State of the Art
Bernard A. Birnbaum, MD
Stephanie R. Wilson, MD
Index terms:
Appendicitis, 751.291
Appendix, CT, 751.12112, 751.12115
Appendix, US, 751.12983
State of the Art
Radiology 2000; 215:337–348
1 From the Department of Radiology,
Hospital of the University of Pennsylva-
nia, 3400 Spruce St, Philadelphia, PA
19104 (B.A.B.); and the Department
of Medical Imaging, the Toronto Hospi-
tal, General Division, Ontario, Canada
(S.R.W.). Received March 10, 1999; revi-
sion requested May 3; revision received
June 29; accepted July 22. Address
correspondence to B.A.B. (e-mail:
birnbaum@oasis.rad.upenn.edu).
r RSNA, 2000
Appendicitis at the Millennium1
Acute appendicitis is a common clinical problem. Accurate and prompt diagnosis is
essential to minimize morbidity. While the clinical diagnosis may be straightforward
in patients who present with classic signs and symptoms, atypical presentations may
result in diagnostic confusion and delay in treatment. Helical computed tomography
(CT) and graded compression color Doppler ultrasonography (US) are highly
accurate means of establishing the diagnosis. These imaging modalities have now
assumed critical roles in the treatment of patients suspected to have appendicitis.
The purpose of this article is threefold: to provide an update on new information
regarding the pathophysiology, clinical diagnosis, and laparoscopic treatment of
acute appendicitis; to describe the state-of-the art use of CT and US in diagnosing
this disease entity; and to address the role of medical imaging in this patient
population.
Appendicitis is the most common cause of acute abdominal pain that requires surgical
intervention in the Western world (1). Patients with the disease may present with a wide
variety of clinical manifestations, and the diagnosis may elude even the most experienced
clinicians (2). Prompt diagnosis is essential to minimize morbidity, which remains
substantial if perforation occurs. The advent of antibiotics and effective surgical manage-
ment have substantially reduced appendicitis-related mortality; however, deaths from
appendicitis still occur, particularly in the elderly.
Appendicitis was rare in the past and remains so in underdeveloped countries (3). There
appears to be no record of early physicians, from Hippocrates to Moses Maimonides,
recognizing this disease entity (3). Although the anatomy of the appendix was well known
by the 18th century, it was not until this time that it was recognized that the appendix
could become inflamed, with possibly fatal consequences (4). Early reports of perityphlitis
and typhlitis in the 19th century appeared to describe a new clinical phenomenon (3,4).
Confusion over this right-lower-quadrant entity existed until Reginald H. Fitz presented his
landmark article in 1886, in which he coined the term ‘‘appendicitis’’ and correctly
classified this disease by describing the appendix as the primary source of inflammation in
acute typhlitis (5). Fitz described the signs and symptoms of acute and perforated
appendicitis, outlined the progression from acute right-lower-quadrant inflammation
through peritonitis and iliac fossa abscess formation, and recommended early appendec-
tomy if there were signs of spreading peritonitis or of clinical deterioration. Shortly
thereafter, Charles McBurney and other pioneering surgeons began to intervene early in
acute appendicitis (6,7). These clinicians advocated prompt clinical diagnosis and surgical
intervention. Their surgical aim was to operate in a timely fashion before appendiceal
perforation and peritonitis developed.
The goal of modern surgical management essentially is the same and focuses on a
balance between the rate of false-negative laparotomy and the rate of perforation at the
time of surgical exploration (8–10). It is tradition that surgeons have diagnosed appendici-
tis on the basis of patient history and physical examination results. The relatively recent
introduction of new imaging technology—in particular, graded compression color Doppler
US and helical computed tomography (CT)—potentially has changed ‘‘the rules of the
game.’’ The purpose of this article is to document recent advances in our understanding of
appendicitis and to define the role of medical imaging in patients with this condition.
ANATOMY AND PATHOPHYSIOLOGY
The adult appendix is a long diverticulum averaging 10 cm in length that arises from the
posteromedial wall of the cecum, approximately 3 cm below the ileocecal valve (11).
337
Although the relationship of the base of
the appendix to the cecum essentially is
constant, the remainder of the appendix
is free, which accounts for its variable
location in the abdominal cavity. The
appendix may lie in a retrocecal, subce-
cal, retroileal, preileal, or pelvic site. This
variability in location may greatly influ-
ence the clinical presentation in patients
with appendicitis (12,13).
Acute appendicitis may occur at any
age, although it is relatively rare at the
extremes of age. The maximum incidence
of the disease occurs in the 2nd decade;
thereafter, disease incidence declines with
age (14,15). The primary pathogenic event
in the majority of patients with acute
appendicitis is luminal obstruction (16–
18). This may result from a variety of
causes, which include fecaliths, lymphoid
hyperplasia, foreign bodies, parasites, and
both primary (carcinoid, adenocarcinoma,
Kaposi sarcoma, and lymphoma) and
metastatic (colon and breast) tumors (19–
26).
Fecaliths, which result from the inspis-
sation of fecal material and inorganic
salts within the appendiceal lumen, are
the most common cause of obstruction
and are present in 11%–52% of patients
with acute appendicitis (20–22). True ap-
pendiceal calculi (hard, noncrushable, cal-
cified stones) are less common than ap-
pendiceal fecaliths (hard but crushable
concretions) but have been shown to be
associated more commonly with perforat-
ing appendicitis and with periappendi-
ceal abscess (20).
Once appendiceal obstruction occurs,
the continued secretion of mucus results
in elevated intraluminal pressure and lu-
minal distention. This stimulates the vis-
ceral afferent nerve fibers that enter the
spinal cord at thoracic levels T8 through
T10, which causes referred epigastric and
periumbilical pain (26). This visceral pain
usually is mild, is poorly localized, and is
4–6 hours in duration. Anorexia, nausea,
and vomiting usually follow as the patho-
physiology worsens (13). Increasing intra-
luminal pressures eventually exceed capil-
lary perfusion pressure, which leads to
venous engorgement, arterial compro-
mise, and tissue ischemia. As the epithe-
lial mucosal barrier becomes compromised,
luminal bacteria multiply and invade the
appendiceal wall, which causes transmu-
ral inflammation. Continued tissue isch-
emia results in appendiceal infarction
and perforation. Inflammation then may
extend to the parietal peritoneum and
adjacent structures, which include the ter-
minal ileum, cecum, and pelvic organs.
