Pediatr Radiol (2014) 44:12431251

DOI 10.1007/s00247-014-3009-x

ORIGINAL ARTICLE

Acute appendicitis in children: ultrasound and CT findings

in negative appendectomy cases
Seong Ho Kim & Young Hun Choi & Woo Sun Kim &
Jung-Eun Cheon & In-One Kim

Received: 26 October 2013 / Revised: 4 March 2014 / Accepted: 21 April 2014 / Published online: 20 May 2014
# Springer-Verlag Berlin Heidelberg 2014

Abstract
Background To decrease the negative appendectomy rate in
children, knowledge of the misleading imaging findings on
US and CT in negative appendicitis cases is important.
Objective To evaluate the negative appendectomy rate and
describe the imaging findings of US and CT that lead radiologists to misdiagnose acute appendicitis in children.
Materials and methods From 2007 to 2013, 374 children
operated for suspected appendicitis were proved to either have
acute appendicitis (n=348) or to be negative for appendicitis
(n=26) on pathological reports. Negative appendectomy rates
were compared among imaging modalities, age groups and
genders. We retrospectively reviewed US and CT findings
from negative appendectomy cases.
Results The overall negative appendectomy rate was 7.0%
(26/374). There were no statistically significant differences
among the subgroups. The most common misleading presentations on US were sonographic tenderness (9/16, 56%) and
non-compressibility (9/16, 56%). The most common misleading finding on CT were the presence of an appendicolith or
hyperdense feces (5/12, 42%). Periappendiceal fat inflammation was observed in only one case of negative appendicitis on
US and on CT.
Conclusion Radiologists can misdiagnose children with
equivocal diameters of appendices as having acute appendicitis when sonographic tenderness or non-compressibility is
present on US and when an appendicolith or hyperdense feces
is noted on CT. The possibility of negative appendicitis should

S. H. Kim : Y. H. Choi (*) : W. S. Kim : J.<E. Cheon : I.<O. Kim

Department of Radiology,
Seoul National University College of Medicine,
Seoul National University Hospital,
101 Daehak-ro, Jongno-gu
Seoul, 110-744, Republic of Korea
e-mail: iater@snu.ac.kr

be borne in mind when periappendiceal fat inflammation is

absent or minimal in indeterminate cases.
Keywords Appendicitis . Negative appendectomy .
Children . Ultrasonography . Computed tomography

Introduction
Acute appendicitis is one of the most frequent causes of acute
abdominal pain in children, and surgery is required when
acute appendicitis is considered to be present. Traditionally
acute appendicitis has been diagnosed solely on the basis of
clinical examinations and laboratory data, without the aid of
diagnostic imaging. However, studies have shown the negative appendectomy rate to be up to 20%, and as high as 40% in
females [13]; it might be even higher in children because of
the difficulty in specifying physical examination findings and
in obtaining clear clinical information. Today, few patients who
are suspected of having acute appendicitis undergo surgery
directly without preoperative imaging such as US or CT [4,
5], both of which have been shown to improve the outcomes of
pediatric patients with acute appendicitis [6, 7]. As a result, the
negative appendectomy rate among children with preoperative
imaging has decreased greatly, although it remains in the range
of 3.66.7% despite the efforts of pediatric radiologists and
surgeons to decrease the negative appendectomy rate in children [810]. We hypothesized that knowledge of the misleading
imaging findings of US and CT in negative appendicitis cases
would be helpful in decreasing the negative appendectomy rate
in children. Although a few studies have described the imaging
findings of US or CT in negative appendectomy cases in
children [11, 12], a more comprehensive overview was needed.
Therefore, the purposes of our study are to identify the negative
appendectomy rate among different imaging modalities, age

1244

groups and genders and to reveal the confusing findings of US

and CT that frequently cause radiologists to misdiagnose acute
appendicitis. We did this by retrospectively reviewing the imaging findings in children pathologically confirmed as being
negative for appendicitis.

