Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Herliczek et al.
MRI of Suspected Appendicitis After Inconclusive Ultrasound

Pediatric Imaging
Original Research

Utility of MRI After Inconclusive

Ultrasound in Pediatric Patients
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With Suspected Appendicitis:

FOCUS ON:

Retrospective Review of 60
Consecutive Patients
Thaddeus W. Herliczek1 OBJECTIVE. The purpose of this study is to examine the utility of appendix MRI in
David W. Swenson evaluation of pediatric patients with right lower quadrant pain and inconclusive appendix so-
William W. Mayo-Smith nography findings.
MATERIALS AND METHODS. A search of the radiology electronic database was
Herliczek TW, Swenson DW, Mayo-Smith WW performed for all appendix MRI examinations performed of pediatric patients within 24
hours after inconclusive appendix sonography from December 1, 2009, through April 26,
2012. Sixty patients underwent appendix MRI within 24 hours of inconclusive sonography
and represented the study cohort. MRI examinations were reviewed independently by two ra-
diologists blinded to the diagnosis and were graded as “positive,” “negative,” or “indetermi-
nate” for acute appendicitis. The final diagnosis was established by review of the surgical and
pathology reports and patients’ electronic medical records.
RESULTS. Ten of 60 patients (17%) had acute appendicitis. Both readers graded the same
12 examinations as positive and the same 48 examinations as negative for acute appendici-
tis, with a kappa value of 1.00 (expected agreement, 0.695). No MRI examination was in-
terpreted as indeterminate. The sensitivity and specificity of MRI for acute appendicitis in
children with inconclusive appendix ultrasound findings were 100% (95% CI, 0.72–1.00) and
96% (95% CI, 0.87–0.98), respectively. The positive predictive value for the examination was
83%, the negative predictive value was 100%, and overall test accuracy was 97%.
CONCLUSION. Our study shows that MRI has a sensitivity of 100% and specificity of 96%
for appendicitis in pediatric patients after inconclusive appendix sonography. We think that MRI
may supplant CT as the secondary modality to follow inconclusive appendix sonography.

Keywords: appendicitis, MRI, pediatric
DOI:10.2214/AJR.12.10078
Received October 1, 2012; accepted after revision
December 4, 2012.
1
All authors: Department of Diagnostic Imaging, Warren
Alpert Medical School of Brown University, 593 Eddy St,
Providence, RI 02904. Address correspondence to
T. W. Herliczek (thaddeus_herliczek@brown.edu).
AJR 2013; 200:969–973
0361–803X/13/2005–969
© American Roentgen Ray Society
A
cute appendicitis is the leading
cause of emergency surgery in the
pediatric population [1]. Clinical
diagnosis of pediatric appendicitis
can be challenging because children often pres-
ent without classic signs and symptoms, mak-
ing imaging an important tool to determine the
cause of abdominal pain in pediatric patients
[2]. The optimal imaging algorithm for pediat-
ric right lower quadrant (RLQ) pain remains
controversial [3–12]. The arguments have cen-
tered on the use of sonography or CT as the ini-
tial imaging modality [3, 4]. Graded-compres-
sion ultrasound is reported to be 88% sensitive
and 94% specific for acute appendicitis [6]. Ul-
trasound does not use ionizing radiation and
provides a relatively low-cost modality to as-
sess pediatric appendicitis and alternative
causes of RLQ pain in children [4]. CT is re-
ported to be 94% sensitive and 95% specific for
acute appendicitis [6]. However, CT exposes
the pediatric patient to ionizing radiation and of-
ten uses IV or oral contrast media.
Historically, our pediatric practice performed
CT of pediatric patients with inconclusive ul-
trasound in accordance with recommendations
by Garcia-Peña et al. [9] and the American
College of Radiology [13]. Given advances
in body MRI software, growing literature to
support the use of MRI to assess appendici-
tis [14–24], increased availability of MRI at
our institution, the reported 97% sensitivity
and 97% specificity of MRI for acute appen-
dicitis in adults [25], and growing concerns
about radiation exposure in the medical liter-
ature and lay press [26, 27], we sought to re-
place CT with MRI in our imaging algorithm
for pediatric RLQ pain and an inconclusive
ultrasound, according to the ALARA (as low
as reasonably achievable) principle. We be-
gan imaging the pediatric appendix with MRI
in December 2009.