Patients typically experience the classic
338 • Radiology • May 2000
migration of pain to the right lower quad-
rant at this stage (13,26). This somatic
pain is continuous and is more severe
than the early visceral pain. The classic
migration of pain need not occur, and the
point of maximal tenderness may be dis-
tinct from McBurney’s point if the appen-
dix is in an atypical location.
Patients with acute appendicitis usu-
ally are afebrile or have a low-grade fever.
Perforation should be suspected when-
ever a patient’s temperature exceeds
38.3°C (27). If perforation does occur,
periappendiceal phlegmon or abscess will
result if the terminal ileum, cecum, and
omentum are able to ‘‘wall off’’ the in-
flammation. Peritonitis usually develops
if there is free perforation into the abdomi-
nal cavity.
Mild acute appendicitis may resolve
spontaneously, with or without antibi-
otic therapy, if the inciting obstruction is
relieved (16,28–33). It is presumed that
this occurs after a soft fecalith is expelled
from the appendiceal lumen or if lym-
phoid hyperplasia is the cause of the
symptoms (30).
Recurrent and chronic forms of appen-
dicitis also have been recognized and
occur with an approximate incidence of
10% and 1%, respectively (31–35). Recur-
rent appendicitis is characterized by a
history of similar episodic attacks of right-
lower-quadrant pain that lead to appen-
dectomy, with a histopathologic diagno-
sis of acute inflammation of the appendix.
Diagnostic criteria for chronic appendi-
citis include a history of right-lower-quad-
rant pain of at least 3 weeks duration, no
alternative diagnosis, histopathologic evi-
dence of chronic active inflammation of
the appendiceal wall or of fibrosis of the
appendix, and complete relief of symp-
toms after appendectomy.
Nearly all patients with recurrent or
chronic appendicitis are able to recall at
least one episode of acute abdominal pain
consistent with acute appendicitis that
was managed nonsurgically. This sug-
gests that recurrent and chronic appendi-
citis can be avoided with the accurate
diagnosis and surgical management of
acute appendicitis (32).
CLINICAL DIAGNOSIS
The clinical diagnosis of acute appendici-
tis is based primarily on patient history
and on physical examination results. In a
classic presentation, a patient with appen-
dicitis has a typical historical sequence of
symptoms (poorly localized periumbili-
cal pain followed by nausea and vomit-
ing, with subsequent migration of pain to
the right lower quadrant) and physical
findings that vary with time and with the
location of the appendix (13,27). This
classic presentation occurs in only 50%–
60% of patients, and the diagnosis may
be missed or delayed when atypical pat-
terns of disease are encountered. Unusual
presentations most likely occur when the
appendix is in an atypical location (hid-
den from the anterior parietal perito-
neum), when the patient is at an extreme
of age, or when the patient is pregnant.
The most valuable elements of the pa-
tient history and physical examination
were recently determined in a meta-
analysis (13) of studies whose authors re-
ported the clinical usefulness of various
signs and symptoms in adults with appen-
dicitis. A diagnosis of appendicitis was
most likely in the presence of right-lower-
quadrant pain, rigidity, and migration of
the initial periumbilical pain to the right
lower quadrant. The absence of right-
lower-quadrant pain and of the classic
migration of pain and the presence of
similar pain in the past were shown to be
historical symptoms that decreased the
likelihood of appendicitis. The authors of
this study (13) stressed that no single
finding is able to help effectively rule out
appendicitis, and they advised close fol-
low-up of patients with abdominal pain
who do not undergo further diagnostic
testing.
The overall accuracy for diagnosing
acute appendicitis is approximately 80%,
which corresponds to a mean false-negative
appendectomy rate of 20% (8,14,15,20,27,
35–42). Diagnostic accuracy varies by sex,
with a range of 78%–92% in male and
58%–85% in female patients. These differ-
ences reflect the fact that appendicitis may
be extremely difficult to diagnose in women
of childbearing age, because symptoms of
acute gynecologic conditions such as pel-
vic inflammatory disease may manifest
similarly (43,44). This diagnostic prob-
lem has led to false-negative appendec-
tomy rates as high as 47% in female
patients aged 10–39 years (41).
Diagnostic accuracy was noted to im-
prove in the United States between 1970
and 1984, from 86% to 92% in male
patients and from 74% to 83% in female
patients (14). In a recent review of medi-
cal records of 4,950 patients who under-
went emergency appendectomy at U.S.
Department of Defense Hospitals world-
wide, the false-negative appendectomy rate
was noted to be 9% in male patients and
19% in female patients (36). These results
suggest that diagnostic accuracy may have
reached a plateau since the mid-1980s.
Birnbaum and Wilson
APPENDICEAL PERFORATION
Early surgical intervention in patients
with acute appendicitis is imperative to
avoid appendiceal perforation, which is
associated with increased morbidity and
mortality compared with nonperforating
appendicitis (8,9). The overall incidence
of perforation is 16%–39%, with a me-
dian of 20% (8,12–14,26,27,35–42). Perfo-
ration rates are strongly age related and
are highest in the very young (40%–57%)
and in the elderly (55%–70%), in whom
misdiagnosis and delayed diagnosis are
common.
The relationship between diagnostic
accuracy and perforation remains contro-
versial. While some authors (8,14) have
reported a linear correlation between diag-
nostic accuracy and the rate of perfora-
tion, authors of more recent studies
(37,39) have refuted any such relation-
ship. Conventional surgical wisdom is
predicated on the belief that an inverse
relationship exists between the normal
appendectomy rate and the perforation
rate (8,9). This historical doctrine asserts
that a false-negative appendectomy rate
of 15%–23% is an appropriate index of
management and that the failure to main-
tain such a surgical threshold is an indica-
tion of insufficient surgical aggressive-
ness and of an excessive rate of
perforation. This ‘‘scare philosophy’’ has
been questioned for some time, as it has
been shown that intensive in-hospital
observation can lead to improved diagnos-
tic accuracy and to fewer false-negative
appendectomies, without affecting the
perforation rate (45). Moreover, recent
reports (39,46) have shown no correla-
tion between the rates of perforation and
false-negative appendectomy.
The rates of perforation and false-
negative appendectomy have been rela-
tively stable over the past half century
(36). This is likely due to the fact that
these are two independent phenomena
with their own influencing factors (46).
Perforation rates correlate with time from
onset of symptoms to treatment and are
highly dependent on both patient-re-
lated (prehospital delay) and physician-
related (in-hospital delay) variables (45–
50).
False-negative appendectomy rates re-
flect the diagnostic difficulty encoun-
tered in differentiating appendicitis from
other acute abdominal conditions. New
imaging technology has the potential to
alter the clinical approach to appendicitis
by improving these clinical outcomes.
