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Appendicitis at the Millennium¹

¹ From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (B.A.B.); and the Department of Medical Imaging, the Toronto Hospital, General Division, Ontario, Canada (S.R.W.). Received March 10, 1999; revision requested May 3; revision received June 29; accepted July 22. Address correspondence to B.A.B. (e-mail: birnbaum@oasis.rad.upenn.edu).

View larger version (146K): [in a new window]   Figure 1. Early acute appendicitis in a 25-year-old man with right-lower-quadrant pain. Transverse helical CT scan obtained with intravenous and oral contrast material and with 5-mm collimation reveals a minimally thickened, minimally distended appendix (arrow) 6-7 mm in diameter, anterolateral to the right psoas muscle (P) and subtle increased attenuation of the periappendiceal fat (arrowhead) posterior to the appendix.

View larger version (111K): [in a new window]   Figure 2a. The value of contrast-enhanced CT in demonstrating early acute appendicitis in a 21-year-old man with acute onset of right-lower-quadrant pain. (a) Transverse CT scan obtained with oral contrast material and 5-mm collimation reveals a nonspecific soft-tissue mass (arrow) posteromedial to the cecum (C) in this patient with a paucity of abdominal fat. (b) Transverse helical CT scan obtained with intravenous and oral contrast material and 5-mm collimation demonstrates that this mass represents a circumferentially thickened, mildly distended, inflamed appendix (straight arrow) with associated focal thickening of the cecal wall (curved arrow). No perforation was seen at surgery. (Reproduced, with permission, from reference 67.)

View larger version (106K): [in a new window]   Figure 2b. The value of contrast-enhanced CT in demonstrating early acute appendicitis in a 21-year-old man with acute onset of right-lower-quadrant pain. (a) Transverse CT scan obtained with oral contrast material and 5-mm collimation reveals a nonspecific soft-tissue mass (arrow) posteromedial to the cecum (C) in this patient with a paucity of abdominal fat. (b) Transverse helical CT scan obtained with intravenous and oral contrast material and 5-mm collimation demonstrates that this mass represents a circumferentially thickened, mildly distended, inflamed appendix (straight arrow) with associated focal thickening of the cecal wall (curved arrow). No perforation was seen at surgery. (Reproduced, with permission, from reference 67.)

View larger version (127K): [in a new window]   Figure 3a. Classic CT findings of acute appendicitis in a 25-year-old man who presented with right-lower-quadrant pain and with exquisite McBurney point tenderness. (a) Transverse CT scan obtained with intravenous and oral contrast material and with 5-mm collimation reveals an obstructing appendicolith (straight solid arrow) within the distended, thick-walled (curved arrow) appendix. Periappendiceal inflammation (open arrow) extends to the anterior abdominal wall, where thickened, enhancing peritoneum (arrowheads) is identified. (b) Caudal helical CT image reveals additional nonobstructing appendicoliths (arrow) within the distended appendix (A). Surgical exploration revealed perforated appendicitis.

View larger version (125K): [in a new window]   Figure 3b. Classic CT findings of acute appendicitis in a 25-year-old man who presented with right-lower-quadrant pain and with exquisite McBurney point tenderness. (a) Transverse CT scan obtained with intravenous and oral contrast material and with 5-mm collimation reveals an obstructing appendicolith (straight solid arrow) within the distended, thick-walled (curved arrow) appendix. Periappendiceal inflammation (open arrow) extends to the anterior abdominal wall, where thickened, enhancing peritoneum (arrowheads) is identified. (b) Caudal helical CT image reveals additional nonobstructing appendicoliths (arrow) within the distended appendix (A). Surgical exploration revealed perforated appendicitis.

View larger version (115K): [in a new window]   Figure 4a. Perforated appendicitis in a 22-year-old woman with a 2-day history of right-lower-quadrant pain. (a) Transverse helical CT scan obtained with oral contrast material and 5-mm collimation reveals nonspecific pericecal phlegmon (arrow) interposed between the cecum (C), inferior liver (L), and right psoas muscle (P). (b) Transverse helical CT scan obtained with intravenous and oral contrast material and with 5-mm collimation clearly demonstrates the remains of an enhancing, fragmented appendix (arrows) centered within the pericecal inflammation. (Reproduced, with permission, from reference 67.)

View larger version (127K): [in a new window]   Figure 4b. Perforated appendicitis in a 22-year-old woman with a 2-day history of right-lower-quadrant pain. (a) Transverse helical CT scan obtained with oral contrast material and 5-mm collimation reveals nonspecific pericecal phlegmon (arrow) interposed between the cecum (C), inferior liver (L), and right psoas muscle (P). (b) Transverse helical CT scan obtained with intravenous and oral contrast material and with 5-mm collimation clearly demonstrates the remains of an enhancing, fragmented appendix (arrows) centered within the pericecal inflammation. (Reproduced, with permission, from reference 67.)

