Pinto Leite Abdominal Imaging • Review

et al.
CT of
Appendicitis

CT Evaluation of Appendicitis
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and Its Complications:

Imaging Techniques and
Key Diagnostic Findings
Nuno Pinto Leite1 OBJECTIVE. This article reviews various CT protocols for appendicitis, identifies key CT
José M. Pereira1 findings for diagnosing appendicitis, discusses unusual manifestations such as chronic and re-
Rui Cunha1 current appendicitis, and profiles imaging features that differentiate appendicitis from other in-
Pedro Pinto1,2 flammatory and neoplastic ileocecal conditions. Patients were studied with helical CT.
Claude Sirlin1,3 CONCLUSION. CT is a highly accurate, noninvasive test for appendicitis, but the opti-
mal CT technique is controversial. Major complications of appendicitis (perforation, abscess
Pinto Leite N, Pereira JM, Cunha R, Pinto P, formation, peritonitis, bowel obstruction, septic seeding of mesenteric vessels, gangrenous ap-
Sirlin C pendicitis) and their management are discussed. Abdominal CT is a well-established technique
in the study of acute abdominal pain and has shown high sensitivity and specificity for diag-
nosing and differentiating appendicitis, providing an accurate diagnosis in the early stages of
disease.

cute appendicitis is one of the pendicitis, especially in children [11–18].

A most common causes of acute ab-

Received September 22, 2004; accepted after revision
December 6, 2004.
Presented at the 2004 annual meeting of the American
Roentgen Ray Society, Miami Beach, FL.
Dedicated to our friend and colleague, Pedro Pinto
(1969–2004).
1Department of Radiology, Hospital São João,
Oporto Medical School, Oporto, Portugal.
2Deceased.
3Present address: Department of Radiology, University of
California, San Diego, 200 W Arbor Dr., San Diego, CA
92103–8756. Address correspondence to C. Sirlin.
AJR 2005; 185:406–417
0361–803X/05/1852–406
© American Roentgen Ray Society
dominal pain, the most common
condition that requires abdominal
surgery in childhood, and the most common
condition associated with lawsuits against
emergency physicians.
Acute appendicitis occurs when the appen-
diceal lumen is obstructed, leading to fluid
accumulation, luminal distention, inflamma-
tion, and, finally, perforation [1–4]. Classic
symptoms of appendicitis are well described
[5]. However, up to one third of patients with
acute appendicitis have atypical presentations
[6]. Moreover, patients with alternative ab-
dominal conditions may present with clinical
findings indistinguishable from acute appen-
dicitis [7]. Thus, although appendicitis tradi-
tionally has been a clinical diagnosis, many
patients are found to have normal appendixes
at surgery. The misdiagnosis of this acute
condition has led to the inappropriate removal
of a normal appendix in 8–30% of patients
[8]. A rate of unnecessary removal as high as
20% has been considered acceptable in the
surgery literature [9, 10]. However, negative
laparotomy can be avoided in many patients if
modern diagnostic methods are used to con-
firm or exclude acute appendicitis.
In the mid 1980s, graded-compression
sonography emerged as a promising imaging
technique for the evaluation of suspected ap-
Sonography is a noninvasive, rapid, widely
available, and relatively inexpensive tech-
nique. Most important, sonography does not
involve the use of ionizing radiation, a key
consideration when imaging otherwise
healthy pediatric and young adult patients,
who are up to 10 times more sensitive to the
effects of radiation than are middle-aged and
elderly adults [19–21]. On the other hand,
sonography is highly operator-dependent, re-
quires a high level of skill and expertise, and
may be difficult in some situations (severe
pain, overlying gas). Sonography is particu-
larly challenging in large and overweight
adults, which is a major limitation to its use in
North America and parts of Europe. More-
over, sonography frequently does not allow
the detection of normal or perforated appen-
dixes [12, 17, 22–29]; thus, sonography may
be of limited benefit in evaluating patients at
the extremes of the disease spectrum. The re-
ported diagnostic accuracy of graded com-
pression sonography varies widely; reported
sensitivity of sonography in children ranges
from 44% to 94%, and specificity, from 47%
to 95% [11–13, 16–18, 25, 30]. In 1995, Orr
et al. [31] performed a meta-analysis of pediat-
ric and adult studies published between 1986
and 1994, showing an overall sonography
sensitivity of 85% and specificity of 92%.
Anecdotally, our personal experience with

