

is a rapid

detect

present with loare self-limited

of the abdomen

CT

helical CT can with a sensitivity

cular on color Doppler sonography. The lesion is characteristically located at the right anteroaspect

level jets are present

ureteral

of detecting

ters. Smith

in

avas-

a distal

technique has replaced the screening method

in-

noncompress-

Note presence of mild inflammatory stranding of adjacent fat Diagnosis was established on basis of characteristic CT and clinical presentation. (Courtesy of Rao PM, Boston, MA)

Obstruction

helical

means

to

that appears

by

hanced

supply

mass

Renal

(arrow). pericolic features

Patients with acute renal obstruction present with RLQ pain when obstruction

metric edema

a congeni-

blood

echogenic,

or cakelike

right

is susceptible

and resolve spontaneously treatment. The sonographic

of

appendici-

the

have

[59]. Patients typically RLQ pain. Symptoms

calized

of epiinfarction

acute that

may

and

individuals

farction

ible,

[57].

infarction

omental

It is theorized

anomalous

some

cases

diagnosis

is segmental

the omentum.

tally

in most

Infarction

The ploic

hemorMass

mild infiltration of thickening of adja-

effect on adjacent bowel, surrounding fat, and focal cent peritoneum

of

Acute

Pain

Fig. 12.-Epiploic appendagitis in 40-year-old woman. Contrast-enhanced CT scan shows fat-attenuation mass with surrounding hyperattenuating rim arising from serosal surface of ascending colon

Fig. 11.-Meckel’s diverticulitis in 53-year-old man. Contrast-enhanced CT scan shows inflammatory mass medial to ileocecal valve (arrow). Note mild perienteric inflammatory stranding and asymmetric thickening of adjacent ileal small-bowel loop. Histologic review of surgical specimen revealed inflamed Meckels diverticulum lined by intestinal and gastric epithelium. (Courtesy of Bauman JS, Norwalk, CT)

tenuation

Abdominal

vessels.

however, is not seen nonexistent

Diagnostic

in cases

efficacy

in which

a ureteral

and hydronephrosis [63].

Color

is

flow

limited,

man with

calculus

is minimal

assessment

Fig. 13.-Right-sided

or of

ureteric jets may help establish the diagnosis if the jet is completely absent or continuous low-

omental infarction

in 70-year-old

acute right lower quadrant pain. ContrastCT scan reveals well-circumscribed, ovoid,

enhanced fat-attenuation

lesion with hyperattenuating streaks ascending colon and right anterolateral abdominal wall (arrow). Underlying colon appears normal. Diagnosis was made on basis of characteristic CT features and clinical presentation. interposed

between

367

Birnbaum

and Jeffrey Fig. 14-Obstructing

ureteral calcu-

lus in 52-year-old man. A, Unenhanced helical CT scan shows

mild right-sided hydronephrosis and perinephnc stranding (arrow). B, Unenhanced helical CT scan at

Downloaded from www.ajronline.org by 37.44.207.171 on 01/20/17 from IP address 37.44.207.171. Copyright ARRS. For personal use only; all rights reserved

level of ureterovesical

obstructing

junction

shows

3-mm calculus in distal (arrow). Calcified pelvic

right ureter phlebolith lies posterolateral to left ureterovesical junction (arrowhead).

and the proven

efficacy

vic

many

imaging,

sonography choice

The

probes

use

adult

women

Doppler

of RLQ

transvaginal

sonography

hemorrhage

or clot appear

Doppler

technique with acute

of high-frequency

with color

in pelconsider

to be the screening

in young

pain.

of sonography investigators

sonography.

rhagic

cysts

forms

and

affords

Pelvic

unparalleled imaging of the female pelvis and should be used routinely in this clinical setting.

nal

low-resistance

wave-

mimic

the

and other

may

of

produces

findings.

show

normal

findings

in pa-

tients

age.

One

should

not assume

cyst

is the

cause

of the patient’s

dilated fallopian tube containing echogenic debris or a fluid-debris level; however, one must

less other sonographic

[66]. veal

cysts between

Clot

a convex

assume

varies

with

clot

formation

is typically border

retraction (Fig. often contains that

an adnexal

symptoms

un-

disorders have been excluded. appearance of hemorrhagic

pus luteum tionship

that

a cobweb

and

clot

and

echogenic

if it is in the

15). Lysed thin

the temporal

blood

echogenic

exclude

rela-

mation, ovarian

lysis

re-

process

of

a cyst

linear

appearance.

The cor-

may

within

strands

Areas

with

early

of

[67]

(Fig.

from

16).

With

transvaginal

rioophoritis.

