Ultrasonography of normal and abnormal appendix in children

Comparison of ultrasound assisted and intraoperative diameter measurement in acute appendicitis

Detailed anamnesis and systematic physical examination are often relevant in the diagnostic routine of acute appendicitis. However, physicians are increasingly motivated to obtain radiological approval. Inherent limitations due to radiologists' experience and the presenting anatomy may result in contradictory outcomes between the described and intraoperative findings. In this study, a comparison of anthropometric measurements of the appendix vermiformis obtained by radiologists and surgeons in children with acute appendicitis is discussed. The external appendiceal diameter in 53 patients who underwent surgery between April 2022 and January 2024 was measured at three different anatomical locations during preoperative ultrasound and intraoperatively with the help of Vernier calipers. Appendectomy materials were classified into negative, acute, and complicated appendicitis subgroups on the basis of histopathological results. The widest median diameter, expressed in millimeters, was analyzed statistically in terms of diagnostic accuracy. Histopathological analysis revealed negative appendectomy in 15.1%, acute appendicitis in 66%, and complicated appendicitis in 18.8% of the patients. The median age at presentation was 11.4 years (4-17.3 years), and 45.3% of the patients were females. The average median appendiceal diameter was 7.8 ± 2.4 mm according to the caliper and 7.9 ± 2.7 mm according to ultrasound (p > 0.05). The evaluation by the caliper revealed a much smaller diameter in 19 patients than did ultrasound. The appendiceal diameter of eight documented negative appendectomy samples was 7 mm or greater. US failed to identify the presence of an appendicolith in 11 cases (20.8%), all of which were disclosed during histopathological evaluation. It is possible to conclude that ultrasound and intraoperative anthropometric measurements correlate according to our study. Diagnostic accuracy, however, which is individually based on ultrasound appendix diameter values greater than 6 mm, is controversial. It is clear that comparison and further reinterpretation of such anthropometric measurements in light of histopathological consequences may help diminish the frequency of negative and perforated appendectomies.

Intestinal Ultrasound in Common Gastrointestinal Disorders: An Evidence-Based Approach

Patients with abdominal symptoms are among the most common to present both urgently and non-urgently for medical evaluation. While intestinal ultrasound (IUS) is useful to aid management of these patients, it is not routinely taught, performed, or included as part of the core set of point-of-care ultrasound competencies. The authors present an approach to performing a systematic, but focused, IUS at the bedside and diagnostic accuracies for small bowel obstruction inflammatory bowel disease, appendicitis, and diverticulitis. An approach on how to integrate IUS findings and common pitfalls will also be discussed.

Novel Ultrasonographic Evaluation of Microvascular Blood Flow for Non-Operative Management of Uncomplicated Acute Appendicitis in Children: A Prospective Clinical Study

OBJECTIVES

To determine whether superb microvascular imaging (SMI) provides a more precise delineation between reversible and irreversible stages of uncomplicated acute appendicitis managed non-operatively.

METHODS

This prospective clinical study examined pediatric patients with acute appendicitis initially treated non-operatively and evaluated using power Doppler (PD) and SMI. We determined case severity, monitor appendiceal blood flow (BF), and appendicitis reversibility. Complicated cases were excluded. Severity was classified using B-mode as well as PD, or SMI: Grade I, smooth wall/normal BF; Grade IIa, irregular wall/increased BF; Grade IIb, irregular wall/decreased BF; and Grade III, absence of wall/loss of BF.

RESULTS

This study examined a total of 100 patients with acute appendicitis, after excluding 29 patients. All 10 patients with normal BF on PD (Grade I) showed similar BF on SMI (Grade I). Among 29 patients with increased BF on PD (Grade IIa), corresponding increased BF was noted on SMI (Grade IIa), and all these patients showed full recovery. Of the 55 patients showing decreased BF on PD (Grade IIb), 52 showed increased BF on SMI (Grade IIa). The remaining three patients, identified with an impacted appendicolith, showed decreased BF on SMI (Grade IIb) and experienced treatment failure, subsequently developing abscesses. In all six patients with undetectable BF on PD (Grade III), SMI similarly could not detect appendiceal BF (Grade III), and non-operative management failed for these patients.

CONCLUSIONS

SMI offers an objective and effective means of delineating the threshold between reversible and irreversible stages in uncomplicated acute appendicitis following non-operative management.

Finding Waldo: Sonographic systematic approach to localize the appendix in children

OBJECTIVES

To describe a systematic scanning approach using anatomical landmarks followed by an assessment of radiology trainees' ability to identify the normal appendix in healthy children.

METHODS

Uncontrolled pre and post study assessing radiology residents' sonographic skills in detecting the normal appendix in healthy children. Initial questionnaire for the trainees' demographics, perceptions and experiences in detecting the appendix with ultrasound in children followed by a precourse test on healthy volunteers. Hands-on training was conducted by describing a systematic sonographic approach to identify the appendix using anatomical landmarks, and then a postcourse test was carried out. The primary outcome was unprompted ability to identify the appendix. Subjective self-scoring of confidence was also recorded.

