Arabinda Pani, HMS III Gillian Lieberman, MD

January 2005

Radiologic Diagnosis of Appendicitis Arabinda Pani, Harvard Medical School, Year III Gillian Lieberman, MD

Arabinda Pani, HMS III Gillian Lieberman, MD

Overview • • • • • •

Introduction: Epidemiology, Pathophysiology Role of Radiologic diagnosis Normal anatomy Appearance in various modalities Criteria for radiologic diagnosis Patient Case: Appendicitis in Pregnancy

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Arabinda Pani, HMS III Gillian Lieberman, MD

Epidemiology •Appendicitis-associated abdominal pain is a common presentation to ED •Peak Incidence: 10 – 30 years of age •Lifetime incidence: 7% in United States •Historically, high rate of false negatives and false positives •20% of diagnoses initially missed •20% of appendectomies revealing a normal appendix 3

Arabinda Pani, HMS III Gillian Lieberman, MD

Pathophysiology • The lumen of the appendix becomes obstructed, leading to increased intraluminal pressure resulting in inflammation, ischemia, and infection • Obstruction is most often secondary to: • • • • •

Appendicoliths Lymphoid hyperplasia Parasite infections Tumors (carcinoid, metastatic) Foreign bodies 4

Arabinda Pani, HMS III Gillian Lieberman, MD

Complications of Appendicitis • • • •

Perforation Abscess formation Generalized peritonitis Small bowel obstruction The rate of complications increases with time until diagnosis and treatment.

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Arabinda Pani, HMS III Gillian Lieberman, MD

Classic Presentation • Dull, generalized abdominal pain, migrates to RLQ over 24 hours • Nausea, Vomiting, Anorexia

• • • • •

Low-grade fever Abdominal tenderness Guarding Rebound tenderness Obturator and Psoas Signs • Elevated WBC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Role of Radiologic Diagnosis • Appendicitis is highly prevalent • Often presents atypically especially in children, women and the elderly • Complications are common and timedependent

Radiologic Diagnosis: • Is effective in significantly increasing diagnostic accuracy • Decreases morbidity and mortality by: •preventing complications •avoiding unnecessary surgeries • Lowers the overall cost of healthcare 7

Arabinda Pani, HMS III Gillian Lieberman, MD

Anatomy

Gray’s Anatomy adam.com

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Arabinda Pani, HMS III Gillian Lieberman, MD

Normal Appendix

contrast-filled appendix on barium study http://www.emedicine.com/radio/topic47.htm

contrast in appendix (CT) 9

Arabinda Pani, HMS III Gillian Lieberman, MD

Ultrasound: Normal Appendix

Longitudinal ultrasonography shows compressible tubular structure with an outer diameter of less than 6 mm. A=Iliac artery; V=Iliac vein. http://emedicine.com/radio/topic47.htm

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Arabinda Pani, HMS III Gillian Lieberman, MD

Normal Appendix: MR

Low Signal Intensity Non-distended Courtesy Dr. Eric Zeikus, PACS:BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Radiologic Findings of Appendicitis • Inflammatory changes • Lumenal obstruction • Appendicoliths

Plain Film

Barium Enema

Film is normal in > 50% of patients with appendicitis

Diagnostic criteria requires visualization of a nonfilling appendix

Only 10% demonstrate a calcified, laminated appendicolith(s) Other findings are nonspecific

Often non-diagnostic with low sensitivity Invasive 12

Arabinda Pani, HMS III Gillian Lieberman, MD

Plain Film: Calcified Appendicolith

http://telesalud.ucaldas.edu.co

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Arabinda Pani, HMS III Gillian Lieberman, MD

Graded Compression Ultrasound •Blind-ended, tubular, noncompressible, aperistaltic structure •Diameter > 6 mm, laminated wall •Increased periappendiceal echogenicity •Appendicolith: echogenic with distal shadowing •Doppler: increased circumferential flow •Perforation/Abscess: thickening of adjacent bowel wall, fluid collections, hypoechoic mass Overall diagnostic accuracy: 85% 14

Arabinda Pani, HMS III Gillian Lieberman, MD

Appendicitis on Ultrasound

Non-compressible, blind-ended 8mm diameter Laminated wall Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

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Arabinda Pani, HMS III Gillian Lieberman, MD

Color Doppler Ultrasound

Circumferential Flow, suggestive of hypervascularity and inflammation Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

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Arabinda Pani, HMS III Gillian Lieberman, MD

Appendicolith on US

• Bright, echogenic focus • Clean distal acoustic shadowing Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

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Arabinda Pani, HMS III Gillian Lieberman, MD

Perforated Appendix on US

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Perforated Appendix with Free Peritoneal Fluid (FF) surrounding loops of bowel (B).

http://lunis.lumc.edu/radiology/Appendicitis

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Arabinda Pani, HMS III Gillian Lieberman, MD

CT Diagnosis Primary Criteria: • Enlarged, inflamed appendix – diameter >6 mm in adults – > 8mm in children

• Appendicolith • Non-contrast filled

Secondary Criteria: • • • •

Wall enhancement Fat stranding Abscess formation Focal thickening of the cecum (arrow-head sign) • Adenopathy • Small bowel obstruction • Free fluid in the pelvis

