When Appendicitis Is Suspected in

Children

Oleh :
Dynna Akmal
 Introduction
Acute appendicitis is the most common
condition requiring emergency abdominal
surgery in the pediatric population, with 60,000–
80,000 cases annually in the United States.
It is one of the major causes of hospitalization
in children. The condition typically develops in
older children and young adults. It is rare under
the age of 2 years. The lifetime risk of acute
appendicitis ranges from 7% to 9%.
 In this article, we review current practice
with respect to the assessment of suspected
acute appendicitis in children, including the
role of imaging in patient assessment, the
diagnostic efficacy of graded-compression
ultrasonography (US) and helical computed
tomography (CT) for diagnosis, the
characteristic imaging appearance of acute
appendicitis at US and CT, and the effect of
cross-sectional imaging on patient outcomes.
 Clinical Assessment
of Acute Appendicitis

Clinical signs and symptoms associated

with acute appendicitis include crampy,
periumbilical or right lower quadrant pain;
nausea; vomiting point tenderness in the right
lower quadrant; rebound tenderness; and
leukocytosis with a left shift.
 Various objective clinical scoring systems
havebeen devised to stratify patient risk of
appendicitis. The most widely used clinical
scoring system is the MANTRELS score (Table).
It incorporates eight clinical and laboratory
factors that were found to be useful in making
the diagnosis of acute appendicitis.
The MANTRELS score has been shown to
be useful in discriminating between children
with acute appendicitis and those without the
disease.
 The MANTRELS Score
Characteristic Points
M igration of pain to 1
right lower quadrant
A norexia 1
N ausea and vomiting 1
T enderness in 2
right lower quadrant
R ebound pain 1
E levated temperature 1
L eukocytosis 2
S hift of white blood cell 1
count to left
Total 10
 Complications

Reported complications include

perforation, abscess formation, peritonitis,
wound infection, sepsis, infertility, adhesions,
bowel obstruction, and death.
 Imaging Assessment
of Acute Appendicitis
Routine use of abdominal radiography in
these children has little value unless bowel
obstruction or perforation is suspected.
Therefore, conventional radiography is not
discussed here, and we focus on the cross-
sectional imaging assessment of acute
appendicitis with graded-compression US and
helical CT.
 The goals of imaging in this condition are to
(a) facilitate an earlier diagnosis of acute
appendicitis or other conditions that it may
mimic,
(b) reduce negative laparotomy and perforation
rates, and
(c) reduce the intensity and cost of care.
 ultrasonography (US)
At the start of the examination, the patient is asked
to point to the site of maximal tenderness. This is useful
to expedite the examination and to aid in locating a
retrocecal appendix. On longitudinal images, the
inflamed, nonperforated appendix appears as a fluid-
filled, noncompressible,blind-ending tubular structure
(Fig 1).
The maximal appendiceal diameter, from outside
wall to outside wall, is greater than 6 mm. In early
nonperforated appendicitis, an inner echogenic lining
representing submucosa can be identified (Fig 1).
 Figure 1. Acute appendicitis. Longitudinal (a) and transverse
(b) US scans through an inflamed appendix
(between electronic calipers) show that it is enlarged. Note the
central echogenic mucosal lining.
Figure 2. Acute appendicitis with target sign. Transverse
US scan through an inflamed appendix shows an intact
echogenic submucosal layer and a fluid-filled lumen
(F), resulting in a “target” appearance.
Other findings of appendicitis include an appendicolith,
which appears as an echogenic foci withacoustic
shadowing (Fig 3)

Figure 3. Acute appendicitis with an appendicolith. Longitudinal (a) and

transverse (b) US scans through an inflamed appendix show an echogenic
appendicolith with acoustic shadowing.
 pericecal or periappendiceal fluid; increased
periappendiceal echogenicity representing fat infiltration (Fig 4);
and enlarged mesenteric lymph nodes. The only US sign that is
specific for appendicitis is an enlarged, noncompressible
appendix measuring greater than 6 mm in maximal diameter.

Figure 4. Acute appendicitis with

increased periappendiceal
echogenicity. Longitudinal US
scan through the righ lower
quadrant shows an area of
increased echogenicity (arrows)
representing infiltration of
mesenteric fat surroundingan
enlarged appendix (between
electronic calipers).
Figure 5. Acute appendicitis with loss of the echogenic
submucosal layer. Longitudinal (a) and transverse (b) US
scans through an inflamed appendix show a diffuse hypoechoic
and enlarged appendix (between electronic calipers),
with loss of the normally echogenic submucosal layer. At surgery,
appendiceal perforation was noted.
The use of color Doppler US provides a useful adjunct in the evaluation of
suspected acute appendicitis. Although color Doppler US does not increase
the sensitivity of the examination, it makes interpretation of the gray-scale US
findings easier and can increase observer confidence in the diagnosis of acute
appendicitis. Color Doppler US of nonperforated appendicitis typically
demonstrates peripheral wall hyperemia, reflecting inflammatory
hyperperfusion (Fig 8)

Figure 8. Acute appendicitis at color Doppler US. Longitudinal (a) and transverse (b) US
images through an inflamed appendix demonstrate marked hyperemia along the
periphery.
 Helical CT
Helical CT has been shown to be a highly
sensitive and specific modality for the
diagnosis of acute appendicitis in children and
adults.
The normal appendix can be identified at
CT in over three-fourths of children . The
appendix arises from the posteromedial
aspect of the cecum, approximately 1–2 cm
below the ileocecal junction (fig 11).
Figure 11. Normal appendix. (a) Axial CT scan obtained through the lower
abdomen with thin collimation following the intravenous and rectal
administration of contrast material demonstrates the normal terminal ileum
(arrows). (b) Axial CT scan obtained 2 cm below a demonstrates the normal
proximal appendix (arrow) originating from the cecal apex. (c) Axial CT scan
obtained 2 cm below b demonstrates the normal distal appendix (arrow).
Note that the appendix does not fill with
contrast material.
a. b.
c. The relationship of the base of
the appendix to the cecum is
constant, but the free end of
the appendix is mobile and
can be directed medially,
caudally, laterally, or
retrocecally. The appendix is
usually curved and may be
tortuous. A segment of the
appendix is commonly noted
at a level higher than the
ileocecal valve. The maximal
normal appendiceal diameter
is quite variable; although it
usually is 7 mm or less, it may
occasionally be larger
 The only CT findings specific for
appendicitis are an enlarged appendix and
cecal apical changes, which represent
contiguous spread of the inflammatory
process to the cecum. The identification of
cecal apical changes is particularly useful in
allowing a confident diagnosis of acute
appendicitis if there is difficulty in identifying
an enlarged appendix (Fig 21).
Figure 21. Acute appendicitis with cecal apical thickening. (a) Axial CT scan obtained through
the upper pelvis
with thin collimation following the intravenous and rectal administration of contrast material
demonstrates focal cecal apical thickening (arrow). (b) Axial CT scan obtained 1 cm below a
demonstrates an enlarged curvilinear appendix (arrow). Note that there is not a good plane of
separation between the appendix and adjacent unopacified small bowel loops. The cecal apical
thickening was helpful in calling attention to the abnormal appendix.

a b