Clinical and imaging mimickers of acute appendicitis in the pediatric population

Colonic Angiolipoma: An Extremely Rare Tumor Clinically Masquerading as Acute Appendicitis

The clinical presentation of right iliac fossa pain, anorexia, and vomiting are the classic clinical features of acute appendicitis. However, a broad spectrum of manifestations may result in a similar clinical picture, including gastrointestinal, genitourinary, and gynecologic pathologies. Imaging studies are crucial to establishing the diagnosis. Here, we report the case of a 58-year-old man who presented to the emergency department with a one-week history of right lower quadrant abdominal pain. The pain was associated with nausea, vomiting, and frequent bowel motions. There was no history of fever or weight loss. The examination of the abdomen showed localized tenderness and guarding in the right iliac fossa. The basic laboratory investigation was within the reference range. The computed tomography scan demonstrated a well-circumscribed intraluminal mass lesion in the ascending colon with no evidence of complete obstruction. The mass was slightly heterogeneous but had fat attenuation. There was no evidence of invasion. There was no stranding of the adjacent fat. The radiological findings were consistent with colonic lipoma. The patient underwent laparoscopic surgery and had a segmental resection of the tumor with primary anastomosis. The appendix was also resected. Histopathological examination showed mature adipose cells along with thin-walled, capillary-sized vessels representing a benign angiolipoma. Further, the resected appendix was completely normal and showed no evidence of acute inflammation. Colonic angiolipoma is an extremely rare tumor. This case demonstrated that a large angiolipoma of the ascending colon may show a presenting clinical picture similar to that of acute appendicitis. Complete resection of the tumor is associated with an excellent outcome.

Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population

Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.

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.

Staged imaging pathway for the evaluation of pediatric appendicitis

PURPOSE

Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy.

METHODS

Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation.

RESULTS

There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6-9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway.

CONCLUSIONS

The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.

Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Alternative diagnoses at paediatric appendicitis MRI

As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institution's experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.

The role of US in finding intussusception and alternative diagnosis: a report of 100 pediatric cases

BACKGROUND

The clinical diagnosis of intussusception remains challenging, because many children with intussusception may present with non-specific signs and symptoms, which overlap with other conditions. Therefore imaging, in particular ultrasonography (US), plays a significant role in the management of these patients.

PURPOSE

To evaluate how US can contribute to the diagnosis in clinically suspected intussusception and finding alternative diagnosis.

MATERIAL AND METHODS

We retrospectively reviewed reports of US examinations and medical records of 100 patients (51 boys, 49 girls; mean age, 23.0 ± 12.1 months) who underwent abdominal US for clinically suspected intussusception. Each US study was assessed for the presence or absence of intussusception and for a possible alternative diagnosis in cases interpreted as negative for intussusception.

RESULTS

Thirty-seven patients had US findings consistent with intussusception, which was confirmed by air enema. In seven patients, US studies were normal. Alternative diagnoses were identified by US for each of the remaining 56 patients, including ileocolitis (n = 20), terminal ileitis (n = 18), mesenteric lymphadenitis (n = 13), choledochal cyst (n = 1), accessory spleen torsion (n = 1), small bowel ileus (n = 1), midgut volvulus with bowel ischemia (n = 1), and hydronephrosis (n = 1).

CONCLUSION

With the high sensitivity and specificity of this study we conclude that US is valuable in detecting intussusception and finding the alternative diagnosis.

Sonography of acute appendicitis and its mimics in children

The diagnosis of acute right lower quadrant pain in a pediatric population is challenging. Acute appendicitis is the most common cause of an acute surgical abdomen. The common mimics of acute appendicitis are acute gastrointestinal and gynecologic diseases. This article reviews the sonographic findings of the spectrum of common acute abdominal emergencies in children with a focus on imaging clues to a specific diagnosis. This awareness can impact on diagnostic accuracy and impact patient management.

Ultrasound in newborns and children suffering from non-traumatic acute abdominal pain: imaging with clinical and surgical correlation

The purpose of this article is to review ultrasonographic appearance of the most common causes of non-traumatic acute abdominal pain in pediatric patients and to understand the applications and limitations of this technique giving a practical approach showing different clinical cases. A pictorial review of cases was made presenting the most common causes of neonatal and pediatric non-traumatic acute abdominal pain; sonographic features are discussed. Ultrasound in conjunction with Color Doppler imaging is a valuable tool in the evaluation of neonatal and pediatric non-traumatic acute abdominal pain; causes of acute abdomen in children could vary depending on the ages of the children.

Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis

OBJECTIVE

Accurate, timely diagnosis of pediatric appendicitis minimizes unnecessary operations and treatment delays. Preoperative abdominal-pelvic computed tomography (CT) scan is sensitive and specific for appendicitis; however, concerns regarding radiation exposure in children obligate scrutiny of CT use. Here, we characterize recent preoperative imaging use and accuracy among pediatric appendectomy subjects.

METHODS

We retrospectively reviewed children who underwent operations for presumed appendicitis at a single tertiary-care children's hospital and examined preoperative CT and ultrasound use with subject characteristics. Preoperative imaging accuracy was compared with postoperative and histologic diagnosis as the reference standard.

