Pe d i a t r i c I m a g i n g • B e s t P r a c t i c e s / R ev i ew

Swenson et al.
Practical Imaging Strategies for Acute Appendicitis in Children

Pediatric Imaging
Best Practices/Review
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved

Practical Imaging Strategies for

Acute Appendicitis in Children
David W. Swenson1 OBJECTIVE. Diagnosing pediatric appendicitis is difficult because clinical findings are
Rama S. Ayyala1 nonspecific. Improved accuracy can be obtained with ultrasound (US), CT, or MRI, despite
Cassandra Sams1 considerable variation in their use at different institutions. This article reviews the evidence
Edward Y. Lee2 for best practices in imaging pediatric appendicitis.
CONCLUSION. When each modality is optimally used, a stepwise imaging approach
Swenson DW, Ayyala RS, Sams C, Lee EY that begins with graded compression US and proceeds to CT or MRI in select cases is cur-
rently best practice.

Keywords: appendicitis, CT, MRI, pediatric, ultrasound
doi.org/10.2214/AJR.18.19778
Received March 1, 2018; accepted after revision
April 11, 2018.
1
Department of Diagnostic Imaging, Warren Alpert
Medical School of Brown University, Rhode Island
Hospital/Hasbro Children’s Hospital, 593 Eddy St,
Providence, RI 02903. Address correspondence to
D. W. Swenson (swenson.david.w@gmail.com).
2
Department of Radiology, Boston Children’s Hospital
and Harvard Medical School, Boston, MA.
AJR 2018; 211:1–9
0361–803X/18/2114–1
© American Roentgen Ray Society
Clinical Vignettes and Questions
A 4-year-old girl with suspected appendicitis
was evaluated at a nearby community hospital.
An attempted ultrasound (US) of her appendix
was nondiagnostic, so CT was performed and
showed a normal appendix (Fig. 1A). The pa-
tient was discharged but presented several days
later to the regional children’s hospital, where
a pediatric radiologist identified the normal ap-
pendix with US (Fig. 1B). The patient was ob-
served overnight, and her symptoms ultimate-
ly resolved. Later that week, a 14-year-old boy
with fever and right flank pain presented direct-
ly to the same children’s hospital. Abdominal
US was performed by another pediatric radiolo-
gist who visualized the appendix and suspected
appendicitis (Fig. 2A). Given several confusing
clinical factors, the surgeon requested con-
firmatory imaging with unenhanced MRI, in
keeping with the locally accepted practice [1].
That examination was definitive for acute ap-
pendicitis (Fig. 2B–2D). The patient underwent
appendectomy without complication.
These scenarios exemplify differing but
similarly effective approaches to diagnostic
imaging of suspected pediatric appendicitis.
Relevant questions include: What is the stan-
dard of care for imaging appendicitis in chil-
dren, how can available imaging modalities be
optimized, and does the available literature es-
tablish a best practice for diagnosing appendi-
citis in children [1–3]?
Background and Importance
Appendicitis is the most common indica-
tion for urgent abdominal surgery in chil-
dren, and the duration of symptoms before
diagnosis and treatment correlates with like-
lihood of appendiceal perforation and re-
lated complications [2–7]. Clinical diagno-
sis remains challenging because symptoms,
physical examination findings, and labora-
tory studies are inconsistent and nonspecific
[8–10]. A recent meta-analysis encompassing
8605 pediatric patients from 21 studies con-
cluded that “once acute appendicitis is sus-
pected, no single history, physical examina-
tion, laboratory finding, or score attained on
[the pediatric appendicitis score] can elimi-
nate the need for imaging studies” [11].
In the most recent version of the American
College of Radiology (ACR) Appropriateness
Criteria for right lower quadrant pain—sus-
pected appendicitis, US, CT, and MRI are rat-
ed as the best modalities for establishing the di-
agnosis, with variations in suggested protocol
depending on clinical and institutional factors
[12]. Each modality has advantages and disad-
vantages (Tables 1–3). In the first clinical vi-
gnette presented, the stepwise US-CT workup
of the 4-year-old girl at the community hospital
is an example of a nonpediatric hospital adher-
ing to the ACR’s guidelines for US-first imag-
ing in young children, whereas the second ex-
ample of the 14-year-old boy being evaluated
with a combined US-MRI pathway represents
a less common but acceptable option for imag-
ing an adolescent with suspected appendicitis.
The clinical value of radiology for diag-
nosing pediatric appendicitis was exempli-
fied by the findings of Garcia Peña et al. [13]
in 2002, who reported decreases in appendi-

AJR:211, October 2018 1

 Swenson et al.
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved

A B
Fig. 1—4-year-old girl with normal gas-filled appendix.
A, Abdominopelvic CT shows appendix (arrow) centered over lumbar spine and surrounded by multiple distended bowel loops. Imaging protocol included both IV and oral
contrast material, but generally oral contrast material is not necessary for assessing appendix in children.
B, Graded compression ultrasound (subsequently performed at children’s hospital) shows appendix (arrow) is located directly between anterior peritoneal reflection and
underlying psoas muscle (S) and adjacent cecum (C). This image illustrates primary purpose of graded compression, which is to displace other bowel and find window for
visualization of appendix.

ceal perforation rates from 35.4% to 15.5%
and negative appendectomy rates from 14.7%
to 4.1% after adoption of a stepwise US-CT
appendix imaging protocol. A more recent
review of 55,227 children treated for ap-
pendicitis at 40 pediatric emergency depart-
ments reported an overall negative appen-
dectomy rate of 3.6%, noting an association
of lower negative appendectomy rates with
institutions utilizing more US and CT [14].
During the last decade, concerns over the
risks of ionizing radiation in children have
led national organizations and medical soci-
eties to encourage decreasing pediatric CT
doses and limiting CT use when possible,

A B

Fig. 2—14-year-old boy with appendix seen in right

lateral abdomen.
A, Graded compression ultrasound shows appendix
is seen folded on itself. Anterior segment (arrow)
is partially compressed, with flattened oval shape
and normal diameter of 5 mm, but posterior segment
(arrowhead) is rounded with diameter of 7 mm. Trace
periappendiceal hypoechoic fluid is seen, which
is nonspecific and may relate to edema or trace
dependent fluid in paracolic gutter.
B–D, Unenhanced coronal T2-weighted HASTE (B),
axial T2-weighted HASTE (C), and axial STIR (D)
images show circumferentially thick-walled (more
than 2 mm thick) appendix (arrows) that measured
up to 9 mm in diameter with prominent surrounding
edema signal within adjacent fat.
C D