Diagnostic evaluation with helical CT
and with graded-compression US may
Volume 215 • Number 2
lower the false-negative appendectomy
rate because of these modalities’ proved
use in providing an accurate diagnosis in
the overwhelming majority of patients
who present with acute right-lower-quad-
rant pain (51). In theory, imaging in
patients with equivocal clinical findings
and with uncertain diagnoses also may
reduce the rate of perforation by shorten-
ing in-hospital delay in treatment. These
imaging examinations should be per-
formed expeditiously to avoid incurring
an increase in the perforation rate.
CT IN ACUTE APPENDICITIS
CT is a highly accurate and effective
cross-sectional imaging technique for di-
agnosing and staging acute appendicitis
(51–62). CT is readily available, is opera-
tor-independent, is relatively easy to per-
form, and has results that are easy to
interpret. Diagnostic sensitivity and speci-
ficity are excellent for the entire spectrum
of disease manifestations and do not de-
crease in the presence of perforation or
aberrant appendiceal location. Moreover,
extremes of body habitus rarely limit
study acquisition or interpretation when
optimized scanning methods are used.
Helical CT has reported sensitivities of
90%–100%, specificities of 91%–99%, ac-
curacies of 94%–98%, positive predictive
values of 92%–98%, and negative predic-
tive values of 95%–100% for the diagno-
sis of acute appendicitis (57–62). These
results are comparable to those achieved
by experienced investigators (54,55) who
have used thin-section, conventional,
contrast material–enhanced CT and are
superior to recently reported clinical accu-
racy (14,36).
CT Technique
All current helical CT protocols for
imaging in patients suspected to have
appendicitis incorporate the prospective
acquisition of thin-section (#5-mm sec-
tion collimation) images in the right lower
quadrant. This scanning philosophy is
based on the fact that CT diagnostic
sensitivity and specificity are maximized
only when a deliberate effort is made to
image the appendix. The value of im-
proved z-axis resolution in this clinical
setting has been demonstrated with both
conventional and helical CT (53,62). In a
recent study, Weltman et al (62) showed
that the use of 5-mm-section helical CT
enabled the improved visualization of
abnormal appendices (94% vs 69%), calci-
fied appendicoliths (38% vs 19%), and
periappendiceal inflammation (98% vs
75%) compared with 10-mm-thick–sec-
tion helical CT in the same patient.
Appendiceal CT protocols differ consid-
erably with regard to the anatomic area to
be included in the scan and to the use of
intravenously, orally, and rectally admin-
istered contrast material. The most popu-
lar and conservative approach is to per-
form helical CT scanning of the entire
abdomen and pelvis with intravenous
and oral contrast material. Proponents of
this technique believe that contrast-
enhanced CT is essential in the diagnosis
and staging of numerous inflammatory,
ischemic, and neoplastic processes that
may cause acute abdominal pain and
may simulate appendicitis (63).
Intravenous contrast material has been
shown to aid in the diagnosis of appendi-
citis by permitting the identification of
the inflamed appendix. This may be criti-
cal in patients with mild appendicitis and
a paucity of mesenteric fat and in those
with perforated appendicitis (51,52).
Opacification of the terminal ileum and
cecum with oral contrast material has
been advocated to avoid false-positive
results, in which fluid-filled terminal ileal
loops are misdiagnosed as distended, in-
flamed appendices (53). Moreover, opaci-
fication of the normal appendix serves to
exclude appendicitis. All of these factors
are operative in children, which has led
to the recommendation that pediatric
appendiceal CT studies be performed with
both intravenous and oral contrast agents
(64).
Adequate enteral opacification of ileo-
cecal bowel may take 45–60 minutes. To
expedite scan acquisition, Rao et al (61)
have promoted a focused appendiceal CT
technique in which a limited helical CT
study of the right lower quadrant is per-
formed after the rapid administration of
colonic contrast material. This technique
has proved to be as accurate as those
techniques in which intravenous and oral
contrast material are administered, while
allowing scanning completion within 15
minutes in the majority of patients exam-
ined. A limitation of this scanning method
is that a minority of patients will require
additional scanning of the proximal abdo-
men or of the distal pelvis to identify
disease not included in the scanning field
of view. If the initial examination results
are negative, the cause of the patient’s
symptoms may go undetected unless the
remainder of the abdomen and pelvis is
imaged.
The fastest CT protocol has been pro-
moted by Lane et al (57,58), who have
advocated use of nonenhanced helical
Appendicitis at the Millennium • 339
 a. b.
Figure 2. The value of contrast-enhanced CT in demonstrating early acute appendicitis in a
21-year-old man with acute onset of right-lower-quadrant pain. (a) Transverse CT scan obtained
with oral contrast material and 5-mm collimation reveals a nonspecific soft-tissue mass (arrow)
Figure 1. Early acute appendicitis in a 25-year-
posteromedial to the cecum (C) in this patient with a paucity of abdominal fat. (b) Transverse
old man with right-lower-quadrant pain. Trans-
helical CT scan obtained with intravenous and oral contrast material and 5-mm collimation
verse helical CT scan obtained with intrave-
demonstrates that this mass represents a circumferentially thickened, mildly distended, inflamed
nous and oral contrast material and with 5-mm
appendix (straight arrow) with associated focal thickening of the cecal wall (curved arrow). No
collimation reveals a minimally thickened,
perforation was seen at surgery. (Reproduced, with permission, from reference 67.)
minimally distended appendix (arrow) 6–7 mm
in diameter, anterolateral to the right psoas
muscle (P) and subtle increased attenuation of
the periappendiceal fat (arrowhead) posterior
to the appendix.

CT of the entire abdomen and pelvis. This

examination may be performed in 10
minutes, does not expose the patient to
the potential risks associated with iodin-
ated contrast agents, requires no bowel
preparation, and represents the most cost-
effective imaging alternative to US. This
procedure is most effective in patients
with large body habitus, as diagnostic
accuracy may be compromised in pa-
tients with little abdominal and intrapel-
vic fat (56,57). These investigators (58,65)
have shown that nonenhanced CT is an
accurate technique for establishing an
alternative diagnosis in patients sus- a. b.
pected to have appendicitis.