Materials and methods

Patients
Our institutional review board approved this study and informed consent requirements were waived. From January
2007 to June 2013, a total of 381 children underwent appendectomies at our hospital. Seven of the 381 patients were
excluded from our study because of other pathologies such
as hematologic malignancy (n=1) or a delay in surgery of
more than 1 week after imaging studies (n=6). Finally, 374
children (236 boys, mean age 9.6 years old, age range 017;
138 girls, mean age 9.4 years old, age range 117) who were
proved to have either acute appendicitis (n=348) or no evidence of appendicitis (n=26) on pathological reports were
enrolled in our study (Fig. 1).

Pediatr Radiol (2014) 44:12431251

by trainees of our institution on an Aplio XG (Toshiba

Medical Systems, Tokyo, Japan, n=5), an iU22 (Philips
Healthcare, Bothell, WA, n = 11), a Sequoia (Acuson
Corp., Mountain View, CA, n=1), or a Logiq 9 (GE
Healthcare, Milwaukee, WI, n=4) unit, all with 3- to 10MHz probes. All 12 children who underwent CT were
imaged with multi-detector row CT systems with 4, 16, 64
or 320 detector rows, including the M8000 (Philips
Healthcare, Cleveland, OH, n=1), LightSpeed Ultra (GE
Healthcare, Milwaukee, WI, n=1), Sensation 16 (Siemens
Healthcare, Forchheim, Germany, n=3), Brilliance 64
(Philips Healthcare, Cleveland, OH, n=5), Sensation 64
(Siemens, Forchheim, Germany, n = 1), and Aquilion
ONE (Toshiba Medical Systems, Otawara, Japan, n=1).
In all 12 children, axial images with a section thickness
of 33.75 mm were acquired after an intravenous injection of
nonionic contrast media (Xenetix 350; Guerbet, France) at a
dose of 1.5 ml per kilogram of body weight. Oral contrast
material was not used in any of the children, and the peak tube
voltage ranged from 80 kVp to 120 kVp according to the body
weights. In eight children with available dose reports, the
mean CT dose index (CTDI) was 4.2 mGy, ranging 1.42
8.8 mGy. The mean dose length product (DLP) was
187.9 mGy*cm, ranging 66461.4 mGy*cm.

Ultrasound and CT
Data and image interpretation
US was performed in 21/26 children and CT was performed in 12/26 children with negative appendectomies.
All 21 children who underwent US imaging were scanned

Fig. 1 Flow chart describing the

study population

All radiologic reports and US and CT findings of negative

appendicitis cases were retrospectively reviewed by two

Pediatr Radiol (2014) 44:12431251

radiologists (KSH and CYH, with 2 and 11 years of pediatric

radiology experience, respectively). Negative appendectomy
rates were calculated according to the type of preoperative
imaging modalities performed: US only, CT only, both US and
CT, and no preoperative imaging. In addition, the children
were classified based on age into four groups to determine the
discrepancy of negative appendectomy rates among the age
groups (ages 0 to 4, 5 to 9, 10 to 13, and 14 to 17 years).
Negative appendectomy rates were obtained for each age
group and both genders.
In the negative appendicitis group, the likelihood of appendicitis was classified based on the original radiologic reports
of US and CT. The likelihood of appendicitis was classified
into five grades as proposed by Stengel et al. [13]: grade 1,
definitely absent; grade 2, non visualized appendix with no
secondary signs of inflammation; grade 3, equivocal; grade
4, probable; and grade 5, high possibility of acute appendicitis. Thereafter we retrospectively reviewed the US images
for the following findings in 16 children in whom appendices were identified on US: maximum diameter of the appendix, presence of an appendicolith, appendiceal wall
thickening, periappendiceal fat inflammation,
periappendiceal fluid collection, lymphadenopathy in the
right lower quadrant of the abdomen, non-appendiceal adjacent bowel wall thickening, reported sonographic tenderness and reported sonographic non-compressibility. CT
findings were also retrospectively reviewed for the following features: maximum diameter of the appendix, presence
of an appendicolith or hyperdense feces, appendiceal wall
thickening and enhancement, periappendiceal fat stranding,
periappendiceal fluid collection, non-appendiceal bowel
wall thickening, gas within the appendix, and lymphadenopathy in the right lower quadrant of the abdomen. All US
and CT findings were reviewed in consensus by the two
reviewers according to the criteria described in previous
studies [1416].
The diameter of the appendix was measured from the outer
to outer walls and was considered to be equivocal if the
appendiceal diameter ranged between 5 and 8 mm. These
numbers were based on the reasoning that the cut-off value
of the appendiceal diameter maximizing sensitivity and specificity is still unclear in children and that the reported diameters of normal appendices have been shown to vary in the
different age groups, with mean values ranging from 3.7 to
6.9 mm [1720]. The diameter of the appendix was considered to be definitely enlarged when it exceeded 8 mm.
Appendicolith was defined as an intra-appendiceal lesion with
evident sonographic characteristics of calcification or that
showing high density similar to bone density on CT [21].
Hyperdense feces were considered to be present if fecal content in the appendiceal lumen was hyperdense to the adjacent

