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DOI:10.2214/AJR.04.1380
AJR 2006; 186:67-74
© American Roentgen Ray Society

Pictorial Essay

Clinical and Imaging Mimickers of Acute Appendicitis in the Pediatric Population

Tammy Sung1, Michael J. Callahan2 and George A. Taylor2

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.

Received August 31, 2004; accepted after revision December 31, 2004.

 
Address correspondence to T. Sung (tsung{at}partners.org).


Abstract
Top
 Abstract
Introduction
 Gastrointestinal Mimickers
 Genitourinary Mimickers
 Chest Mimickers
 Conclusion
 References
 
OBJECTIVE. The purpose of this article is to present the imaging appearance of common mimickers of appendicitis in children with right lower quadrant pain.

CONCLUSION. The majority of children who undergo imaging for suspected appendicitis will end up having an alternative diagnosis. These mimickers can be gastrointestinal, genitourinary, or pulmonary. Familiarity with these alternative diagnoses can aid in the challenging task of imaging right lower quadrant pain in the pediatric population.

Keywords: appendicitis • appendix • gastrointestinal system • genitourinary system • pediatric patients


Introduction
Top
 Abstract
 Introduction
Gastrointestinal Mimickers
 Genitourinary Mimickers
 Chest Mimickers
 Conclusion
 References
 
Although appendicitis is the most common cause of intraabdominal surgery in infancy and childhood, its clinical presentation and imaging evaluation are frequently quite challenging. The literature shows that the majority of patients who are referred for imaging for suspected appendicitis will, in fact, not have the condition. In pediatric patients suspected of having appendicitis, Sivit et al. [1] found that only 38% who underwent CT and 29% who underwent sonography had the condition. The frequency of alternative diagnoses found with diagnostic imaging shows the importance of an understanding of these possibilities, particularly in the pediatric population. This article will familiarize the reader with the radiographic appearance of the wide spectrum of clinical mimickers of appendicitis in children.


Gastrointestinal Mimickers
Top
 Abstract
 Introduction
 Gastrointestinal Mimickers
Genitourinary Mimickers
 Chest Mimickers
 Conclusion
 References
 
Some of the most common clinical and imaging mimickers of appendicitis are primarily abnormalities of the small and large bowel and/or the adjacent mesentery. These gastrointestinal mimickers can be generally grouped as inflammatory, infectious, vascular, or congenital.

Inflammatory Gastrointestinal Mimickers
In a recent series of pediatric patients imaged with CT for suspected appendicitis, the most common alternative diagnosis was mesenteric adenitis [1, 2]. Mesenteric adenitis is classified as primary or secondary depending on whether an identifiable inflammatory process can be found (secondary) or not (primary). Primary mesenteric adenitis is believed to be more common in children than adults. The clinical symptoms of primary mesenteric adenitis are similar to appendicitis: abdominal pain, fever, and elevated WBC. Primary mesenteric adenitis appears as multiple enlarged mesenteric lymph nodes with very mild (< 5 mm), if any, wall thickening of the terminal ileum on CT [3] or sonography (Fig. 1).



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  		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.

 



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  		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).

 



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  		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).

 



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  		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.

 
In the same recent series of pediatric patients imaged with CT for suspected appendicitis, inflammatory bowel disease was the second most common alternative diagnosis. Although inflammatory bowel disease commonly affects children, the repetitive episodic nature of the disease generally clinically distinguishes it from acute appendicitis [4]. However, the diagnosis is often much less clear in the young child, especially when seen in the emergency department during a first episode of abdominal pain. Inflammatory bowel disease can involve the periappendiceal tissues mimicking acute appendicitis both clinically and radiographically [2]. Crohn's disease typically appears on sonography and CT as distal small-bowel wall thickening with associated inflammatory changes or fibrofatty proliferation of the adjacent mesentery (Figs. 2A and 2B).

One of the most common causes of acute abdominal pain in the young child is intussusception, with a peak age between 3 and 9 months. Although pathologic lead points are rare in the pediatric population and most of the intussusceptions are thought to be due to inflammation of Peyer's patches, Meckel's diverticulum, gastrointestinal duplication cysts [5], polyps, and lymphoma may also cause intussusception. Intussusception can clinically mimic appendicitis. Its distinct appearance on both CT and sonography (Fig. 3), however, frequently resolves the clinical dilemma.

Omental infarction is a relatively rare cause of abdominal pain in children, and the presumptive clinical diagnosis is almost always appendicitis. Infarction of the omentum occurs more commonly on the right side than on the left [6]. Although omental infarction is rare in children, obesity has been reported as a risk factor in both the pediatric and adult populations. The increased incidence of this entity may be related to the increased incidence of obesity in the pediatric population [7]. Omental infarction appears as heterogeneous inflammatory stranding anterior to the antimesenteric border of the colon, near the anterior abdominal wall [8] (Fig. 4). While some surgeons advocate nonoperative conservative management of omental infarction, recent studies advise laparoscopic removal of the infarcted gangrenous omentum to avoid possible abscess or adhesions [7, 8].