2 AJR:211, October 2018

 Practical Imaging Strategies for Acute Appendicitis in Children
leading to increased focus on optimizing US
utilization. The multispecialty Image Gently
alliance is an example of this effort. A recent
study of imaging trends in 45 pediatric hos-
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved
pitals throughout the United States indicates
these efforts are having an impact. In 2005,
59.1% of children with appendicitis under-
went CT, but only 25% underwent US [15]. In
2014, 32.7% underwent CT and 61%, US [15].
Some large academic and standalone pediat-
ric hospitals have transitioned to using MRI
as a replacement for CT in the imaging work-
up of suspected appendicitis, thereby avoid-
ing radiation risks altogether. Nevertheless,
MRI for pediatric appendicitis remains un-
common, with a mere 0.03% of pediatric pa-
tients with appendicitis undergoing MRI in
2005, increasing to just 1.0% in 2014 [15].
Although evolving practice patterns at pe-
diatric hospitals are clearly relevant to the
discussion of best practices for diagnosing
pediatric appendicitis, most children with
appendicitis are not diagnosed or treated at
a dedicated pediatric hospital. In a large ret-
rospective cohort study that drew on 2012
data from 4100 hospitals in 44 states in the
United States, over 80% of pediatric appen-
dectomies were performed at nonpediatric
hospitals [16]. In a regional study of practice
patterns in Washington from 2008 to 2012,
over 50% of children who underwent appen-
dectomy had CT as their first imaging study
[17]. Of those patients, nearly 69% were ini-
tially evaluated at a nonpediatric hospital;
only 7% were evaluated at a dedicated chil-
dren’s hospital [17]. Conversely, over 50% of
children who underwent US as their first im-
aging study were initially evaluated at a chil-
dren’s hospital [17].
Acknowledging the extensive reliance
on radiologic imaging to diagnose pediat-
ric appendicitis despite variable imaging ap-
proaches at different hospitals, our purpose
in this article is to investigate evolving best
practices in technique optimization and di-
agnostic performance of US, CT, and MRI
for this indication.
Synopsis and Synthesis of Evidence
We performed a systematic literature re-
view, initially identifying 1295 eligible ar-
ticles through a PubMed search with the
following parameters: published between
1/1/2008 and 12/31/2017; English-language;
and keywords including (pediatric OR chil-
dren) AND (appendix OR right-lower-quad-
rant) AND (ultrasound, OR sonography, OR
sonographic, OR US, OR computed tomogra-
AJR:211, October 2018 3
phy, OR CT, OR magnetic resonance imaging, referenced for background and to provide con-
OR MRI). Every abstract was reviewed by a text for variability in practices. Our search re-
single author to identify original research that sulted in 43 articles, each of which was then
addressed imaging of appendicitis in pediatric reviewed in depth (Table 4), as were relevant
patients by radiologists (age thresholds varied included references.
among different studies, but the maximum
age reported was 22 years [18]) and report- Overview of Imaging Methods for Diagnosing
ed statistics on the diagnostic performance of Acute Appendicitis
US, CT, or MRI in at least 50 patients. Ar- Ultrasound—In most pediatric patients,
ticles concentrating on physical examination appendix US is best performed with a high-
findings, laboratory studies, clinical scoring frequency linear-array transducer (ranging
systems, or some combination thereof as well from 9 to 18 MHz), although curved-array
as case reports, economic analyses, and arti- and lower-frequency transducers may also
cles focusing on outcomes of various medical be useful, particularly in older and larger pa-
and surgical approaches to treatment were not tients [19–21]. With the patient supine, grad-
included for formal review of imaging opti- ed compression should be applied over the
mization and performance, although some are right lower quadrant via the transducer to dis-
TABLE 1:  Major Advantages and Disadvantages of Ultrasound for the
Evaluation of Pediatric Appendicitis
Advantages Disadvantages
Requires no ionizing radiation Accuracy depends on sonographer and radiologist experience
Requires no sedation Diagnostic yield decreases with larger habitus
Imaging findings correlate directly with Less frequent use is associated with increased rate of
physical examination nondiagnostic examinations, which add to overall cost of
imaging workup
Can be highly accurate in experienced Availability varies by institution and time of day
hands
Costs the least of any imaging modality Time-intensive
on a per-examination basis
TABLE 2:  Major Advantages and Disadvantages of CT for the Evaluation of
Pediatric Appendicitis
Advantages Disadvantages
Requires no sedation Exposes patients to risks of ionizing radiation
Short examination time Requires IV contrast material
Highly accurate with decades of widespread use More expensive than ultrasound
Available at all hours in most hospitals
Relative lack of user dependence for obtaining
high-quality imaging
Rarely nondiagnostic
TABLE 3:  Major Advantages and Disadvantages of MRI for the Evaluation of
Pediatric Appendicitis
Advantages Disadvantages
Requires no ionizing radiation Available only at certain institutions
Can be performed without sedation Imaging protocols can be lengthy, resulting in patient discomfort
in most cases
Recently reported diagnostic Some protocols may include sedation and IV contrast material
accuracy comparable to CT
More expensive than CT if performed through abdomen and pelvis
with IV contrast material, though comparable in cost if performed
with limited FOV without contrast material
 Swenson et al.

TABLE 4:  Relevant Articles Evaluating Diagnostic Performance of Ultrasound, CT, and MRI for the Detection of
Acute Appendicitis in the Pediatric Population
Mean Age (y) No. of Sensitivity Specificity PPV NPV
Technique, First Author and Reference Year (Range) Patients (95% CI) (95% CI) (95% CI) (95% CI)
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved

US
Abo [24] 2011 11.8 (2–20) 147 38 (26–52) 97 (90–99)
Athans [64] 2016 11.7 (1–18) 782 88 98 93 96
Binkovitz [78] 2015 11.0 (1–17) 790 95 96 87 99
Blitman [79] 2015 13.0 (1–21) 522 68 98
Chicaiza [28] 2017 10.9 (NR) 320 91 74
Cundy [19] 2016 11.5 (NR) 3799 97 (96–98) 95 (94–96) 88 (86–90) 99 (98–99)
Dibble [1] 2018 11.2 (1–18) 1905 99 (97–99) 97 (96–98) 90 (87–92) 100 (99–100)
Goldin [80] 2011 10.4 (NR) 304 99 95
Kearl [47] 2016 14.5 (NR) 583 82 (74–87) 88 (85–92)
Larson [66] 2015 11.4 (< 21) 1357 71 99 93 94
Nielsen [81] 2015 NR 2033 92 98 30 98
Orth [52] 2014 12.4 (4–17) 81 87 (29–96) 100 (93–100) 100 (87–100) 93 (82–98)
Partain [82] (pretemplate) 2017 NR (5–18) 387 78 (70–85) 88 (83–92) 78 (70–85) 88 (83–92)
Partain [82] (posttemplate) 2017 NR (5–18) 483 84 (67–90) 89 (85–92) 73 (65–80) 94 (91–96)
Schuh [83] 2015 10.4 (4–17) 294 97 (94–100) 91 (87–95) 86 (79–92) 98 (96–100)
Srinivasan [71] 2015 11.3 (1–20) 218 43 (29–58) 92 (86–95)
Thieme [50] 2014 12.0 (4–18) 104 76 (63–86) 89 (76–96) 90 (77–96) 75 (61–85)
Trout [30] 2012 11.1 (< 18) 1009 67 96 76 94
van Atta [68] 2015 NR 512 87 94 88 94
Fallon [65] (before standard reporting) 2015 9.7 (NR) 1235 96 (93–98) 94 (92–95) 83 (79–87) 99 (98–99)
Fallon [65] (after standard reporting) 2015 9.7 (NR) 686 93 (86–96) 93 (90–95) 85 (80–89) 97 (95–98)
Mangona [67] (day shift) 2017 NR (< 19) 2161 94 (92–96) 94 (93–95) 84 (81–86) 98 (97–100)
Mangona [67] (night shift) 2017 NR (< 19) 774 91 (88–96) 91 (89–93) 75 (70–81) 98 (96–99)
Mittal [62] (multicenter) 2013 11.0 (3–18) 965 73 (89–86) 97 (96–98) 93 (87–98) 88 (84–91)
Contrast-enhanced CT
No prior US
Aspelund [53] 2014 12.0 (2–18) 265 100 (97–100) 98 (93–99) 98 (93–99) 100 (96–100)
After US
Abo [24] 2011 11.8 (2–20) 128 96 (86–99) 97 (90–100)
Dillman [46] 2016 12.0 (4–17) 58 100 (72–100) 98 (89–100) 92 (62–100) 100 (92–100)
Chien [70] 2016 13.3 (0–18) 418 96 99 95 99
Srinivasan [71] 2015 11.3 (1–20) 218 86 (72–93) 94 (89–97)
Callahan [34] (before dose reduction) 2015 11.1 (NR) 244 98 (91–100) 93 (91–98)
Callahan [34] (after dose reduction) 2015 12.1 (NR) 250 97 (91–100) 94 (90–97)
Didier [35] (baseline dose) 2015 9.3 (1–18) 192 96 97 91 99
Didier [35] (after dose reduction) 2015 9.5 (1–18) 194 100 99 98 100
Combined US-CT pathway
Krishnamoorthi [63] 2011 10.4 (< 18) 298 99 91 85 99
Ramarajan [18] 2009 NR (1–22) 407 99 91 99 85
Thirumoorthi [72] 2012 10.9 (< 18) 802 94 98 95 97
van Atta [68] 2015 NR 187 96 97 94 98
(Table 4 continues on next page)

4 AJR:211, October 2018

 Practical Imaging Strategies for Acute Appendicitis in Children

TABLE 4:  Relevant Articles Evaluating Diagnostic Performance of Ultrasound, CT, and MRI for the Detection of
Acute Appendicitis in the Pediatric Population (continued)
Mean Age (y) No. of Sensitivity Specificity PPV NPV
Technique, First Author and Reference Year (Range) Patients (95% CI) (95% CI) (95% CI) (95% CI)
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved

MRI
Unenhanced
No prior US
Moore [49] 2012 11.2 (3–17) 208 98 (87–100) 97 (93–99) 89 (76–96) 99 (97–100)
Koning [54] 2014 11.3 (4–20) 364 96 (91–98) 96 (92–98) 93 (87–96) 98 (95–99)
Kulaylat [48] 2015 11.3 (5–17) 510 97 (91–99) 97 (95–99) 92 (87–96) 99 (97–100)
After US
Lyons [55] 2017 12.7 (NR) 89 87 79 63 73
Didier [51] 2017 11.0 (4–18) 98 94 (78–90) 95 (86–99) 91 (75–98) 97 (88–100)
Dillman [46] 2016 11.5 (3–18) 103 94 (73–100) 100 (96–100) 100 (81–100) 99 (94–100)
Herliczek [76] 2013 13.4 (7–17) 60 96 (55–100) 95 (85–98) 81 (51–94) 99 (86–100)
Kearl [47] 2016 14.8 (NR) 205 96 (86–100) 83 (75–88)
Orth [52] 2014 12.4 (4–17) 81 93 (78–99) 98 (90–100) 97 (82–100) 96 (87–100)
Thieme [50] 2014 12.0 (4–18) 104 100 (92–100) 89 (76–96) 92 (82–97) 100 (89–100)
Combined US-MRI pathway
Dibble [1] 2018 11.2 (1–18) 77 88 (61–97) 98 (90–100) 93 (64–99) 97 (88–99)
Contrast-enhanced
After US
Lyons [55] 2017 12.7 (NR) 89 100 92 82 100
Rosines [56] 2014 12.9 (7–19) 49 94 100 100 97
Combined US-MRI pathway
Aspelund [53] 2014 12.3 (1–18) 397 100 (97–100) 99 (97–100) 99 (95–100) 100 (98–100)
Note—NPV = negative predictive value, PPV = positive predictive value, US = ultrasound, NR = not reported.

place overlying bowel loops, their intralumi-
nal contents (particularly gas), or both, there-
by providing a sonographic window through
which to visualize the appendix. The iliac
vessels are an important anatomic landmark
because the appendix either appears draped
over them or is nearby in the majority of pa-
tients [20–22]. If the appendix cannot be vis-
ualized with the patient supine, other useful
techniques include scanning with the patient
in a left lateral decubitus position and apply-
ing posterior manual compression with one
hand while gradually increasing pressure on
the transducer with the other hand [21].
Regarding older patients, there is no evi-
dence-based age limit beyond which US can-
not be used as a primary imaging modality.
The pediatric literature routinely includes pa-
tients into their early 20s, and a seminal pa-
per describing US for appendicitis in 1988
represented a predominantly adult population
[23]. Several recent papers describing tech-
nique optimization are also heavily weighted
toward adult patients [20, 21]. Further, trends
toward decreased visualization of the appen-
dix in larger patients have been seen, but re-
cent papers suggest there is no weight or body
mass index threshold above which US cannot
be diagnostic for appendicitis [24, 25].
A major theme in the literature over the
last decade has been optimizing interpreta-
tion of discrete US imaging features of ap-
pendicitis. Of note, the commonly refer-
enced greater than 6-mm-diameter criterion
originally suggested by Jeffrey et al. [23] in
1988 has generally shifted to a threshold of 7
mm, with most recent authors agreeing that,
although diameter remains a useful criteri-
on for appendicitis, it should not be used in
isolation [26–28]. Significantly, abnormal
echogenicity or so-called infiltration of peri-
appendiceal fat has been found to be a partic-
ularly useful sign of appendicitis on US [20,
26, 27, 29, 30]. Trout et al. [27] found it to be
the only independent statistically significant
parameter to predict appendicitis, with a pos-
itive odds ratio of greater than 60. A loss of
mural stratification or laminar architecture
is another suggestive finding, and apparent
discontinuity of the wall increases the likeli-
hood of perforated appendicitis.
Several oft-mentioned signs of appendici-
tis have been shown to be rather nonspecific
in recent literature. For example, historically
the presence of an appendicolith or any vol-
ume of free fluid was considered suspicious,
yet appendicoliths and small volumes of sim-
ple free fluid can both be seen in the setting of
a healthy appendix [26, 29, 31]. Appendiceal
noncompressibility is inconsistently associ-
ated with appendicitis and can be affected by
patient habitus, variability in pressure applied,
and location of the appendix. Mural and peri-
appendiceal hyperemia is similarly subject to
pitfalls of technique and subjective determina-
tion of what constitutes increased blood flow.
Clearly, the presence of complex fluid or an ab-
scess remains very suggestive of appendicitis,
even when the appendix is not itself well seen.
CT—A major benefit of CT is its relative
lack of variability in providing high-quality
diagnostic imaging. The ACR recommends