View larger version (141K): [in a new window]   Figure 5. Perforated appendicitis in a 30-year-old woman with right-sided pelvic pain and tenderness. Transverse helical CT scan obtained with intravenous and oral contrast material and with 5-mm collimation reveals a calcified appendicolith (arrow) centered within an inflammatory mass along the right pelvic sidewall.

View larger version (141K): [in a new window]   Figure 6. Distal appendicitis in a 71-year-old woman with right midabdominal pain. Transverse helical CT scan obtained with intravenous and oral contrast material and with 5-mm collimation reveals a medially located, mobile cecum (C) within the midabdomen. The appendiceal tip (arrow) appears minimally distended secondary to an obstructing appendicolith. Subtle increased attenuation of the periappendiceal fat (arrowheads) is present. Surgical exploration revealed nonperforated appendicitis.

View larger version (115K): [in a new window]   Figure 7a. Classic features of acute appendicitis at US in a 36-year-old woman with right-lower-quadrant pain. (a) Long-axis and (b) cross-sectional US images of the right lower quadrant obtained with a linear 7-4-MHz transducer show an 8-mm-diameter, blind-ended, tubular structure with a laminated wall. The appendix (A) was not compressible and showed no peristalsis. (c) Cross-sectional US image obtained through the base of the appendix (A) and (d) color Doppler US image obtained at the same level as c show a very thick wall (arrow) of the appendix, with virtually circumferential flow in the wall of the inflamed appendix.

View larger version (108K): [in a new window]   Figure 7b. Classic features of acute appendicitis at US in a 36-year-old woman with right-lower-quadrant pain. (a) Long-axis and (b) cross-sectional US images of the right lower quadrant obtained with a linear 7-4-MHz transducer show an 8-mm-diameter, blind-ended, tubular structure with a laminated wall. The appendix (A) was not compressible and showed no peristalsis. (c) Cross-sectional US image obtained through the base of the appendix (A) and (d) color Doppler US image obtained at the same level as c show a very thick wall (arrow) of the appendix, with virtually circumferential flow in the wall of the inflamed appendix.

View larger version (121K): [in a new window]   Figure 7c. Classic features of acute appendicitis at US in a 36-year-old woman with right-lower-quadrant pain. (a) Long-axis and (b) cross-sectional US images of the right lower quadrant obtained with a linear 7-4-MHz transducer show an 8-mm-diameter, blind-ended, tubular structure with a laminated wall. The appendix (A) was not compressible and showed no peristalsis. (c) Cross-sectional US image obtained through the base of the appendix (A) and (d) color Doppler US image obtained at the same level as c show a very thick wall (arrow) of the appendix, with virtually circumferential flow in the wall of the inflamed appendix.

View larger version (149K): [in a new window]   Figure 7d. Classic features of acute appendicitis at US in a 36-year-old woman with right-lower-quadrant pain. (a) Long-axis and (b) cross-sectional US images of the right lower quadrant obtained with a linear 7-4-MHz transducer show an 8-mm-diameter, blind-ended, tubular structure with a laminated wall. The appendix (A) was not compressible and showed no peristalsis. (c) Cross-sectional US image obtained through the base of the appendix (A) and (d) color Doppler US image obtained at the same level as c show a very thick wall (arrow) of the appendix, with virtually circumferential flow in the wall of the inflamed appendix.

View larger version (113K): [in a new window]   Figure 8. Endovaginal US image obtained with a curvilinear 8-4-MHz probe in a 57-year-old woman not suspected clinically to have appendicitis shows a blind-ended, tubular structure confirmed as the appendix (A). The distended lumen was filled with pus at surgery. The origin of the appendix from the cecum is often not shown with the endovaginal technique. (Reproduced, with permission, from reference 86.)

View larger version (120K): [in a new window]   Figure 9. Appendicitis with appendicolith. Long-axis US image of the right lower quadrant, obtained with a curvilinear 7-4-MHz probe, shows the inflamed appendix (A) as a blind-ended, tubular structure with a fluid-filled lumen. An appendicolith (arrow) is seen as a dependent, shadowing, echogenic focus. (Reproduced, with permission, from reference 86.)

View larger version (141K): [in a new window]   Figure 10. Ruptured appendix with abscess formation in a 76-year-old man with right-lower-quadrant pain and tenderness. Long-axis US image, obtained in the emergency department through the right lower quadrant with a curvilinear 7-4-MHz probe, shows the remnants of the decompressed perforated appendix (A), with discontinuity of its wall (arrowheads). A dumbbell-shaped abscess (a) surrounds both the anterior and the posterior aspects of the appendix.

View larger version (153K): [in a new window]   Figure 11. Focal perforation of the tip of the appendix in a 40-year-old woman who was receiving chemotherapy, had right-lower-quadrant pain, and was clinically suspected to have typhlitis. Long-axis US image of the appendix (A), obtained with a curvilinear 7-4-MHz probe, shows the blind-ended, tubular structure that originates from the base of the cecum (C). The wall layers are no longer defined, which is suggestive of gangrenous change. Surrounding the appendix is a halo of increased echogenicity consistent with inflamed fat (F). Gas bubbles (arrows) outside the tip of the appendix suggest a localized perforation.