Emerg Radiol
DOI 10.1007/s10140-015-1372-z
ORIGINAL ARTICLE
CT differentiation between tubo-ovarian and appendiceal origin
of right lower quadrant abscess: CT, clinical, and laboratory
correlation
Nurith Hiller 1,3 & Tal Fux 1 & Anna Finkelstein 1 & Haggi Mezeh 2 &
Natalia Simanovsky 1
Received: 18 November 2015 / Accepted: 15 December 2015
# American Society of Emergency Radiology 2015
Abstract To investigate which clinical, laboratory, and CT
findings potentially facilitate the differential diagnosis be-
tween tubo-ovarian abscess (TOA) and periappendicular
abscess (PAA), we retrospectively reviewed abdominal
CT examinations and medical records for all women who
presented to our medical center with unilateral right pelvic
abscess formation who underwent CT evaluation from
2004–2014. A wide spectrum of clinical data and imaging
findings were recorded. CT diagnoses were made in con-
sensus by two experienced body radiologists blinded to the
final diagnosis. Findings associated with the infections
were compared using the chi-square (χ2) or the Fisher ex-
act test. Ninety-one patients were included; 58 with PAA
(mean age 46 years) and 33 with TOA (mean age 37 years).
Pain on cervical motion (67 %) and vaginal discharge
(21 %) were significantly more common in TOA; other
clinical signs were similar. The presence of right ovarian
vein entering the mass on CT had 100 % specificity and
94 % sensitivity to TOA. Distended right fallopian tube
(79 %), mass posterior to mesovarium (76 %), contralateral
pelvic fat stranding (55 %), and thickening of sacrouterine
ligaments (55 %) were significantly more common in
TOA. Positive "arrowhead sign" (91 %), mesenteric
* Nurith Hiller
hiller@netvision.net.il
1
Department of Radiology, Hadassah Hebrew University Medical
Center, Jerusalem, Israel
2
Surgery, Hadassah Hebrew University Medical Center,
Jerusalem, Israel
3
Department of Radiology, Hadassah Mount Scopus Medical Center,
POB – 24035, Jerusalem 91240, Israel
lymphadenopathy (85 %), small bowel wall thickening
(55 %), fluid in the right paracolic gutter (50 %), and cecal
wall thickening (48 %) were significantly more common in
PAA;internal gas was revealed only in PAA (33 %).
Distinct CT features can increase diagnostic certainty re-
garding the origin of right lower quadrant abscess in
women.
Keywords Tubo-ovarian abscess . Periappendicular abscess .
Computed tomography
Introduction
CT is frequently used for diagnosis of abdominal and pelvic
pain. When a right pelvic abscess is seen in female patients,
the differential diagnosis includes periappendicular abscess
(PAA) versus tubo-ovarian abscess (TOA). An accurate diag-
nosis is important since the management of these conditions is
quite different.
PAA is a frequent complication of acute appendicitis and is
caused by Escherichia coli or Bacteroides in a majority of the
patients [1]. PAA is usually managed with percutaneous drain-
age and antibiotics, and interval appendectomy is generally
indicated [2–5]. TOA is a complication of pelvic inflammato-
ry disease (PID), with ascending vaginal or cervical infections
progressing to endometritis, salpingitis, and later, pyosalpinx.
Spread of infection from the fallopian tubes to the ovaries may
result in unilateral or bilateral TOA. The causative agents are
typically Neisseria gonorrhoeae, Chlamydia trachomatis, or
mixed aerobic and anaerobic flora [6–9]. TOA is usually treat-
ed conservatively with intravenous antibiotics. Percutaneous
drainage or surgery is required in selective cases resistant to
antibiotic treatments.[10, 11].