RESULTS

A three-hour hands-on workshop was conducted. Sixteen radiology trainees participated and were randomly distributed to four stations, each with different ultrasound machines and healthy volunteers. Fifteen had a precourse assessment, and 12 completed the postcourse assessment. Before the course, 3/15 (20%) identified the appendix, while 10/12 (83%) identified the appendix afterward. After the course, participants perceived finding the appendix easier than before. There was no statistically significant difference in the participants' perceived confidence in detecting the appendix.

CONCLUSIONS

With the described scanning technique, most of the participants were able to identify the normal appendix after receiving short hands-on training. This highlights the importance of targeted training of radiology trainees and nonradiologists.

Evaluating the Diagnostic Efficacy of Computed Tomography in Appendicitis Cases With Negative Ultrasound Findings

INTRODUCTION

Acute appendicitis (AA) is a prevalent cause of abdominal pain, and accurate diagnosis is critical to prevent complications such as perforation. While ultrasound (USG) is often the first imaging modality, its limitations necessitate alternative approaches, particularly in cases where USG results are negative.

OBJECTIVES AND AIMS

This study aims to evaluate the diagnostic accuracy of computed tomography (CT) in identifying appendicitis in patients presenting with negative USG findings.

MATERIALS AND METHODS

A prospective observational study was conducted at a tertiary care hospital in Pondicherry, India, involving 70 patients with clinically suspected appendicitis and negative USG results. All patients underwent CT imaging, and findings were analyzed to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy.

RESULTS

Of the 70 patients, 35 were diagnosed with appendicitis based on CT findings, yielding a sensitivity of 100%, a specificity of 65.71%, a PPV of 74.47%, an NPV of 100%, and an overall accuracy of 82.86%. The study also identified other conditions, such as mesenteric lymphadenitis and ureteric calculus, in patients with negative appendicitis diagnoses.

CONCLUSIONS

CT is a highly effective imaging modality for diagnosing appendicitis in patients with negative USG results. The use of CT significantly aids in clinical decision-making, reducing the rates of unnecessary surgeries and complications.

Acute Appendicitis in the Setting of Infectious Mononucleosis: A Case Report

Infectious mononucleosis (IM) is a viral illness caused by the Epstein-Barr virus that typically manifests with pharyngitis, lymphadenopathy, and fatigue. In rare cases, IM can cause acute appendicitis. We present the case of an 18-year-old female who arrived at the emergency department with worsening abdominal pain and an ongoing cough. Initial imaging showed a questionably dilated appendix, and a follow-up examination revealed cervical lymphadenopathy. She later returned to the ED with severe abdominal pain, clinical signs of acute appendicitis, and a positive monospot test, which led to an appendectomy. This case illustrates the need for complete history taking and thorough physical examination in patients with acute appendicitis, as their condition may be due to an atypical underlying cause.

Ultrasound Assessment in Children With Suspected Appendicitis: Time to Revise Diagnostic Criteria: A Prospective Cohort Study

Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis.

Interpretable and intervenable ultrasonography-based machine learning models for pediatric appendicitis

Appendicitis is among the most frequent reasons for pediatric abdominal surgeries. Previous decision support systems for appendicitis have focused on clinical, laboratory, scoring, and computed tomography data and have ignored abdominal ultrasound, despite its noninvasive nature and widespread availability. In this work, we present interpretable machine learning models for predicting the diagnosis, management and severity of suspected appendicitis using ultrasound images. Our approach utilizes concept bottleneck models (CBM) that facilitate interpretation and interaction with high-level concepts understandable to clinicians. Furthermore, we extend CBMs to prediction problems with multiple views and incomplete concept sets. Our models were trained on a dataset comprising 579 pediatric patients with 1709 ultrasound images accompanied by clinical and laboratory data. Results show that our proposed method enables clinicians to utilize a human-understandable and intervenable predictive model without compromising performance or requiring time-consuming image annotation when deployed. For predicting the diagnosis, the extended multiview CBM attained an AUROC of 0.80 and an AUPR of 0.92, performing comparably to similar black-box neural networks trained and tested on the same dataset.

Gastrointestinal Ultrasound in Emergency Setting

Acute bowel diseases are responsible for more than one third of subjects who were referred to the emergency department for acute abdominal pain and gastrointestinal evaluation. Gastrointestinal ultrasound (GIUS) is often employed as the first imaging method, with a good diagnostic accuracy in the setting of acute abdomen, and it can be an optimal diagnostic strategy in young females due to the radiation exposure related to X-ray and computed tomography methods. The physician can examine the gastrointestinal system in the area with the greatest tenderness by ultrasound, thus obtaining more information and data on the pathology than the standard physical examination. In this comprehensive review, we have reported the most relevant indications and advantages to using ultrasound in the investigation of abdominal acute pain.

Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

The role of hematological parameters in distinguishing acute appendicitis from lymphoid hyperplasia

BACKGROUND

One of the most misdiagnosed appendicular pathologies is lymphoid hyperplasia (LH) that can be managed con-servatively when identified early and is self-limiting. The aim of this retrospective study was to compare acute appendicitis (AA) with LH in terms of hematological parameters to determine whether there is a hematological predictor to distinguish the two diseases.

METHODS

Complete blood cell counts of patients with AA were compared with those having LH.

