Shawn
P. Quillin,
MD
Marilyn
Appendicitis Color Doppler
terms:
Appendicitis,
dix, US, 751.1298 tract, 751.291
Children,
#{149}
751.291
Siegel,
MD
in Children: Sonography’
The authors used color Doppler ultrasonography (US) to evaluate 33 children with suspected appendicitis and found locally increased blood flow in all of 10 patients with appendicitis or periappendiceal abscess; the studies were normal in 16 patients without appendicitis. The grayscale sonographic results were concordant in all 26 of these patients. In two other patients with presumptive mesenteric adenitis and in one patient with a hemorrhagic ovarian cyst at gray-scale US, color Doppler imaging showed no increased perfusion and aided in confirming the absence of a significant inflammatory process. In four other children, color Doppler US clarified gray-scale sonographic findings that might have been confused with complicated appendicitis and aided in the diagnosis of other causes of acute abdominal pain. These findings indicate that color Doppler US is a useful adjunct to gray-scale US in evaluating children with suspected acute appendicitis. Index
J.
Appen-
#{149}
CUTE appendicitis mon indication
is the for
1992;
corn-
abdominal surgery in children In most patients, the diagnosis
(1,2). of ap-
pendicitis
of his-
tory
is made
on
the
basis
and
physical examination. In cases in which the clinical presentation is confusing, gray-scale ultrasonography pression
in recent and has ificity
(US) with graded become widely
has
ranging
Another ment creasing
assess strate
ated
from
80%
important
recent
tumors
(10).
lesions
Accordingly,
blood could
with
US and
color
finding
Doppler
of increased
sonographic
flow
order. We evaluated in a study of children who
postu-
that
the
would
aid in
of this
dis-
this hypothesis with suspected
were
referred
for
AND
a 5-month
to February
20,
performed
color
period 1992)
(October
we
1, 1991,
In addition,
US
were (4).
a
images
were and then Doppler
bongitudi-
of the right
imaging
lower
in all paUS was
was
per-
performed
images
sensitivity.
dynamically
for
the
described and
magnified
color
was
with
first obtained color Doppler
on electronically maximize
pelvis
sonographic Examinations
Transverse
nab gray-scale
formed. Color
no
technique
Puylaert
quadrant tients,
of the
performed
graded-compression by
Color during
to gain
the
was
examina-
tion to maximize visualization of vessels, while avoiding excessive artifactual color noise. Color persistence was adjusted to
the
maximum
filter
was
setting,
adjusted
(100 Hz).
The
used
to ensure
small
vessels
lower
velocity
tings,
velocities
and
to the
lowest and
the bandpass lowest
flow
optimum
setting
settings
were
visualization
to optimize
diastolic
of
detection
flow.
as low
US, in addition US, in children symptoms sugges-
and
examinations
The sidered
of
At these
set-
as 0.6 cm/sec
was
Doppler med by included;
if increased
studies, only staff pediatric during the
examined The
at night
protocol
approved
by
Human
Studies
the requirement cause of the
the
those patients radiologists study interval, for
this
Washington
Committee,
for negligible
informed
risks
were
examwere five
cx-
study
could
consent associated
be-
digitally recordings
considered
in the
the
noses
for appendicitis
were if the compressible
appendix,
were
was
demonstrated
The
appendix.
confirmatory
all patients,
or fluid was evidence of apof color analysis
positive
of the
sonograms
or other
mass
vascularity
wall
ap-
of an appendicolith
or a periappendiceal considered confirmatory pendicitis. The results
were
on
were conif there
of a blind-ending
Identification
no visible
waived
recorded
these digital retrospectively.
visualization
pendix.
for appendicitis ileum were
was
University
which
were
results of gray-scale US positive for appendicitis
tive of (but presumably not considered sufficiently diagnostic for) acute appendicitis. This study population consisted of 33 consecutive children. There were 19 girls and 14 boys, aged 2-18 years (mean age, 11 years). To ensure high quality of the
cluded.
with
in girls with of appendicitis.