AJR:211, October 2018 5


CT with IV contrast material as a second-line
modality after indeterminate US in patients
younger than 14 years old and ranks it as an
appropriate first-line modality for older pa-
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved
tients [12]. Oral contrast material is general-
ly not necessary and results in delayed imag-
ing, though it may be helpful in some smaller
patients with minimal intraabdominal fat [12,
32]. When patients undergo CT, dose opti-
mization techniques should be used to mini-
mize radiation exposure while maintaining di-
agnostic utility, in keeping with the as low as
reasonably achievable (ALARA) principle. In
2015, researchers reported that helical CT us-
ing a standard reconstruction algorithm could
be performed with 50% dose reduction without
negatively impacting rates of appendix visual-
ization, degrading diagnostic yield of CT, or in-
creasing negative appendectomy rates in clini-
cal practice [33, 34]. Similarly, another group
used iterative reconstruction methods to reduce
CT radiation dose by 45% from their baseline
of a pediatric weight-based filtered back pro-
jection technique, with similar diagnostic ac-
curacy [35]. Optimizing CT dose and decreas-
ing CT utilization through incorporation of a
stepwise US-CT pathway represents a valuable
opportunity for nonpediatric institutions to im-
plement quality improvement in their practices,
because numerous articles over the last decade
have documented increased CT utilization and
higher radiation doses at general hospitals than
at pediatric hospitals [36–42].
As in the US literature, several recent ar-
ticles debunk the commonly referenced
threshold of larger than 6 mm diameter for
suggesting appendicitis on CT, noting that ap-
pendiceal diameters are normally distribut-
ed, with 95% CIs including diameters up to
8.7 mm and up to 39% of normal appendixes
measuring 6 mm or more [43, 44]. This grow-
ing body of evidence highlights the impor-
tance of secondary signs of appendicitis on
CT, including wall thickening, hyperenhance-
ment, periappendiceal inflammation, phleg-
mon, or abscess. As has been reported, in the
absence of such findings, CT can be interpret-
ed as negative for appendicitis with negative
predictive value (NPV) of 98.7%, despite non-
visualization of the appendix [45].
MRI—Over the last decade, MRI has re-
placed CT for imaging pediatric appendicitis
at some institutions, most frequently as part of
a stepwise imaging algorithm after indetermi-
nate US. Published MRI protocols for pedi-
atric appendicitis vary considerably, although
multiplanar T2-weighted fast spin-echo se-
quences with or without fat saturation and in-
6 AJR:211, October 2018
Swenson et al.
version recovery sequences are common to all
protocols. Although several institutions have
reported excellent diagnostic performance
with only these sequences, others routinely
include DWI, and some routinely add fat-sat-
urated T1-weighted imaging before and after
IV administration of gadolinium-based con-
trast agents [1, 46–57]. To our knowledge, no
conclusive evidence has been advanced that
contrast-enhanced imaging improves over-
all diagnostic yield for appendicitis compared
with unenhanced protocols, though the former
may be helpful in some scenarios and likely
aids in characterizing signs of perforation and
abscess [54–58]. Of note, although a common-
ly cited disadvantage of MRI in children is the
need for sedation (with its attendant risks), the
vast majority of institutions reporting their ex-
perience with MRI for pediatric appendicitis
use no sedation despite imaging children as
young as 4 years old.
In parallel with recent US and CT studies re-
fining imaging criteria for appendicitis, sever-
al papers have focused on specifying relevant
MRI findings. Diameters of at least 7 mm and
wall thickness of 2 mm or more are associated
with appendicitis, but these thresholds should
not be considered definitive without associated
findings of inflammation, including mural and
periappendiceal edema signal, or restricted dif-
fusion and increased enhancement within the
wall and adjacent tissues [51, 59]. Appendico-
liths can sometimes be seen as a signal void on
multiple sequences but can be difficult to dis-
tinguish from gas bubbles on MRI. Free fluid is
nonspecific, as on other modalities [51].
Evidence Assessment in Support of Each
Imaging Modality
Ultrasound—In two separate meta-anal-
yses of imaging for pediatric appendicitis,
Doria et al. [60] in 2006 and Zhang et al. [61]
in 2017 reported pooled US sensitivities of
88% and 89% and specificities of 94% and
97%, respectively. Though our review of ar-
ticles from the last 10 years revealed similar
reported diagnostic performance of US (Table
4), we noted substantial variability in how US
results were classified as positive or negative
for statistical analysis (e.g., retrospective grad-
ing of original free text reports vs prospec-
tive standardized reporting, with inconsistent
classifications for indeterminate or equivo-
cal studies), which is more important for the
discussion of establishing and adopting best
practices. This variability has real-world im-
plications both for radiologists who are try-
ing to incorporate US into their imaging al-
gorithm and for clinicians who rely on the US
report to determine treatment.
Two different well-designed studies ex-
emplify this variation. In one single-insti-
tution study, pediatric radiologists directly
performed US examinations and confident-
ly visualized the entire appendix in 91.7%
of 3799 children [19]. They reported a sensi-
tivity of 97% and specificity of 95% for ap-
pendicitis, where “post-hoc processing was
performed to recategorize equivocal exami-
nations as positive, and nonvisualization ex-
aminations as negative” [19]. By contrast, a
multiinstitutional study of eight hospitals per-
forming pediatric appendix US “defined a
positive US as the radiologist read ‘appendici-
tis’ or ‘perforated appendicitis’” based on vi-
sualization of an abnormal appendix with or
without secondary signs and a negative US as
all other reported US results including ‘nor-
mal’, ‘appendix not visualized’, ‘equivocal’,
and ‘other’” [62]. They found sensitivities of
35–86% and specificities of 96–99% [62]. Al-
though pooled statistics from numerous stud-
ies provide valuable insight into the general
performance of US for diagnosing pediatric
appendicitis, the challenge of directly com-
paring these two studies (one defines equivo-
cal studies as positive; the other defines them
as negative) draws attention to what we con-
sider the most significant theme from the lit-
erature over the last decade: optimizing the
clinical applicability of appendix US by clari-
fying what is meant by terms like indetermi-
nate, borderline, equivocal, and suspicious.
This endeavor is particularly relevant given
examples of academic practices that have re-
ported equivocal US results in 47–64% of pe-
diatric patients or nonvisualization of the ap-
pendix in up to 75% of patients [18, 30, 63].
Several groups have recently described
their prospectively implemented systems for
structured reporting of appendix US, each ad-
dressing indeterminate results with variations
for appendixes not or only partially visualized
with or without secondary signs of appendici-
tis versus partially or fully visualized appen-
dixes with borderline, equivocal, or suspicious
(but not diagnostically conclusive) findings of
appendicitis [64–68]. These groups routinely
categorize the nonvisualized or incompletely
visualized appendix without secondary signs
of appendicitis as a negative study. Support-
ing this practice, Cohen et al. [69] reported an
NPV of 98.9% in patients with nonvisualized
appendixes (as long as they did not have leu-
kocytosis), which was equivalent to the 98.7%