1245

bowel wall. The mural thickness of the appendix was measured from the hyperechoic luminal interface to the outer
hyperechoic serosal layer on US. The appendiceal wall was
considered to be thickened when the maximal mural thickness
was measured at larger than 2.2 mm [22].
Periappendiceal fat inflammation on US was defined as
hyperechoic, thickened intra-abdominal fatty tissue around the
appendix [19]. Lymphadenopathy was defined as an enlarged
lymph node with the shortest diameter larger than 8 mm [23].
Sonographic tenderness and sonographic non-compressibility
were evaluated only in cases that were available in the original
radiologic reports. The presence of evident signs of inflammation at the adjacent organs covered in the imaging modalities
was evaluated in order to differentiate secondary inflammatory
changes of the appendix from acute appendicitis.
Statistical analysis
All statistical analysis was performed using commercially available software (MedCalc for Windows, version 12.7.0; MedCalc
Software, Mariakerke, Belgium). Both the chi-square test and
Fisher exact test were used to evaluate the difference in negative
appendectomy rate among the variable groups. A P-value of
less than 0.05 was considered statistically significant.

Results
US or CT was performed in 359 children during the study
period and neither US nor CT was performed in the remaining
15 children prior to appendectomy. One hundred seventy-two
children underwent only US prior to appendectomy and 133
underwent only CT prior to appendectomy. Fifty-four children
underwent both US and CT, with 49 children undergoing US
first and 5 undergoing CT first. In the group negative for
appendicitis (n=26), 12 children underwent only US prior to
appendectomy, 3 underwent only CT, and 9 underwent both
US and CT, with 8 children undergoing US first and 1 undergoing CT first. The remaining two children did not undergo an
imaging study prior to appendectomy (Fig. 1). All imaging
studies were performed within 1 day after the presentation of
acute abdominal pain.
Surgical resection and histopathological findings
Among the 374 children, 348 were confirmed to have acute
appendicitis with or without perforation, while 26 children
showed no evidence of appendicitis on surgical and pathological reports. The time interval between imaging and appendectomy in the negative appendicitis group varied, ranging
from 0 to 5 days, with a mean interval of 0.67 day. All 26

1246

Pediatr Radiol (2014) 44:12431251

children with negative appendicitis underwent appendectomy

either via open surgery (n=9) or laparoscopically (n=17)
performed by two pediatric surgeons with more than 10 years
of experience. All resected appendices were reviewed by one
gastrointestinal pathologist with more than 20 years of experience. The pathologists did not mention the term appendicitis if there was no evidence of appendicitis on histology.
Instead, the pathologists used other pathological terms, including fecalith (n=3), serosal or subserosal congestion (n=19),
fecalith with subserosal or serosal congestion (n=1), no diagnostic abnormalities (n=1), mild lymphoplasmacytic infiltration (n=1) and periappendicitis (n=1).