406 AJR:185, August 2005

 CT of Appendicitis

Fig. 1—CT scan after oral contrast administration in 32-year-old woman with normal
appendix. Note normal appendix with intraluminal enteric contrast material and gas
(arrows). Appendix wall is nearly imperceptibly thin.
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A B
Fig. 2—6-year-old girl with acute appendicitis.
A and B, CT scans obtained before (A) and after (B) IV contrast administration illustrate benefit of IV contrast material in difficult cases. Unenhanced scan is indeterminate
because appendix is not confidently visualized. Enhanced scan shows dilated appendix with thickened, hyperenhancing wall (arrows, B). Notice mural stratification of appen-
dix wall.

sonography in the diagnosis of appendicitis
has been disappointing. We reserve sonogra-
phy as the initial examination in children, ad-
olescents, thin adults, and women of repro-
ductive age with possible gynecologic
presentations, but if the sonographic results
are negative or inconclusive, we generally
proceed with CT.
CT has high accuracy for the noninvasive
assessment of patients with suspected appendi-
citis, with reported sensitivities of 88–100%,
specificities of 91–99%, positive predictive
values of 92–98%, negative predictive values
of 95–100%, and accuracies of 94–98% [8,
32–34], and has emerged as the technique of

AJR:185, August 2005 407

 Pinto Leite et al.
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Fig. 3—38-year-old man with early, acute appendicitis. Unenhanced CT scan shows Fig. 4—20-year-old man with acute appendicitis. Oral and IV contrast-enhanced CT
inflamed appendix measuring 10 mm in transverse diameter (arrows). Note low- scan shows thickened, fluid-filled appendix (arrows).
attenuation edema in submucosal layer of appendix. No appendicoliths, free air,
adjacent fluid collection, or fat stranding is seen. Surgery confirmed early, nonper-
forated appendicitis.

choice in many centers for imaging evaluation
of these patients [35–37]. More recently, sev-
eral authors have also reported the accuracy of
helical CT for the diagnosis of acute appendi-
citis in children [11, 36, 38–40]. Important ad-
vantages of CT are that it depicts the appendix,
the periappendiceal tissues, and other intraab-
dominal structures. Thus, CT allows the radi-
ologist to confidently exclude appendicitis if a
normal appendix is visualized and to diagnose
appendicitis if the appendix is abnormal. Im-
portantly, by depicting the severity and exten-
sion of the inflammatory process, CT can also
help guide appropriate management. CT has
several important disadvantages, however.
The most serious is that it uses ionizing radia-
tion. Radiation dose depends on CT technique.
This article reviews CT technique, key CT
findings, complications, unusual manifesta-
tions, and differential diagnosis.
CT Technique
Because visualization of both the normal
(Fig. 1) and the inflamed appendix can be chal-
lenging, especially in asthenic patients with a
paucity of visceral fat [41], meticulous tech-
nique is important. Nevertheless, the optimal
CT technique for appendicitis remains contro-
versial, and a variety of methods have been ad-
vocated. It is generally accepted that appen-
diceal CT should incorporate thin-section
scanning (5 mm) through the right lower quad-
rant (RLQ) to improve identification of the ap-
pendix, but debate exists regarding the need for
IV contrast material, the use and route of en-
teric contrast agents, and the necessity for
scanning the entire abdomen and pelvis versus
performing a focused data acquisition through
the RLQ. The most commonly used CT tech-
nique for studying the appendix is a scan of the
entire abdomen and pelvis after both oral and
IV administration of contrast material [42], but
several other approaches are possible. We de-
scribe the most commonly used CT techniques
in the evaluation of appendicitis.
Unenhanced CT
Some centers advocate examination without
oral or IV contrast material [8, 32]. Unen-
hanced scanning eliminates patient prepara-
tion time to receive enteric contrast material—
thus expediting the examination and diminish-
ing the risk of appendiceal perforation before
scanning—and also eliminates the risks asso-
ciated with IV contrast injection. Ege et al. [41]
reported a sensitivity of 96%, specificity of
98%, positive predictive value of 97%, and
negative predictive value of 98%. On the basis
of these results, the authors recommended that
if no definite inflammatory changes are de-
tected with unenhanced CT, patient clinical
monitoring could be done [43]. However,
other authors found less promising results for
unenhanced CT. Heaston et al. [3] showed a
sensitivity of 84% and a specificity of 92%.
Our anecdotal experience is that unenhanced
CT accuracy probably depends on the patient’s
body habitus (particularly visceral fat content),
although to our knowledge this hypothesis has
not yet been tested.
Focused CT
Some authors advocate a focused CT exam-
ination from the right renal lower pole through
the entire pelvis with various combinations of
oral, rectal, and IV contrast media. Focused CT
has the advantage of decreasing patient radia-
tion dose, which is especially desirable in pe-