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  		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.

 



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  		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.

 



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  		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).

 



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  		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.

 



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  		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.

 



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  		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).

 



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  		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].

 



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  		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.

 



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  		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.

 



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  		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).

 



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  		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).

 



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  		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).

 



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  		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.

 
In primary epiploic appendagitis, torsion or inflammation of the peritoneal outpouchings of the colon is the mechanism of localized abdominal pain. Although appendagitis occurs more frequently on the left, the symptoms can mimic appendicitis when the cecum is involved [9]. Imaging characteristics on CT are low-attenuation oval or round mass with periappendiceal inflammatory stranding and normal adjacent colonic wall thickness (Fig. 5). While these CT changes will completely resolve 6 months after the acute presentation, the findings will persist in varying degrees for up to 6 months and can mimic acute appendicitis. Absence of abdominal pain within the region can help differentiate an acute from a resolving episode [9].



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  		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).

 



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  		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.

 



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  		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).

 



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  		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.

 



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  		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.

 
Congenital Mimickers
Meckel's diverticulum is the most common congenital anomaly affecting the gastrointestinal tract [10]. Complications include Meckel's diverticulitis, intussusception, and inflammation with possible perforation and peritonitis [11]. In a study of 10 pediatric cases of Meckel's diverticulitis, six patients presented with clinical signs and imaging findings that were suggestive of acute appendicitis. Meckel's diverticulitis can appear on a sonogram as a noncompressible, hypoechoic structure in the right iliac fossa with a diameter varying from 0.8 to 1.2 cm [12]. It can also have other CT findings that are similar to acute appendicitis (Figs. 6A and 6B).

Gastrointestinal duplication cysts are most frequently found in the terminal ileum. Because of its anatomic proximity to the appendix and clinically similar presentation, ulceration of a distal ileal duplication cyst can mimic acute appendicitis [10]. On a sonogram, a gastrointestinal duplication cyst is a cystic structure with alternating hyperechoic surface corresponding to the mucosal layer and a surrounding hypoechoic rim corresponding to the muscular layer (gut signature). On CT, a duplication cyst typically appears as a round, well-defined, fluid-attenuation mass (Fig. 7).

Vasculitis Mimicker
When children with Henoch-Schönlein purpura present with severe abdominal pain before the onset of the characteristic purpuric rash, the clinical diagnosis can be unclear [10] (Fig. 8). Although the precise cause of this immune-mediated hypersensitivity angiitis is unknown, prior exposure to certain drugs and infectious agents is thought to be related. The entity occurs almost exclusively in patients 3 to 23 years old. Gastrointestinal manifestations including abdominal pain, nausea, and vomiting occur in 60% of patients. Edema and blood in the submucosal and mural layers can occur with skip areas and can mimic inflammatory bowel disease. The self-limited process and normalization of the bowel with healing can help differentiate the entities [13].

Infectious Mimicker
In the United States, ascariasis is an unusual cause of bowel inflammation and obstruction. The diagnosis can be made with a variety of techniques, such as barium fluoroscopy or CT [14]. We, however, present its appearance on a sonogram of a child with right lower quadrant pain (Fig. 9). Although ascariasis is a somewhat rare diagnosis, all the patients in one study were referred with a clinical diagnosis of appendicitis [14].


Genitourinary Mimickers
Top
 Abstract
 Introduction
 Gastrointestinal Mimickers
 Genitourinary Mimickers
Chest Mimickers
 Conclusion
 References
 
Pyelonephritis (Figs. 10A and 10B) and renal colic (Figs. 11A and 11B) are clinical entities that can mimic appendicitis. In particular, patients with acute right-sided pyelonephritis frequently present with fever, elevated WBC, right-flank pain, and emesis. While during the early stage of infection, the kidney can appear sonographically normal [5], a sonogram of pyelonephritis can also appear as a hypoechoic region with loss of corticomedullary junction and decreased flow (Fig. 10B). Urolithiasis is uncommon in children, but its presentation in these patients is much more variable than in adults [15]. Causes of stones in children also vary with metabolic disease and infections, with Klebsiella and Proteus organisms being just a few of the reported causes [5].

One of the more challenging clinical dilemmas is the adolescent female patient with right lower quadrant pain. Acute and subacute gynecologic diseases can cause clinical symptoms and imaging findings that are similar to acute appendicitis. Our institution has adopted algorithms that are guided by the sex and age of the patient that help determine the appropriate first step in imaging the patient. Common gynecologic diseases in the pediatric population that can present with right lower quadrant pain include surgical emergencies such as ovarian torsion, ovarian tumors, and hemorrhagic ovarian cysts.

Ovarian torsion in children often occurs without any underlying ovarian pathology and is thought to be due to the increased motility of the adnexa [16]. Just as in the adult population, the presence of arterial flow can be found sonographically in torsed ovaries [17]. On a sonogram, an enlarged ovary (Figs. 12A and 12B) is the most common finding of a torsed ovary with an ovarian volume upper limit of 4-5 cm3 in prepubertal girls [17].