Tuboovarian

internal

an ectopic

septations,

low-level

a

preg-

Because

gas,

identification

pelvic

abscess

source

such

may

Ovarian

abscesses

rarely

of a gas-containing

suggest

a gastrointestinal

appendicitis,

torsion

diverticulitis,

most

commonly

cysts

or tumors.

include ing

prominent

reveal con-

or

absent

low-velocity

be preserved

as

result

Transvaginal

mural echoes,

irregularity, and

fluid-

acteristically venous flow differential

of

color

diagnosis

ovary

that may be [68, 69]. venous

sonography; cm/sec)

dual

Doppler

shows

features

arterial

at the periphery its

of the

blood

supply.

char-

sonography

complete

absence

is nonviable includes

is

contain-

central

Doppler (25

[73].

relate

be

Fig. 18.-Ruptured woman. Transvaginal

right adnexal

The

CT

to the

findings

appearance

fallopian

tube

often appears as a thickened tubular or comma-shaped

structure

that

ovary.

extends

from

The

ovary

may

complete

tional

findings

peculiar

protrusion

the uterus,

intrauterine

preg-

vessels fected

and

enhancement. hemoperitoneum,

of include

seem [75].

in 27-year-old

to

Because

entities

may

the clinical

of appendicitis from many gynecologic disorders may be difficult, sonography should be performed routinely in young

adult

women

with

is also

favored

in pregnant

Addi-

pediatric

a blood the

of clinical pain.

raphy

engorged around

RLQ

with

with

drape

spectrum

acute

[74].

is continuous

prominently

that

pregnancy

differentiation

cor-

hemorrhagic

that

ovary

the uterine

Conclusion A broad cause

involved

adnexa

appear

absence

The

the

and

hemorrhagic

the

of ovarian

of both

tube

and

ectopic

sonogram shows echogenic ring of ectopic gestation (straight arrow) and echogenic cul-de-sac fluid representing hemoperitoneum (curved arrow). Ectopic pregnancy was surgically confirmed.

fallopian

find-

intrauterine [71]. Ec-

Pain

af-

ing

patients

radiation.

optimized initial minate

RLQ

sonogram,

and

of its lack of ionizclinically indicated, an

When

correct diagnosis

Sonog-

women

because

CT examination, imaging

pain.

technique

will in most

used or

after

facilitate

either

as the

an indeter-

a rapid

and

cases.

from

the ovary Doppler

suggestive

that

sonog-

of the diag-

18).

findings

logic disorders ovarian cysts ation

(humay

torsion

sonographic

color

is strongly

CT

in 24-

Abdominal

may be accurately diagnosed an extrauterine yolk sac or livVisualization of an echogenic ad-

has prominent

The

beta-hCG

either an abnormal or an ectopic pregnancy

topic pregnancy by identifying

of Acute

nua to the abnormal-appearing

test effecpossibility. If levels

transvaginal

to differentiate

be

who

women

pregnancy

gonadotropin)

with

must

their reproduc-

diagnostic

this

the test is positive,

nancy

active

pain during

A negative

excludes

man

pregnancy

in all sexually

considered

acute appendicitis

mesosalpinx

an avas-

der(Fig. 17). The

Sonography

Patient was 18 weeks pregnant and presented with quadrant pain directly over sonographically visualthat myoma is avascular on color Doppler sonogram, infarction or degeneration. Patient made an uneventtreatment with analgesics.

sonography

myoma

and

of most

acute

are nonspecific. typically appear H)

adnexal

gyneco-

Hemorrhagic as high-attenu-

masses.

Follicular

cysts

may present with extensive hemoperitoneum if cyst rupture occurs with continued

bleeding (Fig. 19). A diagnosis rian abscess is made if a tubular, tic

pelvic

mass

characteristic findings

include

floor

fascial

pelvic

fat,

AJR:170,

is identified

history

and

February

in a patient

(Fig.

indistinctness

planes,

increased

anterior

1998

of tuboovaseptate, cys-

20).

with

Supportive of

the

density

displacement

pelvic

of the of the

Fig. 19.-Hemorrhagic

cyst in 25-year-old woman with severe acute right lower quadrant pain. Contrast-enhanced

CT scan reveals high-attenuation right adnexal cystic mass (arrow) with surrounding pelvic hemorrhage me fundus (U) is displaced laterally. Surgical exploration revealed extensive hemoperitoneum resulting tured corpus luteal cyst.

(H). Uterfrom rup-

369

Birnbaum

and Jeffrey

28.

Jeffrey

RB Jr. Jam KA, Nghiem

diagnosis

of acute

falls.

1994:162:55-59

AiR

HV. Sonographic

appendicitis:

interpretive

pit-

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29. Lim HK, Lee WJ, Kim TH, Namgung S. Lee Si, Lim JH. Appendicitis: usefulness of color Doppler US. Radiology 1996:201:221-225 30.