408 AJR:185, August 2005


diatric patients [34, 42, 44, 45]. In one study,
Fefferman et al. [44] reported high sensitivity
(97%), specificity (93%), positive predictive
value (90%), and negative predictive value
(98%). However, the focused CT technique
has some limitations. In one study of 100 pa-
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tients presenting to the emergency department
with RLQ pain, Kamel et al. [45] showed that
if only focused CT had been performed, 7% of
patients with abnormalities outside the pelvis
(4% of whom required surgery) would be un-
diagnosed. They concluded that both abdomi-
nal and pelvic CT examinations are necessary
because there are many possible upper abdom-
inal causes of RLQ pain in patients with clini-
cally suspected appendicitis.
Use of Enteric Contrast Material
Most investigators recommend the use of
enteric contrast material, either oral or rectal
[33, 46–49], claiming that positive enteric
contrast material decreases the number of
false-negative cases and improves character-
ization of appendicitis and detection of its
complications.
Rectal administration—Cecal opacifica-
tion and distention may be achieved by rec-
tal administration of 800–1,500 mL of con-
trast material [33, 43, 49]. The contrast agent
is given with the patient on the CT gurney as
a bolus under gravity control without fluoro-
scopic visualization. Several studies have
shown high accuracy of appendicitis CT in
both adults and children after rectal contrast
material administration [34, 43, 50]. In one
study, helical CT with rectal contrast mate-
rial was as accurate (98%) as helical CT with
both oral and rectal contrast material [33].
Rectal contrast material distends the cecum,
delineates the thickness of its wall, and
opacifies an unobstructed appendix. By dis-
tending the cecal lumen, this technique de-
picts several cecal signs of appendicitis, in-
cluding the arrowhead sign, the “cecal bar”
sign, and focal cecal apical thickening
[46–49]. These signs are discussed further in
the subsection Cecal Changes under Key CT
Findings. An important advantage of rectal
contrast administration is that it is relatively
fast to perform and the patient does not need
to wait the 1–2 hr usually required with the
oral route for terminal ileal and cecal visual-
ization. Disadvantages of routine rectal con-
trast administration include patient discom-
fort, inconsistent opacification of the
terminal ileum, and logistical or procedural
difficulties. Rectal contrast material is con-
traindicated in neutropenic patients and
AJR:185, August 2005
CT of Appendicitis
those with peritoneal signs or other evidence
of gross perforation.
Oral administration—Distal small-bowel
and cecal opacification may be achieved by
oral administration of 800–1,000 mL of con-
trast material in small increments over 1.5–2
hr. Opacification of these structures is often
helpful because otherwise they may mimic or
obscure an abnormal appendix. Unfortunately,
oral contrast administration delays the exami-
nation. Moreover, optimal opacification of the
ileocecal region is often not achieved because
of variability in gastrointestinal transit time
and patient compliance; patients with abdomi-
nal pain are often nauseated and may not toler-
ate oral contrast material [51]. In our experi-
ence, oral contrast material is not usually
beneficial except in cases of perforation, when
oral contrast material can help identify extralu-
minal fluid collections.
Use of IV Contrast Material
Although some authors believe that the
use of enteric contrast material alone is ade-
quate to diagnose appendicitis, other authors
believe that IV contrast material is neces-
sary. IV contrast material can be especially
helpful in subtle cases and in patients with
minimal intraabdominal fat by showing en-
hancement of the appendiceal wall [49,
52–54] (Fig. 2). Complications such as ap-
pendiceal perforation, extraappendiceal
fluid collections, abscess formation, and
septic seeding of the mesenteric–portal
venous system are also better characterized
after IV contrast administration [52, 55].
Furthermore, IV contrast material is useful
to diagnose and assess other causes of ab-
dominal pain, including pancreatitis, inflam-
matory bowel disease, and pyelonephritis
[49, 52–55]. Disadvantages include possible
adverse reactions and costs.
Unenhanced CT with Selective
Use of Contrast Material
An alternative, theoretically more elegant
approach, is unenhanced CT with the selective
use of contrast material. In this approach, pa-
tients with suspected appendicitis are initially
evaluated with unenhanced CT. If unenhanced
images are conclusive (i.e., positive or nega-
tive for appendicitis), no further imaging is
necessary. However, if findings are inconclu-
sive, a repeat scan is performed with contrast
material. The type of contrast material (IV,
oral, rectal) and the imaging volume (e.g., fo-
cused RLQ scan or scan of the entire abdomen
and pelvis) are chosen by the interpreting radi-
ologist. This approach permits immediate im-
aging assessment of patients with suspected
appendicitis and rational choice of contrast
material tailored to a particular patient if the
preliminary unenhanced scan is inconclusive.
Disadvantages of this approach are that it re-
quires monitoring by the radiologist to deter-
mine whether contrast administration is
needed and that it results in additional scan-
ning in patients in whom unenhanced images
are inconclusive, thereby increasing radiation
exposure and potentially delaying diagnosis.
Tamburrini et al. [56] found that in 25% of pa-
tients, the preliminary images were inconclu-
sive and additional scanning with contrast ma-
terial was necessary. The frequency with
which additional scanning is necessary may be
influenced by patient demographic factors
(age, sex) and visceral fat content; this is under
active investigation.
Our Approach
The large number of proposed CT tech-
niques presents a challenge to radiologists
who wish to start using CT for diagnosis of
appendicitis at their institution. The simplest
and most widely used technique is CT with
both oral and IV contrast material. However,
as discussed previously, we find that positive
oral and IV contrast material are not helpful in
most patients.
On the basis of our personal experience
and to satisfy the needs of our emergency de-
partment colleagues, we tailor our protocol
according to the patient’s clinical presenta-
tion and other factors. If the patient is a
child, adolescent, thin young adult, or repro-
ductive-age woman with a possible gyneco-
logic source of pain, try sonography first; if
that is inconclusive, perform CT with IV
contrast material. If the patient is a large
adult, try unenhanced CT with selective use
of contrast material. This method expedites
the CT examination, which is critical for our
emergency department physicians. If the
symptoms have persisted for more than 72
hr, try CT with oral and IV contrast material
because of the high probability of perfora-
tion. If the patient has a history of cancer,
inflammatory bowel disease, immune defi-
ciency, or lower abdominal or pelvic sur-
gery, try CT with oral and IV contrast ma-
terial because there is a high pretest
probability of disorders other than appendi-
citis and possibly distorted anatomy.
The individualized approach advocated
here may be impractical in nonacademic in-
stitutions or in institutions that rely on remote
409
 Pinto Leite et al.

