The challenging ultrasound diagnosis of perforated appendicitis in children: constellations of sonographic findings improve specificity

Background Rapid and accurate diagnosis of appendicitis, particularly with respect to the presence or absence of perforation, is essential in guiding appropriate management. Although many studies have explored sonographic findings associated with acute appendicitis, few investigations discuss specific signs that can reliably differentiate perforated appendicitis from acute appendicitis prior to abscess formation. Objective The purpose of our study was to identify sonographic findings that improve the specificity of US in the diagnosis of perforated appendicitis. Our assessment of hepatic periportal echogenicity, detailed analysis of intraperitoneal fluid, and formulation of select constellations of sonographic findings expands upon the literature addressing this important diagnostic challenge. Materials and methods We retrospectively reviewed 116 abdominal US examinations for evaluation of abdominal pain in children ages 2 to 18 years from January 2008 to September 2011 at a university hospital pediatric radiology department. The study group consisted of surgical and pathology proven acute appendicitis ( n = 51) and perforated appendicitis ( n = 22) US exams. US exams without a sonographic diagnosis of appendicitis ( n = 43) confirmed by follow-up verbal communication were included in the study population as the control group. After de-identification, the US exams were independently reviewed on a PACS workstation by four pediatric radiologists blinded to diagnosis and all clinical information. We recorded the presence of normal or abnormal appendix, appendicolith, appendiceal wall vascularity, thick-walled bowel, dilated bowel, right lower quadrant (RLQ) echogenic fat, increased hepatic periportal echogenicity, bladder debris and abscess or loculated fluid. We also recorded the characteristics of intraperitoneal fluid, indicating the relative quantity (number of abdominal regions) and quality of the fluid (simple fluid or complex fluid). We used logistic regression for correlated data to evaluate the association of diagnosis with the presence versus absence of each US finding. We conducted multivariable analysis to identify constellations of sonographic findings that were predictive of perforated appendicitis. Results The individual US findings of abscess/loculated fluid, appendicolith, dilated bowel and increased hepatic periportal echogenicity were significantly associated with perforated appendicitis when compared with acute appendicitis ( P