Table 2 Preoperative interpretations of US in the negative appendicitis

group (n=21) (report-based classification)

Negative appendectomy rate

Retrospective analysis of radiologic reports and imaging

findings of US in negative appendicitis group

The overall negative appendectomy rate in children was 7.0%

(26/374) at our institution. Performing US alone for the diagnosis of acute appendicitis resulted in a negative appendectomy rate of 7.0% (12/172), while performing CT alone resulted
in a negative appendectomy rate of 5.3% (7/133). When both
US and CT were performed, negative appendectomy rate was
9.3% (5/54). Negative appendectomy rate was highest in the
age group of 04 years (5/39, 12.8%) and the negative
appendectomy rate in boys was slightly higher than in girls
(19/236, 8.1% vs. 7/138, 5.1%). However there were no
statistically significant differences in negative appendectomy rate among the imaging modalities, age groups or
genders (Table 1).
Table 1 Negative appendectomy rates in subgroups of children. There
was no statistically significant difference between genders, nor among
modalities or age groups

Whole group
Imaging modalities
US only
CT only
Both US and CT
No imaging
Age groups
04
59
1013
1417
Gender
Male
Female

Number of negative
appendicitis cases

Negative
appendectomy rate

26/374

7.0%

12/172
7/133
5/54
2/15

7.0%
5.3%
9.3%
13.3%

5/39
8/152
8/126
5/57

12.8%
5.3%
6.3%
8.8%

Preoperative interpretation

Numbers (percentage)

Non-visualized appendix
Equivocal finding
Probable acute appendicitis
Tip appendicitis

5 (24%)
3 (14%)
11 (52%)
5

Early (mild) appendicitis

High possibility of appendicitis

6
2 (10%)
21

A total of 21 of 26 children with negative appendicitis

underwent US prior to surgery. Analysis of the US reports
revealed that the most frequent preoperative interpretation of
US examinations was probable acute appendicitis (grade 4,
n=11). Two cases were even reported as being highly suggestive of acute appendicitis (grade 5, n=2) (Table 2).
The imaging findings of 16 cases in which appendices were
identified on US are shown in Table 3 (Fig. 2).
Periappendiceal fat inflammation was noted in one of the 16
cases, and in that case colitis and secondary inflammatory
changes in the appendix were evident on US (Fig. 3).

Table 3 Retrospective evaluation of US findings in 16 children in the

negative appendicitis group in whom appendices were identified on US
US findings

n=16

Mean diameter of appendix (mm)

Appendicolith
Appendiceal wall thickening (MMT >2.2 mm)

6.4 (range: 5.08.0)

0 (0%)
3 (19%)

Periappendiceal fat inflammation

Periappendiceal fluid collection
RLQ lymphadenopathy
Non appendiceal bowel wall thickening
Sonographic tendernessa
Non-compressibilityb

1 (6%)
3 (19%)
8 (50%)
5 (31%)
9 (56%)
9 (56%)

MMT maximal mural thickness, RLQ right lower quadrant

a

19/236

8.1%

7/138

5.1%

Sonographic tenderness was included only when there was a description

of this finding on the initial report

Sonographic non-compressibility of the appendix was included only

when there was a description of this finding on the initial report

Pediatr Radiol (2014) 44:12431251

1247

Fig. 2 Preoperative US findings in a 7-year-old boy proved to be

negative for appendicitis. a US image demonstrates a normal diameter
of the appendix without significant appendiceal wall thickening (arrows).
b The tip of appendix is equivocal in size, measuring approximately
7.3 mm, and the maximal mural thickness measures 1.8 mm (arrow).

There were no signs of periappendiceal fat echogenicity or

periappendiceal fluid collection. Some lymph nodes were observed near
the appendix (not shown). The operator in this US examination reported
positive sonographic tenderness and non-compressibility of the appendix

Fig. 3 Preoperative US findings in a 2-year-old boy proved to be

negative for appendicitis. a US image demonstrates periappendiceal fat
inflammation and a small amount of periappendiceal fluid (arrow). The
appendix is equivocal in diameter, measuring approximately 6.3 mm. b

The remarkable thickening of the ascending colon (arrow) and terminal

ileum (arrowhead) is seen on another US image. The final diagnosis was
infectious colitis with associated secondary inflammatory changes in the
appendix