Figure 3. Classic CT findings of acute appendicitis in a 25-year-old man who presented with
right-lower-quadrant pain and with exquisite McBurney point tenderness. (a) Transverse CT scan
CT Criteria for the Diagnosis obtained with intravenous and oral contrast material and with 5-mm collimation reveals an
of Acute Appendicitis obstructing appendicolith (straight solid arrow) within the distended, thick-walled (curved arrow)
appendix. Periappendiceal inflammation (open arrow) extends to the anterior abdominal wall,
Visualization of the appendix is where thickened, enhancing peritoneum (arrowheads) is identified. (b) Caudal helical CT image
strongly dependent on the type and qual- reveals additional nonobstructing appendicoliths (arrow) within the distended appendix (A).
Surgical exploration revealed perforated appendicitis.
ity of the CT examination, although ap-
pendiceal size, the amount of periappen-
diceal fat, and the degree of ileocecal
bowel opacification are important influ- ceived rectal contrast material. When appendix is identified or if a calcified
encing factors (51,52). In complicated seen, the normal appendix appears as a appendicolith is seen in association with
cases, dynamic cine review of images on tubular or ringlike pericecal structure that pericecal inflammation (51–54). The ap-
the CT console may facilitate recognition is either totally collapsed or partially filled pearance of the abnormal appendix var-
of the appendix, terminal ileum, and with fluid, contrast material, or air. In our ies with the stage and severity of the
cecum. The normal appendix is identified experience, the normal appendiceal wall disease process. The CT findings are most
in 67%–100% of symptomatic adults who measures less than 1–2 mm in thickness. subtle in patients with mild, nonperforat-
undergo thin-section helical CT of the The periappendiceal fat should appear ing appendicitis who undergo scanning
right lower quadrant (57,59–62,66). homogeneous, although a thin mesoap- shortly after the onset of symptoms. In
Appendiceal visualization is technique pendix may be present. these patients, the appendix may appear
dependent, with the highest detection A definitive CT diagnosis of acute ap- as a minimally distended, fluid-filled, tu-
rates reported in patients who have re- pendicitis can be made if an abnormal bular structure 5–6 mm in diameter sur-

340 • Radiology • May 2000 Birnbaum and Wilson


a.
Figure 4. Perforated appendicitis in a 22-year-old woman with a 2-day history of right-lower-
quadrant pain. (a) Transverse helical CT scan obtained with oral contrast material and 5-mm
collimation reveals nonspecific pericecal phlegmon (arrow) interposed between the cecum (C ),
inferior liver (L), and right psoas muscle (P ). (b) Transverse helical CT scan obtained with
intravenous and oral contrast material and with 5-mm collimation clearly demonstrates the
remains of an enhancing, fragmented appendix (arrows) centered within the pericecal inflamma-
tion. (Reproduced, with permission, from reference 67.)
Figure 5. Perforated appendicitis in a 30-year-
old woman with right-sided pelvic pain and
tenderness. Transverse helical CT scan obtained
with intravenous and oral contrast material and
with 5-mm collimation reveals a calcified ap-
pendicolith (arrow) centered within an inflam-
matory mass along the right pelvic sidewall.
rounded by the homogeneous fat attenu-
ation of the normal mesentery. This
appearance is seen in only the most incipi-
ent forms of acute appendicitis and, in
our experience, occurs in fewer than 5%
of patients who undergo scanning.
Most patients who undergo CT demon-
strate greater degrees of luminal disten-
tion and evidence of transmural inflam-
mation (Fig 1). The inflamed appendix
Volume 215 • Number 2
b.
usually measures 7–15 mm in diameter.
Circumferential and symmetric wall thick-
ening is nearly always present and is best
demonstrated on images obtained with
intravenous contrast material enhance-
ment (51,52) (Fig 2). The thickened wall
usually is homogeneously enhanced, al-
though mural stratification in the form of
a target sign may be noted.
Periappendiceal inflammation is pre-
sent in 98% of patients with acute appen-
dicitis (61,62) (Fig 3). Although linear fat
stranding, local fascial thickening, and
subtle clouding of the mesentery are char-
acteristic findings in nonperforated ap-
pendicitis, they may be seen with mi-
croperforation. Other important findings
include focal cecal apical thickening and
the arrowhead sign. The latter finding
occurs when cecal contrast material fun-
nels symmetrically at the cecal apex to
the point of appendiceal occlusion (68).
This secondary finding of appendicitis
has a high specificity and may help to
establish the diagnosis in equivocal cases.
Perforated appendicitis is usually ac-
companied by pericecal phlegmon or ab-
scess formation. Associated findings in-
clude extraluminal air, marked ileocecal
thickening, localized lymphadenopathy,
peritonitis, and small-bowel obstruction.
Contrast-enhanced CT may be useful in
cases of perforation by demonstrating the
remains of a fragmented appendix (Fig 4).
If the abnormal appendix is not seen, a
specific diagnosis of appendicitis can be
made by identifying an appendicolith
within a periappendiceal abscess or phleg-
mon (Fig 5). New imaging technology is
especially useful in this regard, as appen-
dicolith detection rates for helical CT are
approximately twice those for conven-
tional CT (53,57,60,61,69).
Although a pericecal phlegmon or ab-
scess is strongly suggestive of appendici-
tis, these are nonspecific findings that
may be seen with other disease entities
(51,52). If substantial inflammation is
present within the right lower quadrant,
it may be difficult to differentiate primary
appendicitis with secondary inflamma-
tion of the cecum and terminal ileum
from ileocolitis with secondary inflamma-
tion of the appendix.
The CT findings of recurrent and chronic
appendicitis are identical to those of acute
appendicitis (70). Distal appendicitis is diag-
nosed when CT reveals appendicitis that
involves the distal, ‘‘upstream’’ aspect of
the appendix, with a normal appearance of
the proximal appendix and cecal apex (71).
An obstructing appendicolith often is iden-
tified at the transition point between the
normal and abnormal appendiceal seg-
ments (Fig 6). The proximal appendix in
these cases may be collapsed or partially
filled with contrast material or with air.
CT Staging of Acute Appendicitis
CT is of considerable value in the treat-
ment of patients who present with a
periappendiceal mass, because of its abil-
ity to directly depict the periappendiceal
region (72,73). CT can be used to accu-
rately stage the extent of periappendiceal
inflammation and to reliably differenti-
ate periappendiceal abscess from phleg-
mon. This distinction is of critical impor-
tance to the surgeon, as it may be impossible
to distinguish these entities on the basis of
clinical grounds alone (74,75).
Many surgeons believe that there is
little value in attempting to drain a non-
liquefied phlegmon and prefer initial non-
surgical treatment with antibiotic therapy
in such cases. Patients with well-defined and
well-localized periappendiceal abscesses
typically benefit from CT-directed percu-
taneous catheter drainage. In either case,
interval appendectomy may be performed
after an appropriate period. Patients with
extensive and poorly defined collections
usually require immediate surgical explo-
ration and abscess drainage (73).