Overall Accuracy: 98% 19

Arabinda Pani, HMS III Gillian Lieberman, MD

Uncomplicated Appendicitis: CT

• • •

Non-contrast filled Enlarged appendix, 14 mm in diameter Adjacent fat stranding

Courtesy of Dr. Michael Geary, PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Coronal CT: Enhancing Wall

PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

CT: Appendicolith

http://www.madisonradiologists.com/SvcCTAbdominalPain.htm

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Arabinda Pani, HMS III Gillian Lieberman, MD

Arrowhead Sign

Mural thickening of the cecum at the base of an obstructed appendix http://lunis.lumc.edu/radiology/Appendicitis/ctfindings.htm

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Arabinda Pani, HMS III Gillian Lieberman, MD

Periappendiceal Abscess

Courtesy of Dr. Damon Soeiro; PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Coronal CT: Abscess

PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Our Patient Otherwise healthy, 33 year old female at 20 weeks gestation, presented to ED with 6 days of abdominal pain. Pain was described as epigastric and crampy in nature. Denied nausea, vomiting. Reported loss of appetite, chills, and a low-grade fever. Temp 99.4 WBC: 10.2 Abdomen: soft, gravid, diffusely tender to palpation; no rigidity or rebound tenderness 26

Arabinda Pani, HMS III Gillian Lieberman, MD

Diagnostic Complications in Pregnancy • Pregnancy alters the position of the appendix • Atypical clinical presentation • Increased risk of perforation • Association with premature labor, decreased birth weight

•Ultrasound is modality of choice but diagnosis can be impeded by body habitus and anatomic displacement of the appendix •CT exposes the fetus to radiation

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Arabinda Pani, HMS III Gillian Lieberman, MD

Patient Evaluation by Ultrasound • Focal rounded area of increased echogenicity with a hypoechoic rim and increased vascularity suspicious for an inflamed appendix • Localized to the patient’s area of tenderness • Noncompressible

PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Doppler Ultrasound Findings

• Transverse view demonstrated increased circumferential flow in the wall of the appendix, suggestive of hypervascularity secondary to inflammation

PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Diagnosis of Appendicitis in Pregnancy Advantages of MR •Visualize an abnormal appendix in atypical locations •Visualize adjacent inflammatory processes •Different sequences +/contrast •No known biologic risks to fetus

Diagnostic Findings • Enlarged appendix > 6mm • Periappendiceal inflammatory changes • T2/fat-suppressed images: high signal intensity of an inflamed appendix 30

Arabinda Pani, HMS III Gillian Lieberman, MD

HASTE Sequence, Coronal View • Appendix location: posterior and superior to the uterus • Distended at: 10 mm in the middle; 18 mm at tip • Associated fat stranding

Courtesy of Dr. Eric Zeikus, PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Sagittal View

• Fluid-filled lumen • Thickened wall

PACS: BIDMC

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Arabinda Pani, HMS III Gillian Lieberman, MD

Conclusion of Case • Patient proceeded to surgery for a laparoscopic appendectomy, performed without complications. • On gross appearance, the appendix was inflamed and gangrenous. • Post-op ultrasound demonstrated a normal, unchanged fetus. • Pathology: specimen consistent with acute appendicitis with evidence of perforation • The mother carried fetus to term, delivered without complications. 33

Arabinda Pani, HMS III Gillian Lieberman, MD

Acknowledgements • • • • • • • •

Michael Geary, MD Arati Khanna, MD Damon Soeiro, MD Atif Zaheer, MD Eric Zeikus, MD Gillian Lieberman, MD Pamela Lepkowski Larry Barbaras 34

Arabinda Pani, HMS III Gillian Lieberman, MD

References • • • • • • • • •

Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348. Checkoff JL, Wechsler RJ, Nazarian LN. Chronic Inflammatory Appendiceal Conditions That Mimic Acute Appendicitis on Helical CT. Am. J. Roentgenol. 2002 179: 731-734 Cobben LP, Groot I, Haans L et al. MRI for Clinically Suspected Appendicitis During Pregnancy. Am. J. Roentgenol. 2004 183: 671-675 Eyvazzadeh AD, Pedrosa I, Rofsky N M et al. MRI of Right-Sided Abdominal Pain in Pregnancy. Am. J. Roentgenol. 2004 183: 907-914 Lee J, Jeong YK, Hwang JC, et al. Graded Compression Sonography with Adjuvant Use of a Posterior Manual Compression Technique in the Sonographic Diagnosis of Acute Appendicitis Am. J. Roentgenol. 2002 178: 863-868. Novelline, RA. Helical CT in Emergency Radiology. Radiology 1999 213: 321339. Rosen MP, Sands DZ, Esterbrook H, et al. Impact of Abdominal CT on the Management of Patients Presenting to the Emergency Department with Acute Abdominal Pain. Am. J. Roentgenol. 2000 174: 1391-1396 Somani R, Gordon C, McArthur R. Appendicitis in pregnancy: a rare presentation. CMAJ 2003 168: 1020 Wise SW, Labuski MR, Kasales CJ, et al. Comparative Assessment of CT and Sonographic Techniques for Appendiceal Imaging Am. J. Roentgenol. 2001 176: 933-941 35