Sonographic tenderness and non-compressibility were each

reported in 9/16 cases.
Retrospective analysis of radiologic reports and imaging
findings of CT in negative appendicitis group
A total of 12 of 26 children who later proved to be negative for
appendicitis underwent CT prior to emergent appendectomy
(CT alone [n=3] or both US and CT [n=9]). The preoperative
interpretations of CT were as follows: equivocal (grade 3, n=
3); probable acute appendicitis (grade 4, n=8); and high
possibility of appendicitis (grade 5, n=1). Among the probable appendicitis cases, four were considered to be tip appendicitis, and another four were considered to be the early stages
of acute appendicitis.
Imaging findings of the 12 cases with CT are shown in
Table 4. In all cases except one, the appendices were in the
range of an equivocal diameter. One case showed an enlarged

Table 4 Retrospective analysis of CT findings in the negative appendectomy group (n=12)

CT findings

n=12

Mean diameter of appendix (mm)

6.9 (range 5.28.7)

Appendicolith or high-density material

Appendiceal wall thickening (MMT >2.2 mm)
Suspicious appendiceal wall enhancement
Periappendiceal fat stranding
Periappendiceal fluid
Evident non-appendiceal bowel wall thickening
Gas within the appendix
RLQ lymphadenopathy

5 (42%)
3 (25%)
3 (25%)
1 (8%)
2 (17%)
4 (33%)
6 (50%)
7 (58%)

MMT maximal mural thickness, RLQ right lower quadrant

1248

Pediatr Radiol (2014) 44:12431251

Fig. 4 Contrast-enhanced CT in a 7-year-old boy later proved to be

negative for appendicitis. a The appendix is prominent (8 mm) with
possible hyperdense feces (arrow). There is no evidence of periappendiceal
fat stranding or periappendiceal fluid collection. Note the normal
intraluminal gas within the proximal segment of the appendix (arrowhead).

b The distal segment of the appendix (arrows) is also prominent in size,

measuring approximately 7 mm, but again, there were no associated
secondary findings such as periappendiceal fat stranding or periappendiceal
fluid collection. The boy was reported as having probable acute appendicitis, but the case was finally confirmed as negative appendicitis

appendix 8.7 mm in diameter; this case was finally confirmed

as hemolytic uremic syndrome after an E. coli infection. In
addition, appendicolith or hyperdense feces was observed in
five cases (42%) (Fig. 4). Periappendiceal fat infiltration was
noted in only one case, in which associated findings of
perirenal fat stranding, facial thickening and a small amount
of ascites suggestive of an upper urinary tract infection were
evident on CT (Fig. 5).

We reviewed the imaging findings on US and CT in negative

appendectomy cases in children. The main findings of our
study are as follows: (1) The overall negative appendectomy

rate in children was 7.0% (26/374). (2) All children with

preoperative imaging and negative appendectomies showed
prominent appendices of equivocal (n=23) or evident size
(n=1). (3) For US, the presence of either sonographic tenderness or sonographic non-compressibility was the most common misleading finding in patients negative for appendicitis.
(4) For CT, the presence of an intraluminal appendicolith or
hyperdense feces was the most common misleading finding
resulting in the misinterpretation of acute appendicitis. (5)
Furthermore we found that the absence of periappendiceal fat
inflammation provides clues for the exclusion of acute appendicitis in cases with an equivocal diameter of the
appendix.
In a previous study, Bachur et al. [24] reported an overall
negative appendectomy rate of 3.6%, which is lower than that

Fig. 5 Contrast-enhanced CT in an 11-year-old boy later proved to be

negative for appendicitis. a There is enhancement of the appendix
(arrow). Note the periappendiceal fat stranding and a small amount of
periappendiceal fluid. b Sagittal reconstruction of the right kidney shows

heterogeneous parenchymal enhancement and perirenal infiltrations suggestive of upper urinary tract infection. Inflammatory changes in the
appendix were secondary to the upper urinary tract infection rather than
acute appendicitis