coverage of after-hours cases. A uniform pro-
tocol may be preferred. The chosen protocol
must satisfy the needs of referring clinicians
and be appropriate for the patient population.
Our emergency department colleagues, for
example, place a premium on expediting the
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gorithm for the interpretation of CT find-
ings. This algorithm is based on personal ex-
perience and the authors’ interpretation of
presented and published data. It has not been
tested. Testing and refinement of the pro-
posed algorithm will require further study.
ening of the lateral conal fascia (Fig. 7) and
mesoappendix, extraluminal fluid (Fig. 7),
phlegmon, abscess (Fig. 10), ileocecal mild
lymph node enlargement, and inflammatory
thickening of contiguous structures. Struc-
tures that may be secondarily inflamed de-

examination, and most of our patients are
overweight adults. For this reason, we per-
form unenhanced CT with the selective use of
contrast material in most patients.
Key CT Findings
CT findings of acute appendicitis are di-
vided into appendiceal, cecal, and periappen-
diceal changes [4, 34, 46, 57].
Appendiceal Changes
One of the CT hallmarks of acute appen-
dicitis is appendiceal thickening (Figs. 3 and
4). Most authors have extrapolated from the
sonography literature on appendicitis [27]
and define appendiceal thickening on CT as
outer-wall-to-outer-wall transverse diameter
greater than 6 mm. Unfortunately, sono-
graphic data of appendiceal diameter were
based on images obtained with graded
compression of the RLQ, which may alter
appendiceal diameter, whereas CT images are
obtained without compression. Thus, extrapola-
tion from sonography to CT may not be valid.
For this and other reasons, some authors define
appendiceal thickening on CT as transverse
diameter greater than 7 mm [11]. However,
even a diameter threshold of 7 mm may be
inappropriate. Brown et al. [58] showed that
the normal appendix measures greater than
6 mm in 42% of asymptomatic outpatient
adults; they defined the upper limit of nor-
mal as 10 mm. On the basis of these results,
an appendiceal diameter of 6–10 mm is in-
determinate. Because of considerable over-
lap between the normal and abnormal appen-
dix, we believe that any single-diameter
threshold is too simplistic. Instead, the ap-
pendiceal diameter probably should be inter-
preted in the context of clinical and other CT
findings. Table 1 summarizes a proposed al-
Additional appendiceal signs include ap-
pendiceal wall thickening (wall ≥ 3 mm)
(Figs. 5 and 6), appendiceal wall hyperen-
hancement (Figs. 2 and 4–6), mural stratifica-
tion of the appendiceal wall (Fig. 2), appendi-
colith(s) (Figs. 5 and 7), and intramural gas.
Appendicoliths are present in one third of pa-
tients with appendicitis. Although associated
with appendicitis, appendicoliths are not di-
agnostic and have low specificity as isolated
findings because they are commonly present
in asymptomatic subjects. Appendicoliths
may have prognostic importance, however,
because their presence increases the likeli-
hood of appendiceal perforation (Fig. 5; also
see the following text).
Cecal Changes
Key CT findings involving the cecum
involve the cecal apex and include cecal api-
cal thickening (Fig. 8), the arrowhead sign
(Fig. 9), and the cecal bar sign. Diffuse as op-
posed to apical cecal thickening is also possi-
ble, but this is less specific for appendicitis.
The arrowhead sign refers to focal cecal wall
thickening centered on the appendiceal ori-
fice: enteric contrast material in the cecal lu-
men points to the abnormal appendix and as-
sumes a triangular configuration, mimicking
an arrowhead. The cecal bar sign refers to in-
flammatory soft tissue at the base of the ap-
pendix that separates the appendix from the
contrast-filled cecum. The cecal arrowhead
and bar signs are applicable only in patients in
whom enteric contrast material distends the
cecum; these signs are best visualized after
rectal contrast administration.
Inflammatory Changes in RLQ
Periappendiceal inflammation includes pe-
riappendiceal fat stranding (Figs. 5–7), thick-
pend on the anatomic location of the appendix
and include the ascending colon, terminal il-
eum, sigmoid, and urinary bladder (Fig. 6).
Periappendiceal signs are not specific for ap-
pendicitis [4], however, because they are
present in a wide spectrum of other RLQ dis-
orders. Moreover, the sensitivity of these
signs may be decreasing because CT is being
performed earlier in the course of acute ap-
pendicitis. This gradual change in practice
has reduced the prevalence and severity of pe-
riappendiceal fat stranding and other inflam-
matory changes on CT [57].
Comparison of Individual CT Signs
In a recent study, Choi et al. [57] per-
formed a statistical analysis of the individual
CT findings and concluded that appendiceal
enlargement, appendiceal wall thickening,
periappendiceal fat stranding, and appen-
diceal wall enhancement were significantly
more associated with acute appendicitis than
with other findings.
Major Complications
Perforation
If appendicitis is allowed to progress, por-
tions of the appendiceal wall eventually be-
come ischemic or necrotic [1, 59] and the ap-
pendix perforates. On CT, perforation is
suggested by the presence of localized peri-
appendiceal inflammation, although this is a
nonspecific finding. Interestingly, visualiza-
tion of appendicoliths on CT increases the
probability of appendiceal perforation [1,
27, 60], possibly because appendicoliths ac-
celerate the rate at which perforation occurs.
Thus, the presence of one or more appendi-
coliths in association with periappendiceal
inflammation is virtually diagnostic of per-
foration [60] (Figs. 5 and 7). Even in the ab-

TABLE 1: Proposed Algorithm for Interpretation of Appendicitis CT in Symptomatic Patients