The majority of female patients presenting to the emergen-
cy department with right lower quadrant pain will undergo
imaging evaluation. Ultrasound is usually used as a primary
diagnostic tool if PID is considered. CT is the imaging exam-
ination of choice when the diagnosis of TOA is not suspected
or when findings at ultrasound are equivocal [12].
The ultrasound, CT, and MRI appearance of PAA and TOA
is very similar; thus, the differential diagnosis based on imag-
ing is often difficult. Several articles have compared the clin-
ical and laboratory findings in acute appendicitis and pelvic
inflammatory disease (PID) [13–15], and one study com-
pared imaging findings [16]. In this paper, comparison
was made between the CT features of TOA in 48 patients
and a group of 84 patients with acute appendicitis, Only 24
patients in this group had a true PAA. The CT findings
described were therefore not specific for PAA. We aimed
to retrospectively identify any definitive clinical, laborato-
ry and, especially, CT findings that may allow confident
differentiation between TOA and PAA.
Patients and methods
IRB approval was obtained for our retrospective study and the
requirement for informed consent was waived.
We retrospectively searched our hospital registry for female
patients who were treated in our medical center for unilateral
right pelvic abscess due to complicated PID or acute appen-
dicitis and who underwent CT evaluation of the abdomen and
pelvis during a 10-year period, starting on January 1, 2004.
Women with bilateral TOA or bilateral pyosalpinx were ex-
cluded. The discharge diagnosis, which was established ac-
cording to surgical findings or clinical follow-up, was consid-
ered as the standard of reference for the correct diagnosis.
For all patients included in the study, medical files were
reviewed for age and clinical and laboratory data. Clinical
parameters included location of abdominal pain, tenderness
on palpation, presence of a palpable mass in the right lower
quadrant (RLQ), tenderness on cervix motion, uterine dis-
charge, signs of peritonitis, leukocytosis (white blood cell
count [WBC] > 10,000), fever, diarrhea, and vomiting.
Treatment received, duration of the hospital stay, and final
diagnosis on discharge were also recorded.
Only CT examinations performed at presentation were
reviewed. CT images were evaluated separately by two expe-
rienced body radiologists (N.H. and N.S., 26 and 23 years of
experience, respectively) on our hospital PACS system
(Centricity PACS, GE Healthcare). The reviewers were
blinded to the original CT reports and to the final clinical
and surgical outcome. Cases of interobserver disagreement
were resolved by consensus.
General CT findings were noted, including abscess diame-
ter, abscess wall thickness, retroperitoneal lymphadenopathy,
Emerg Radiol
and the presence/absence of right hydronephrosis. CT param-
eters that were expected to aid in differential diagnosis were
the appearance of the appendix (normal or abnormal), the
relationship between the abscess and the meso-ovary, a right
ovarian vein entering the mass, a distended right fallopian
tube, a thickened sacrouterine ligament, a thickened cecal wall
and presence of the Barrowhead sign^ (focal thickening of the
cecal wall at the base of the appendix), gas or calcification
inside the abscess, an identifiable/unidentifiable right ovary,
a thickened small bowel or rectosigmoid wall, stranding of
pelvic fat remote from the right lower quadrant (RLQ), RLQ
mesenteric lymph node enlargement (>10 mm), free fluid in
the pelvis, and fluid in the right paracolic gutter. We noted the
presence of each of these CT parameters for every patient.
CT scans were performed using dual-slice CT (Twin Flash,
Phillips HealthCare, Eindhoven, The Netherlands), a 16-slice
scanner (LightSpeed, GE Healthcare, Milwaukee, WI, USA),
or a 128-slice scanner (Optima 660, GE HealthCare,
Milwaukee, WI, USA). Images were acquired at the
hepatoportal phase using standard scan parameters after oral
and IV contrast administration in all patients. Slice thickness
ranged between 5 and 2.5 mm. Coronal and sagittal reforma-
tions were available for each examination.
Statistical analysis was performed for the variables using
the chi-square test (χ2) or the Fisher exact test. P < 0.05 was
considered statistically significant.
Results
A total of 91 patients met inclusion criteria, including 58 who
were treated for PAA (64 %) and 33 who received treatment
for TOA (36 %). The mean age of the PAA group was slightly
higher (mean 43 years, range 18–89), versus a mean of
37 years (range 21–54) in the TOA group. Pain was localized
to the right lower quadrant in 59 % and diffuse in 29 % of PAA
patients. In patients with TOA the pain was diffuse in 47 %
and localized to the RLQ only in 35 % of the cases. Clinical
and laboratory findings in both groups are summarized in
Table 1. Pain on cervical motion and vaginal discharge were
significantly more frequent in the TOA group; however, these
clinical findings appeared in a relatively small number of
patients. Sensitivity, specificity, PPV, and NPV for pain on
cervical motion and vaginal discharge were 67, 93, 83, and
85 %, versus 21, 98, 69, and 87 %, respectively, for differ-
entiating TOA and PAA. In patients with PAA, abdominal
pain was more frequently localized to the RLQ, while
women in the TOA group more frequently described dif-
fuse lower abdominal pain. All other clinical signs were
similar between the groups.
The causative organism was isolated in 19 women with
PAA (33 %) and seven TOA patients (21 %). In most cases,
multiple pathogens were identified. The leading causative
Emerg Radiol