In a recent retrospective review of the diagnosis in the pediatric emergency care setting of ovarian masses, 73% of 51 patients with ovarian masses had abdominal pain and 38% of these patients had the preliminary diagnosis of appendicitis [18]. Neoplasms make up 40% of ovarian masses in the pediatric population and the majority of these are benign mature teratomas (Figs. 13A and 13B). A small percentage of ovarian tumors in children are malignant and include germ cell, epithelial, and stromal tumors.

Hemorrhage into a follicular cyst is a frequent cause of lower abdominal pain in the pubertal population [5]. The sonographic appearance of hemorrhagic ovarian cysts is extremely variable, but classic findings include a complex adnexal mass with increased through-transmission (Figs. 14A and 14B).

Infected urachal remnant (Fig. 15) can also represent a cause, almost unique to the pediatric population, of right lower quadrant pain [1]. When the urachal remnant becomes infected, the acute symptoms of abdominal pain and fever almost always have a presumptive diagnosis of appendicitis. While imaging can correctly diagnose this entity, there is a case report of a child having the diagnosis made intraoperatively after he was misdiagnosed with periappendiceal abscess [19]. Keeping this entity in mind may spare a child an unnecessary emergency surgery.


Chest Mimickers
Top
 Abstract
 Introduction
 Gastrointestinal Mimickers
 Genitourinary Mimickers
 Chest Mimickers
Conclusion
 References
 
The causes of right lower quadrant pain are not limited to the abdomen or the pelvis. Multiple studies have shown lower-lobe pneumonia as a cause of pain, and this condition should be considered both clinically and radiographically.


Conclusion
Top
 Abstract
 Introduction
 Gastrointestinal Mimickers
 Genitourinary Mimickers
 Chest Mimickers
 Conclusion
References
 
Imaging of acute right lower quadrant pain in the pediatric population is challenging and requires knowledge of the imaging findings of acute appendicitis and its mimickers.


References
Top
 Abstract
 Introduction
 Gastrointestinal Mimickers
 Genitourinary Mimickers
 Chest Mimickers
 Conclusion
 References
 

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  2. Callahan MJ, Rodriguez DP, Taylor GA. How I do it: CT of appendicitis in children. Radiology 2002;224 : 325-332[Abstract/Free Full Text]
  3. Macari M, Hines J, Balthazar E, et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. AJR2002; 178:853 -858[Abstract/Free Full Text]
  4. Ruess L, Blask ARN, Bulas DI, et al. Inflammatory bowel disease in children and young adults: correlation of sonographic and clinical parameters during treatment. AJR 2000;175 : 79-84[Abstract/Free Full Text]
  5. Carty HM. Paediatric emergencies: non-traumatic abdominal emergencies. Eur Radiol 2002;12 : 2835-2848[Medline]
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  8. Grattan-Smith JD, Blews DE, Brand T. Omental infarction in pediatric patients: sonographic and CT findings. AJR2002; 178:1537 -1539[Abstract/Free Full Text]
  9. Singh AK, Gervais DA, Hahn PF, Rhea J, Mueller PR. CT appearance of acute appendagitis. AJR 2004;183 : 1303-1307[Abstract/Free Full Text]
  10. Kirks DR. Practical pediatric imaging: diagnostic radiology of infants and children, 3rd ed. Philadelphia, PA: Lippincott-Raven, 1998:926 -933
  11. Cavanaugh RM. Non-gynecologic causes of unexplained lower abdominal pain in adolescent girls: two clinical cases and review of the literature. J Pediatr Gynecol 2004;17 : 257-266[CrossRef]
  12. Baldisserotto M, Maffazzoni DR, Dora MD. Sonographic findings of Meckel's diverticulitis in children. AJR2003; 180:425 -428[Abstract/Free Full Text]
  13. Özdemir H, Isik S, Buyan N, et al. Sonographic demonstration of intestinal involvement in Henoch-Schönlein syndrome. Eur J Radiol 1995; 20:32 -34[Medline]
  14. Malde HM, Chadha D. Roundworm obstruction: sonographic diagnosis. Abdom Imaging 1993;18 : 274-276[Medline]
  15. Fisher JD, Reeves JJ. Presentation variability of acute urolithiasis in school-aged children. Am J Emerg Med2004; 22:108 -110[Medline]
  16. Bennet GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. RadioGraphics 2002;22 : 785-801[Abstract/Free Full Text]
  17. Garel L, Dubois J, Grignon A, et al. US of the pediatric female pelvis: a clinical perspective. RadioGraphics2001; 21:1393 -1407[Abstract/Free Full Text]
  18. Pomeranz AJ, Sabnis S. Misdiagnoses of ovarian masses in children and adolescents. Pediatr Emerg Care 2004;20 : 172-174[Medline]
  19. Allen JW, Song J, Velcek FT. Acute presentation of infected urachal cysts: case report and review of diagnosis and therapeutic interventions. Pediatr Emerg Care 2004;20 : 108-111[Medline]

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