US IN ACUTE APPENDICITIS
US is a widely available and inexpensive
modality with the potential for highly
Appendicitis at the Millennium • 341
accurate imaging in the patient suspected
to have acute appendicitis. Although op-
erator skill is an important factor in all US
examinations, it has particular impor-
tance in the examination of the patient
with right-lower-quadrant pain. The learn-
ing curve required to develop the tech-
nique for scanning the right lower quad-
rant is considerable, and there are many
pitfalls to be aware of (76). Nonetheless,
the criteria for the US-based diagnosis of
acute appendicitis are well established
and reliable (28,51,77). In the patient in
whom acute appendicitis does not ex-
plain his or her pain, US is also highly
useful in identifying an alternate diagno-
sis (78).
In experienced hands, US has reported
sensitivities of 75%–90%, specificities of
86%–100%, accuracies of 87%–96%, posi-
tive predictive values of 91%–94%, and
negative predictive values of 89%–97%
for the diagnosis of acute appendicitis
(28,79–82). The inexperienced sonolo-
gist, working with poor equipment and/or
technique, will not provide the excellent
results possible with this modality.
US Technique
US examination of the patient suspected
to have appendicitis should include a
thorough evaluation of both the abdo-
men and the pelvic organs. In women in
whom the answer is not evident after the
performance of these two examinations,
endovaginal US should be added. This is
of particular importance if one considers
the overlap in the symptoms of appendi-
citis with those of gynecologic disease in
women in the childbearing years. A gyne-
cologic explanation for the symptoms
may be evident on the endovaginal im-
ages. Conversely, the appendix may have
a pelvic location, in which case it may be
seen clearly on the endovaginal image
when it is not evident on the suprapubic
image.
The specific US approach to the right
lower quadrant should include graded
compression US, a technique first popular-
ized by Puylaert (77) by using high-
frequency linear probes. It describes the
use of uniform pressure on the region of
interest by the handheld US transducer.
Normal and gas-filled loops of gut will be
either displaced from the field of view or
compressed between the layers of muscu-
lature of the anterior and the posterior
abdominal walls. In contrast, abnormal
loops of gut, or the obstructed appendix,
will be noncompressible and optimally
seen on the graded compression image.
In addition to its benefit of showing the
342 • Radiology • May 2000
obstructed appendix as a noncompress-
ible loop of gut, the technique also allows
for successful examination of the patient
who may have peritoneal irritation and
sensitivity. If a normal, rapid US tech-
nique were used or if the transducer were
repeatedly placed on the skin surface and
removed, rebound tenderness would be
elicited, and the uncomfortable patient
would react quickly with termination of
the examination.
In contrast, graded compression US,
with slow and gentle maintained pres-
sure, allows for a lengthy and successful
evaluation of the area of interest in even
the most uncomfortable and reluctant of
patients. The patient is also able to pro-
vide input as to the point of maximal
tenderness, which often is useful in focus-
ing the examination in the correct area
(83).
High-frequency linear probes for graded
compression US are still in wide use today
in patients suspected to have appendici-
tis. We have found, however, that in
many patients, the currently popular cur-
vilinear probes work equally well and
provide a slightly larger field of view and
greater penetration. This is of particular
benefit in the obese patient in whom it is
difficult to scan adequately with a poorly
penetrating, linear-array, small-parts
transducer. We believe that the critical
factor is a transducer with a variable or
short focal zone and with a frequency of
5–9 MHz.
The addition of color Doppler US also
is of benefit in the evaluation of inflam-
matory conditions of the intestinal tract.
The activity of inflammation is propor-
tional to the amount of color signal de-
tected within the gut wall (84,85). The
normal gut is thin walled and compliant
and frequently shows peristaltic activity.
Hence, the detection of color Doppler
ultrasound signals from the normal gut is
extremely difficult.
In contrast, the thick-walled and non-
compressible appendix, maintained in a
fixed position by the compressing trans-
ducer, will show circumferential color
when inflamed. The contribution of
Doppler US is most evident in the case of
the equivocal gray-scale US examination,
in which it is uncertain as to whether the
imaged appendix is normal or inflamed
(84). Although each generation of US
equipment shows improved sensitivity in
the detection of Doppler ultrasound sig-
nals, inflamed gut uniformly will show
greater flow than normal gut. We have
found that the degree of bowel perfusion
may be overestimated with power Dopp-
ler US because the power Doppler ultra-
Figure 6. Distal appendicitis in a 71-year-old
woman with right midabdominal pain. Trans-
verse helical CT scan obtained with intrave-
nous and oral contrast material and with 5-mm
collimation reveals a medially located, mobile
cecum (C ) within the midabdomen. The appen-
diceal tip (arrow) appears minimally distended
secondary to an obstructing appendicolith. Subtle
increased attenuation of the periappendiceal
fat (arrowheads) is present. Surgical explora-
tion revealed nonperforated appendicitis.
sound signal is sensitive to motion arti-
fact. We therefore prefer to use color
Doppler US to detect genuine blood flow
signal.
An excellent routine for the actual US
examination of the right lower quadrant
is to scan in the transverse plane by
starting from the tip of the liver and
proceeding to the pelvic brim. Several
sweeps from the lateral aspect to the
medial aspect may be necessary. The as-
cending colon usually is appreciated by
its gas content and haustral pattern. In
the location of the cecum, careful atten-
tion should be paid to inflammatory
changes in the perienteric fat and the
appendix itself. Sagittal and oblique im-
ages should then be obtained until the
entire region of interest has been scanned.
Detailed images are obtained of the ap-
pendix, if it is seen. We start the examina-
tion with a curvilinear transducer appro-
priate for the patient: a 3.5-MHz transducer
for large patients and a 5-MHz transducer
for thin patients. The linear transducer is
used last, for more detailed images of the
gut.
US Criteria for the Diagnosis
of Acute Appendicitis
Rigorous adherence to the criteria for
diagnosing appendicitis is recommended.
The inflamed appendix is seen as a blind-
Birnbaum and Wilson

a. b.
c. d.