NPV for a negative US during which the nor-
 Practical Imaging Strategies for Acute Appendicitis in Children
mal appendix was identified. This approach to
US reporting can aid in decreasing utilization
of secondary imaging in patients without oth-
erwise compelling clinical indications for ad-
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved
ditional workup.
CT—Doria et al. [60] and Zhang et al. [61]
reported pooled sensitivities of 94% and 95%
and specificities of 95% and 92%, respective-
ly, for CT in diagnosing pediatric appendicitis.
Our review of the literature from the last de-
cade shows similar diagnostic performance of
CT (Table 4) but again reveals important vari-
ations in patient selection and reporting that
should be acknowledged. Historically, CT was
often the first and only imaging performed, but
in all but one of the studies reporting CT di-
agnostic performance during the last decade,
nearly all patients were first imaged with US;
only those with nondiagnostic examinations
underwent CT [53]. This shift reflects the broad
acceptance of a staged US-CT pathway at chil-
dren’s hospitals. Of note, in some articles, the
statistics represent the performance of CT
alone (i.e., only reflecting the diagnostic per-
formance of CT in a population of patients who
had prior indeterminate US), whereas in oth-
ers they represent the overall performance of a
stepwise US-CT algorithm (i.e., reflecting the
entire population of patients imaged with US,
including the subset who went on to CT) [18,
24, 34, 35, 46, 63, 68, 70–72]. We discerned no
difference in diagnostic performance between
these groups, reinforcing the point that US can
be incorporated into the diagnostic workup
of pediatric appendicitis without compromis-
ing diagnostic yield or clinical outcomes [73].
Given its historic and continued excellent di-
agnostic performance, its broad availability re-
gardless of geography, hospital type, or time of
day, and progressive success at minimizing ra-
diation exposure while maintaining diagnostic
yield for appendicitis, CT remains the diagnos-
tic imaging reference standard against which
emerging technologies (including MRI) must
be compared [33–35, 60, 61, 74].
MRI—Three recent meta-analyses ad-
dressed performance of MRI for pediatric ap-
pendicitis, including Duke et al. [75] in 2016,
Moore et al. [58] in 2016, and Zhang et al.
[61] in 2017, with reported pooled sensitivities
of 96%, 96.5%, and 98%, and specificities of
96%, 96.1%, and 97%, respectively. The stud-
ies we reviewed (Table 4) showed similar diag-
nostic performance, noting that several of the
most recent studies were not included in prior
meta-analyses [1, 47, 51, 55]. Two institutions
used MRI as a primary or single-stage imaging
modality (i.e., without prior US), one routine-
AJR:211, October 2018 7
ly with IV contrast enhancement and the other
without [48, 49, 54]. All other groups imaged
with US first, followed by variable MRI proto-
cols for indeterminate or equivocal cases. Most
articles from these US-MRI institutions report-
ed only the performance of MRI, but two re-
ported the overall performance of the stepwise
US-MRI pathway [1, 46, 47, 50–53, 55, 56, 76].
The published literature over the last de-
cade implies that performance of nonsedated
MRI (with or without IV contrast enhance-
ment) is comparable to CT with IV contrast
enhancement for diagnosing pediatric ap-
pendicitis [53, 61, 77]. The ALARA principle
suggests that MRI may therefore be an ide-
al replacement for CT. However, thus far, all
published studies of MRI for pediatric appen-
dicitis reflect the experience of large academ-
ic referral centers that generally have greater
access to MRI and more specialized radiolo-
gists to interpret the examinations than may
be available in broader practice. There is no
study to our knowledge that proves similar di-
agnostic efficacy can be achieved in general
community hospitals, whereas CT performed
in such a setting and interpreted by nonpediat-
ric radiologists has been shown to be similarly
accurate to CT at standalone children’s hospi-
tals [17]. Therefore, our review of the evidence
supporting MRI for pediatric appendicitis
suggests that it remains a promising modality
that plays a role in evolving best practice im-
aging algorithms at some specialized centers.
However, its efficacy has not yet been estab-
lished in broader clinical settings, namely the
more than 80% of children noted previously
who are diagnosed and treated for appendici-
tis at nonpediatric hospitals [16].
Evidence-Based Guidelines
Within the limits of available resources, a
stepwise approach of initial US followed by
CT or MRI when necessary is the current best
practice for imaging suspected pediatric ap-
pendicitis. Ideally, radiologists should per-
form or closely supervise the graded compres-
sion US examination [1, 12, 19], recognizing
that there is no evidence-based age thresh-
old above which US is demonstrably less ef-
fective, while acknowledging that diagnostic
yield declines with increasing weight or body
mass index [24, 25]. Structured reporting is
ideal for US of the appendix, and a high-qual-
ity US examination that fails to visualize the
appendix but shows no secondary signs of in-
flammation should be considered negative, a
distinct reporting category from otherwise in-
determinate or equivocal studies [64–69].
If CT is determined to be the next best im-
aging modality at an institution, as is likely to
be the case in many if not most hospitals for the
foreseeable future, ALARA principles oblige
the managing radiologists to optimize proto-
cols so that radiation dose is decreased as much
as possible while maintaining diagnostic accu-
racy [12, 33–35]. If an institution decides to in-
corporate MRI into their pediatric appendicitis
imaging workup, it can be performed without
IV contrast material or sedation in patients as
young as 4 years old, recognizing that in some
scenarios the addition of IV contrast material is
helpful for problem-solving.
Outstanding Issues That Warrant
Research
A major theme in the literature over the
last decade has been the effort to further de-
fine both the normal range of variation in the
appearance of the appendix and the diagnos-
tic value of individual imaging signs of appen-
dicitis on US, CT, and MRI. This area of re-
search remains valuable, because discrepancies
between current studies persist and the era of
individualized medicine will increasingly re-
quire optimized sensitivity and specificity of
diagnosis. Along those lines, a more holistic in-
corporation of all clinical, laboratory, and im-
aging data into a multivariate diagnostic ap-
proach remains an area of active research that
warrants radiologist participation and leader-
ship. Clinical interest in improving patient ex-
perience and outcomes through selectively
treating some pediatric patients with antibiot-
ics rather than surgery is also growing. Imag-
ing findings distinguishing uncomplicated and
complicated appendicitis will likely be relevant
to these decisions.
Multiinstitutional studies comparing im-
aging pathways will be important to establish
generalizability of published results with US-
CT and US-MRI approaches, and economic
analyses will be valuable for guidance of poli-
cy discussions at local and national levels.
Conclusion
Pediatric appendicitis remains the most
common indication for urgent abdominal
surgery in children, and imaging with US,
CT, and MRI plays a crucial role in estab-
lishing an accurate diagnosis. There is broad
variation in imaging techniques and diagnos-
tic performance for each of these modalities,
yet when optimized they can all yield excel-
lent diagnostic results with minimal risk to
the patient. A stepwise imaging approach
that begins with graded compression US and