RESULTS

One-hundred-ninety-five patients (118 male/77 female) underwent appendectomy. Histopathological examination re-vealed acute AA in 161 patients (82.6%), and negative appendectomy (NA) in 19 patients (9.7%). Of the NA specimens, 16 were LH (8.2%). Thirteen patients (6.7%) had AA with simultaneous LH. White blood cell count (p=0.030, neutrophil (p=0.009), neutrophil per-centage (p=0.009), and neutrophil/lymphocyte ratio (p=0.007) were significantly higher in AA whereas lymphocyte count (p=0.027), lymphocyte percentage (p=0.006) were significantly higher in LH. Multi logistic regression analysis revealed white blood cell count as the only independent predictor in distinguishing AA from LH with a 69.1% sensitivity, 80.0% specificity, 77.5% positive predictive value, and 72.1% negative predictive value. The cut-off value for white blood cell count was 11.3 Ku/L, and every one unit (1000/mm3) increase in white blood cell count raises the risk of AA by 1.24 times, while values below this value will increase the likelihood of LH.

CONCLUSION

The most predictive complete blood count parameter in distinguishing LH from AA appears to be as white blood cell count.

Role of Ultrasonography and Inflammatory Markers in Predicting Complicated Appendicitis

AIM

The aim is to compare the diagnostic accuracy of laboratory investigations and ultrasonography (USG) in distinguishing complicated appendicitis (C-AA) from uncomplicated appendicitis (UC-AA).

MATERIALS AND METHODS

Forty-six children who underwent appendicectomy at our center between November 2018 and July 2020 were included. Based on intraoperative findings, they were divided into two groups - complicated (perforated, gangrenous, or associated with fecal peritonitis; n = 18) and UC-AA (n = 28). USG findings and inflammatory markers were compared in both groups at admission.

RESULTS

At admission, the mean values for total leukocyte count (TLC) (16090.56 vs. 11739.29 per mm³), high sensitivity C-reactive protein (hsCRP) (35.8 vs. 31.62 mg/L), and procalcitonin (PCT) (3.83 vs. 1.41 ng/mL) were significantly higher in C-AA. Visualization of a blind tubular aperistaltic structure was the only sonographic sign showing statistical significance - significantly lower in C-AA (50% vs. 90%). Independent predictors of C-AA were - duration of symptoms >48 h (odds ratio [OR] 6.3), free fluid/loculated collection in right iliac fossa (OR 3.75), TLC >11000/mm³ (OR 3.6), hsCRP >35 mg/L (OR 6.0), PCT >0.6 ng/mL (OR 4.02), and nonvisualization of appendix on USG (OR 8.33). Biochemical factors were sensitive (89%) and specific (55%) in differentiating C-AA from UC-AA but the addition of sonological parameters significantly improved the specificity of predicting complicated AA to 61% (P = 0.0036).

CONCLUSION

Combining laboratory data with sonological findings significantly improves the predictive value for differentiating C-AA from UC-AA and can help decide operative approach and prognosticating.

Sonographic diagnosis of appendicitis: A pictorial essay and a new diagnostic maneuver

While many cases of appendicitis are easy to diagnose clinically, a significant number need further workup in the form of imaging. Ultrasound and CT are both used extensively to diagnose or exclude appendicitis, or arrive at an alternate diagnosis. Ultrasound has many advantages but can be a difficult modality to use due to, among other reasons, the anatomical variations in appendicial location. The true retrocolic appendix is particularly difficult to diagnose with ultrasound. This pictorial essay examines the ultrasound features of normal and diseased appendix and proposes a new examining station, the prone view, for visualizing true retrocolic appendicitis.

Value of Periappendiceal Fat Sign on Ultrasound in Acute Appendicitis

Introduction

Acute right lower quadrant abdominal pain is one of the most common surgical presentations to the emergency department with acute appendicitis being the topmost differential diagnosis. Although computed tomography (CT) is the gold standard in diagnosing appendicitis, in our setup ultrasound is often the initial imaging modality available in urgent care settings especially for children and pregnant females. On ultrasound, an inflamed appendix has a diameter of 6 mm or more and is non-compressible. Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that supports the sonographic diagnosis of acute appendicitis. To determine the association of periappendiceal fat echo sign (PFES) on ultrasound in surgically proven cases of acute appendicitis.

Methods

This cross-sectional study was held at the Department of Radiology at the Aga Khan University Hospital in Karachi, Pakistan. Periappendiceal fat echogenicity was assessed and prospectively graded in 59 patients. These patients had sonographic features of acute appendicitis which was later confirmed by surgery. Data were collected on a proforma and later analyzed. Frequency of increased periappendiceal fat echogenicity in acute appendicitis was calculated. Association of PFES with gender and ascites was evaluated with Fischer's exact test and with patient's age and appendiceal diameter was assessed using analysis of variance (ANOVA).

Results

Increased periappendiceal fat echogenicity was seen in 89.8% of patients with acute appendicitis. 10.2% of patients had acute appendicitis with normal surrounding fat. Mean appendiceal diameter in patients with grade 3 PFES was significantly more than those with grade 2 or grade 1 PFES. PFES had no association with age and gender of the patient or with ascites.