Interpretation CT Findings Recommendation
Excludes appendicitis < 6-mm appendix or > 6-mm appendix completely gas-filled Work up other causes of RLQ pain
Possible appendicitis 6- to 10-mm appendix without any other CT signs Observation if symptomatic
Probable appendicitis 6- to 10-mm appendix + WT + WHE (no FS) Surgery if symptomatic
Definite appendicitis > 10-mm appendix or 6- to 10-mm appendix + WT + WHE + FS Surgery if symptomatic
Note—This algorithm is based on authors’ personal experience and interpretation of published data from their and other institutions. Accuracy of the proposed algorithm
has not been tested. RLQ = right lower quadrant, WT = wall thickening (appendiceal wall ≥ 3 mm), WHE = wall hyperenhancement, FS = fat stranding.

410 AJR:185, August 2005

 CT of Appendicitis
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Fig. 5—33-year-old man with acute appendicitis. Axial oblique reformatted image of Fig. 6—27-year-old woman with acute appendicitis. Axial CT image after IV and oral
CT study after administration of oral and IV contrast material shows distended contrast administration shows thickened appendiceal wall, with wall enhancement
appendix with wall enhancement (arrow) and appendicolith (arrowhead). Note peri- (arrow) and fat stranding. Note thickening of adjacent bladder wall (arrowheads)
appendiceal fat stranding. Surgery confirmed perforated appendix. caused by inflammatory process.

Fig. 7—32-year-old man with acute appendicitis. Unenhanced CT shows appendi- Fig. 8—17-year-old boy with acute appendicitis. CT with oral contrast material
colith (arrowhead), periappendiceal fat stranding (black arrows), lateral conal fascia shows cecal apical wall thickening (arrowheads).
thickening (white arrow), and periappendiceal fluid.

sence of periappendiceal changes, a CT find- study, Horrow et al. [61] showed that a ded- enhancing appendiceal wall—allows excel-
ing of a thickened appendix and one or more icated search for five specific CT findings— lent sensitivity (95%) and specificity (95%)
appendicoliths is suspicious for perforation extraluminal air, extraluminal appendi- for perforation in patients with known ap-
or impending perforation. In a retrospective colith, abscess, phlegmon, and a defect in the pendicitis who underwent preoperative CT.

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Fig. 9—16-year-old girl with acute appendicitis. Axial CT after oral and IV contrast Fig. 10—47-year-old man with periappendiceal abscess. Helical CT after IV contrast
material shows cecal wall thickening around appendiceal orifice. Enteric contrast injection shows periappendiceal abscess extending into psoas muscle (arrow-
material in cecal lumen points to enlarged appendix (arrow) and assumes triangular heads).
configuration (arrowhead sign [arrowhead]).

A B
Fig. 11—21-year-old man with mesenteric adenitis.
A and B, Unenhanced axial CT shows enlarged mesenteric lymph nodes (A, arrows) and normal appendix (B, arrowhead).

412 AJR:185, August 2005

 CT of Appendicitis
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Fig. 12—41-year-old man with cecal diverticulitis. Helical CT after oral and IV con- Fig. 13—52-year-old woman with epiploic appendagitis. Axial IV contrast-enhanced
trast administration shows diverticulum in cecum (arrow) and mild surrounding fat CT shows small fat-attenuation lesion (arrowhead) adjacent to right colon with round
stranding. Note normal appendix (arrowhead) and engorged vasa recta. hyperdense focus in center (arrow). Note also asymmetric thickening of adjacent
colon and infiltration of mesenteric fat.