Table 1 Clinical and laboratory data in TOA and PAA groups CT findings contributing to a diagnosis of PAA are sum-
Clinical parameters PAA (N = 58) TOA (N = 33) P value marized in Table 2. The right ovary was seen in 57/58 women
with PAA (98 %, P < 0.0001), achieving a sensitivity of 98 %,
Pain on cervical motion 4 (7 %) 22 (67 %) 0.0001 but specificity of only 67 % since one third of women with
Vaginal discharge 1 (2 %) 7 (21 %) 0.03 TOA also presented a visible right ovary. A positive
Vomiting 12 (21 %) 3 (9 %) 0.15 Barrowhead sign^ had 91 % sensitivity and 94 % specificity
Diarrhea 13 (22 %) 6 (18 %) 0.63 due to its detection in 52/58 cases of PAA (91 %) versus only
Palpable mass 12 (21 %) 1 (3 %) 0.27 2/33 patients with TOA (6 %, P < 0.0001). Findings of gas in
Local tenderness 56 (97 %) 33 (100 %) 0.53 the abscess, appendicolith, and cecal wall thickening were
Peritonitis 18 (31 %) 9 (27 %) 0.7 characteristics of PAA, with specificities of 100, 97, and
Leucokytosis ( 10.000) 42 (75 %) 24 (76 %) 0.88 91 %, respectively (Fig. 1a, b). Sensitivity was lower, since
Fever 38 °C 14 (24 %) 11 (33 %) 0.34 far fewer women presented these findings; nevertheless, the
differences in prevalence for PAA versus TOA were highly
Chi square (χ2 ) test P < 0.05 was considered significant significant (P < 0.0001, P < 0.001, and P < 0.001, respective-
ly). Additional signs that were seen in both PAA and TOA, but
more common in PAA were enlarged mesenteric lymph nodes
agent in patients with PAAwas E. coli (14, 24 %), followed by (P < 0.0001), small bowel wall thickening (p < 001), and fluid
group B streptococcus (12, 21 %) and Bacteroides fragilis (5, in the right paracolic gutter (P < 0.003).
9 %). Among women with TOA, E. coli was isolated in seven CT findings which aided in the diagnosis of TOA are pre-
patients (21 %) and group B streptococcus in three (9 %). sented in Table 3. Detection of an ovarian vein entering the
Other infectious agents such as Staphylococcus aureus, mass had very high sensitivity (94 %) and specificity (100 %)
Actinomyces, Maroxella catarrhalis, Enterococcus faecalis, based on its detection in 31/33 women with TOA (94 %) and
Proteus mirabilis, or Eubacterium lentum were isolated in no case of PAA (P < 0.0001) (Fig. 2). Visualization of a
seven patients with PAA (12 %) and two with TOA (6 %). distended right fallopian tube had 97 % specificity and 79 %
Ten patients with PAA (17 %) and 4 with TOA (12 %) sensitivity due to its detection in 26/33 cases of TOA (79 %)
underwent surgery. Twenty two patients with PAA (38 %) but only 2/58 cases of PAA (3 %, P < 0.0001). Presacral fluid
and eight with TOA (24 %) underwent percutaneous drainage was seen in 11/33 women with TOA but only 3/58 patients
of the abscess. All patients were treated with antibiotics. with PAA (5 %, P < 0.0003) leading to a specificity of 95 %
The maximal axial dimension of the abscess ranged for TOA. Remote fat stranding at the contralateral side of the
from 3 to 99 mm (mean 50 mm) for TOA and 15 mm to pelvis was significantly common in TOA (58 %) as compared
90 mm (mean 47 mm) for PAA (P = 0.471). Abscess wall to PAA (12 %). Thickening of the sacrouterine ligaments,
thickness ranged from 3 to 11 mm (mean 6 mm) for TOA implying deep pelvic infection, were significally more com-
and 3 to 13 mm (mean 6 mm) for TOA (P = 0.177). mon in TOA (39 %) compared to PAA (7 %) (Fig 3a, b).
Enlarged retroperitoneal lymph nodes were present in 54 % Rectosigmoid wall thickening also had high specificity
of TOA and 36 % of PAA patients (P = 0.089). Right (95 %) due to its presence in 11/33 cases of TOA (33 %)
hydronephrosis was detected in 9 % of TOA and 12 % of and only 4/58 of PAA (7 %, p < 0.0001). In women diagnosed
PAA cases (P = 0.742). None of these findings proved useful with PAA, the appendix presented an abnormal appearance in
in differentiating PAA from TOA. 47 cases (81 %), a normal appearance in seven (12 %), and