AJR:200, May 2013 969


Previous literature regarding MRI of the
pediatric appendix has described the utility
of MRI in preselected pediatric patients with
acute appendicitis that was visualized conclu-
sively with ultrasound [19], the use of MRI as
an initial imaging modality in children with
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RLQ pain [20, 23], the ability of MRI to re-
veal the normal appendix in asymptomatic
children [21], and the speed and utility of 3-T
MRI in children with appendicitis found on
ultrasound, CT, or both [24]. In 2002, Hör-
mann et al. [21] suggested that MRI should
be considered as an alternative to CT in pedi-
atric patients with inconclusive appendix ul-
trasound. Yet, to the best of our knowledge,
no previous work has analyzed the utility of
MRI performed after inconclusive ultrasound
in pediatric patients with RLQ pain and clini-
cally suspected appendicitis.
The purpose of this study is to evaluate
the utility of appendix MRI in evaluation
of pediatric patients with RLQ pain and
inconclusive appendix sonography findings.
Materials and Methods
This retrospective study was approved by
our institutional review board, and the need for
informed consent waived. It was conducted in
accordance with the HIPAA.
Patient Population
A search of the radiology electronic database
was performed for all appendix MRI examina-
tions performed for pediatric patients from De-
cember 1, 2009, through April 26, 2012. This
search yielded 67 patients. Next, the electron-
ic medical record (EMR) was searched for all of
these patients to identify those for whom appendix
MRI was performed within 24 hours of an incon-
clusive ultrasound examination. This yielded 60
patients (28 boys and 32 girls) with an average age
of 13.4 years (range, 7–17 years) who represented
the study cohort.
Ultrasound was considered inconclusive if the
appendix was not identified and if either of the fol-
lowing two scenarios was present: there were sec-
ondary ultrasound signs of appendicitis (RLQ in-
flammation, intraperitoneal collection, or fluid),
or there was a high clinical concern for appendi-
citis. Clinical criteria used to decide whether to
perform appendix MRI were left to the discretion
of the referring pediatrician, pediatric emergency
medicine physician, or pediatric surgeon.
The average time between the inconclusive ul-
trasound and appendix MRI was 5.1 hours (range,
1–24 hours), with 88% (53/60) of MRI examina-
tions performed within 6 hours of the inconclu-
sive ultrasound.
970 AJR:200, May 2013
Herliczek et al.
Proof of Diagnosis
Twelve of the 60 patients underwent surgery,
and 48 patients were followed clinically. Ten of
the 60 patients (17%) in our cohort had acute ap-
pendicitis on review of operative and pathology
reports. The average age of the 10 patients with
acute appendicitis was 13.1 years (range, 9–16
years), with nine of 10 being male.
Fifty of the 60 patients (83%) in our study did
not have appendicitis. Two of these 50 patients un-
derwent surgery, but a normal appendix was found
at surgery and on pathologic examination. The
first of these two patients was a 17-year-old boy
who underwent appendectomy because of clini-
cal suspicion for acute appendicitis. His appendix
was normal according to both the operative and
pathology reports. He was discharged on postop-
erative day 2 with a diagnosis of mesenteric ade-
nitis. The second patient with a normal appendix
at surgery and on pathologic examination was a
14-year-old girl. She was discharged on postoper-
ative day 4 with a diagnosis of abdominal pain, not
otherwise specified. Forty-eight of the 50 patients
without appendicitis improved clinically and did
not undergo surgery at our institution. Twenty-
nine of the 48 patients who did not undergo appen-
dectomy after MRI were observed for an average
of 1.4 days (range, 1–4 days). Nineteen of the 48
patients who did not undergo appendectomy after
MRI were discharged from the emergency depart-
ment without observation after MRI. Most (36/48)