In that study, the individual finding with
highest sensitivity was a mural enhancement
defect (64%).
Periappendiceal Abscess
Abscess is the most frequent complication
of perforation. The abscess remains localized
if periappendiceal fibrinous adhesions develop
before rupture. CT shows a loculated, rim-en-
hancing fluid collection that may have mass ef-
fect on adjacent bowel loops [59] (Fig. 10). If
the abscess is large (> 4 cm), percutaneous
drainage followed by delayed appendectomy
is the preferred treatment [43].
Peritonitis
Bacterial peritonitis, a dangerous compli-
cation, is due to early appendiceal rupture
before formation of inflammatory adhe-
sions. This complication is more common in
young children because progression to per-
foration tends to be rapid [59, 62]. CT and
sonography show interloop fluid and
free-fluid tracking along the peritoneal re-
flections, sometimes far from the appendix.
Common locations are the pelvis; the para-
colic gutters; and the subhepatic, sub-
phrenic, and hepatorenal spaces. Fluid in the
lesser sac suggests other diagnoses, such as
pancreatitis or perforated peptic ulcer. Con-
trast-enhanced CT helps differentiate bacte-
rial peritonitis from ascites by showing en-
hancement and thickening of peritoneal
reflections, inflammatory changes in the
mesentery and omentum, engorgement of
regional mesenteric vessels, and hyperemic
changes in contiguous bowel segments.
Bowel Obstruction
Uncommonly, patients with acute appendi-
citis present with mechanical obstruction,
likely secondary to entrapment of the distal il-
eum in a periappendiceal inflammatory mass.
More commonly, small-bowel obstruction is
a late complication of appendectomy and is
caused by postoperative fibrous adhesions in
the peritoneal cavity.
Septic Seeding of Mesenteric Vessels
Appendicitis can be complicated by pyle-
phlebitis, pylethrombosis, or hepatic abscess
caused by ascending infection along the
draining mesenteric–portal venous system.
Occasionally, patients with cryptogenic por-
tal hypertension due to pylethrombosis have a
recent or remote history of appendicitis.
Gangrenous Appendicitis
Gangrenous appendicitis is the result of in-
tramural and arterial thromboses. CT findings
include pneumatosis, shaggy appendiceal
wall, and patchy areas of mural nonperfusion.
Unusual Manifestations
In addition to acute appendicitis, appendic-
ular obstruction may occasionally produce
milder, more chronic inflammation. Two
similar entities have been described, recurrent
appendicitis and chronic appendicitis. Recur-
rent appendicitis refers to repeated episodes
of RLQ pain that, after appendectomy, are
proven to be the result of an inflamed appen-
dix. Chronic appendicitis refers to RLQ pain
of at least 3 weeks’ duration that completely
disappears after appendectomy. Pathologic
examination shows chronic active inflamma-
tion of the appendiceal wall or fibrosis of the
appendix. In both entities, clinical presenta-
tion is usually more insidious than with acute
appendicitis. CT findings are generally indis-
tinguishable from those of early acute appen-

AJR:185, August 2005 413


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dicitis: mild wall thickening and mural hyper-
enhancement with minimal to no fat
stranding. Surgery is curative but does not
necessarily need to be performed on an emer-
gent basis. With increasing frequency, these
patients are being treated with antibiotics and
elective surgery weeks to months later, rather
than with emergent surgery.
Differential Diagnosis
Several alternative conditions may mimic
appendicitis clinically and on CT. Correct di-