videotape, and were reviewed
prospectively
Doppler
to graded-compression referred with signs
children
obtained
US
was accompanied occasionally by color aliasing. Pulsed Doppler waveforms were not routinely obtained in this study. All
METHODS
184:745-747
1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 5 Kingshighway Blvd. St Louis, MO 63110. Received March 2, 1992; revision requested March 26; revision received April 15; accepted April 20. Address reprint requests to M.J.S. C RSNA, 1992
Doppler
be detectable. Unfortunately, the improved sensitivity to low-velocity flow
gastrointestinal
Over
of color
setting. were
commercially available, real-time scanner, with a 5-MHz linear-array transducer (Acuson, Mountain View, Calif). The right lower quadrant was evaluated in all pa-
adjusted
flow in the be detected
diagnosis
appendicitis US.
and
we
lated that increased inflamed appendix
the
(3-9).
develop-
inflammatory
performance
appendicitis
in medical imaging is the inuse of color Doppler US to flow in vessels and to demonthe local hyperperfusion associ-
with
the
in this clinical All sonograms
performed evidence
cornaccepted
to 95%
with
tients.
years as an aid to diagnosis reported sensitivity and spec-
MATERIALS Radiology
most
emergency
results negative
considered cecum and
of
and terminal if there was
abnormal
color
flow,
findings.
Final
diag-
follow-up
in
established
with
as detailed
as follows.
745
lb.
Ia. Figures appendix
1, 2. (1) Acute with increased
echoic
mass
Figures
b
(arrows).
3, 4.
appendicitis. peripheral =
(3) Normal
bladder.
right
2.
(a) Longitudinal and (b) transverse sonograms of the right lower quadrant show a hypoechoic blood flow. (2) Perforated appendicitis. Longitudinal sonogram shows hyperperfusion within Scale
lower
indicates
fluid-filled a hypo-
centimeters.
quad-
rant. Longitudinal sonogram shows minimal scattered color Doppler signal in the soft tissues.
(4) Mesenteric
adenitis.
demonstrates
small
lymph
nodes
(arrows)
enteric
vessels.
Note
Transverse
hypoechoic anterior
the absence
scan
mesenteric to small
mes-
of hyper-
perfusion.
RESULTS In nine patients, gray-scale US showed the typical findings of uncomplicated acute appendicitis (a noncompressible, blind-ending tububar structure with a diameter 6 mm). Periappendiceab fluid was present in two patients, and an appendicolith was seen in one patient. Color Doppler US in all of these patients demonstrated easily seen yessels
coursing
through
the
periphery
of the dilated appendix, consistent with hyperperfusion accompanying inflammation (Fig 1). At operation, all nine patients had nonperforated appendicitis. The appendiceab specimens
measured
between
5 and
12 cm
in length (mean, 6.5 cm) and between 0.6 to 3 cm in diameter (mean, 1.1 cm). In another patient, a hypoechoic bower pelvic mass was depicted at gray-scale abscess
US, suggesting either an or stool-filled sigmoid colon.
Color Doppler US showed increased flow within the mass (Fig 2), and abscess
was
diagnosed
The
diagnosis
citis
with
prospectively.
of perforated
periappendiceab
appendiabscess
for-
mation was confirmed at surgery. In 16 patients, the gray-scale images were normal. Color Doppler US in 746
Radiology
3.
these patients showed only scattered bow-intensity signals that are typical of normal soft tissues (Fig 3). At clinical follow-up, all of these patients had spontaneous resolution of symptoms. One patient was diagnosed with a viral syndrome and the remainder with abdominal pain of unknown origin. Gray-scale sonograms in two patients showed normal bowel, enbarged mesenteric nodes in the right bower quadrant, and no visualized appendix. Color Doppber US showed no increased blood flow (Fig 4). On the basis of visualization of enlarged lymph nodes, a presumptive diagnosis of mesenteric adenitis was made. The patients were treated with analgesics, and their symptoms resolved. In one patient, gray-scale US enabbed identification of an enlarged
4.
right ovary choic area oes. Normal
containing a central with scattered internal ovarian parenchyma
aneechwas
noted around the cystic lesion. Color Doppler US showed small vessels in the periphery of the ovary and no detectable flow in the cystic component. A hemorrhagic cyst was suspected, and a follow-up sonogram showed resolution of the mass. At gray-scale sonography, four patients were
had confusing clarified with
Two
patients
pressibbe,
had thickened
findings that color Doppler
incompletely loops
US.
comof terminal
ibeum and no visualized appendix. On the basis of these findings, inflammatory bowel disease was suspected, but
inflamed
appendiceab cluded.
color
In the
Doppler
bowel
consequent
rupture
could
first
of these
to
not
be cx-
patients,
US demonstrated September
in1992
5, 6.