Figure 7. Classic features of acute appendicitis at US in a 36-year-old woman with right-lower-
quadrant pain. (a) Long-axis and (b) cross-sectional US images of the right lower quadrant
obtained with a linear 7-4-MHz transducer show an 8-mm-diameter, blind-ended, tubular structure
with a laminated wall. The appendix (A ) was not compressible and showed no peristalsis. (c) Cross-
sectional US image obtained through the base of the appendix (A) and (d) color Doppler US image
obtained at the same level as c show a very thick wall (arrow) of the appendix, with virtually
circumferential flow in the wall of the inflamed appendix.
ing acute appendicitis (28). Circumferential
color in the wall of the inflamed appendix
on color Doppler US images is strongly
supportive evidence of active inflamma-
tion (Fig 7c, 7d).
The course of the appendix is variable
and includes both retrocecal and pelvic
locations. The appendix in the former
location often is best appreciated on scans
obtained with the transducer positioned
adjacent to the cecum or to the ascending
colon, with an oblique plane of insonation.
Figure 8. Endovaginal US image obtained The pelvic appendix, in comparison, of-
with a curvilinear 8-4-MHz probe in a 57-year-
old woman not suspected clinically to have
ten is best seen in women with endovagi-
appendicitis shows a blind-ended, tubular struc- nal scanning (Fig 8). Different degrees of
ture confirmed as the appendix (A). The dis- bladder filling also will influence the abil-
tended lumen was filled with pus at surgery. ity to see a pelvic appendix.
The origin of the appendix from the cecum is Appendicoliths appear as bright, echo-
often not shown with the endovaginal tech- genic foci with clean distal acoustic shad-
nique. (Reproduced, with permission, from ref-
erence 86.)
owing (Fig 9). Their identification within
the appendix or in the adjacent perien-
teric soft tissue after perforation is highly
associated with a positive diagnosis. Fail-
ended, tubular structure with a laminated ure to see an appendicolith, in contrast, is
wall that arises from the base of the noncontributory. Appendicoliths with-
cecum (Fig 7a, 7b). It should be aperistal- out actual calcium content may show a
tic and noncompressible. A threshold di- similar appearance to calcified appendico-
ameter of 6 mm is invaluable for diagnos- liths on US images, and their identifica-
Volume 215 • Number 2
tion is most helpful in this clinical situa-
tion.
Prior to the actual perforation of the
appendix, ischemic and gangrenous
change in the appendiceal wall may lead
to focal or generalized loss of definition
of the wall layers (87). With gangrene,
color Doppler US may show decreased or
no perfusion.
With perforation of the appendix, the
distended appendix may no longer be
visualized at US examination. Although
the criteria for the diagnosis of appendici-
tis are focused on the appendix itself,
inflammatory changes in the perienteric
fat are often the first and most obvious
findings at US examination. Inflamed fat
appears at US as an ‘‘echogenic mass
effect.’’ It separates the inflamed gut from
the surrounding gut and other organs.
The hyperemia seen in the inflamed gut
extends to the inflamed fat, as seen at
color Doppler US (88). Phlegmonous
change manifests as hypoechoic zones
with poor margination within the in-
flamed fat that blend imperceptibly at its
margins with the fatty tissue (89). Lique-
faction and abscess formation will mani-
fest as an actual fluid component (Fig 10).
Gas bubbles within a collection suggest
either perforation or gas-forming organ-
isms. A localized perforation of the appen-
diceal tip may show gas pockets localized
to the perforation site, with disruption of
the wall at that point (Fig 11).
Sympathetic thickening of the adja-
cent terminal ileum and ascending colon
may lead to the erroneous interpretation
of the site of the original problem. Color
Doppler US contributes to the distinction
of sympathetic thickening of the gut from
inflammatory thickening, with less hyper-
emic response in the sympathetic process.
Pitfalls in Diagnosis
The most common sources of error in
the overdiagnosis of appendicitis with US
include misinterpretation of the terminal
ileum as the appendix and misinterpreta-
tion of a normal appendix as an inflamed
appendix. The terminal ileum, in con-
trast to the appendix, does not attach to
the base of the cecum, is not blind-ended,
and shows frequent peristaltic activity.
Also, the terminal ileum usually is oval in
cross-section as compared with the appen-
dix, which is round.
The normal appendix is seen infre-
quently at US, although it may be seen,
particularly in thin patients, with excel-
lent-quality examinations. Rioux (90) de-
scribed the visualization of the normal
appendix in an amazing 102 of 125 (82%)
Appendicitis at the Millennium • 343
patients without acute appendicitis. In
our experience and in that of others
(28,82), this number usually is substan-
tially lower, 0%–4%, in the adult popula-
tion, regardless of technique. The thresh-
old diameter of 6 mm, above which
inflammation is present, is invaluable in
distinguishing the normal appendix from
the inflamed appendix, as the diameter of
the normal compressed appendix is in-
variably less than this (28). Color Doppler
US also is essential in distinguishing the
normal from the inflamed appendix, as
the hyperemia of inflammation will not
manifest in the normal structure (84).
The spontaneous resolution of appendi-
citis is a relatively uncommon but docu-
mented condition that is a component of
overdiagnosis (30,91). Affected patients
may show true features of appendicitis at
US, but their clinical condition favors conser-
vative treatment, during which their
symptoms subside. These patients are not
encountered with any frequency, and fol-
low-up examination to show the return
of US features to normal is appropriate.
The underdiagnosis of appendicitis is
much more difficult to address. Tech-
nique is of the utmost importance, as is
adherence to the diagnostic criteria. Poor-
quality examinations undoubtedly ac-
count for some diagnostic errors. If in-
flammation is localized to only the tip of
the appendix, an incomplete examina-
tion also could lead to an erroneous im-
pression that the appendix is normal.
Lim et al (92) emphasized the require-
ment of visualizing the entire length of
the appendix to avoid a false-negative
diagnosis. Other problems may be related
to a position of the appendix that makes
it more difficult to appreciate, in particu-
lar when it is in the true pelvis and when
it is retrocecal. Furthermore, perforation
of the appendix may lead to decompres-
sion of the appendiceal lumen, such that
the appendix, per se, is no longer seen.
This removes the specificity of the US
study and also may lead to diagnostic
errors.
Interpretation of US findings in the
patient with inflammatory bowel disease,
especially Crohn disease, also may be
difficult at times. The appendix may be
involved in the inflammatory process of
Crohn disease, or, conversely, appendici-
tis may be the first manifestation of this
disease (93,94).
US VERSUS CT
Patients with clinical signs and symp-
toms typical of acute appendicitis un-
344 • Radiology • May 2000
Figure 9. Appendicitis with appendicolith.