Conclusion

Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that helps support its sonographic diagnosis.

Comparison of Clinical Characteristics According to the Existence of Secondary Appendicitis in Pediatric Acute Enterocolitis: A Single Center Study

PURPOSE

In patients with acute enterocolitis, radiologic findings are sometimes accompanied by secondary inflammation of the appendix. The purpose of this study was to evaluate the clinical features of acute enterocolitis with secondary inflammation of the appendix.

METHODS

Medical records from patients who underwent abdominal ultrasonography or computed tomography (CT) among those admitted for acute enterocolitis were retrospectively reviewed. Clinical features were compared by distinguishing patients with inflammation of the appendix from those without, based on their symptoms and laboratory findings.

RESULTS

Of the 165 patients, 12 (7.3%) had secondary inflammation of the appendix on ultrasonography and/or CT. Patients with secondary inflammation of the appendix were significantly older than those without (11.7 vs. 6.1 years, p=0.011) and more frequently had fever (83.3% vs. 49.0%, p=0.033), and high values of C-reactive protein (CRP) (5.38 vs. 0.32 mg/dL, p<0.001). The proportion of bacterial pathogens was higher in patients with secondary inflammation of the appendix (60% vs. 15.1%, p=0.004).

CONCLUSION

Patients with acute enterocolitis accompanied by secondary appendicitis more commonly have fever, higher CRP levels, higher bacterial pathogen detection rates, and longer hospital stays. Treatment equivalent to that of bacterial infection is required for patients with secondary appendicitis, and that their symptoms should be closely and continuously monitored and followed-up.

Rising incidence of appendiceal neoplasms over time: Does pathological handling of appendectomy specimens play a role?

BACKGROUND

Appendectomy is the most common emergent surgical procedure. Primary appendiceal neoplasms are rare entities that are usually detected incidentally in less than 2% of all appendectomies. The increase in the incidence rates of appendiceal neoplasms over time raises the question whether there is an actual change in the disease occurrence or is it a matter of increased recognition and reporting of what would have been previously missed and undiagnosed.

OBJECTIVES

In our study, we aimed to review the archived tissue specimens of patients who were diagnosed with appendiceal neoplasms during the past decade at our institution and compare our clinical experience with published data to identify possible reasons that contribute to the increase in incidence rates of such neoplasms over the past few years.

METHODS

Using a pathological database of surgical specimens from patients who underwent appendectomies between January 01, 2010 and September 30, 2020 at a large academic medical center, a single-center retrospective cohort analysis was performed, and medical charts of patients were reviewed.

RESULTS

Of the total 1568 patients included, 102 (6.5%) had appendiceal neoplasms divided between primary (79.4%) and secondary/metastatic (20.6%) neoplasms. Annual incidence of appendiceal neoplasms over the past 10 years in our institution demonstrated an increasing trend from 5.6% in 2010 to 12.7% in 2020, which we hypothesize might be attributed to submitting more representative sections of the appendix for pathological examination than we had previously. Our results also showed that 2.8% of patients initially presenting with a typical clinical picture of acute appendicitis had appendiceal neoplasms as a truly incidental finding, while 20.3% of patients who underwent elective appendectomies for a suspicious appendiceal mass were found to be neoplastic. Interestingly, among the 80 cases of epithelial neoplasms, more non-carcinoid neoplasms were detected than carcinoid tumors.

CONCLUSION

Based on our results and what has been published recently, we confirm an additional increase in incidental appendiceal neoplasms found in appendectomies performed for a clinical picture of acute appendicitis, which may be related to more thorough specimen assessment. Whether this is clinically impactful remains to be determined. However, these data support a modification in the way appendectomy specimens are handled in pathology labs post-operatively.

The Borderline-Size Appendix: Grayscale, Color Doppler, and Spectral Doppler Findings That Improve Specificity for the Sonographic Diagnosis of Acute Appendicitis

Diagnostic criteria for acute appendicitis using graded compression sonography have been well established based on the maximum outer diameter (MOD) of the appendix, with MOD values of <6 mm nearly always indicating normal appendices and MOD values of >8 mm nearly always indicating appendicitis. However, the "borderline-size" appendix, meaning one whose MOD lies between these ranges (ie, an appendix with MOD of 6-8 mm), presents a diagnostic dilemma because appendices in this size range are neither clearly normal nor abnormal when diagnosis is based on the MOD alone; accordingly, such borderline MOD values are diagnostically equivocal, and sonographic diagnosis must rely on sonographic findings other than the MOD. The goal of this review was to examine the additional sonographic findings that can add specificity and help enable an accurate diagnosis to be made in patients with borderline-size appendices.

Pediatric emergency gastrointestinal ultrasonography: pearls & pitfalls

Ultrasonography is an essential tool in pediatric imaging, particularly in the emergency setting. Although ultrasound is often the favored initial modality for abdominal imaging in children, it is highly operator-dependent and therefore prone to misinterpretation which can lead to false positive or negative exams, or even incorrect diagnoses. Conditions discussed in this series include ileocolic intussusception, hypertrophic pyloric stenosis, appendicitis, and ingested foreign bodies. We will review diagnostic criteria, highlight crucial findings, and illustrate commonly-encountered difficulties and mimics.