RESULTS

Most children (395/423, 93.4%) who underwent an operation for appendicitis during 2009-2010 had preoperative imaging. Final diagnoses included normal appendix (7.3%) and perforated appendicitis (23.6%). In multivariable analysis, initial evaluation at a community hospital versus the children's hospital was associated with 4.4-fold higher odds of obtaining a preoperative CT scan (P = .002), whereas preoperative ultrasound was less likely (odds ratio 0.20; P = .003). Ultrasound and CT sensitivities for appendicitis were diminished for studies performed at community hospitals compared with the children's hospital. Girls were 4.5-fold more likely to undergo both ultrasound and CT scans and were associated with lower ultrasound sensitivity for appendicitis.

CONCLUSIONS

Widespread preoperative imaging did not eliminate unnecessary pediatric appendectomies. Controlling for factors potentially associated with referral bias, a CT scan was more likely to be performed in children initially evaluated at community hospitals compared with the children's hospital. Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are urgently needed.

Infections and infestations of the gastrointestinal tract. Part 2: parasitic and other infections

The purpose of this article is to provide a comprehensive review of the imaging findings of various parasitic infestations and other miscellaneous infections affecting the gastrointestinal tract. Barium examinations play an important role in the diagnostic workup of parasitic intestinal infections. Knowledge of differential diagnosis, sites of involvement, and imaging features of different infections and infestations can help in accurate diagnosis and guide treatment.

Divertículo de Meckel ao Doppler em cores: relato de dois casos

O divertículo de Meckel é a anomalia congênita mais comum do trato gastrintestinal e a hemorragia é a complicação mais frequente. Cintilografia, ultrassonografia modo B e com Doppler, e tomografia computadorizada podem ser utilizadas para detectar complicações. Descrevemos dois casos de divertículo de Meckel complicado detectados à ultrassonografia, cujos achados foram diferentes dos descritos na literatura.

Appendiceal hyperemia and/or distention is not always appendicitis: appendicitis mimicry in the pediatric population

Appendicitis is the most common surgical cause of acute abdominal pain in the pediatric population. Several conditions can mimic the clinical presentation of appendicitis, leaving imaging as an essential modality to uncover the etiology, yet under certain circumstances, it can be misleading. Here, we present three cases where findings on multidetector computerized tomography scans supported the diagnosis of appendicitis, yet an alternate cause was found. These cases highlight a particular pitfall of satisfaction of search.

Imaging of acute appendicitis in children: EU versus U.S. ... or US versus CT? A North American perspective

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources.

Fat-containing lesions revealed by CT in children with right lower quadrant pain

Suspected appendicitis is the most common indication for emergent abdominal surgery in children. The clinical diagnosis of appendicitis can be challenging, and CT is playing an increasing role in the evaluation of right lower quadrant pain. Occasionally, alternative diagnoses to appendicitis can be suggested on CT. The appreciation of a fat-containing lesion in the right lower quadrant will often allow a specific diagnosis. Importantly, many of these lesions are self-limited and treated nonoperatively. The purpose of this pictorial essay is to illustrate the spectrum of fat-containing lesions that can present as alternative diagnoses to appendicitis on CT scans performed for the evaluation of right lower quadrant pain in children.

Sonography of acute right lower quadrant pain: importance of increased intraabdominal fat echo

OBJECTIVE

The purpose of our study was to assess the diagnostic usefulness of increased intraabdominal fat echo during the sonographic evaluation of patients with acute right lower quadrant (RLQ) pain.

SUBJECTS AND METHODS

A total of 328 consecutive patients (132 male and 196 female; mean age, 28+/-15 [SD] years) with acute RLQ pain prospectively underwent transabdominal sonography by one of three experienced radiologists. The radiologists prospectively graded intraabdominal fat echo using a 3-point scale: 1, normal; 2, slight increase; and 3, marked and diffuse increase. Final diagnoses were made using surgical or pathologic findings or by clinical follow-up. Of the 328 patients, 11 were lost to follow-up and excluded from analysis. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of increased intraabdominal fat echo were calculated for a positive final diagnosis.

RESULTS

Final diagnoses were negative (n=103), acute appendicitis (n=137), right colonic diverticulitis (n=18), mesenteric lymphadenitis (n=13), enteritis (n=26), and others (n=20). Grades of intraabdominal fat echo were grade 1 (n=158), grade 2 (n=35), and grade 3 (n=124). Overall, fat echo grades 2 or 3 were more frequently observed in patients with a positive final diagnosis (73% [157/214] vs 2% [2/103], p<0.001) than in those with a negative final diagnosis. Sensitivity, specificity, accuracy, PPV, and NPV of increased intraabdominal fat echo for a positive final diagnosis were 73%, 98%, 81%, 99%, and 64%. Increased intraabdominal fat echo was documented in 89% (122/137) of cases of acute appendicitis and in 100% (18/18) of cases of right colonic diverticulitis.

CONCLUSION

An increased intraabdominal fat echo on sonography is highly specific for the presence of RLQ inflammatory disease.