Figures
(5) Yersinia enterocolitis. Lonsonogram demonstrates thickened,
gitudinal hypoechoic
creased
bowel
(6) Hemorrhagic
no
6.
creased rather
flow centrally than peripherally,
enteritis
rather
within mucosa suggesting
than
an
extrinsic
in-
flammatory process (Fig 5). Stool tures yielded Yersinia enterocolitica. the second patient, color Doppler scans
showed
perfusion pendicitis
no
evidence
of hyper-
in the bowel. Because with perforation was
strong clinical was performed:
cubIn US
consideration, Mesenteric
apstill a
surgery adenitis
and a normal appendix were found. A third patient had a complex right bower quadrant mass with a large anechoic area at gray-scale US, suggesting either abscess cyst with hemorrhage. US showed no evidence
or a mesenteric Color Doppler of increased
blood flow, supporting a diagnosis of cyst (Fig 6). At surgery, a torsive, hemorrhagic mesenteric cyst and a normal appendix were found. The fourth patient had a right-sided renal transplant. A right lower quadrant calcification seen on an abdominal radiograph was thought possibly to be
an
appendicolith.
showed
an echogenic
shadowing cification,
Color
Gray-scale
focus
corresponding but no appendix
Doppler
attention calcification,
with to the cabwas seen.
US, with
to the region showed
US
particular
no
around the increased
blood flow. The patient’s symptoms resolved spontaneously. The calcification was thought to be dystrophic secondary
to prior
surgery.
medical
diseases
surgical
conditions
Acute problem
abdominal in childhood.
pain
is a frequent In several large
series, nonspecific abdominal pain accounted for 30%-38% of cases,
Volume
184
Number
#{149}
3
for
and
30%-38%
(1,2).
Appendicitis is the cause of the majority of surgical emergencies in children. The diagnosis often can be made on the basis of the presence of typical clinical features. However, in a substantial number of cases, clinical findings are indeterminate. In these patients, high-resolution, gray-scale US
has
proved
to be a useful
tic technique. in some series 90% or greater
diagnos-
The reported sensitivity has been found to be (4,7,9). In our small
series of patients, the sensitivity of US for enabling identification of appendicitis was 100%.
US also has been used to aid in the diagnosis of other conditions in patients with suspected appendicitis. However, the overall frequency with which US enables establishment of alternative diagnoses in children with suspected appendicitis is only about 60% (8). Gynecobogic diseases, gastrointestinal abnormalities, and urinary tract diseases account for the majority of these alternative diagnoses. Findings in recent studies have shown
that
color
Doppler
US
associated
with
scale
US alone.
Color
tis in four
Doppler
US did
provide a simple means to confirm the gray-scale US findings, with no
cyst.
Longitudi-
blood
flow.
Normal
in the iliac artery
blood
and vein
(ar-
of our
33 patients
and
sup-
ported the possibility of other causes of acute abdominal pain. This is important because, as noted earlier, the sensitivity of gray-scale US for enabling detection in children of causes of acute abdominal pain other than appendicitis is only about 60% (8). Our promising results indicate that, where available, color Doppler US is a useful adjunct to conventional US in assessment of suspected appendicitis in children. A larger prospective study
to confirm
be undertaken.
our
findings
should
#{149}
References 1. 2. 3.
4. 5.
Jones PF. Active observation in management of acute abdominal pain in childhood. Br Med J 1976; 2:551-553. Winsey HS. Acute adominalpain in childhood: analysis of a year’s admissions. Br Med 1967; 1:653-655. Abu-YousefMM, BleicherJJ, MaherjW, Urdaneta LF, Franken EAJr, Metcalf AM. Highresolution sonography of acute appendicitis. AJR 1987; 149:5-58. Puylaert JCBM. Acute appendicitis: US evaluation using graded compression. Radiology 1986; 158:3-360. PuylaertJCBM, Rutgers RB, Lalisang RI, et al. A prospective study of ultrasonography in the diagnosis of appendicitis. N Englj Med 1987; 317:666-669.