patients who did not undergo appendectomy after
MRI were discharged with a diagnosis of gastro-
enteritis or abdominal pain, not otherwise speci-
fied. One of these patients was readmitted 2 weeks
later and was diagnosed with Crohn disease at co-
lonoscopy. The other 12 patients were discharged
with the following diagnoses: four with ruptured
or hemorrhagic ovarian cysts, two with mesenteric
adenitis, two with omental infarcts, two with pel-
vic inflammatory disease, and one each with cho-
lelithiasis and nephrolithiasis.
MRI Technique
Forty-nine MRI examinations were performed
on 1.5-T systems (Magnetom Espree or Sympho-
ny, Siemens Healthcare), and 11 examinations
were performed on a 3-T system (Verio, Siemens
Healthcare). The 3-T system was installed at our
institution in December 2010. Patients were im-
aged on the next available MRI system without re-
gard to field strength.
All appendix MRI sequences were acquired
from the inferior poles of the kidneys through the
urinary bladder without sedation or contrast media.
The MRI protocol varied over time as our experi-
ence with pediatric appendix MRI grew. Howev-
er, all examinations included a single-plane STIR
sequence and a coronal T2-weighted 3D turbo
spin-echo sequence (SPACE) with multiplanar re-
constructions and/or T2-weighted single-shot tur-
bo spin-echo (i.e., HASTE) without fat saturation
in multiple planes. Most examinations (51/60) in-
cluded an axial true fast imaging with steady-
state precession (TrueFISP) sequence. Seventeen
of 60 examinations included in-phase and out-of-
phase T1-weighted imaging. All sequences except
SPACE were obtained with breath-holding. SPACE
was acquired during shallow free breathing. Imag-
ing parameters are noted in Table 1. Image acquisi-
tion time varied from 10 to 66 minutes, with an av-
erage of 30.5 minutes. All patients undergoing MRI
after inconclusive ultrasound tolerated the exami-
nation successfully.
Image Interpretation
The 60 MRI examinations were reviewed in-
dependently by one board-certified fellowship-
trained pediatric radiologist with 3 years of ex-
perience and one third-year radiology resident
physician. Readers were aware of the indication
for the examination, but were otherwise blinded to
surgical-pathologic findings and clinical follow-up.
Reader 1 provided the initial interpretation for 28
of 60 examinations and performed review of these
examinations at least 8 weeks (range, 8–60 weeks)
removed from the time of initial interpretation.
Examinations were graded by each reader inde-
pendently as “positive,” “negative,” or “indetermi-
nate” regarding the presence of acute appendicitis.
Readers assessed the following factors: appendix
visualization, appendiceal diameter (> 7 mm was
considered pathologic), appendiceal mural thicken-
ing of more than 3 mm, appendiceal mural edema
(i.e., increased mural signal intensity on T2-weight-
ed imaging), the presence of appendiceal intralumi-
nal fluid (i.e., increased intraluminal signal intensity
on T2-weighted imaging), the presence of periap-
pendiceal inflammation (i.e., increased periappendi-
ceal signal intensity on T2-weighted imaging), the
presence of RLQ inflammation (i.e., increased sig-
nal intensity on STIR), and the presence of an ap-
pendicolith (i.e., focal round well-circumscribed
intraluminal hypointensity on all sequences). If an
abnormal appendix and secondary findings were
identified, the reader assigned a grade of positive
(Figs. 1 and 2). If a normal appendix was identified
(Fig. 3), the reader assigned a grade of negative. If
the appendix was not identified, the reader assigned
a grade of negative if no inflammatory changes were
identified in the RLQ on the STIR sequence. If the
appendix was not identified, but RLQ inflammatory
changes were present on the STIR image and no al-
ternate cause of RLQ pain was identified, the read-
er was to assign a grade of indeterminate. Alternate
causes of RLQ pain were recorded when present.
 MRI of Suspected Appendicitis After Inconclusive Ultrasound