Semi-dynamic Control of FCM Initialization for Automatic Extraction of Inflamed Appendix from Ultrasonography

BACKGROUND

Current naked-eye examination of the ultrasound images for inflamed appendix has limitations due to its intrinsic operator subjectivity problem.

OBJECTIVE

In this paper, we propose a fully automatic intelligent method for extracting inflamed appendix from ultrasound images. Accurate and automatic extraction of inflamed appendix from ultrasonography is a major decision making resource of the diagnosis and management of suspected appendicitis.

METHODS

The proposed method uses Fuzzy C-means learning algorithm in pixel clustering with semi-dynamic control of initializing the number of clusters based on the intensity contrast dispersion of the input image. Thirty percent of the prepared ultrasonography samples are classified into four different groups based on their intensity contrast distribution and then different number of clusters are assigned to the images in accordance with such groups in Fuzzy C-means learning process.

RESULTS

In the experiment, the proposed system successfully extracts the target without human intervention in 82 of 85 cases (96.47% accuracy). The proposed method also shows that it can cover the false negative cases occurred previously that used self-organizing map as the learning engine.

CONCLUSION

Such high level reliable correct extraction of inflamed appendix encourages to use the automatic extraction software in the diagnosis procedure of suspected acute appendicitis.

Appendicular Lymphoid Hyperplasia in the Differential Diagnosis of Acute Appendicitis: Sonographic Findings

Objectives:

To describe sonographic findings of appendicular lymphoid hyperplasia (ALH) and to report demographic data of patients with ALH operated for acute appendicitis (AA).

Materials and Methods:

In a retrospective study, 694 biopsies of consecutive AA surgeries with previous ultrasonography (US) were reviewed, after selecting the ALH cases.

Results:

Twenty-five ALH cases were proved histologically (3.8% of appendectomies). The mean age was 13 years, with 84% under 20 years. US findings showed increased appendiceal diameter (average 7 mm) (82%), hypoechogenic pseudonodular mucosal thickening (50%), concentric parietal thickening (13%), and periappendiceal inflammatory changes (18%). In four cases, a normal appendix was noted on US, with two associated with intestinal intussusceptions.

Conclusion:

ALH is a benign entity most frequent in children that can predispose to AA. Both pathologies can increase the appendiceal diameter. In the pediatric group, ALH could be considered when hypoechogenic pseudonodular appendicular mucosal thickening in the absence of periappendiceal inflammatory changes occurs.

Acute Appendicitis or Lymphoid Hyperplasia: How to Distinguish More Safely?

PURPOSE

Lymphoid hyperplasia can be an important mimicker of acute appendicitis by creating a non-compressible appendix more than 6 mm in diameter. The aim of this study was to evaluate methods of distinguishing lymphoid hyperplasia and appendicitis on the basis of sonography, lamina propria thickness, and Alvarado scoring.

METHODS

This retrospective study included 259 patients (142 appendicitis, 117 lymphoid hyperplasia). The US (ultrasound) reports of the patients were reviewed and the maximum diameter of the appendix, the presence or absence of increased echogenicity of the surrounding pericaecal fat, local fluid collection, the presence of reactive lymph nodes in the periappendiceal area, and mural hyperemia within the appendix were recorded.

RESULTS

The use of additional sonographic criteria, lamina propria thickness (≤1 mm is indicative for appendicitis), or Alvarado scoring (>6 mm is indicative for appendicitis) provided a true-positive diagnosis for acute appendicitis.

CONCLUSION

The presence of local fluid collection in the periappendiceal area and a lamina propria thickness ≤ 1 mm are the most successful parameters for distinguishing appendicitis from lymphoid hyperplasia.

Vomiting and Dehydration in a 2-Year-Old

A 2-year-old girl with a past medical history of cutaneous mastocytosis and eczema presented with 1 day of yellow-green, nonbloody vomiting, bradycardia, and listlessness. She was evaluated by her pediatrician and sent to the emergency department because of concern for dehydration. In the emergency department, she improved with fluid rehydration but still had decreased energy and bradycardia. Her electrocardiogram revealed sinus bradycardia, and laboratory results did not reveal any electrolyte abnormalities. Glucose levels were normal. An abdominal radiograph revealed a moderate-to-large stool burden, and the results of a computed tomography scan of the head were normal. An abdominal ultrasound was obtained to evaluate for intussusception. The ultrasound revealed a blind-ending tubular structure in the right-lower quadrant with adjacent free fluid, which was concerning for appendicitis. The patient was admitted to the surgical service for further management and was taken to the operating room, where a definitive diagnosis was made.

Diagnostic accuracy of surgeon performed ultrasound (SPU) for appendicitis in children

AIM

Compare the diagnostic accuracy of surgeon performed ultrasound to radiology performed ultrasound in children presenting with suspected appendicitis to a tertiary care pediatric hospital in Australia.

METHODS

Children under 16 presenting to the emergency department of The Children's Hospital at Westmead were considered for the study. Patients with obvious signs of appendicitis not requiring ultrasound and those with established ultrasound diagnosis of appendicitis were excluded. Ultrasound was performed by a Pediatric Surgeon (SPU) after obtaining consent. The treating team was blinded to the results. Patient underwent formal ultrasound in radiology (RPU) and treatment was based on the formal report. SPU result was reviewed by a radiologist blinded to results of RPU. The results were compared.