6. 7. 8. 9.
appendicitis.
The addition of color Doppler US did not increase the sensitivity of the cxamination for detecting appendicitis compared with the sensitivity of gray-
in-
appreciable increase in examination time (average, 1-2 minutes) or in cost (when using instruments already equipped for Doppler imaging). Indeed, it is our impression that use of color Doppler US made interpretation of these studies easier and increased observer confidence. In this preliminary study, there were no false-negative or false-positive diagnoses of appendicitis with color Doppler US. Additionally, the results of color Doppler US helped to exclude appendici-
is a reli-
abbe technique for enabling detection of increased blood flow accompanying certain inflammatory processes, such as epididymo-orchitis (10,11). In this preliminary study, we have shown that color Doppler US can also demonstrate the expected hyperperfusion
DISCUSSION
for 20%-36%,
and
the mucosa.
demonstrates a complex mass increased sound transmission
increased
flow is seen rowheads).
(arrows)
within
mesenteric
nal sonogram (arrows) with and
wall
flow centrally
10. 11.
Jeffrey RB, Laing FC, Lewis FR. Acute appendicitis: high-resolution real-time US findings. Radiology 1987; 163:11-14. Jeffrey RB, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167:327-329. Siegel MJ, Card CC, Surratt S. Ultrasonography of acute abdominal pain in children. JAMA 1991; 266:1987-1989. Vinault F, Filiatrault D, Brandt ML, Garel L, Grignon A, Ouimet A. Acute appendicitis in children: evaluation with US. Radiology 1990; 176:501-504. Foley WD, Erickson SJ. Color Doppler flow imaging. AIR 1991; 156:3-13. Middleton WD, Siegel BA, Melson GL, Yates CK, Andriole GL. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 1990; 177:177-181.
Radiology
747
#{149}
P. Quillin,
MD
Marilyn
Appendicitis Color Doppler
terms:
Appendicitis,
dix, US, 751.1298 tract, 751.291
Children,
#{149}
751.291
Siegel,
MD
in Children: Sonography’
The authors used color Doppler ultrasonography (US) to evaluate 33 children with suspected appendicitis and found locally increased blood flow in all of 10 patients with appendicitis or periappendiceal abscess; the studies were normal in 16 patients without appendicitis. The grayscale sonographic results were concordant in all 26 of these patients. In two other patients with presumptive mesenteric adenitis and in one patient with a hemorrhagic ovarian cyst at gray-scale US, color Doppler imaging showed no increased perfusion and aided in confirming the absence of a significant inflammatory process. In four other children, color Doppler US clarified gray-scale sonographic findings that might have been confused with complicated appendicitis and aided in the diagnosis of other causes of acute abdominal pain. These findings indicate that color Doppler US is a useful adjunct to gray-scale US in evaluating children with suspected acute appendicitis. Index
J.
Appen-
#{149}
CUTE appendicitis mon indication
is the for
1992;
corn-
abdominal surgery in children In most patients, the diagnosis
(1,2). of ap-
pendicitis
of his-
tory
is made
on
the
basis
and
physical examination. In cases in which the clinical presentation is confusing, gray-scale ultrasonography pression
in recent and has ificity
(US) with graded become widely
has
ranging
Another ment creasing
assess strate
ated
from
80%
important
recent
tumors
(10).
lesions
Accordingly,
blood could
with
US and
color
finding
Doppler
of increased
sonographic
flow
order. We evaluated in a study of children who
postu-
that
the
would
aid in
of this
dis-
this hypothesis with suspected
were
referred
for
AND
a 5-month
to February
20,
performed
color
period 1992)
(October
we
1, 1991,
In addition,
US
were (4).
a
images
were and then Doppler
bongitudi-
of the right
imaging
lower
in all paUS was
was
per-
performed
images
sensitivity.
dynamically
for
the
described and
magnified
color
was
with
first obtained color Doppler
on electronically maximize
pelvis
sonographic Examinations
Transverse
nab gray-scale
formed. Color
no
technique
Puylaert
quadrant tients,
of the
performed
graded-compression by
Color during
to gain
the
was
examina-
tion to maximize visualization of vessels, while avoiding excessive artifactual color noise. Color persistence was adjusted to
the
maximum
filter
was
setting,
adjusted
(100 Hz).