TABLE 1:  Appendix MRI Parameters, by Sequence and Magnet Strength dix MRI for acute appendicitis in pediatric patients
after an inconclusive ultrasound were calculated us-
Sequence, Magnet Strength TR/TE Slice Thickness (mm) Gap (mm)
ing Excel (Microsoft). The kappa value for interob-
Coronal T2-weighted 3D turbo spin-echo server reliability of the two readers was also calcu-
1.5 T 1500/203–205 0.9–1 0 lated using Excel. A kappa value greater than 0.8 is
defined as very good agreement beyond chance, a
3T 2000–2180/125–135 1 0
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value between 0.40 and 0.8 indicates moderate-to-

HASTE good agreement beyond chance, and a value of less
1.5 T 900–1420/100–102 4–5 4–5.5 than 0.40 indicates fair-to-poor agreement [28]. The
3T 1000–1300/83–101 4–6 4–6 expected rate of agreement (Pe) was calculated.

STIR
Results
1.5 Ta 2400–9770/90–97 4 4 All 10 MRI examinations of the patients
3 Tb 2300–4030/89–100 4 4 with acute appendicitis were graded as posi-
True fast imaging with steady-state tive by both readers. There were two false-pos-
precession itive MRI readings by both readers (the same
1.5 T 4.3–9/2.15–2.4 4–5 4–6 two patients). The first was a 17-year-old boy
imaged at 1.5 T (Fig. 4). He was discharged
3T 3.5–4.4/1.5–2.5 4 4
from our emergency department the same day
T1 weighted without appendectomy after resolution of clin-
1.5 T ical symptoms. His discharge diagnosis was
In-phase 147/4.77 8 10 abdominal pain, not otherwise specified. Re-
view of the EMR indicated that he did not re-
Out-of-phase 147/2.33 8 10
turn to our institution for appendectomy. The
3T second was a 14-year-old girl who was imaged
In-phase 4.76/2.45 3 10 at 3 T and underwent subsequent appendecto-
Out-of-phase 4.36/1.33 3 1 my. Her appendix was noted to be normal in
both the operative note and pathology report.
Note—The FOV varied with patient size.
aInversion time was 150–160 ms. She was discharged on postoperative day 4
bInversion time was 220 ms. with a diagnosis of abdominal pain, not oth-
erwise specified. All true-positives had an ap-
Patients with acute appendicitis documented in agnosis, and subsequent appendectomy at our in- pendix diameter of at least 9 mm, whereas the
operative notes and pathology reports were con- stitution. The EMR was reviewed, on average, two false-positive appendixes measured 8 mm
sidered true-positives. Patients with normal ap- 14.5 months (range, 4–30.5 months) after the MRI in diameter at the tip only.
pendix documented in either operative or pa- to obtain as complete a picture as possible of the There were 48 true-negative MRI readings
thology reports and patients who did not have patients’ final diagnoses and follow-up. by both readers (the same 48 patients). The sen-
an appendectomy at our institution were consid- sitivity and specificity of MRI for acute appen-
ered true-negatives. The EMR of the patients dis- Statistical Analysis dicitis in children with inconclusive ultrasound
charged without appendectomy were reviewed for The sensitivity, specificity, positive predictive val- findings were 100% (95% CI, 0.72–1.00) and
length of admission or observation, discharge di- ue, negative predictive value, and accuracy of appen- 96% (95% CI, 0.87–0.98), respectively. The

Fig. 1—12-year-old boy with acute appendicitis. Axial
1.5-T STIR image shows hypointense appendicolith
(arrow) centrally within lumen of distended appendix,
with mural edema and periappendiceal inflammation.
A B
Fig. 2—16-year-old boy with acute appendicitis.
A, Axial 1.5-T HASTE image shows retrocecal appendix (arrow) with mural edema, intraluminal fluid, and
periappendiceal edema.
B, Coronal 1.5-T STIR image shows conspicuous inflamed appendix (arrow) and periappendiceal edema.