Discussion

Pediatr Radiol (2014) 44:12431251

observed in our study. This discrepancy could be because most

of our cases were initially assessed by radiology trainees in the
emergency room; trainees typically have less experience in
diagnosing acute appendicitis in children. A nationwide report
by Oyetunji et al. [25] found a negative appendectomy rate of
6.7%, which is similar to our results. We also found that CT
showed a relatively lower negative appendectomy rate when
compared with US, albeit without statistical significance,
most likely because US is more dependent than CT on the
operators skill. As for age groups, both Bachur et al. [24]
and Oyetunji et al. [25] reported that the negative appendectomy rate in the age group younger than 5 years was
significantly higher than that in other age groups, also similar
to our results. However, our study could not verify its
statistical significance. Oyetunji et al. [25] also reported that
the negative appendectomy rate among boys was significantly lower than that in girls (5.1 vs. 9.3%, P<0.001). However
Wagner et al. [5] found no significant difference in negative
appendicitis rates between boys and girls, although there was
a trend toward a lower rates among men compared with
women (6.3 vs. 8.5%, P=0.09). Our results are different
from those of Oyetunji et al. [25] and Wagner et al. [5] in
that the negative appendicitis rate of boys was higher than
that of girls in our study, even though there was no statistical
significance. This could be explained by our smaller sample
size and other influences such as the age factor, since our
study population had relatively lower-age boys (mean
8.3 years) when compared to girls (mean 11.1 years), with
a bigger proportion of the age group younger than 5 years in
boys.
When we reviewed the preoperative interpretations of US
and CT, the majority of children who had undergone negative
appendectomy had radiologic reports suspicious for, probable, or consistent with acute appendicitis (21/24, 87.5%).
Three cases had readings of equivocal appendicitis (3/24,
12.5%). Only two children underwent negative appendectomy
without preoperative radiologic studies. There were no cases
with preoperative interpretations negative for appendicitis.
Thus most of the negative appendectomy cases at our institution had some degree of radiologic suspicion of acute appendicitis, and according to our results, false-positive image
interpretations seem to have been a major contributor to the
negative appendectomy rate.
All 16 negative appendectomy cases with US and all 12
with CT except one showed an equivocal diameter of the
appendix. Only one case with CT showed an enlarged appendix of 8.7 mm. When we adopted the widely used criterion of
6 mm, most of the negative appendectomy cases (16/24, 67%)
showed appendices larger than 6 mm. It is well-known that the
appendiceal diameter is the most powerful single diagnostic
criterion in the diagnosis of acute appendicitis [2, 8]. However
the appendix may be enlarged in cases without significant
inflammation but with congestion only, especially when an

1249

intraluminal appendicolith or hyperdense feces is present [26].

Taylor et al. [11] also reported that an enlarged appendix
(>6 mm) was not sufficient for the diagnosis of acute
appendicitis.
We also found that sonographic tenderness (n=9) and noncompressibility of the US probe (n=9) were common misleading findings of US. Trout et al. [12] reported that the lack
of compressibility (80%) on US examination was the most
commonly cited finding in false-positive cases followed by an
appendiceal diameter larger than 6 mm (54%). Our findings
support the results of that study. Sonographic noncompressibility may be unreliable in children because crying
and noncompliance often result in rigidity of the abdomen,
which can hinder adequate compression of the appendix.
Additionally, our results suggest that sonographic tenderness
could be one of the most common misleading findings in
false-positive cases. Although tender points can facilitate the
finding of an inflamed appendix, according to Sohail et al.
[27], radiologists must be careful in interpreting sonographic
tenderness in children because pediatric patients symptoms
often present ambiguously and inaccurately, especially in
children of younger ages who have an inability to verbalize
their symptoms clearly.
As for CT, our results suggest that radiologists most commonly misdiagnose cases when an appendicolith or
hyperdense feces is present (n=5). Studies have shown that
the presence of an isolated appendicolith on CT without any
other inflammatory sign is insufficient to diagnose an acute
inflamed appendix [11, 21, 28]. The presence of an
appendicolith or hyperdense feces can indeed increase the
incidence of appendicitis, but we should bear in mind that
these findings can also be incidentally detected in normal
patients [28]. The next most common cause of misinterpretation on CT according to our study results was secondary
changes in the appendix related to other diseases, including
nonspecific colitis (n=2), hemolytic uremic syndrome (n=1)
and acute pyelonephritis (n=1). Because approximately 40%
of patients clinically suspected of having acute appendicitis
are confirmed to have other conditions, according to a study
by Pooler et al. [29], the appendix can show secondary inflammatory changes from pathologies in adjacent structures.
Thus, radiologists should always pay attention to surrounding
structures when interpreting imaging in patients suspected of
having acute appendicitis.
Our study showed that when confronted with equivocally
enlarged appendices, we should seek associated inflammatory signs, such as signs of periappendiceal fat inflammation
as well as correlation with clinical findings. A moderate to
severe degree of periappendiceal inflammatory infiltrates can
show high specificity (94.9%) in the prediction of acute
appendicitis, according to Lai et al. [30]. Thus, if the appendix shows equivocal findings with a lack of periappendiceal
fat inflammation, we would recommend imaging follow-up