proceeds to CT or MRI in select cases is cur-
rently the best practice.
References
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved
1. Dibble EH, Swenson DW, Cartagena C, Baird GL,
Herliczek TW. Effectiveness of a staged US and
unenhanced MR imaging algorithm in the diag-
nosis of pediatric appendicitis. Radiology 2018;
286:1022–1029
2. Guthery SL, Hutchings C, Dean JM, Hoff C. Na-
tional estimates of hospital utilization by children
with gastrointestinal disorders: analysis of the
1997 kids’ inpatient database. J Pediatr 2004;
144:589–594
3. Hall MJ, DeFrances CJ, Williams SN, Golosins-
kiy A, Schwartzman A. National Hospital Dis-
charge Survey: 2007 summary. Natl Health Stat
Rep 2010; 29:1–20, 24
4. Bickell NA, Aufses AH, Rojas M, Bodian C. How
time affects the risk of rupture in appendicitis.
J Am Coll Surg 2006; 202:401–406
5. Bonadio W, Brazg J, Telt N, et al. Impact of in-
hospital timing to appendectomy on perforation
rates in children with appendicitis. J Emerg Med
2015; 49:597–604
6. Papandria D, Goldstein SD, Rhee D, et al. Risk of
perforation increases with delay in recognition
and surgery for acute appendicitis. J Surg Res
2013; 184:723–729
7. Stevenson MD, Dayan PS, Dudley NC, et al. Time
from emergency department evaluation to opera-
tion and appendiceal perforation. Pediatrics 2017;
139:e20160742
8. Bundy DG, Byerley JS, Liles EA, Perrin EM,
Katznelson J, Rice HE. Does this child have ap-
pendicitis? JAMA 2007; 298:438–451
9. Kharbanda AB, Stevenson MD, Macias CG, et al.
Interrater reliability of clinical findings in chil-
dren with possible appendicitis. Pediatrics 2012;
129:695–700
10. Kharbanda AB. Appendicitis: do clinical scores
matter? Ann Emerg Med 2014; 64:373–375
11. Benabbas R, Hanna M, Shah J, Sinert R. Diagnos-
tic accuracy of history, physical examination,
laboratory tests, and point-of-care ultrasound for
pediatric acute appendicitis in the emergency de-
partment: a systematic review and meta-analysis.
Acad Emerg Med 2017; 24:523–551
12. Smith MP, Katz DS, Lalani T, et al. ACR appro-
priateness criteria right lower quadrant pain—sus-
pected appendicitis. Ultrasound Q 2015; 31:85–91
13. Garcia Peña BM, Taylor GA, Fishman SJ, Mandl
KD. Effect of an imaging protocol on clinical out-
comes among pediatric patients with appendicitis.
Pediatrics 2002; 110:1088–1093
14. Bachur RG, Hennelly K, Callahan MJ, Monuteaux
MC. Advanced radiologic imaging for pediatric
appendicitis, 2005–2009: trends and outcomes.
8 AJR:211, October 2018
Swenson et al.
J Pediatr 2012; 160:1034–1038
15. Otero HJ, Crowder L. Imaging utilization for the
diagnosis of appendicitis in stand-alone children’s
hospitals in the United States: trends and costs.
J Am Coll Radiol 2017; 14:603–608
16. Tian Y, Heiss KF, Wulkan ML, Raval MV. Assess-
ment of variation in care and outcomes for pediat-
ric appendicitis at children’s and non-children’s
hospitals. J Pediatr Surg 2015; 50:1885–1892
17. Kotagal M, Richards MK, Flum DR, Acierno SP,
Weinsheimer RL, Goldin AB. Use and accuracy
of diagnostic imaging in the evaluation of pediat-
ric appendicitis. J Pediatr Surg 2015; 50:642–646
18. Ramarajan N, Krishnamoorthi R, Barth R, et al.
An interdisciplinary initiative to reduce radiation
exposure: evaluation of appendicitis in a pediatric
emergency department with clinical assessment
supported by a staged ultrasound and computed
tomography pathway. Acad Emerg Med 2009;
16:1258–1265
19. Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke
RJ, Goh DW. Benchmarking the value of ultra-
sound for acute appendicitis in children. J Pediatr
Surg 2016; 51:1939–1943
20. Lee MW, Kim YJ, Jeon HJ, Park SW, Jung SI, Yi
JG. Sonography of acute right lower quadrant
pain: Importance of increased intraabdominal fat
echo. AJR 2009; 192:174–179
21. Lee JH, Jeong YK, Park KB, Park JK, Jeong AK,
Hwang JC. Operator-dependent techniques for
graded compression sonography to detect the ap-
pendix and diagnose acute appendicitis. AJR
2005; 184:91–97
22. Gongidi P, Bellah RD. Ultrasound of the pediatric
appendix. Pediatr Radiol 2017; 47:1091–1100
23. Jeffrey RB, Laing FC, Townsend RR. Acute ap-
pendicitis: sonographic criteria based on 250 cas-
es. Radiology 1988; 167:327–329
24. Abo A, Shannon M, Taylor G, Bachur R. The in-
fluence of body mass index on the accuracy of ul-
trasound and computed tomography in diagnosing
appendicitis in children. Pediatr Emerg Care
2011; 27:731–736
25.
Butler M, Servaes S, Srinivasan A, Edgar
JC, Del Pozo G, Darge K. US depiction of the ap-
pendix: role of abdominal wall thickness and ap-
pendiceal location. Emerg Radiol 2011; 18:525–531
26. Goldin AB, Khanna P, Thapa M, McBroom JA,
Garrison MM, Parisi MT. Revised ultrasound cri-
teria for appendicitis in children improve diagnos-
tic accuracy. Pediatr Radiol 2011; 41:993–999
27.
Trout AT, Sanchez R, Ladino-Torres MF.
Reevaluating the sonographic criteria for acute ap-
pendicitis in children: a review of the literature
and a retrospective analysis of 246 cases. Acad
Radiol 2012; 19:1382–1394
28. Chicaiza HP, Malia L, Mulvey CH, Smith SR. Re-
visiting the appendiceal diameter via ultrasound
for the diagnosis of acute appendicitis. Pediatr
Emerg Care 2017 Oct 2 [Epub ahead of print]
29. Estey A, Poonai N, Lim R. Appendix not
seen: the predictive value of secondary inflamma-