Table 2 CT findings favoring a diagnosis of PAA

CT Findings PAA (N = 58) TOA (N = 33) P value PPV NPV Sensitivity Specificity Accuracy

Visualization of the right ovary 57 (98 %) 11 (33 %) 0.0001 84 % 96 % 98 % 67 % 88 %

Positive Barrowhead sign^ 52 (91 %) 2 (6 %) 0.0001 96 % 86 % 91 % 94 % 92 %
Enlarged mesenteric lymph nodes > 10 mm 49 (85 %) 11 (33 %) 0.0001 82 % 71 % 85 % 67 % 79 %
Small bowel wall thickening 32 (55 %) 7 (21 %) 0.001 82 % 50 % 55 % 79 % 64 %
Fluid in the right paracolic gutter 29 (50 %) 6 (18 %) 0.003 83 % 48 % 50 % 82 % 62 %
Cecal wall thickening 28 (48 %) 3 (9 %) 0.0001 90 % 50 % 48 % 91 % 64 %
Appendicolith present 19 (33 %) 1 (3 %) 0.001 95 % 45 % 33 % 97 % 57
Gas in the abscess 19 (33 %) 0 (0 %) 0.0001 100 % 46 % 33 % 100 % 58 %

Chi square (χ2 ) test P < 0.05 was considered significant

 Emerg Radiol

Fig. 1 CT of the abdomen and

pelvis in a 27-year-old woman
with PAA in (a) coronal and (b)
axial planes. A large abscess is
seen at the RLQ, adjacent to the
cecum (A). Marked thickening of
the cecal wall is seen with an
"arrowhead sign" (white arrows).
Part of the appendix is visible
with thickened wall and
intraluminal calcified
appendicolith (dashed arrow).
Note effacement of the pelvic fat
only on the right side (black
arrows)

