Professional Documents
Culture Documents
DOI 10.1007/s00247-014-2873-8
ORIGINAL ARTICLE
Received: 17 October 2013 / Accepted: 6 January 2014 / Published online: 26 January 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Background We encountered multiple cases in which the US
appearance of ruptured appendicitis mimicked intussusception, resulting in diagnostic and therapeutic delay and multiple
additional imaging studies.
Objective To explore the clinical and imaging discriminatory
features between the conditions.
Materials and methods Initial US images in six children (age
16 months to 8 years; 4 boys, 2 girls) were reviewed independently and by consensus by three pediatric radiologists. These
findings were compared and correlated with the original reports and subsequent US, fluoroscopic, and CT images and
reports.
Results All initial US studies demonstrated a multiple-ringlike appearance (target sign, most apparent on transverse
views) with diagnostic consensus supportive of intussusception. In three cases, US findings were somewhat discrepant
with clinical concerns. Subsequently, four of the six children
had contrast enemas; two were thought to have partial or
complete intussusception reduction. Three had a repeat US
examination, with recognition of the correct diagnosis. None
of the US examinations demonstrated definite intralesional
lymph nodes or mesenteric fat, but central echogenicity
caused by debris/appendicolith was misinterpreted as fat. All
showed perilesional hyperechogenicity that, in retrospect, represented inflamed fat walling off of the perforated appendix.
There were four CTs, all of which demonstrated a double-ring
appearance that correlated with the US target appearance, with
B. Newman (*) : M. Schmitz : R. Gawande : S. Vasanawala :
R. Barth
Department of Radiology, Stanford University,
Lucile Packard Childrens Hospital, 725 Welch Road, MC 5913,
Stanford, CA 94305, USA
e-mail: bevn@stanford.edu
Introduction
Acute appendicitis and ileocolic intussusception are common
causes of acute abdominal pain in young children. Timely and
accurate diagnosis of these conditions is essential for prompt,
appropriate treatment and minimization of patient morbidity.
Imaging evaluation of abdominal pain in children often
begins with a sonogram of the abdomen and pelvis [1]. The
typical sonographic appearances of acute appendicitis and
intussusception have been well illustrated [24]. Several potential mimics of intussusception on imaging have been described [1, 5, 6]. Little, however, has been written regarding
the confusion of the sonographic appearances of ruptured
appendicitis and intussusception. We consider ruptured appendicitis to be an important mimic of intussusception, with
potential for delayed diagnosis or misdiagnosis. We also suggest that careful examination of specific findings on a sonogram can help in differentiating the conditions in a timely
fashion.
536
Results
The number of cases scanned in the same hospital ER for
appendicitis or intussusception over the exact time period is
not known. However a report from the same hospital noted
that approximately 1,200 children were evaluated in the ER
for suspected appendicitis during a 5-year period between
2003 and 2008 [7]. The six children described in the current
report (Table 1) (20062013) ranged in age from 16 months to
8 years (mean age 4.4 years); there were 4 boys and 2 girls
(Table 1). All six children presented with abdominal pain; four
of the six had a history of fever or were febrile in the ER; three
of six had an elevated white blood cell count (Table 1). Three
children (ages 68 years) were older than the typical age for
pediatric ileocolic intussusception, and in two cases clinical
symptoms of periumbilical- to right-lower-quadrant pain were
more typical of appendicitis than intussusception.
Clinical findings
n=6
Abdominal pain6
Fever4
Elevated WBC3
Idiopathic ileocolic intussusception4
Intussuscepting calcified ileocolic mass1
Ileoileal intussusception1
Suggested ruptured appendicitis3
(additional clinical information and consultation
available, all three scanned directly by
radiologist, one case after negative enema
Normal1
Pericolic inflammation, loculated free air1
(suggestive of ruptured appendicitis)
Intussusception reduced2 (partial in 1)
All diagnostic of ruptured appendicitis
Initial US diagnosis
n=6
Repeat US
n=3
Contrast enema
interpretation
n=4
Contrast-enhanced
CT
n=4
Surgery
n=6
537
mass (Fig. 3). The child who was thought to have had an
intussusception reduced on enema had progressive clinical
symptoms of right lower quadrant pain and fever. He
underwent a repeat US with direct scanning by an attending
pediatric radiologist and discussion with the pediatric surgeon.
Although the US appearance was similar to that of the prior
study, marked echogenicity was recognized around the mass,
suggesting inflammation, leading to the conclusion that ruptured appendicitis was probably a more likely diagnosis. This
resulted in a confirmatory CT scan and prevented a planned
repeat enema for intussusception reduction (Fig. 2).
A total of four children had contrast-enhanced CTs demonstrating ruptured appendicitis. All the CT examinations
demonstrated a double-ring appearance correlating with the
US findings of the target sign, with inner and outer rings
representing the dilated appendix and walled-off appendiceal
rupture, respectively (Figs. 1, 2 and 3), with variable
538
surrounding phlegmon or fluid. Reaching the correct diagnosis of ruptured appendicitis took between 3 h and 24 h in these
six children, with a mean of 10.5 h.