RESULTS

65 children underwent ultrasound. 35 were male. Median age was 10 (range3-15). Median weight was 36 kg (range 12.6-76.2 kg), z-score median 0.21 (-1.83 to 2.74). Symptom duration ranged from few hours to 2 weeks but majority (45) had symptoms for less than 48 h. Prevalence of appendicitis was 45%. Thirty two underwent surgery. Negative appendicectomy rate was 9.4%. Thirty three did not have surgery. 8 represented but only one proceeded to appendicectomy. SPU was done earlier than RPU (median 12 h vs 14.15 h) p = 0.088. Diagnostic accuracy using ROC did not reveal significant difference.

CONCLUSION

SPU can be performed earlier than RPU with reliable accuracy. Training surgical trainees will enable early diagnosis and management of appendicitis.

A Pediatric Foreign Body Appendicitis Can Cause a Pitfall in Imaging

Although foreign body (FB) ingestion is common in childhood, most cases do not have any clinical significance. Radiologic evaluation is crucial to determine the exact location of a persistent foreign body because it dictates the therapeutic approach. In this case report, we present a child with appendiceal perforation caused by a FB and emphasize pitfalls in preoperative imaging assessment. A 3-year-old boy presented with subtle abdominal pain duration for three months. The preoperative imaging examinations were consistent with an intraluminal metallic pin. However, the operative findings and postoperative pathological examination showed that the pin perforated the appendiceal wall, causing chronic inflammatory changes with an omental reaction around the extraluminal part of the pin. The patient underwent appendectomy with an uneventful course. Foreign body is a rare cause of appendiceal perforation with resultant appendicitis. Imaging may reveal some clues regarding the location, but the interpretation of radiologic data could be quite challenging.

Ultrasound features of secondary appendicitis in pediatric patients

Purpose

The purpose of this study was to evaluate the ultrasonographic findings of secondary appendicitis (SA) and to discuss the differential findings compared with primary appendicitis.

Methods

In this study, we analyzed the ultrasonographic findings of 94 patients under 15 years old of age treated at our institution from May 2005 to May 2014 who had bowel inflammation and an inflamed appendix with a maximal outer diameter >6 mm that improved with nonsurgical treatment (the SA group). Ninety-nine patients with pathologically proven acute appendicitis (the primary appendicitis [PA] group) from June 2013 to May 2014 and 44 patients with pathologically negative appendectomy results from May 2005 to May 2014 were also included to compare the ultrasonographic features of these conditions. A retrospective review of the ultrasonographic findings was performed by two radiologists. The clinical and laboratory findings were also reviewed. The results were statically analyzed using analysis of variance, the Pearson chi-square test, and the two-tailed Fisher exact test.

Results

Compared with PA, cases of SA had a smaller diameter (9.8 mm vs. 6.6 mm, P<0.001), and were less likely to show periappendiceal fat inflammation (98% vs. 6%, P<0.001) or an appendicolith (34% vs. 11%, P<0.001). SA showed mural hyperemia on color Doppler ultrasonography as frequently as PA (P=0.887).

Conclusion

The ultrasonographic features of SA included an increased diameter compared to a healthy appendix and the same level of hyperemia as in PA. However, the diameter was commonly in the equivocal range (mean diameter, 6.6 mm), and periappendiceal fat inflammation was rarely present in SA.

Ultrasound of the pediatric appendix

Appendicitis is the most common pediatric surgical emergency. Ultrasound (US) receives the highest appropriate rating scale in children with right lower quadrant pain suspected to have appendicitis. The US exam of the appendix has improved since Puylaert pioneered the technique of graded compression in 1986. In this article, we review ultrasonography of the pediatric appendix as it pertains to the normal appendix, acute appendicitis and the different sonographic manifestations. We also briefly describe technical optimization of image acquisition, common pitfalls and differential diagnoses.

Independent Preoperative Predictors of Prolonged Length of Stay after Laparoscopic Appendectomy in Patients over 30 Years of Age: Experience from a Single Institution

Prompt discharge after laparoscopic appendectomy (LA) is a marker of quality of care, fiscally desirable and feasible in select patients. Patients over 30 comprise a more heterogeneous cohort known to experience worse outcomes after LA. We aimed to identify easily available preoperative risk factors portending a postoperative length of stay ≥2 days among patients above age 30. In this investigation, 296 included patients from a single institution who underwent LA for acute appendicitis from 2010 to 2014 were retrospectively reviewed for preoperative demographics, laboratory studies, comorbidities, presentation characteristics, radiographic finding, and other rationally selected factors for association with postoperative length of stay ≥2 days. Bivariate and multivariate analysis was conducted to determine independent risk factors, which were subsequently modeled via receiver-operating characteristic curve generation and Kaplan-Meier analysis. “Classic” presentation [odds ratio (OR) = 0.5, P = .02], elevated red cell distribution width (RDW; OR = 1.5/% increase, P = 0.004) as well as evidence of rupture on CT (OR = 6.9, P < 0.001) were independently associated with postoperative length of stay ≥ 2 days. Modeling length of stay using these factors generated an area under the curve of 0.713 ± 0.037. Kaplan-Meier analysis of “classic” presentation, elevated RDW, and evidence of rupture on CT through the fifth postoperative day generated log-rank P values of 0.02, 0.05, and ≤ 0.001, respectively. In summary, lack of “classic” presentation, elevated RDW, and CT evidence of rupture are novel risk factors for prolonged postoperative length of stay in LA patients over 30. These findings may help target patients most appropriate for prompt discharge.

