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Why We Miss the Diagnosis of Appendicitis on Abdominal CT: Evaluation of Imaging Features of Appendicitis Incorrectly Diagnosed on CT

Charles D. Levine1,2, Orna Aizenstein2, Ofer Lehavi3 and Aryeh Blachar2

1 Department of Radiology, University of Medicine and Dentistry in New Jersey, 150 Bergen St., Newark, NJ 07103.
2 Department of Radiology, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv 62469, Israel.
3 Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 62469, Israel.



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  		Fig. 1. —CT scan obtained in 72-year-old woman with appendicitis. Distended appendix (arrow) and surrounding inflammatory changes are easily identified due to abundant intraabdominal fat, allowing confident diagnosis of appendicitis.

 


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  		Fig. 2. —CT scan obtained in 67-year-old man with appendicitis. Although cecum (long arrow) is well opacified, there is no intraperitoneal fat to aid in visualization of appendix. Note also suboptimal small-bowel opacification (short arrow) in right lower quadrant, contributing to difficulty in diagnosis. Diagnosis of appendicitis was confirmed at surgery although not diagnosed on either preoperative or even retrospective evaluation of CT scan.

 


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  		Fig. 3. —CT scan obtained in 62-year-old man with appendicitis. Patient's radiology request form noted "epigastric pain—peptic ulcer disease versus pancreatitis." Distended appendix (long arrow) and inflammatory changes (short arrow) in adjacent fat were not noted.

 


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  		Fig. 4A. —16-year-old boy with appendicitis. Scout radiograph of abdomen shows dilated loops (arrow) of small bowel in central abdomen.

 


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  		Fig. 4B. —16-year-old boy with appendicitis. CT scan shows dilated loops of small bowel (long arrows), with collapse of colon (short arrows). Scan was interpreted as showing distal small-bowel obstruction, but at surgery, appendicitis was found with no evidence of small-bowel obstruction.

 


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  		Fig. 5. —CT scan obtained in 49-year-old man with appendicitis. Optimal opacification of cecum and small bowel allows easy identification of distended, inflamed appendix (long arrow) and eccentric cecal wall thickening (short arrow).

 


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  		Fig. 6. —CT scan obtained in 75-year-old woman with appendicitis. Inflammatory changes (short arrow) are noted in right lower quadrant. However, appendix (long arrow) is difficult to discern, appearing similar to other adjacent fluid-filled, unopacified small bowel loops. Surgery confirmed perforated appendicitis.

 

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