agnosis is important because many of these
differential entities are self-limited and re-
spond to conservative management.
Mesenteric Adenitis
Mesenteric adenitis is the most common al-
ternative condition identified at negative ap-
pendectomy. It is a benign inflammation of the
ileocolic lymph nodes that is usually caused by
Yersinia enterocolitica, Y. pseudotuberculosis,
or Campylobacter jejuni. CT findings include
enlargement (> 5 mm) of mesenteric lymph
nodes, thickening of the adjacent cecum and il-
eum, and a normal appendix [63] (Fig. 11).
Cecal Diverticulitis
Cecal diverticulitis is relatively uncommon
in North American and European popula-
tions, accounting for only 5% of all diverticu-
litis cases. For reasons that are not completely
clear, it is distinctly more common in Asians.
414
Pinto Leite et al.
Fig. 14—30-year-old man with omental infarction. Abdominal CT shows well-circum-
scribed region of inflamed omental fat, with streaklike areas of inflammatory strand-
ing (arrowheads).
CT findings of cecal diverticulitis include fo-
cal pericecal inflammatory changes, slight
mural thickening, and visualization of one or
more diverticula. Identifying the inflamed ce-
cal diverticulum allows accurate diagnosis of
cecal diverticulitis [64]. The inflamed diver-
ticulum contains gas, fluid, contrast material,
or calcified material. Visualization of a nor-
mal appendix helps confirm the diagnosis. If
the normal appendix is not visualized, the dif-
ferential diagnosis is difficult [63, 65]
(Fig. 12).
Epiploic Appendagitis
Epiploic appendagitis is an uncommon con-
dition caused by inflammation, torsion, or is-
chemia of an epiploic appendage. On CT, there
is a small fat-attenuation mass contiguous with
the colon and having a hyperattenuating rim. A
round or linear hyperdense focus in the center
of the mass thought to represent a thrombosed
central vein is characteristic but is not always
present. Other possible findings are focal
thickening of the adjacent bowel, infiltration of
mesenteric fat, and focal thickening of the sur-
rounding peritoneum [66] (Fig. 13).
Omental Infarction
Omental infarction is a rare condition in
which there is segmental infarction of some
portion of the omentum. CT features include
a well-circumscribed region of inflamed
omental fat with haziness and streaklike areas
of inflammatory stranding [63] (Fig. 14). De-
pending on the location, omental infarction
may mimic acute appendicitis, epiploic ap-
pendagitis, or diverticulitis.
Crohn’s Disease
Crohn’s disease is a chronic granulomatous
inflammatory condition that can involve any
segment of the gastrointestinal tract but most
commonly involves the terminal ileum and
right colon. CT helps exclude appendicitis and
shows features characteristic of Crohn’s dis-
ease. Affected bowel usually shows prominent
circumferential wall thickening. In acute and
subacute cases, IV contrast administration
shows bowel wall mural stratification (target
sign). Characteristically, skip lesions are
present. Local proliferation of mesenteric fat
around the affected bowel, prominent vessels
in the hypertrophied fat, fistulas, sinus tracts,
and abscesses are frequently found [43, 67,
68]. Importantly, Crohn’s disease may involve
the appendix and cause a chronic granuloma-
tous appendicitis, which is usually managed
conservatively.
Infectious Terminal Ileitis
Bacterial, mycobacterial, parasitic, and vi-
ral pathogens can cause terminal ileitis either
in isolation or in association with mesenteric
adenitis. CT typically shows mild terminal il-
eal wall thickening (< 5 mm) and, if present,
findings of mesenteric adenitis.
AJR:185, August 2005