Long-axis US image of the right lower quad-
rant, obtained with a curvilinear 7-4-MHz
probe, shows the inflamed appendix (A) as a
blind-ended, tubular structure with a fluid-
Figure 10. Ruptured appendix with abscess
filled lumen. An appendicolith (arrow) is seen
formation in a 76-year-old man with right-
as a dependent, shadowing, echogenic focus.
lower-quadrant pain and tenderness. Long-axis
(Reproduced, with permission, from reference
US image, obtained in the emergency depart-
86.)
ment through the right lower quadrant with a
curvilinear 7-4-MHz probe, shows the rem-
nants of the decompressed perforated appen-
dergo immediate surgery without radio- dix (A), with discontinuity of its wall (arrow-
logic evaluation. Radiologic imaging heads). A dumbbell-shaped abscess (a) surrounds
both the anterior and the posterior aspects of
usually is requested in patients with atypi-
the appendix.
cal or confusing clinical findings. The
choice between US and CT in this clinical
setting largely is dependent on institu-
tional preference and on available exper-
tise, although patient age, sex, and body
habitus are important influencing factors.
US is rapid, noninvasive, inexpensive,
and requires no patient preparation or
contrast material administration. Because
US involves no ionizing radiation and
excels in the depiction of acute gyneco-
logic conditions, it is recommended as
the initial imaging study in children, in
young women, and during pregnancy. CT
represents an excellent diagnostic alterna-
tive for all other patients. CT is comple-
mentary to US and is recommended
whenever US results are suboptimal, inde-
terminate, or normal in patients with
acute abdominal pain. US is also comple-
Figure 11. Focal perforation of the tip of the
mentary to CT and may be particularly appendix in a 40-year-old woman who was
useful in thin patients in whom the re- receiving chemotherapy, had right-lower-quad-
sults of initial CT, no matter how it is rant pain, and was clinically suspected to have
performed, are equivocal. typhlitis. Long-axis US image of the appendix
An important limitation of US is that (A), obtained with a curvilinear 7-4-MHz probe,
the sensitivity and specificity for perfo- shows the blind-ended, tubular structure that
originates from the base of the cecum (C). The
rated appendicitis are lower than those wall layers are no longer defined, which is
typically seen for nonperforated appendi- suggestive of gangrenous change. Surrounding
citis. A noncompressible appendix may the appendix is a halo of increased echo-
be identified in only 38%–55% of pa- genicity consistent with inflamed fat (F). Gas
tients with perforation (95,96). The US- bubbles (arrows) outside the tip of the appen-
aided diagnosis of perforated appendicitis dix suggest a localized perforation.
depends on the identification of second-
ary findings, which, in combination, pro-
vide a specificity of only 60% (87). CT is is particularly useful for characterizing
preferred in patients suspected to have periappendiceal inflammatory masses.
appendiceal perforation because diagnos- In the only prospective study to our
tic accuracy remains high and because CT knowledge to date in which these modali-
Birnbaum and Wilson
ties are compared, Balthazar et al (54)
showed CT to be superior to graded com-
pression US in the diagnosis of acute
appendicitis. Analysis of the data for CT
and US revealed similar specificities (89%
vs 91%, respectively) and positive predic-
tive values (96% vs 95%, respectively);
however, CT demonstrated higher sensi-
tivity (96% vs 76%), accuracy (94% vs
83%), and negative predictive value (95%
vs 76%). CT was shown to be more accu-
rate in staging periappendiceal inflamma-
tion, more useful in diagnosing acute
abdominal conditions unrelated to appen-
dicitis, and more sensitive in demonstrat-
ing a normal appendix and in excluding
acute appendicitis from the differential
diagnosis. Further prospective investiga-
tion is needed to confirm these results.
Use for provision of an alternate diagno-
sis to explain the patient’s symptoms is a
benefit of both US and CT in the patient
suspected to have acute appendicitis
(51,65,78,95). The differential diagnosis
includes all surgical and nonsurgical con-
ditions that cause abdominal pain, since
appendicitis may mimic any of these
diseases. The most common conditions
discovered at false-negative appendec-
tomy vary from study to study but in-
clude, in approximate order of frequency,
abdominal pain of unknown cause, pel-
vic inflammatory disease and other acute
gynecologic disorders, mesenteric lymph-
adenitis, acute gastroenteritis and other
acute gastrointestinal tract diseases, and
urinary tract infection and obstruction.
Careful US and CT evaluation of the
right lower quadrant will result in a cor-
rect diagnosis in most patients. Although
intestinal diseases often demonstrate over-
lapping imaging features, the addition of
relevant clinical history usually narrows
the differential to a few diagnostic enti-
ties. In certain gastrointestinal disorders,
a constellation of findings may be noted
that permits a precise diagnosis to be made.
A suggested approach is to first confirm
or exclude the diagnosis of acute appendi-
citis. Once the appendiceal region is
cleared, the cecum and ascending colon
should be carefully examined for poten-
tial involvement by cecal neoplasm, cecal
diverticulitis, typhlitis, or segmental coli-
tis. Diseases that involve primarily the
pericolonic fat, such as primary epiploic
appendagitis and omental infarction, are
then excluded.
Focus is then turned to the terminal
ileum and its subtended mesentery. Gas-
trointestinal diseases to consider in this
anatomic location include acute terminal
ileitis, mesenteric lymphadenitis, and Crohn
disease. Genitourinary disease then should
Volume 215 • Number 2
be excluded, including acute pyelonephri-
tis, ureteral obstruction, complications of
ovarian cysts and masses, and acute post-
partum ovarian vein thrombosis. In adult
patients, one must also consider acute
cholecystitis, which may mimic acute
appendicitis if the enlarged gallbladder
extends into the right-lower quadrant;
pancreatitis; sigmoid diverticulitis; bowel
ischemia; and bowel obstruction.
US and CT have replaced barium en-
ema examination as the primary means
of examining patients suspected to have
appendicitis. Barium enema examination
is not obsolete, however, and may be
useful in evaluating complex colonic ab-
normalities detected with cross-sectional
imaging (51). While investigators have
explored the potential of magnetic reso-
nance imaging (97) and radioactive iso-
tope imaging (98,99) in patients with
acute appendicitis, there is no current
practical role for these imaging modali-
ties in this patient population.