was not observed in four patients (7 %). In women with TOA,
the appendix was abnormal in three cases (9 %), normal in 26
(79 %), and obscure in four (12 %), with the difference reaching
statistical significance (P < 0.0001, the Fisher exact test).
Discussion
Based on our results, CT evaluation would appear to enable a
reliable differential diagnosis between PAA and TOA in wom-
en presenting with acute lower abdominal pain and complex
inflammatory mass at the RLQ. In this patient series, the pres-
ence of an ovarian vein entering the mass on CT had 100 %
specificity and 94 % sensitivity to TOA, and a distended right
tube had 97 % specificity, while the arrowhead sign had 94 %
specificity and 91 % sensitivity for PAA. Internal gas ap-
peared exclusively in PAA. In addition, a variety of other
characteristics detected on contrast CT examinations had sig-
nificantly different prevalence in the two groups of patients.
Several publications have described the CT features of
appendiceal and adnexal pathologies including TOA and
PAA [17–23]/ Only one study compared imaging findings in
PID and acute appendicitis [16]. The authors compared TOA
to acute appendicitis including 24 cases of true PAA and
found a significantly higher prevalence of an abnormal ovary,
periovarian fat stranding, and rectosigmoid wall thickening in
patients with PID, compared with significantly greater preva-
lence of cecal wall thickening and pericecal fat stranding in
acute appendicitis. Generally, our findings are in concordance
with these results, although Eshed et al. have described inter-
nal gas in 12 % of cases with TOA, as opposed to no such case
in our study. In our series, which included only patients with
more severe cases of these infections who presented with ab-
scess formation, a large number of specific CT findings were
investigated and all were associated with significant differ-
ences in frequency among patients diagnosed with PAA ver-
sus those with TOA. In 98 % of patients with TOA, the right
ovarian vein could be seen entering the abscess; thus, this sign
may be very useful when trying to differentiate between an
adnexal or appendiceal origin of RLQ abscess. Location of the
abscess posterior to meso-ovary, contralateral fat involvement
(due to the more diffuse nature of the pelvic infection),

Table 3 CT findings favoring a diagnosis of TOA

CT findings TOA (N = 33) PAA (N = 58) P value PPV NPV Sensitivity Specificity Accuracy

Right ovarian vein entering mass 31 (94 %) 0 (0 %) 0.0001 100 % 97 % 94 % 100 % 99 %

Distended right tube 26 (79 %) 2 (3 %) 0.0001 93 % 88 % 79 % 97 % 91 %
Mass posterior to right mesovarium 25 (76 %) 9 (16 %) <0.0001 74 % 86 % 76 % 84 % 82 %
Sacrouterine ligament thickening 18 (55 %) 7 (12 %) 0.0001 72 % 77 % 55 % 88 % 77 %
Contralateral fat stranding 19 (58 %) 7 (12 %) 0.0001 73 % 78 % 58 % 88 % 78 %
Rectosigmoid wall thickening 13 (39 %) 4 (7 %) <0.0001 76 % 73 % 39 % 93 % 74 %
Presacral fluid 11 (33 %) 3 (5 %) <0.0003 79 % 71 % 33 % 95 % 73 %
Free fluid in the pelvis 21 (64 %) 18 (31 %) <0.003 54 % 77 % 64 % 69 % 68 %

Chi square (χ2 ) test P < 0.05 was considered significant

Emerg Radiol

mesosalpinx normally arches anteriorly and superiorly to the

Fig. 2 Coronal image of abdominal-pelvic CT in a 37-year-old woman
with right TOA (A). The right gonadal vein is slightly dilated and is
clearly entering the abscess (white arrow). Thickening of neighboring
small bowel loops is demonstrated (dashed black arrow). Note hyperemia
of the mesentery at the left upper abdomen, remotely from the abscess
(black arrows)
sacrouterine ligaments involvement (result of deep pelvic in-
fection), and rectosigmoid wall thickening, as well as a
distended right fallopian tube were significantly more com-
mon in TOA patients.
The mesosalpinx is the part of the broad ligament between
the ovarian ligament, ovary, and fallopian tube. Because the
mesovarium and ovary, location of the abscess posterior to the
mesovarium was much more common in TOA. The adnexa
are located relatively deep in the pelvis, and inflammation
originating from the adnexa is more likely to involve deep
pelvic structures such as the sacro-uterine ligaments and
rectosigmoid wall. In addition, reactive fluid is more com-
mon in the presacral and Douglas space if the origin of
pathology is in the pelvis. These findings are consistent
with previous papers describing the CT appearance of
TOA [19]. As PID is usually a diffuse and often bilateral
process, pelvic fat stranding may be present diffusely even
in cases of unilateral adnexal abscess, including stranding
that is contralateral to the abscess.
In cases of PAA, the right ovary could be identified in the
majority of the cases, especially when following the right
gonadal vein into the pelvis. The infection in these cases
was more localized to the right lower quadrant and cecal area,
resulting in more frequent visualization of the arrowhead sign
[24] as well as thickening of cecal and adjacent small bowel
walls. Free peritoneal fluid was most commonly located in
the right paracolic gutter and reactive lymphadenopathy
was common at the right mesentery. Internal appendicolith
was present in only 33 % of women with PAA. We were
able to identify a normally appearing appendix in seven
patients with PAA. These cases may represent tip appendi-
citis complicated to PAA.
Although gynecological origin is always considered in a
female patient with an acute abdominal pain, the spectrum
of differential diagnosis is wide and clinical symptoms over-
lap. Defining the origin of a RLQ abscess in young females is
potentially problematic, but may often be essential to ensure
appropriate management, including consideration of interval
appendectomy.
In cases when a normal appendix could be visualized or
bilateral tubo-ovarian abscesses are seen, the diagnosis is
straight forward. However, when a female patient of reproduc-
tive age presents with unilateral right pelvic abscess and no