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Fig. 15—48-year-old woman with appendiceal mucocele.
A and B, Axial (A) and coronal reformatted (B) CT scans obtained after oral and IV contrast administration show distended appendiceal lumen caused by abnormal mucus
accumulation (arrows).
Perforated Cecal and Appendiceal Carcinoma
Small cecal and appendicular carcinomas
can occlude the appendicular lumen, causing
secondary appendicitis. Also, cecal carcinoma
can perforate and mimic acute appendicitis.
Although benign and malignant causes of ap-
pendicitis can be similar in appearance, they
usually occur in different age groups. Malig-
nant causes are extremely rare in young pa-
tients and usually are encountered only in eld-
erly patients. CT findings include nodular and
asymmetric thickening of the cecum or appen-
diceal base. An intraluminal lesion may be vis-
ible and show enhancement after IV contrast
administration. Correctly suggesting the possi-
bility of malignant appendicitis is important
because it may alter the surgical approach.
Appendiceal Mucocele
Appendiceal mucocele is a well-capsulated
cystic mass in the pericecal region represent-
ing the distended appendiceal lumen caused
by abnormal mucus accumulation (Fig. 15).
Usually the cystic mass displaces the adjacent
bowel loops, typically without periappen-
diceal inflammation or abscess. Unenhanced
CT may show curvilinear or punctate calcifi-
cations in the mucocele wall. The wall en-
hances after IV contrast administration. Focal
AJR:185, August 2005
CT of Appendicitis
A B
nodular thickening in the wall of the muco-
cele suggests the presence of a mucinous
cystadenocarcinoma [69].
Conclusion
Helical CT is an accurate, effective tech-
nique for diagnosing acute appendicitis. Al-
though the optimal CT technique for evalua-
tion of patients with suspected acute
appendicitis is controversial, results from
many studies show appendicitis CT to be
highly accurate independently of the chosen
protocol. Familiarity with CT findings is im-
portant for the correct diagnosis of acute ap-
pendicitis, differentiation of appendicitis
from other entities, and identification of com-
plications. CT does have important disadvan-
tages, however. These include the use of ion-
izing radiation, possible adverse reactions to
IV contrast material, discomfort caused by
enteric agents, limited assessment of acute
gynecologic disorders, and potentially inade-
quate RLQ visualization in thin individuals.
For these reasons, sonography will continue
to play an important role. In our opinion,
sonography probably should be performed
first in children, adolescents, thin young
adults, and women of reproductive age with
possible gynecologic causes of pain.
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