1250

as well as correlation with clinical findings rather than immediate surgery because our results demonstrate that the possibility of negative appendicitis is present when the appendix is
equivocal in diameter without associated periappendiceal fat
inflammation. We believe the following two findings may be
helpful in ascertaining periappendiceal inflammation. First,
inflamed fat is usually not movable and can be consistently
observed even after compression with the probe. Second, an
increased Doppler signal within the hyperechoic fat tissue
may be helpful. In our study, periappendiceal fat inflammation
on US and fat stranding on CT were noted in only one
negative appendectomy case per modality. Even such changes, however, were observed to be related to the inflammatory
condition of adjacent bowel loops or organs and not to acute
appendicitis. Therefore, the absence of periappendiceal fat
inflammation or stranding may provide clues for radiologists
to exclude acute appendicitis in indeterminate cases in which
the appendix is equivocal in size.
Our study has several limitations. First, US and CT
findings were evaluated only in children with negative
appendicitis, which is why we only described imaging
findings without performing statistical analysis. However,
these descriptions presented us with some confusing US
and CT findings in diagnosing acute appendicitis and may
be a good consideration in the clinical setting, especially
for trainees working in the emergency room. Second, our
study was retrospectively designed, and the possibility of
bias was present in reviewing the US and CT findings
because we were aware of the pathological diagnosis of
negative appendicitis. Third, there is a possibility that
some of our negative appendectomy rate cases were cases
of spontaneously resolving appendicitis [31] because of
the time delay between imaging and surgery. However
such a chance was very low because surgery was performed within 2 days after imaging in 23 of 24 (95%)
cases. Last, the reliability of sonographic tenderness and
non-compressibility is uncertain, because there were no
reports of these findings in 44% (7/16) of the children
who underwent US; furthermore these subjective findings
were evaluated by trainees.

Conclusion
The negative appendectomy rates were similar among imaging modalities and age groups, and between genders.
Most negative appendicitis cases on US examinations were
related to sonographic tenderness or sonographic noncompressibility. At CT the most common misleading finding was the presence of an appendicolith or hyperdense
feces. The diagnosis of appendicitis needs to be critically
queried when the appendiceal diameter is equivocal and
there is no periappendiceal fat inflammation.