Fig. 3 a Axial images from

pelvic CT of a 38-year-old female
with right TOA (A). The mass is
located posterior to the right
mesovarium (M), deep in the pel-
vis. Anterior pelvic fat effacement
is seen bilaterally (white arrows).
b Axial CT image at the level of
the cervix showing thickening of
the sacrouterine ligaments (black
arrows) and small amount of
presacral fluid (dashed arrow)

appendix or appendicolith is visualized, the differential diag-
nosis becomes more difficult. Previous studies comparing
clinical and laboratory findings in acute appendicitis and
PID [13–15] found that patients with appendicitis tend to pres-
ent with vomiting, anorexia, focal abdominal pain, and leuko-
cytosis, with left shift appearing more frequently compared to
patients with PID. Clinical symptoms, including pain location,
are not very helpful in the differentiation between these con-
ditions. Tenderness on cervix motion, vaginal discharge, and
diffuse abdominal tenderness were more frequently observed
in patients with PID. Our results support these findings, but
among all the clinical and laboratory signs, we found that only
differences in the prevalence of tenderness on cervix motion
and vaginal discharge reached statistical significance. In addi-
tion, these findings were not frequent in patients with TOA
and therefore have low practical reliability.
Our study has several limitations inherited mainly from its
retrospective nature. In addition, although data was collected
for a period spanning 10 years in a large medical center, the
number of patients was relatively small, especially in the TOA
group. This is probably due to the fact that patients with TOA
are usually diagnosed and followed with ultrasound, without
the need for CT. The long study period also spanned years of
major technical advances in computed tomography; thus,
some imaging studies in the series were performed using pre-
vious generation CT scanners. In addition, not all patients had
pathologic/surgical confirmation, and there could be cases
where the exact origin of the abscess is not clear. The next
step would be to see how these criteria perform when applied
prospectively.
Conclusions
Differentiation between TOA and PAA when RLQ abscess is
present in a young woman is a diagnostic challenge.
Familiarity with all CT features of PAA and TOA in case of
RLQ abscess is crucial for accurate diagnosis and appropriate
treatment. The most accurate CT characteristic was identifica-
tion of ovarian vein entering the inflammatory mass in TOA
patients. Inflammatory changes involving the deep pelvis and
contralateral pelvic fat are more consistent with TOA while
CT changes located in the pericecal area, cecal wall thicken-
ing, and gas in the abscess cavity are more likely to originate
from the appendix.
Acknowledgment The authors wish to thank Shifra Fraifeld, a medical
writer and research associate in the Department of Radiology, for her
editorial assistance with the preparation of this material.
Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict of
interest.
Emerg Radiol
References
1. Weigelt JA (2007) Empiric treatment options in the manage-
ment of complicated intra-abdominal infections. Cleve Clin J
Med 74(Suppl 4):S29–S37
2. Brown CV, Abrishami M, Muller M, Velmahos GC (2003)
Appendiceal abscess: immediate operation or percutaneous drain-
age? Am Surg 69:829–832
3. Gee D, Babineau TJ (2004) The optimal management of adult
patients presenting with appendiceal abscess: "conservative" vs im-