Automatic Extraction of Appendix from Ultrasonography with Self-Organizing Map and Shape-Brightness Pattern Learning

Accurate diagnosis of acute appendicitis is a difficult problem in practice especially when the patient is too young or women in pregnancy. In this paper, we propose a fully automatic appendix extractor from ultrasonography by applying a series of image processing algorithms and an unsupervised neural learning algorithm, self-organizing map. From the suggestions of clinical practitioners, we define four shape patterns of appendix and self-organizing map learns those patterns in pixel clustering phase. In the experiment designed to test the performance for those four frequently found shape patterns, our method is successful in 3 types (1 failure out of 45 cases) but leaves a question for one shape pattern (80% correct).

Another mistaken case of appendicitis

In 2010, when I was 17, I presented to hospital with progressive discomfort and pain in the right iliac fossa when eating and moving, associated with mild fever and diarrhoea. Appendicitis was suspected but immediate surgery was deferred, as the inflammatory markers did not adequately support the clinical diagnosis of appendicitis. Further tests, including MRI, were then undertaken. The MRI showed evidence of terminal ileitis and a normal appendix. Crohn's disease was considered as part of the differential diagnosis. However, a Yersinia enterocolitica infection was subsequently confirmed. The episode highlighted several learning points including preventing unnecessary surgery and the advantages of using a multidisciplinary approach involving imaging the abdomen and microbiological input.

Sonographic distinction between acute suppurative appendicitis and viral appendiceal lymphoid hyperplasia ("pink appendix") with pathological correlation

The viral etiology of mesenteric lymphadenitis may also affect the lymphoid tissue of the appendix in children giving rise to symptomatic appendiceal lymphoid hyperplasia, the so-called "pink appendix." The present study used ultrasound (US) to determine if certain sonographic features correlated with appendiceal pathological findings. Our results indicate that a fluid-filled appendix always correlates with a suppurative or mixed pathological appearance that likely merits surgery. A lymphoid predominant pathological appearance occurred only in cases where appendiceal wall thickening alone was seen on US. This pilot project therefore shows that US has the potential to stratify acute appendix patients into different treatment regimens, given that lymphoid hyperplasia could be treated conservatively. Further studies correlating other clinicoradiological parameters with this sonographic appearance are warranted.

A glimpse towards the vestigiality and fate of human vermiform appendix-a histomorphometric study

INTRODUCTION

The vermiform appendix in human is considered to be a vestigial organ by most of the authors. Absence of appendix is already reported in Indian population. Whether the human appendix is performing any function is debatable but when present it can create trouble. So if there is no appendix we can escape the ill-effects of the organ. With this hope the study has been done to see whether the appendix is really going to be rudimentary or absent or not. Marerials and Methods: Length, external diameter, number of lymphoid follicles, maximum diameter of the follicle or submucous coat, thickening of the muscle coat and seromucosal thickening of freshly removed appendix from human cadavers were seen. After fixation in 10% formal saline tissues were stained with haematoxylin-eosin stain and photographs were taken. The results had been tabulated and statistically correlated.

RESULT

The parameters like number of lymphoid follicles, length and diameter all are changed as per the age advancement which is strictly indicating some functional activities of the organ which is against the idea of vestigiality of the appendix.

CONCLUSION

Human appendix cannot be called a vestigial organ unless the functional inactivity is proved. Lymphoid changes which occur after birth to provide the gut immunity is needed to be proved by further studies. There might be incidental absence or rudimentary appendix in human body, but that does not indicate that we would not have any appendix in future.

Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study

BACKGROUND

Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults; so far, not much is known about the safety and efficacy of this treatment in children. The aims of this study were to investigate the feasibility of a randomized controlled trial (RCT) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach.

METHODS

In a multicenter, prospective cohort study patients aged 7-17 years with a radiologically confirmed simple appendicitis were eligible. Intravenous antibiotics (amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily) were administered for 48-72 hours. Clinical reevaluation every 6 hours, daily blood samples, and ultrasound follow-up after 48 hours was performed. In case of improvement after 48 hours, oral antibiotics were given for a total of 7 days. At any time, in case of clinical deterioration or non-improvement after 72 hours, an appendectomy could be performed. Follow-up continued until 8 weeks after discharge. Adverse events were defined as major complications of antibiotic treatment, such as allergic reactions, perforated appendicitis, and recurrent appendicitis.

RESULTS

Of 44 eligible patients, 25 participated (inclusion rate, 57%; 95% CI, 42%-70%). Delayed appendectomy was performed in 2, and the other 23 were without symptoms at the 8 weeks follow-up. Minor complications occurred in three patients. None of the patients suffered from an adverse event or a recurrent appendicitis.

