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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
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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.
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J Surg
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ders.
1985; 150:90-96
7. Puylaert
Focused
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Radiology
JBCM.
Acute
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in the diag1987;317:
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FC, Lewis
FR. Acute
appen-
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12.
High-resoluAJR
1987;
RR.
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real-time
nosis
ultrasonography:
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in the diag-
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sign 36.
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20.
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