The
used
to ensure
small
vessels
lower
velocity
tings,
velocities
and
to the
lowest and
the bandpass lowest
flow
optimum
setting
settings
were
visualization
to optimize
diastolic
of
detection
flow.
as low
US, in addition US, in children symptoms sugges-
and
examinations
The sidered
of
At these
set-
as 0.6 cm/sec
was
Doppler med by included;
if increased
studies, only staff pediatric during the
examined The
at night
protocol
approved
by
Human
Studies
the requirement cause of the
the
those patients radiologists study interval, for
this
Washington
Committee,
for negligible
informed
risks
were
examwere five
cx-
study
could
consent associated
be-
digitally recordings
considered
in the
the
noses
for appendicitis
were if the compressible
appendix,
were
was
demonstrated
The
appendix.
confirmatory
all patients,
or fluid was evidence of apof color analysis
positive
of the
sonograms
or other
mass
vascularity
wall
ap-
of an appendicolith
or a periappendiceal considered confirmatory pendicitis. The results
were
on
were conif there
of a blind-ending
Identification
no visible
waived
recorded
these digital retrospectively.
visualization
pendix.
for appendicitis ileum were
was
University
which
were
results of gray-scale US positive for appendicitis
tive of (but presumably not considered sufficiently diagnostic for) acute appendicitis. This study population consisted of 33 consecutive children. There were 19 girls and 14 boys, aged 2-18 years (mean age, 11 years). To ensure high quality of the
cluded.
with
in girls with of appendicitis.
videotape, and were reviewed
prospectively
Doppler
to graded-compression referred with signs
children
obtained
US
was accompanied occasionally by color aliasing. Pulsed Doppler waveforms were not routinely obtained in this study. All
METHODS
184:745-747
1 From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 5 Kingshighway Blvd. St Louis, MO 63110. Received March 2, 1992; revision requested March 26; revision received April 15; accepted April 20. Address reprint requests to M.J.S. C RSNA, 1992
Doppler
be detectable. Unfortunately, the improved sensitivity to low-velocity flow
gastrointestinal
Over
of color
setting. were
commercially available, real-time scanner, with a 5-MHz linear-array transducer (Acuson, Mountain View, Calif). The right lower quadrant was evaluated in all pa-
adjusted
flow in the be detected
diagnosis
appendicitis US.
and
we
lated that increased inflamed appendix
the
(3-9).
develop-
inflammatory
performance
appendicitis
in medical imaging is the inuse of color Doppler US to flow in vessels and to demonthe local hyperperfusion associ-
with
the
in this clinical All sonograms
performed evidence
cornaccepted
to 95%
with
tients.
years as an aid to diagnosis reported sensitivity and spec-
MATERIALS Radiology
most
emergency
results negative
considered cecum and
of
and terminal if there was
abnormal
color
flow,
findings.
Final
diag-
follow-up
in
established
with
as detailed
as follows.
745
lb.
Ia. Figures appendix
1, 2. (1) Acute with increased
echoic
mass
Figures
b
(arrows).
3, 4.
appendicitis. peripheral =
(3) Normal
bladder.
right
2.
(a) Longitudinal and (b) transverse sonograms of the right lower quadrant show a hypoechoic blood flow. (2) Perforated appendicitis. Longitudinal sonogram shows hyperperfusion within Scale
lower
indicates
fluid-filled a hypo-
centimeters.
quad-
rant. Longitudinal sonogram shows minimal scattered color Doppler signal in the soft tissues.
(4) Mesenteric
adenitis.
demonstrates
small
lymph
nodes
(arrows)
enteric
vessels.
Note
Transverse
hypoechoic anterior
the absence
scan
mesenteric to small
mes-
of hyper-
perfusion.
RESULTS In nine patients, gray-scale US showed the typical findings of uncomplicated acute appendicitis (a noncompressible, blind-ending tububar structure with a diameter 6 mm). Periappendiceab fluid was present in two patients, and an appendicolith was seen in one patient. Color Doppler US in all of these patients demonstrated easily seen yessels
coursing
through
the
periphery
of the dilated appendix, consistent with hyperperfusion accompanying inflammation (Fig 1). At operation, all nine patients had nonperforated appendicitis. The appendiceab specimens
measured
between
5 and
12 cm
in length (mean, 6.5 cm) and between 0.6 to 3 cm in diameter (mean, 1.1 cm). In another patient, a hypoechoic bower pelvic mass was depicted at gray-scale abscess
US, suggesting either an or stool-filled sigmoid colon.