mediate operative management. Curr Surg 61:524–528
4. Lasson A, Lundagards J, Loren I, Nilsson PE (2002) Appendiceal
abscesses: primary percutaneous drainage and selective interval ap-
pendicectomy. Eur J Surg 168:264–269
5. Oliak D, Yamini D, Udani VM et al (2001) Initial nonoperative
management for periappendiceal abscess. Dis Colon Rectum 44:
936–941
6. Eschenbach DA, Buchanan TM, Pollock HM et al (1975)
Polymicrobial etiology of acute pelvic inflammatory disease. N
Engl J Med 293:166–171
7. Soper DE, Brockwell NJ, Dalton HP (1992) Microbial etiology of
urban emergency department acute salpingitis: treatment with
ofloxacin. Am J Obstet Gynecol 167:653–660
8. Sweet RL, Draper DL, Schachter J, James J, Hadley WK, Brooks
GF (1980) Microbiology and pathogenesis of acute salpingitis as
determined by laparoscopy: what is the appropriate site to sample?
Am J Obstet Gynecol 138:985–989
9. Sweet RL (2009) Treatment strategies for pelvic inflammatory dis-
ease. Expert Opin Pharmacother 10:823–837
10. Lareau SM, Beigi RH (2008) Pelvic inflammatory disease and
tubo-ovarian abscess. Infect Dis Clin North Am 22:693–708
11. Sweet RL (2001) Anaerobic-aerobic pelvic infection and pelvic
abscess. In: Sweet RL, Gibbs RS (eds) Infectious diseases of the
female genital tract, 4th edn. Lippincott Williams & Wilkinspp,
Philadelphia, pp 189–206
12. Schuler JG, Shortsleeve MJ, Goldenson RS, Perez-Rossello JM,
Perlmutter RA, Thorsen A (1998) Is there a role for abdominal
computed tomographic scans in appendicitis? Arch Surg 133:
373–376
13. Bongard F, Landers DV, Lewis F (1985) Differential diagnosis of
appendicitis and pelvic inflammatory disease. A prospective analy-
sis. Am J Surg 150:90–96
14. Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y
(2007) Clinical prediction rule to distinguish pelvic inflammatory
disease from acute appendicitis in women of childbearing age. Am J
Emerg Med 25:152–157
15. Webster DP, Schneider CN, Cheche S, Daar AA, Miller G (1993)
Differentiating acute appendicitis from pelvic inflammatory disease
in women of childbearing age. Am J Emerg Med 11:569–572
16. Eshed I, Halshtok O, Erlich Z et al (2011) Differentiation between
right tubo-ovarian abscess and appendicitis using CT—a diagnostic
challenge. Clin Radiol 66:1030–1035
17. Feldberg MA, Hendriks MJ, van Waes PF (1985) Computed to-
mography in complicated acute appendicitis. Gastrointest Radiol
10:289–295
18. Gale ME, Birnbaum S, Gerzof SG, Sloan G, Johnson WC, Robbins
AH (1985) CT appearance of appendicitis and its local complica-
tions. J Comput Assist Tomogr 9:34–37
19. Hiller N, Sella T, Lev-Sagi A, Fields S, Lieberman S (2005)
Computed tomographic features of tuboovarian abscess. J Reprod
Med 50:203–208
20. Jeong WK, Kim Y, Song SY (2007) Tubo-ovarian abscess: CT and
pathological correlation. Clin Imaging 31:414–418
21. Wilbur AC, Aizenstein RI, Napp TE (1992) CT findings in
tuboovarian abscess. AJR Am J Roentgenol 158:575–579
Emerg Radiol
22. Gaetke-Udager K, Maturen KE, Hammer SG (2014) Beyond acute
appendicitis: imaging and pathologic spectrum of appendiceal pa-
thology. Emerg Radiol 21(5):535–542
23. Martin M, Lubrano J, Azizi A, Paquette B, Badet N, Delabrousse E
(2015) Inflammatory appendix mass in patients with acute
appendicitis: CT diagnosis and clinical relevance. Emerg Radiol
22(1):7–12
24. Rao PM, Wittenberg J, McDowell RK, Rhea JT, Novelline RA
(1997) Appendicitis: use of arrowhead sign for diagnosis at CT.
Radiology 202:363–366