Pediatr Radiol (2014) 44:12431251

Conflicts of interest None

References
1. Morse BC, Roettger RH, Kalbaugh CA et al (2007) Abdominal CT
scanning in reproductive-age women with right lower quadrant abdominal pain: does its use reduce negative appendectomy rates and
healthcare costs? Am Surg 73:580584
2. Pinto Leite N, Pereira JM, Cunha R et al (2005) CT evaluation of
appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol 185:406417
3. Antevil J, Rivera L, Langenberg B et al (2004) The influence of age
and gender on the utility of computed tomography to diagnose acute
appendicitis. Am Surg 70:850853
4. Raman SS, Osuagwu FC, Kadell B et al (2008) Effect of CT on false
positive diagnosis of appendicitis and perforation. N Engl J Med 358:
972973
5. Wagner PL, Eachempati SR, Soe K et al (2008) Defining the
current negative appendectomy rate: for whom is preoperative
computed tomography making an impact? Surgery 144:276
282
6. Pena BM, Taylor GA, Fishman SJ et al (2000) Costs and
effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children. Pediatrics 106:
672676
7. Cuschieri J, Florence M, Flum DR et al (2008) Negative appendectomy and imaging accuracy in the Washington state surgical care and
outcomes assessment program. Ann Surg 248:557563
8. Colvin JM, Bachur R, Kharbanda A (2007) The presentation of
appendicitis in preadolescent children. Pediatr Emerg Care 23:849
855
9. Doria AS (2009) Optimizing the role of imaging in appendicitis.
Pediatr Radiol 39:S144148
10. Flum DR, Koepsell T (2002) The clinical and economic
correlates of misdiagnosed appendicitis: nationwide analysis.
Arch Surg 137:799
11. Taylor GA, Callahan MJ, Rodriguez D et al (2006) CT for suspected
appendicitis in children: an analysis of diagnostic errors. Pediatr
Radiol 36:331337
12. Trout AT, Sanchez R, Ladino-Torres MF et al (2012) 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 42:813823
13. Stengel JW, Webb EM, Poder L et al (2010) Acute appendicitis:
clinical outcome in patients with an initial false-positive CT diagnosis. Radiology 256:119126
14. Keyzer C, Tack D, de Maertelaer V et al (2004) Acute appendicitis:
comparison of low-dose and standard-dose unenhanced multidetector row CT. Radiology 232:164172
15. Pereira JM, Sirlin CB, Pinto PS et al (2004) Disproportionate fat
stranding: a helpful CT sign in patients with acute abdominal pain.
Radiographics 24:703715
16. Rettenbacher T, Hollerweger A, Macheiner P et al (2001) Outer
diameter of the vermiform appendix as a sign of acute appendicitis:
evaluation at US. Radiology 218:757762
17. Akay HO, Akpinar E, Ozmen CA et al (2007) Visualization of the
normal appendix in children by non-contrast MDCT. Acta Chir Belg
107:531
18. Ozel A, Orhan UP, Akdana B et al (2011) Sonographic appearance of
the normal appendix in children. J Clin Ultrasound 39:183186
19. Wiersma F, Srameck A, Holscher HC (2005) US features of the
normal appendix and surrounding area in children. Radiology 235:
10181022

Pediatr Radiol (2014) 44:12431251

20. Searle AR, Ismail KA, MacGregor D et al (2013) Changes in the
length and diameter of the normal appendix throughout childhood. J
Pediatr Surg 48:15351539
21. Lowe LH, Penney MW, Scheker LE et al (2000) Appendicolith revealed on CT in children with suspected appendicitis: how specific is it
in the diagnosis of appendicitis? AJR Am J Roentgenol 175:981984
22. Je BK, Kim SB, Lee SH et al (2009) Diagnostic value of maximalouter-diameter and maximal-mural-thickness in use of ultrasound for
acute appendicitis in children. World J Radiol 15:29002903
23. Karmazyn B, Werner EA, Rejaie B et al (2005) Mesenteric lymph
nodes in children: what is normal? Pediatr Radiol 35:774777
24. Bachur RG, Hennelly K, Callahan MJ et al (2012) Diagnostic imaging and negative appendectomy rates in children: effects of age and
gender. Pediatrics 129:877884
25. Oyetunji TA, Onguti SK, Bolorunduro OB et al (2012) Pediatric
negative appendectomy rate: trend, predictors, and differentials. J
Surg Res 173:1620

1251
26. Park NH, Oh HE, Park HJ et al (2011) Ultrasonography of normal
and abnormal appendix in children. World J Radiol 3:85
27. Sohail S, Siddiqui KJ (2009) Doptaus a simple criterion for
improving sonographic diagnosis of acute appendicitis. J Pak Med
Assoc 59:7579
28. Rollins MD, Andolsek W, Scaife ER et al (2010) Prophylactic
appendectomy: unnecessary in children with incidental
appendicoliths detected by computed tomographic scan. J Pediatr
Surg 45:23772380
29. Pooler BD, Lawrence EM, Pickhardt PJ (2012) Alternative diagnoses
to suspected appendicitis at CT. Radiology 265:733742
30. Lai V, Chan WC, Lau HY et al (2012) Diagnostic power of various
computed tomography signs in diagnosing acute appendicitis. Clin
Imaging 36:2934
31. Cobben LP, De Van Otterloo AM, Puylaert JB (2000) Spontaneously
resolving appendicitis: frequency and natural history in 60 patients.
Radiology 215:349352

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.