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Mimics of Appendicitis: Alternative Nonsurgical Diagnoses with Sonography and CT

Adriaan C. van Breda Vriesman1 and Julien B. C. M. Puylaert2

1 Department of Radiology, Rijnland Hospital, Simon Smitweg 1, P.O. Box 4220, NL-2350 CC, Leiderdorp, The Netherlands.
2 Department of Radiology, MCH Westeinde Hospital, The Hague, The Netherlands.


Figure 1
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  		Fig. 1A —34-year-old healthy volunteer with normal appendix. Longitudinal (A) and transverse (B) sonograms show appendix as blind-ended compressible tubular structure with gut signature (arrowheads) with diameter less than 7-mm cutoff point, surrounded by normal noninflamed fat.

 

Figure 2
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  		Fig. 1B —34-year-old healthy volunteer with normal appendix. Longitudinal (A) and transverse (B) sonograms show appendix as blind-ended compressible tubular structure with gut signature (arrowheads) with diameter less than 7-mm cutoff point, surrounded by normal noninflamed fat.

 

Figure 3
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  		Fig. 2 —50-year-old man with normal appendix. Unenhanced CT shows air-filled nondistended appendix (arrowhead) with homogeneous periappendiceal fat without fat stranding.

 

Figure 4
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  		Fig. 3A —19-year-old woman with appendicitis. Longitudinal sonogram shows enlarged appendix (arrow) surrounded by hyperechoic inflamed fat (arrowheads).

 

Figure 5
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  		Fig. 3B —19-year-old woman with appendicitis. Transverse power Doppler sonogram shows hypervascularity of appendiceal wall.

 

Figure 6
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  		Fig. 4 —43-year-old man with appendicitis. Contrast-enhanced CT depicts fluid-filled distended appendix (arrow) with periappendiceal fat stranding.

 

Figure 7
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  		Fig. 5 —14-year-old boy with mesenteric adenitis. Sonogram of right lower quadrant shows cluster of enlarged mesenteric lymph nodes (arrowheads). Appendix was normal (not shown) and no other abnormalities were found. IVC = inferior vena cava.

 

Figure 8
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  		Fig. 6A —39-year-old man with bacterial ileocecitis. Sonograms show moderate mural thickening of terminal ileum and cecum surrounded by normal noninflamed fat. Moderate mesenteric lymphadenopathy was also present (not shown).

 

Figure 9
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  		Fig. 6B —39-year-old man with bacterial ileocecitis. Sonograms show moderate mural thickening of terminal ileum and cecum surrounded by normal noninflamed fat. Moderate mesenteric lymphadenopathy was also present (not shown).

 

Figure 10
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  		Fig. 7A —29-year-old woman with epiploic appendagitis. Sonogram of right lower quadrant reveals hyperechoic inflamed fatty mass (arrowheads) adjacent to colon (arrow) at spot of maximum tenderness.

 

Figure 11
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  		Fig. 7B —29-year-old woman with epiploic appendagitis. On unenhanced CT, fatty lesion contains characteristic hyperattenuating ring (arrows) corresponding to thickened visceral peritoneal lining.

 

Figure 12
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  		Fig. 8A —41-year-old man with omental infarction. Sonogram of right middle abdomen shows large area of inflamed intraperitoneal fat (arrowheads).

 

Figure 13
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  		Fig. 8B —41-year-old man with omental infarction. Unenhanced CT depicts lesion as cakelike area of slightly dense inflamed omental fat (arrowheads) larger than in epiploic appendagitis and lacking hyperattenuating ring.

 

Figure 14
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  		Fig. 9 —47-year-old woman with acute right lower quadrant pain. Unenhanced CT shows ovoid inflamed fatty mass (arrowhead) with normal regional bowel loops. Shape and size of lesion suggest epiploic appendagitis, but lesion does not contain hyperattenuating ring. In this case, it is difficult to discriminate between epiploic appendagitis or small omental infarction.

 

Figure 15
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  		Fig. 10A —51-year-old man with right-sided colonic diverticulitis. Unenhanced CT shows extensive fat stranding along cecal wall (arrowheads) and normal appendix (arrow).

 

Figure 16
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  		Fig. 10B —51-year-old man with right-sided colonic diverticulitis. Sonogram proves to be valuable adjunct to CT, revealing cause of inflammation by depicting inflamed cecal diverticulum (arrow) surrounded by hyperechoic fat.

 

Figure 17
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  		Fig. 11 —64-year-old woman with right-sided colonic diverticulitis. Unenhanced CT depicts inflamed cecal diverticulum (arrow) with fecolith surrounded by fat stranding.

 

Figure 18
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  		Fig. 12A —28-year-old man with acute ileocecal Crohn's disease. Sonograms show transmural wall thickening of terminal ileum (arrows) in longitudinal (A) and transverse (B) section with hyperechoic inflammatory changes of surrounding fat (arrowheads).

 

Figure 19
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  		Fig. 12B —28-year-old man with acute ileocecal Crohn's disease. Sonograms show transmural wall thickening of terminal ileum (arrows) in longitudinal (A) and transverse (B) section with hyperechoic inflammatory changes of surrounding fat (arrowheads).

 

Figure 20
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  		Fig. 12C —28-year-old man with acute ileocecal Crohn's disease. Contrast-enhanced CT confirms wall thickening and luminal narrowing of terminal and preterminal ileum (arrowheads) with regional fat stranding.

 

Figure 21
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  		Fig. 13 —2-year-old boy with ileocecal intussusception. Transverse sonogram of right lower abdomen shows targetlike mass representing intussusception of distal ileum (arrowhead) into cecum (arrow).

 

Figure 22
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  		Fig. 14A —39-year-old woman with pelvic inflammatory disease. Transvaginal sonogram shows inhomogeneously enlarged right ovary (arrowheads).

 

Figure 23
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  		Fig. 14B —39-year-old woman with pelvic inflammatory disease. Contrast-enhanced CT shows enlargement of ovaries (B, arrows) with ill-defined contours of ovaries and uterus and some free pelvic fluid (C, arrow).

 

Figure 24
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  		Fig. 14C —39-year-old woman with pelvic inflammatory disease. Contrast-enhanced CT shows enlargement of ovaries (B, arrows) with ill-defined contours of ovaries and uterus and some free pelvic fluid (C, arrow).

 

Figure 25
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  		Fig. 15 —77-year-old man with right ureteral stone. Unenhanced CT shows obstructing calcification (arrow) within distal ureteral lumen.

 

Figure 26
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  		Fig. 16A —40-year-old woman with right ureteral stone. Sonograms show right-sided hydronephrosis (A) and obstructing calculus (B, arrow) in distal ureter at level of iliac artery (A) and iliac vein (V).

 

Figure 27
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  		Fig. 16B —40-year-old woman with right ureteral stone. Sonograms show right-sided hydronephrosis (A) and obstructing calculus (B, arrow) in distal ureter at level of iliac artery (A) and iliac vein (V).

 

Figure 28
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  		Fig. 17A —68-year-old woman with rectus sheath hematoma. Sonogram depicts small painful lesion (arrow) within sheath of rectus abdominis muscle in right lower quadrant. Lesion contains fluid-fluid level.

 

Figure 29
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  		Fig. 17B —68-year-old woman with rectus sheath hematoma. Unenhanced CT depicts lesion as partly hyperdense mass (arrow) within rectus sheath.

 

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