Gaensler Townsend

EHL, Jeffrey RR. Sonography

RB Jr, Laing in patients with

pected acute appendicitis: alternative diagnoses. AiR 31.

with

acute

33. Grosskreutz

pendicitis:

1. de Dombal FT. Introduction. In: de Dombal FT. ed. Diagnosis of acute abdominal pain, 2nd ed. Edinburgh:

Churchill

Livingstone,

1991:1-10

2. Berry J Jr. Malt RA. Appendicitis

near

4. Bongard

its cente-

agnosis disease.

of appendicitis Am

J Surg

and

pelvic

inflammatory

ders.

1985; 150:90-96

7. Puylaert

Focused

appendix CT technique: l997;202:20-21

Radiology

JBCM.

Acute

appendicitis:

a

prospective nosis

study of ultrasonography

of appendicitis.

N EngI

in the diag1987;317:

J Med

RB Jr. Laing

FC, Lewis

FR. Acute

appen-

dicitis: high-resolution real-time US findings. Radiology 1987;l63:l 1-14 10. Abu-Yousef MM, Bleicher JJ, Maher JW, Urdaneta LF, Franken EA Jr. MetcalfAM. tion sonography of acute appendicitis. 149:53-58 I I. Jeffrey RB Jr. Using FC, Townsend

12.

High-resoluAJR

1987;

RR.

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real-time

nosis

ultrasonography:

of acute

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a new

tool

in the diag-

Am

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1988:155:

93-97 13. Schwerk WB, Wichtrup B, RuschoffJ, Rothmund M. Acute and perforated appendicitis: current experience with ultrasound-aided diagnosis. World J Surg 1990;14:27l-276 14. Rioux M. Sonographic detection of the normal and abnormal appendix. AiR 1992; 158:773-778 15. Sivit CJ. Newman KD, Boenning DA, et al. Ap-

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WC,

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34.

5, Goff WB II, Balsara

EK,

Siegelman

AH.

its local

CT

complications.

23. Balthazar BA.

EJ, Megibow

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sign 36.

tion in acute appendicitis: of 100 patients. Radiolog

Assist

vW,

technique

prospective examination.

39.

26. Malone

Radiology

evaluation

and

sonography

prospective

with

of acute

40.

abscess.

MP, Tolentino CS. Periapmasses: CF-directed man-

inflammatory

agement

and

Radiolog’

1988; 167: 13-16 K, Muto T, Morioka

Sugihara

1986;

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clinical

T. Diverticular

of 61 5 cases.

outcome

disease Dis

in

70

patients.

Y, Asano

A, Yama-

of the colon Colon

in Japan:

1984;

Rectum

Townsend verticulitis

RR, Jeffrey differentiated

41.

appendicitis:

43.

Wada M, Kikuchi Y, Doy M. Uncomplicated acute diverticulitis of the cecum and ascending colon: sonographic findings in 18 patients. AiR 1990;155: El, Megibow AJ, Gordon RB, Hulnick D. Cecal diverticulitis: evaluation with C’!’. Radiology 1987: 162:79-81 Ekberg 0, Jones B, Herlinger H. Infections and

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Teefey

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WP.

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of un46.

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MP,

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47.

AiR

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Saunders, MA,

RM,

Le-

of gastrointestinal

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Goldfogel

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GA,

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of neutropenic

1987:149:731-733

Adams GW, Rauch Ri, Kelvin FM, Silverman PM, Korobkin M. CT detection of typhlitis. J Comput

Delaney

heli-

Montana

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TL,

1989:152:

283-287

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AS, Melliere

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42. Balthazar

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1993; 160:763-766 27. Lane MJ, Katz DS, Ross BA, Clautice-Engle

RB Jr. Laing FC. Cecal difrom appendicitis using

1229-1230

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Jr. Federle MP, Wing DR. CT in the man-

of periappendiceal

review

AJ,

correla-

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AJ Jr. Wolf CR, Maimed

BF. Diagnosis enhanced

1997;202:

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AJ, Siegel SE, Birnbaum

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1994;32:

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agement

1988;

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1994:190:31-35 25. Rao PM, Rhea JT, Novelline RA, et al. CT

at CT.

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graded-compression

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for diagnosis

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high-resolution Roshkow

Clin

35. Rao PM, Wittenberg J, McDowell RK, Rhea IT, Novelline RA. Appendicitis: use of arrowhead

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Assist

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Assist Tomogr l985;9:34-37 21. Balthazar El, Megibow AJ. RB, Naidich DP, Beranbaum citis.AiR l986;147:705-710

normal appendix. 12:595-601

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38. Jeffrey RB Jr. Federle

SS. Computed

5, Burkhard

J Comput

1991; 15:575-577 Birnbaum BA, Balthazar El. CT of appendicitis

146:1 161-I

appearance

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885-898

1981:81:900-904

Robbins

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J Med

1989;

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22.

666-669 9. Jeffrey

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