CONCLUSION

Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children; the intervention seems to be safe.

Acute appendicitis in children: ultrasound and CT findings in negative appendectomy cases

BACKGROUND

To decrease the negative appendectomy rate in children, knowledge of the misleading imaging findings on US and CT in negative appendicitis cases is important.

OBJECTIVE

To evaluate the negative appendectomy rate and describe the imaging findings of US and CT that lead radiologists to misdiagnose acute appendicitis in children.

MATERIALS AND METHODS

From 2007 to 2013, 374 children operated for suspected appendicitis were proved to either have acute appendicitis (n = 348) or to be negative for appendicitis (n = 26) on pathological reports. Negative appendectomy rates were compared among imaging modalities, age groups and genders. We retrospectively reviewed US and CT findings from negative appendectomy cases.

RESULTS

The overall negative appendectomy rate was 7.0% (26/374). There were no statistically significant differences among the subgroups. The most common misleading presentations on US were sonographic tenderness (9/16, 56%) and non-compressibility (9/16, 56%). The most common misleading finding on CT were the presence of an appendicolith or hyperdense feces (5/12, 42%). Periappendiceal fat inflammation was observed in only one case of negative appendicitis on US and on CT.

CONCLUSION

Radiologists can misdiagnose children with equivocal diameters of appendices as having acute appendicitis when sonographic tenderness or non-compressibility is present on US and when an appendicolith or hyperdense feces is noted on CT. The possibility of negative appendicitis should be borne in mind when periappendiceal fat inflammation is absent or minimal in indeterminate cases.

Sonography of the normal appendix: its varied appearance and techniques to improve its visualization

The sonographic identification of the normal appendix is crucial to the success of ultrasound as an effective screening method for diagnosing acute appendicitis. The normal appendix can be challenging to identify on sonography, however, because it is a narrow tubular structure and has variable sonographic appearances. Moreover, the tip of the appendix can be quite variable in location. In this article, we review the various sonographic appearances of the normal appendix and highlight strategies to improve its visualization.

Ultrasound assessment of acute appendicitis in paediatric patients: methodology and pictorial overview of findings seen

Acute appendicitis is a common surgical emergency in the paediatric population. Computed tomography (CT) has been shown to have high accuracy and low operator dependence in the diagnosis of appendicitis. However, with increased concerns regarding CT usage in children, ultrasound (US) is the imaging modality of choice in patients where appendicitis is suspected. This review describes and illustrates the step-wise graded-compression technique for the visualisation of the appendix, the normal and pathological appearances of the appendix, as well as the imaging characteristics of the common differentials.

• A step-wise technique improves the chances of visualisation of the appendix.

• There are often several causes for the non-visualisation of the appendix in children.

• A pathological appendix has characteristic US signs, with several secondary features also identified.

• There are multiple common differentials to consider in the paediatric patient.

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis

The purposes of this study were to revisit the utility of ultrasonography (USG) as a primary imaging modality in acute appendicitis (AA) and to establish the role of CT scan as a second-line/problem-solving modality. All cases of suspected AA were referred for urgent USG. USG was done with standard protocol for appendicitis. Limited computed tomographic (CT) scan [NCCT ± CECT (IV contrast only)] was done for the lower abdomen and pelvis where sonographic findings were equivocal. One hundred and twenty-one patients were referred for USG for suspected appendicitis. Eight-four patients underwent surgery for AA based on clinical as well as imaging findings, of whom 76 had appendicitis confirmed at histopathology. Three patients were misdiagnosed (3.6 %) on USG as appendicitis. Of 76 patients of appendicitis confirmed histopathologically, 63 (82.8 %) had features of appendicitis on USG and did not require any additional imaging modality. Of 121 patients, 12 (10 %) needed CT scan because of atypical features on USG. Of these 12 patients, seven had retrocecal appendicitis, and three high-up paracolic appendicitis. USG alone had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81, 88, 92.6, 71.6, and 83 %, respectively. When combined with CT scan in select cases, the sensitivity, specificity, PPV, NPV, and accuracy of combined USG + CT scan were 96 % (P = 0.0014), 89 %, 93 %, 93.5 % (P = 0.0001), and 93 % (P = 0.0484), respectively. Twenty-eight (23 %) patients were given alternative diagnosis on USG. Dedicated appendiceal USG should be used as a primary imaging modality in diagnosing or excluding AA. Appendiceal CT can serve as a problem-solving modality.

A rare case of an appendiceal mass masquerading as a pelvic tumour and causing bilateral hydronephrosis

Diagnosing acute appendicitis in children can be difficult due to atypical presenting symptoms. While there are reported cases of acute appendicitis or appendiceal masses causing unilateral hydronephrosis, bilateral hydronephrosis as a complication of appendiceal mass is very rare. We report a case of a child who presented with cardinal symptomatology associated with the urogenital tract. Ultrasound (US) investigation showed a pelvic mass causing bilateral hydronephrosis. An initial diagnosis of a pelvic teratoma was made based on the US and computed tomography (CT) scan findings. The final diagnosis of an appendiceal mass causing bilateral hydronephrosis was established intraoperatively.