tory sonographic signs. Pediatr Emerg Care 2013;
29:435–439
30. Trout AT, Sanchez R, Ladino-Torres MF,
Pai DR, Strouse PJ. A critical evaluation of US for
the diagnosis of pediatric acute appendicitis in a real-
life setting: how can we improve the diagnostic value
of sonography? Pediatr Radiol 2012; 42:813–823
31. Gongidi P, Bellah RD. Ultrasound of the pediatric
appendix. Pediatr Radiol 2017; 47:1091–1100
32. Garcia M, Taylor G, Babcock L, et al. Computed
tomography with intravenous contrast alone: the
role of intra-abdominal fat on the ability to visual-
ize the normal appendix in children. Acad Emerg
Med 2013; 20:795–800
33. Callahan MJ, Kleinman PL, Strauss KJ, et al. Pe-
diatric CT dose reduction for suspected appendi-
citis: a practice quality improvement project using
artificial Gaussian noise. Part 1. Computer simu-
lations. AJR 2015; 204:[web]W86–W94
34. Callahan MJ, Anandalwar SP, MacDougall RD, et
al. Pediatric CT dose reduction for suspected ap-
pendicitis: a practice quality improvement project
using artificial gaussian noise. Part 2. Clinical
outcomes. AJR 2015; 204:636–644
35. Didier RA, Vajtai PL, Hopkins KL. Iterative re-
construction technique with reduced volume CT
dose index: diagnostic accuracy in pediatric acute
appendicitis. Pediatr Radiol 2015; 45:181–187
36. Neff LP, Ladd MR, Becher RD, Jordanhazy RA,
Gallaher JR, Pranikoff T. Computerized tomogra-
phy utilization in children with appendicitis: dif-
ferences in referring and children’s hospitals. Am
Surg 2011; 77:1061–1065
37. Anderson KT, Putnam LR, Caldwell KMB, et al.
Imaging gently? Higher rates of computed tomog-
raphy imaging for pediatric appendicitis in non–
children’s hospitals. Surgery 2017; 161:1326–1333
38. Anderson KT, Greenfield S, Putnam LR,
et al. Don’t forget the dose: improving computed
tomography dosing for pediatric appendicitis.
J Pediatr Surg 2016; 51:1944–1948
39. Glass CC, Saito JM, Sidhwa F, et al. Diag-
nostic imaging practices for children with sus-
pected appendicitis evaluated at definitive care
hospitals and their associated referral centers.
J Pediatr Surg 2016; 51:912–916
40. Badru F, Piening N, To A, et al. Imaging for acute
appendicitis at nonpediatric centers exposes chil-
dren to excess radiation. J Surg Res 2017;
216:201–206
41. Menoch M, Simon HK, Hirsh D, et al. Imaging for
suspected appendicitis: variation between aca-
demic and private practice models. Pediatr Emerg
Care 2017; 33:147–151
 Practical Imaging Strategies for Acute Appendicitis in Children
42. Snow A, Milliren CE, Graham DA, et al. Quality
of pediatric abdominal CT scans performed at a
dedicated children’s hospital and its referring in-
stitutions: a multifactorial evaluation. Pediatr Ra-
Downloaded from www.ajronline.org by Kaohsiung Medical University on 08/18/18 from IP address 163.15.154.53. Copyright ARRS. For personal use only; all rights reserved
diol 2017; 47:391–397
43. Orscheln ES, Trout AT. Appendiceal diameter:
CT versus sonographic measurements. Pediatr
Radiol 2016; 46:316–321
44. Trout AT, Towbin AJ, Zhang B. The pediatric ap-
pendix: defining normal. AJR 2014; 202:936–945
45. Garcia K, Hernanz-Schulman M, Bennett DL,
Morrow SE, Yu C, Kan JH. Suspected appendici-
tis in children: diagnostic importance of normal
abdominopelvic CT findings with nonvisualized
appendix. Radiology 2009; 250:531–537
46. Dillman JR, Gadepalli S, Sroufe NS, et al. Equivo-
cal pediatric appendicitis: unenhanced MR imag-
ing protocol for nonsedated children—a clinical
effectiveness study. Radiology 2016; 279:216–225
47. Kearl YL, Claudius I, Behar S, et al. Accuracy of
magnetic resonance imaging and ultrasound for
appendicitis in diagnostic and nondiagnostic stud-
ies. Acad Emerg Med 2016; 23:179–185
48. Kulaylat AN, Moore MM, Engbrecht BW,
et al. An implemented MRI program to eliminate
radiation from the evaluation of pediatric appen-
dicitis. J Pediatr Surg 2015; 50:1359–1363
49. Moore MM, Gustas CN, Choudhary AK, et al.
MRI for clinically suspected pediatric appendici-
tis: an implemented program. Pediatr Radiol
2012; 42:1056–1063
50. Thieme ME, Leeuwenburgh MMN, Valdehueza
ZD, et al. Diagnostic accuracy and patient accep-
tance of MRI in children with suspected appendi-
citis. Eur Radiol 2014; 24:630–637
51. Didier RA, Hopkins KL, Coakley FV, Krishnaswami
S, Spiro DM, Foster BR. Performance characteris-
tics of magnetic resonance imaging without con-
trast agents or sedation in pediatric appendicitis.
Pediatr Radiol 2017; 47:1312–1320
52. Orth RC, Guillerman RP, Zhang W, Masand P,
Bisset GS 3rd. Prospective comparison of MR im-
aging and US for the diagnosis of pediatric appen-
dicitis. Radiology 2014; 272:233–240
53. Aspelund G, Fingeret A, Gross E, et al. Ultraso-
nography/MRI versus CT for diagnosing appendi-
citis. Pediatrics 2014; 133:586–593
54. Koning JL, Naheedy JH, Kruk PG. Diagnostic
performance of contrast-enhanced MR for acute
appendicitis and alternative causes of abdominal
pain in children. Pediatr Radiol 2014; 44:948–955
55. Lyons GR, Renjen P, Askin G, Giambrone AE,
Beneck D, Kovanlikaya A. Diagnostic utility of
intravenous contrast for MR imaging in pediatric
appendicitis. Pediatr Radiol 2017; 47:398–403
56. Rosines LA, Chow DS, Lampl BS, et al. Value of
gadolinium-enhanced MRI in detection of acute