All six children eventually had surgical confirmation of
ruptured appendicitis with no evidence of appendiceal or other
intussusception; in three cases laparoscopic appendectomy
and drainage were performed acutely. One of these children
developed subsequent adhesive small-bowel obstruction
requiring additional surgery. One child underwent percutaneous abscess drainage by interventional radiology, developed a
colocutaneous fistula and had a subsequent interval appendectomy and drain removal. Two other children were treated with
antibiotics acutely with interval appendectomy (Table 1).
Upon further review of the initial US examinations, all six
children demonstrated an appearance suggesting multiple
concentric rings of bowel (target sign, most apparent on
539
The clinical presentations of children with acute appendicitis (including ruptured appendicitis) or intussusception can
overlap, with both conditions capable of resulting in leukocytosis, fever and acute abdominal pain. A palpable mass in the
right flank or lower abdomen is also common to both entities.
Idiopathic intussusception is most often seen in children,
mostly boys, between 6 months and 3 years of age and is
considered to be related to hypertrophy of bowel lymphoid
tissue (Peyer patches), often triggered by a preceding gastrointestinal illness. Intussusception in neonates, as well as older
children, is less likely to be idiopathic and is frequently
associated with a pathological lead point such as a Meckel
diverticulum, duplication cyst, appendicitis, inspissated meconium (in cystic fibrosis), or a neoplasm such as a polyp or
lymphoma [8]. Small-bowel intussusception can be a transient
incidental finding on imaging, but symptomatic cases might
require operative management, especially in postoperative
patients, in association with small-bowel obstruction and with
a longer segment of involvement [9, 10].
US examination is often the first imaging study performed
in children with an acute abdominal presentation. Because of
concerns for radiation exposure, especially in young children,
CT is reserved for cases in which US findings are equivocal or
non-diagnostic [1, 7]. The classic sonographic appearance of
ileocolic intussusception is well-established [13, 5]. US is
considered a very good imaging study for the detection of
intussusception, with reported sensitivity of 100% and
Discussion
Acute abdominal pain in children is a common diagnostic
dilemma, with acute appendicitis and intussusception
representing two of the most important diagnostic considerations [1, 6]. The classic symptoms of acute appendicitis
include anorexia, periumbilical pain followed by right lower
quadrant pain, and vomiting, which can be present in many
other causes of acute abdominal pain in children.
Classic symptoms of intussusception include intermittent
abdominal pain and irritability with later diarrhea, bloody
stools and lethargy, although approximately half of patients
do not present with typical symptoms [1, 5].
540
Conclusion
Ruptured appendicitis is an important mimic of intussusception on US examination. Being mindful of ruptured appendicitis as a diagnostic possibility in children with atypical age or
clinical features and US findings suggestive of intussusception should allow for careful attention to subtle differences in
the sonographic appearances between the entities. Particular
attention should be paid to evaluating the presence of surrounding inflamed fat in appendicitis and intralesional
hypoechoic lymph nodes in ileocolic intussusception. An
inner crescent of echogenic mesenteric fat between bowel
loops is a virtually pathognomonic feature of intussusception
that was not definitely present in our cases of ruptured appendicitis, although it was misinterpreted as such when central
541
References
1. Cogley JR, OConnor SC, Houshyar R et al (2012) Emergent pediatric US: what every radiologist should know. Radiographics 32:
651665
2. Anderson DR (1999) The pseudokidney sign. Radiology 211:395
397
3. Del-Pozo G, Albillos JC, Tejedor D (1996) Intussusception: US
findings with pathologic correlationthe crescent-in-doughnut sign.
Radiology 199:688692
4. Sivit CJ (1993) Diagnosis of acute appendicitis in children: spectrum
of sonographic findings. AJR Am J Roentgenol 161:147152
5. Daneman A, Navarro O (2003) Intussusception. Part 1: a review of
diagnostic approaches. Pediatr Radiol 33:7985
6. Van Breda Vriesman AC, Puylaert JB (2006) Mimics of appendicitis:
alternative nonsurgical diagnoses with sonography and CT. AJR Am
J Roentgenol 186:11031112
7. Krishnamoorthi R, Ramarajan N, Wang NE et al (2011) Effectiveness
of a staged US and CT protocol for the diagnosis of pediatric
appendicitis: reducing radiation exposure in the age of ALARA.
Radiology 259:231239
8. Williams H (2008) Imaging and intussusception. Arch Dis Child
Educ Pract Ed 93:3036
9. Ko SF, Lee TY, Ng SH et al (2002) Small bowel intussusception in
symptomatic pediatric patients: experiences with 19 surgically proven cases. World J Surg 26:438443
10. Lioubashevsky N, Hiller N, Rozovsky K et al (2013) Ileocolic versus
small-bowel intussusception in children: can US enable reliable
differentiation? Radiology 269:266271
11. Tejani C, Phatak T, Sivitz A (2012) Right lower-quadrant pain
more than one diagnosis. Pediatr Emerg Care 28:12241226
12. Christianakis E, Sakelaropoulos A, Papantzimas C et al (2008) Pelvic
plastron secondary to acute appendicitis in a child presented as
appendiceal intussusception. A case report. Cases J 1:135
13. Dietz KR, Merrow AC, Podberesky DJ et al (2013) Beyond acute
appendicitis: imaging of additional pathologies of the pediatric appendix. Pediatr Radiol 43:232242, quiz 259
Copyright of Pediatric Radiology is the property of Springer Science & Business Media B.V.
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.