Perforated appendicitis: an underappreciated mimic of intussusception on ultrasound

Beverley Newman, Matthew Schmitz, Rakhee Gawande, Shreyas Vasanawala, Richard Barth

Research output: Contribution to journalArticle

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-ring-like 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 inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis. Conclusion: Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.

Original languageEnglish (US)
Pages (from-to)535-541
Number of pages7
JournalPediatric Radiology
Volume44
Issue number5
DOIs
StatePublished - May 1 2014
Externally publishedYes

Fingerprint

Intussusception
Appendicitis
Fats
Enema
Rupture
Lymph Nodes
Pediatrics
Therapeutics

Keywords

  • Appendicitis
  • Children
  • Computed tomography
  • Intussusception
  • Ultrasound

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Radiology Nuclear Medicine and imaging

Cite this

Perforated appendicitis : an underappreciated mimic of intussusception on ultrasound. / Newman, Beverley; Schmitz, Matthew; Gawande, Rakhee; Vasanawala, Shreyas; Barth, Richard.

In: Pediatric Radiology, Vol. 44, No. 5, 01.05.2014, p. 535-541.

Research output: Contribution to journalArticle

Newman, Beverley ; Schmitz, Matthew ; Gawande, Rakhee ; Vasanawala, Shreyas ; Barth, Richard. / Perforated appendicitis : an underappreciated mimic of intussusception on ultrasound. In: Pediatric Radiology. 2014 ; Vol. 44, No. 5. pp. 535-541.
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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-ring-like 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 inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis. Conclusion: Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.",
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