EFFECT OF IMAGING
ON CLINICAL OUTCOMES
Outcome studies in which the medical
and financial implications of radiologic
imaging in patients suspected to have
acute appendicitis are assessed have be-
gun to appear in the literature. Recent
investigations (55,59) have shown that
the judicious use of CT in patients with
equivocal clinical findings results in lower
false-negative appendectomy rates when
compared with the historical rate of 15%–
20% promoted by aggressive surgical phi-
losophy. Balthazar et al (55) demon-
strated that CT led to an overall false-
negative appendectomy rate of 4%, with
a rate of 8.3% in female patients of child-
bearing age. This was accomplished with-
out incurring an increase in the perfora-
tion rate, which, at 22%, was similar to
that in previously published reports (8,12–
14,26,27,35–42). Schuler et al (59) used
CT to achieve a false-negative appendec-
tomy rate of 6% (three of 52 appendecto-
mies) in patients with clinically equivocal
appendicitis. This figure was substantially
lower than the 21% (11 of 52 appendecto-
mies) false-negative appendectomy rate
observed in a control group of patients
who immediately underwent surgery af-
ter being judged clinically likely to have
appendicitis.
Similar results have been reported by
very experienced sonologists. Ooms et al
(95) documented their experience with
graded compression US over 4 years in
patients who were clinically suspected to
have acute appendicitis but were without
signs of an appendiceal mass. The false-
negative appendectomy rate at Ooms et
al’s institution decreased from 32% in
1985 to 12% in 1986 and to 7% from
1987 to 1989. At the same time, delay in
treatment beyond 6 hours, due to diagnos-
tic uncertainty in patients with surgically
proved acute appendicitis, decreased from
11% to 4% to 2% over these same periods.
These investigators noted that although
US enhanced diagnostic accuracy, it could
not entirely replace careful clinical evalu-
ation and observation. This was empha-
sized by the fact that 16% of patients in
this study who had normal or nondiag-
nostic US results eventually received a
diagnosis of acute appendicitis.
Well-performed cost-effectiveness stud-
ies are needed to evaluate the utility of
diagnostic imaging in this clinical set-
ting. In the most detailed study to our
knowledge to date, Rao et al (100) showed
that the routine use of appendiceal CT in
patients in the emergency department
who meet clinical criteria for hospital
admission for suspected appendicitis im-
proves patient care both by averting un-
necessary appendectomy and by averting
delays before necessary medical or surgi-
cal treatment. Their cost analysis demon-
strated that this imaging philosophy im-
proved the use of hospital resources,
because savings achieved by eliminating
unnecessary surgery and in-hospital ob-
servation outweighed the cost of perform-
ing routine appendiceal CT.
The importance of avoiding unneces-
sary surgery was also stressed by Schuler
et al (59), who evaluated the added ex-
pense of performing routine abdominal
CT in patients suspected to have appendi-
citis and compared it with the expense of
false-negative appendectomy. These in-
vestigators analyzed 1997 Medicare reim-
bursement rates for these procedures and
found that if a hospital’s false-negative
appendectomy rate is 13%–15% or higher,
it would be cost-effective to perform ab-
dominal CT in every patient suspected to
have appendicitis to achieve a 7% false-
negative appendectomy rate. The authors
noted that their study results were based
on the use of Medicare payment data and
that their conclusions may be limited be-
cause these figures did not accurately repre-
sent the true cost of the services provided.
LAPAROSCOPIC
APPENDECTOMY
The surgical removal of the appendix
prior to perforation is the goal of treat-
Appendicitis at the Millennium • 345
ment in patients with acute appendicitis.
Although appendectomy procedures are
performed conventionally by using an open
laparotomy technique, laparoscopic appen-
dectomy has become an increasingly
popular technique in recent years. First
performed by Semm, a German gynecolo-
gist, in 1980 (101,102), laparoscopic ap-
pendectomy was met originally with dis-
belief in the surgical community, and it
was not until 1988 that the first laparo-
scopic cholecystectomy was performed in
the United States.
Although the current response to lapa-
roscopic appendectomy has not been uni-
formly favorable (103–105), comparative
studies (106) and meta-analyses of ran-
domized controlled trials (107,108) sug-
gest that laparoscopic appendectomy has
several distinct advantages over the open
technique, which include reduced length
of hospital stay, faster return to normal
activity, fewer wound infections, earlier
return to consumption of solid foods, and
some decreased demand for narcotic anal-
gesia (109). The cosmetic benefit, with
decreased scar production, is a strong
motivation on the part of the patient in
choosing between open and laparoscopic
procedures (Poulin EC, oral communica-
tion, 1999). Increased duration of operat-
ing time and use of disposable products
are associated with an increased overall
cost for the laparoscopic technique as
compared with that for open appendec-
tomy (104). Nonetheless, this procedure
has enthusiastic advocates and is now
widely performed in spite of some con-
tinuing skepticism (Poulin EC, oral com-
munication, 1999). The laparoscopic ap-
proach may not be optimal in patients
with complications of appendicitis; in some
centers, preoperative imaging is now be-
ing used to triage patients appropriately
for laparoscopic versus open surgery.
SUMMARY
Helical CT and graded compression color
Doppler US are powerful imaging tools
that substantially improve diagnostic ac-
curacy in patients with clinically equivo-
cal appendicitis. Both imaging modalities
have changed the approach to the diagno-
sis of acute appendicitis, although their
exact roles as diagnostic aids are still
being defined. Opinion now varies as to
whether these tests should be performed
in all patients suspected to have acute
appendicitis or if they should be reserved
for select patients with atypical or confus-
ing clinical presentations.
Results of retrospective studies have
346 • Radiology • May 2000
shown that diagnostic imaging may im-
prove patient care by lowering the false-
negative appendectomy rate (55,59,95,
100). There is a critical need to perform
well-designed prospective studies to con-
firm this observation and to address other
measures of clinical outcome and cost-
effectiveness.
CT, US, and serial patient observations
should be compared in a cost-benefit
analysis to determine the value of appen-
diceal imaging in patients who are at
intermediate risk for appendicitis and who
typically are admitted for serial observa-
tion. Preadmission imaging in these pa-
tients may lead to earlier diagnosis, lower
in-hospital perforation rates, and reduced
hospital stays.
There is also a need to prospectively
compare the accuracy of diagnostic imag-
ing with that of surgical decision making
in patients who have a high risk of appen-
dicitis. These results are needed to define
the potential role of appendiceal imaging
in patients who normally undergo imme-
diate surgical exploration. Because appen-
dectomy costs up to 25 times as much as
imaging, it may be cost-effective to per-
form imaging in most, if not all, patients.
Finally, future investigations are also
needed to compare the diagnostic accu-
racy and cost-effectiveness of helical CT
with those of graded compression US in
both pediatric and adult patients. There is
no question that diagnostic imaging has
changed the ‘‘rules of the game’’; now is
the time to define these rules.
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