appendicitis in children and adolescents. AJR
AJR:211, October 2018 9
2014; 203:[web]W543–W548
57. Rosenbaum DG, Askin G, Beneck DM, Kovan-
likaya A. Differentiating perforated from non-
perforated appendicitis on contrast-enhanced
magnetic resonance imaging. Pediatr Radiol
2017; 47:1483–1490
58. Moore MM, Kulaylat AN, Hollenbeak CS, Eng-
brecht BW, Dillman JR, Methratta ST. Magnetic
resonance imaging in pediatric appendicitis: a sys-
tematic review. Pediatr Radiol 2016; 46:928–939
59. Swenson DW, Schooler GR, Stamoulis C, Lee EY.
MRI of the normal appendix in children: data to-
ward a new reference standard. Pediatr Radiol
2016; 46:1003–1010
60. Doria AS, Moineddin R, Kellenberger CJ, et al. US
or CT for diagnosis of appendicitis in children and
adults? A meta-analysis. Radiology 2006; 241:83–94
61. Zhang H, Liao M, Chen J, Zhu D, Byanju S. Ultra-
sound, computed tomography or magnetic reso-
nance imaging: which is preferred for acute ap-
pendicitis in children? A meta-analysis. Pediatr
Radiol 2017; 47:186–196
62. Mittal MK, Dayan PS, Macias CG, et al. Perfor-
mance of ultrasound in the diagnosis of appendi-
citis in children in a multicenter cohort. Acad
Emerg Med 2013; 20:697–702
63. Krishnamoorthi R, Ramarajan N, Wang NE, et al.
Effectiveness of a staged US and CT protocol for
the diagnosis of pediatric appendicitis: reducing
radiation exposure in the age of ALARA. Radiol-
ogy 2011; 259:231–239
64. Athans BS, Depinet HE, Towbin AJ, Zhang Y,
Zhang B, Trout AT. Use of clinical data to predict
appendicitis in patients with equivocal US find-
ings. Radiology 2016; 280:557–567
65. Fallon SC, Orth RC, Guillerman RP, et al. Devel-
opment and validation of an ultrasound scoring
system for children with suspected acute appendi-
citis. Pediatr Radiol 2015; 45:1945–1952
66. Larson DB, Trout AT, Fierke SR, Towbin AJ. Im-
provement in diagnostic accuracy of ultrasound of
the pediatric appendix through the use of equivocal
interpretive categories. AJR 2015; 204:849–556
67. Mangona KLM, Guillerman RP, Mangona VS, et
al. Diagnostic performance of ultrasonography for
pediatric appendicitis: a night and day difference?
Acad Radiol 2017; 24:1616–1620
68. van Atta AJ, Baskin HJ, Maves CK, et al. Imple-
menting an ultrasound-based protocol for diag-
nosing appendicitis while maintaining diagnostic
accuracy. Pediatr Radiol 2015; 45:678–685
69. Cohen B, Bowling J, Midulla P, et al. The non-di-
agnostic ultrasound in appendicitis: is a non-visu-
alized appendix the same as a negative study? J
Pediatr Surg 2015; 50:923–927
70. Chien M, Habis A, Glynn L, O’Connor A, Smith
TL, Prendergast F. Staged imaging pathway for
the evaluation of pediatric appendicitis. Pediatr
Surg Int 2016; 32:671–678
71. Srinivasan A, Servaes S, Pena A, Darge K. Utility
of CT after sonography for suspected appendicitis
in children: integration of a clinical scoring sys-
tem with a staged imaging protocol. Emerg Radi-
ol 2015; 22:31–42
72. Thirumoorthi AS, Fefferman NR, Ginsburg HB,
Kuenzler KA, Tomita SS. Managing radiation ex-
posure in children: reexamining the role of ultra-
sound in the diagnosis of appendicitis. J Pediatr
Surg 2012; 47:2268–2272
73. Bachur RG, Levy JA, Callahan MJ, Rangel SJ,
Monuteaux MC. Effect of reduction in the use of
computed tomography on clinical outcomes of ap-
pendicitis. JAMA Pediatr 2015; 169:755–760
74. Burr A, Renaud EJ, Manno M, et al. Glowing in
the dark: time of day as a determinant of radio-
graphic imaging in the evaluation of abdominal
pain in children. J Pediatr Surg 2011; 46:188–191
75. Duke E, Kalb B, Arif-Tiwari H, et al. A systematic
review and meta-analysis of diagnostic perfor-
mance of MRI for evaluation of acute appendici-
tis. AJR 2016; 206:508–517
76. Herliczek TW, Swenson DW, Mayo-Smith WW.
Utility of MRI after inconclusive ultrasound in
pediatric patients with suspected appendicitis: ret-
rospective review of 60 consecutive patients. AJR
2013; 200:969–973
77. Kinner S, Pickhardt PJ, Riedesel EL, et al. Diag-
nostic accuracy of MRI versus CT for the evalua-
tion of acute appendicitis in children and young
adults. AJR 2017; 209:911–919
78. Binkovitz LA, Unsdorfer KM, Thapa P, et al. Pe-
diatric appendiceal ultrasound: accuracy, deter-
minacy and clinical outcomes. Pediatr Radiol
2015; 45:1934–1944
79. Blitman NM, Anwar M, Brady KB, Taragin BH,
Freeman K. Value of focused appendicitis ultra-
sound and Alvarado score in predicting appendi-
citis in children: can we reduce the use of CT?
AJR 2015; 204:[web]W707–W712
8 0. Goldin AB, Khanna P, Thapa M, McBroom JA,
Garrison MM, Parisi MT. Revised ultrasound cri-
teria for appendicitis in children improve diagnos-
tic accuracy. Pediatr Radiol 2011; 41:993–999
81. Nielsen JW, Boomer L, Kurtovic K, et al. Reduc-
ing computed tomography scans for appendicitis
by introduction of a standardized and validated
ultrasonography report template. J Pediatr Surg
2015; 50:144–148
82. Partain KN, Patel AU, Travers C, et al. Improving
ultrasound for appendicitis through standardized
reporting of secondary signs. J Pediatr Surg 2017;
52:1273–1279
83. Schuh S, Chan K, Langer JC, et al. Properties of se-
rial ultrasound clinical diagnostic pathway in sus-
pected appendicitis and related computed tomogra-
phy use. Acad Emerg Med 2015; 22:406–414