AJR:200, May 2013 971

 Herliczek et al.

positive predictive value for the examination

was 83% (95% CI, 0.55–0.95), and the nega-
tive predictive value was 100% (95% CI, 0.93–
1.00), with an overall test accuracy of 97%.
None of the MRI examinations was inter-
preted as indeterminate regarding the pres-
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ence or absence of acute appendicitis by ei-

ther reader. Interobserver agreement was very
good, with a kappa value of 1.00 (Pe, 0.695).
The normal appendix was identified in
83% of cases by reader 1 (35/41 [85%] at
1.5-T MRI and 5/7 [71%] at 3-T MRI) and
in 88% of the cases by reader 2 (36/41 [88]
at 1.5-T MRI and 6/7 [86%] at 3-T MRI).
Readers 1 and 2 excluded acute appendicitis Fig. 3—16-year-old girl with abdominal pain, not Fig. 4—17-year-old boy with abdominal pain, not
when the appendix was not visualized and no otherwise specified. Normal retrocecal appendix otherwise specified. Axial 1.5-T spatial and chemical-
RLQ inflammation was present in eight pa- (arrow) is seen on 3-T coronal HASTE image. shift encoded excitation image shows mural
thickening, intraluminal fluid, and periappendiceal
tients and six patients, respectively. stranding at 8-mm diameter appendix tip (arrow).
MRI detected an alternate cause of RLQ Image was interpreted by both readers as positive
pain in four patients, including two patients for appendicitis, but his symptoms improved without
appendectomy.
with omental infarction (Fig. 5), one with
a hemorrhagic ovarian cyst, and one with
citis conclusively because we had neither false- Previous investigations of pediatric appen-
cholelithiasis.
negative nor inconclusive examinations. Every dix MRI differ from our work. Hörmann et al.
patient with proven appendicitis had an abnor- [21] and Baldisserotto et al. [22] performed ap-
Discussion
mal appendix identified on MRI by both ob- pendix MRI in asymptomatic pediatric volun-
Our study shows that MRI has 100% sensi-
servers, with very good interobserver agree- teers. Baldisserotto et al. identified 48% of nor-
tivity and 96% specificity for acute appendicitis
ment (κ = 1.00). It has been previously found mal appendixes in this population. This is lower
in pediatric patients with RLQ pain and incon-
that in cases where a normal appendix is not than our observers’ rates of 83% and 87.5%.
clusive ultrasound. MRI had a negative predic-
visualized by CT, the absence of RLQ inflam- Our rates of identification of the normal ap-
tive value of 100% and an overall test accuracy
matory changes accurately excludes acute ap- pendix are similar to the 86% rate reported by
of 97%. All 10 patients with proven acute ap-
pendicitis in 98% of patients 15–91 years old, Hörmann et al. Yet, our study population dif-
pendicitis had a positive MRI interpretation.
with a negative predictive value of 98.7% in fers from the patients in the studies by Baldis-
Furthermore, there were no false-negative ex-
patients 0.1–18.6 years old [29, 30]. Although serotto et al. and Hörmann et al. because they
aminations, implying that a negative MRI may
a large prospective analysis is needed to illus- imaged asymptomatic volunteers only, where-
be sufficient to exclude appendicitis. Two MRI
trate the utility of MRI in the setting of the non- as children with RLQ pain and inconclusive
examinations were false-positive in that the ex-
visualized appendix, our data suggest that ap- ultrasound (who would have proceeded previ-
amination was graded as positive by both re-
pendicitis may be excluded by MRI, even when ously to CT) comprised our study group. The
viewers, but neither patient had acute appendi-
the normal appendix is not clearly identified. performance of MRI in symptomatic children
citis. In both of these patients, the abnormality
found on MRI was seen only in the tip of the
appendix, and the diameter was 8 mm, com-
pared with 9 mm or larger in all true-positive
MRI examinations. Our MRI readings for the
presence or absence of acute appendicitis were
completely concordant between both a fellow-
ship-trained pediatric radiology attending phy-
sician and a third-year radiology resident. This
finding implies that MRI readings are sensitive,
specific, and reproducible despite variable lev-
els of training and experience with MRI.
Our results are similar to published sensi-
tivity and specificity rates of CT for appendi-
citis, which, to date, has been considered the
reference standard for pediatric appendicitis. A B
The meta-analysis by Doria et al. [6] notes that Fig. 5—11-year-old boy with omental infarction.
CT has a sensitivity and specificity of 94% and A, Coronal 1.5-T spatial and chemical-shift encoded excitation image shows both omental infarction (white
arrow) and normal appendix (black arrow).
95%, respectively, for acute appendicitis. We B, Axial 1.5-T STIR image shows omental infarction (white arrow) with conspicuous edema and surrounding
show that MRI confirms or excludes appendi- fluid (black arrow).

