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Clinical and Imaging Mimickers of Acute Appendicitis in the Pediatric Population

¹ Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
² Department of Radiology, Children's Hospital Boston, Boston, MA 02115.

View larger version (100K): [in a new window]   Fig. 1 —8-year-old girl with mesenteric adenitis who presented with right lower quadrant pain and fever. Transverse sonogram shows several hypoechoic lymph nodes (arrows) in mesentery of right lower quadrant.

View larger version (94K): [in a new window]   Fig. 2A —13-year-old boy with Crohn's disease who presented with fever and right lower quadrant pain. Oblique sagittal sonogram of right lower quadrant shows long segment of thickened terminal ileum (arrow). Note echogenic, inflamed surrounding mesenteric fat (F).

View larger version (116K): [in a new window]   Fig. 2B —13-year-old boy with Crohn's disease who presented with fever and right lower quadrant pain. Transverse helical CT image with oral and IV contrast material shows thickening of terminal ileum (white arrows) with surrounding inflammatory change and fibrofatty proliferation (black arrow). Note thickening of base of cecum (arrowhead).

View larger version (148K): [in a new window]   Fig. 3 —3-year-old boy with idiopathic intussusception who presented with abdominal pain and emesis. Transverse sonogram shows heterogeneous central-echogenic mass (M) with peripheral hypoechoic bowel (arrows) consistent with intussusception containing fat and bowel. Intussusception was reduced by air-contrast enema.

View larger version (138K): [in a new window]   Fig. 4 —9-year-old girl with omental infarction who presented with right lower quadrant pain and nausea. Transverse helical CT image with oral contrast shows inflammatory stranding along antimesenteric border of colon (arrow). Patient was taken to surgery and omental infarction was evident.

View larger version (85K): [in a new window]   Fig. 5 —11-year-old boy with right-sided abdominal pain who has primary epiploic appendagitis. Transverse helical CT image with IV and oral contrast shows round paracolic mass (white arrow) adjacent to ascending colon with central hyperdense "dot" (arrowhead). There is surrounding inflammatory fat stranding (black arrow). Findings are consistent with epiploic appendagitis.

View larger version (91K): [in a new window]   Fig. 6A —10-year-old boy with perforated Meckel's diverticulitis who presented with diffuse abdominal pain and distention. Transverse helical CT image with IV and oral contrast shows focally enhancing hollow viscus (white arrow) anterior to rectum. Note nondependent extraluminal gas indicating perforation (black arrows).

View larger version (113K): [in a new window]   Fig. 6B —10-year-old boy with perforated Meckel's diverticulitis who presented with diffuse abdominal pain and distention. Sagittal reconstruction of helical CT with IV and oral contrast shows tubular structure with enhancing wall (white arrows) and extraluminal gas (black arrow). Patient was taken to surgery, which showed Meckel's diverticulitis.

View larger version (93K): [in a new window]   Fig. 7 —2-year-old boy with gastrointestinal duplication cyst who presented with intermittent abdominal pain. Transverse helical CT with IV and oral contrast shows round, well-delineated, hypodense mass (arrow) within colon at hepatic flexure with rim of enhancement. Patient was taken to surgery and cecal duplication cyst was found.

View larger version (119K): [in a new window]   Fig. 8 —3-year-old girl with Henoch-Schönlein purpura who presented with abdominal pain. Transverse helical CT image with oral and IV contrast shows wall thickening of ascending colon (white arrow) and descending colon (black arrow).

View larger version (94K): [in a new window]   Fig. 9 —12-year-old boy with ascariasis after recent 1-year stay in Pakistan. Patient presented with abdominal pain, emesis, and fever. Transverse sonogram shows curvilinear structure within bowel with hyperechoic outer walls (arrows) and hypoechoic central line (arrowhead) consistent with ascariasis worm. Sonogram can show single central echogenic line when bowel is collapsed, alternating hyperechoic with central hypoechoic lines when bowel is distended, or target sign when in transverse plane of imaging of worm in alimentary canal [5].

View larger version (100K): [in a new window]   Fig. 10A —6-year-old girl with pyelonephritis who presented with abdominal pain and low-grade fever. Transverse helical CT with IV and oral contrast shows focal area of hypodensity within lower pole of right kidney (arrow) consistent with decreased perfusion.

View larger version (109K): [in a new window]   Fig. 10B —6-year-old girl with pyelonephritis who presented with abdominal pain and low-grade fever. Sagittal power Doppler sonogram of right kidney shows absent flow at inferior pole of kidney (arrow) consistent with focal pyelonephritis. Patient was treated with IV antibiotics.

View larger version (144K): [in a new window]   Fig. 11A —19-year-old woman with renal colic who presented with right lower quadrant pain and vomiting. Sagittal sonogram of right kidney shows moderate hydronephrosis (arrow) secondary to obstruction at level of right ureterovesical junction (UVJ) (see below).

View larger version (130K): [in a new window]   Fig. 11B —19-year-old woman with renal colic who presented with right lower quadrant pain and vomiting. Transverse sonogram of pelvis shows right hydroureter secondary to large calcification (white arrow) with shadowing (black arrows) at right UVJ with associated edema (arrowheads).

View larger version (106K): [in a new window]   Fig. 12A —7-year-old girl with ovarian torsion who presented with sudden onset of right lower quadrant pain, emesis, and elevated WBC. Transverse helical CT with IV and oral contrast shows enlarged, homogeneous right ovary (white arrow). Healthy appendix was identified and there was no free fluid (not shown). Note normal left ovary (black arrow).

View larger version (93K): [in a new window]   Fig. 12B —7-year-old girl with ovarian torsion who presented with sudden onset of right lower quadrant pain, emesis, and elevated WBC. Sagittal sonogram of right ovary in same patient shows enlarged ovary with peripherally located follicles (arrows). Doppler sonogram shows no flow within ovary. Patient was taken to surgery and right ovary was detorsed in operating room.

View larger version (102K): [in a new window]   Fig. 13A —10-year-old girl with torsion of dermoid cyst who presented with right lower quadrant pain, anorexia, and emesis. Transverse helical CT with IV and oral contrast shows large pelvic mass that measures 10.5 cm x 8.4 cm with large calcification (black arrow), fat (white arrows), and septations (arrowheads).

View larger version (54K): [in a new window]   Fig. 13B —10-year-old girl with torsion of dermoid cyst who presented with right lower quadrant pain, anorexia, and emesis. Correlating helical CT image with bone windows shows teeth (arrows) within calcified portion of mass. Diagnosis was confirmed on pathology.

View larger version (162K): [in a new window]   Fig. 14A —18-year-old woman with hemorrhagic cyst who presented with right lower quadrant pain and vomiting. Transverse sonogram shows enlarged right ovary (white arrows) with increased through-transmission (black arrows).

View larger version (131K): [in a new window]   Fig. 14B —18-year-old woman with hemorrhagic cyst who presented with right lower quadrant pain and vomiting. Transverse helical CT with oral and IV contrast performed after sonogram because of strong clinical suspicion of appendicitis. It shows heterogeneous right adnexal mass with increased enhancement (arrow) with no CT evidence of acute appendicitis.

View larger version (126K): [in a new window]   Fig. 15 —17-year-old boy with infected urachal cyst who presented with right lower quadrant pain and chills. Transverse helical CT with IV and oral contrast shows heterogeneous soft-tissue mass (arrow) contiguous with the anterior bladder wall with irregular enhancing wall and adjacent soft-tissue stranding. Two punctate foci of calcification (arrowhead) are visible within left aspect of wall. Patient was treated with antibiotics and subsequent imaging showed improvement in inflammatory stranding.

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