972 AJR:200, May 2013

 MRI of Suspected Appendicitis After Inconclusive Ultrasound
with inconclusive ultrasound is likely to be
more relevant clinically than the utility of MRI
in asymptomatic patients.
There are several limitations to our study, in-
cluding a small sample population, limited di-
rect clinical follow-up for all of our true-neg-
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atives, and variation in MRI field strength and
protocols over time as our practice evolved. Al-
though it is possible that our true-negative pa-
tients underwent appendectomy at another hos-
pital after discharge from our institution, this is
unlikely because ours is the only pediatric hos-
pital in our state. Although comparing the util-
ity of 1.5- and 3-T systems would be of interest
because the shorter acquisition time and great-
er signal-to-noise ratio of 3-T systems could be
beneficial in smaller younger patients, we did
not attempt to compare the utility of different
field strengths for pediatric appendicitis be-
cause of the small sample size. We imaged pa-
tients with inconclusive ultrasound in the next
available MRI system at our institution, regard-
less of field strength. One other possible limita-
tion is that one of the readers had interpreted the
original examinations at the time of original di-
agnosis, but we attempted to minimize this po-
tential bias by the long interval between the ini-
tial read and the secondary read (a minimum of
8 weeks, up to a maximum of 60 weeks).
Our results and those of earlier studies [14–
24] depict the evolving roles of ultrasound, CT,
and MRI in evaluating pediatric appendicitis.
Moore et al. [23] postulated that an algorithm
of ultrasound followed by MRI might be the
best imaging algorithm for pediatric RLQ pain.
Imaging algorithms for pediatric appendi-
citis without CT lack ionizing radiation and
follow the ALARA principle. An algorithm
wherein MRI follows inconclusive ultrasound
in pediatric patients with RLQ pain is likely to
be used at institutions currently using CT after
inconclusive ultrasound. We think that staged
MRI following inconclusive ultrasound is the
best imaging algorithm for pediatric RLQ
pain because of its demonstrated sensitivity
and specificity for appendicitis in this popu-
lation and its lack of ionizing radiation. Still,
further research is needed to elucidate the ef-
fectiveness of this staged algorithm compared
with other imaging algorithms for pediatric
RLQ pain (ultrasound first, MRI first, and
staged CT following inconclusive ultrasound)
and to optimize MRI protocols.
In conclusion, our study shows that MRI
has high sensitivity and specificity for ap-
pendicitis in pediatric patients with incon-
clusive ultrasound.
AJR:200, May 2013 973
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