Color Doppler US showed increased flow within the mass (Fig 2), and abscess
was
diagnosed
The
diagnosis
citis
with
prospectively.
of perforated
periappendiceab
appendiabscess
for-
mation was confirmed at surgery. In 16 patients, the gray-scale images were normal. Color Doppler US in 746
Radiology
3.
these patients showed only scattered bow-intensity signals that are typical of normal soft tissues (Fig 3). At clinical follow-up, all of these patients had spontaneous resolution of symptoms. One patient was diagnosed with a viral syndrome and the remainder with abdominal pain of unknown origin. Gray-scale sonograms in two patients showed normal bowel, enbarged mesenteric nodes in the right bower quadrant, and no visualized appendix. Color Doppber US showed no increased blood flow (Fig 4). On the basis of visualization of enlarged lymph nodes, a presumptive diagnosis of mesenteric adenitis was made. The patients were treated with analgesics, and their symptoms resolved. In one patient, gray-scale US enabbed identification of an enlarged
4.
right ovary choic area oes. Normal
containing a central with scattered internal ovarian parenchyma
aneechwas
noted around the cystic lesion. Color Doppler US showed small vessels in the periphery of the ovary and no detectable flow in the cystic component. A hemorrhagic cyst was suspected, and a follow-up sonogram showed resolution of the mass. At gray-scale sonography, four patients were
had confusing clarified with
Two
patients
pressibbe,
had thickened
findings that color Doppler
incompletely loops
US.
comof terminal
ibeum and no visualized appendix. On the basis of these findings, inflammatory bowel disease was suspected, but
inflamed
appendiceab cluded.
color
In the
Doppler
bowel
consequent
rupture
could
first
of these
to
not
be cx-
patients,
US demonstrated September
in1992
5, 6.
Figures
(5) Yersinia enterocolitis. Lonsonogram demonstrates thickened,
gitudinal hypoechoic
creased
bowel
(6) Hemorrhagic
no
6.
creased rather
flow centrally than peripherally,
enteritis
rather
within mucosa suggesting
than
an
extrinsic
in-
flammatory process (Fig 5). Stool tures yielded Yersinia enterocolitica. the second patient, color Doppler scans
showed
perfusion pendicitis
no
evidence
of hyper-
in the bowel. Because with perforation was
strong clinical was performed:
cubIn US
consideration, Mesenteric
apstill a
surgery adenitis
and a normal appendix were found. A third patient had a complex right bower quadrant mass with a large anechoic area at gray-scale US, suggesting either abscess cyst with hemorrhage. US showed no evidence
or a mesenteric Color Doppler of increased
blood flow, supporting a diagnosis of cyst (Fig 6). At surgery, a torsive, hemorrhagic mesenteric cyst and a normal appendix were found. The fourth patient had a right-sided renal transplant. A right lower quadrant calcification seen on an abdominal radiograph was thought possibly to be
an
appendicolith.
showed
an echogenic
shadowing cification,
Color
Gray-scale
focus
corresponding but no appendix
Doppler
attention calcification,
with to the cabwas seen.
US, with
to the region showed
US
particular
no
around the increased
blood flow. The patient’s symptoms resolved spontaneously. The calcification was thought to be dystrophic secondary
to prior
surgery.
medical
diseases
surgical
conditions
Acute problem
abdominal in childhood.
pain
is a frequent In several large
series, nonspecific abdominal pain accounted for 30%-38% of cases,
Volume
184
Number
#{149}
3
for
and
30%-38%
(1,2).
Appendicitis is the cause of the majority of surgical emergencies in children. The diagnosis often can be made on the basis of the presence of typical clinical features. However, in a substantial number of cases, clinical findings are indeterminate. In these patients, high-resolution, gray-scale US
has
proved
to be a useful
tic technique. in some series 90% or greater
diagnos-
The reported sensitivity has been found to be (4,7,9). In our small
series of patients, the sensitivity of US for enabling identification of appendicitis was 100%.
US also has been used to aid in the diagnosis of other conditions in patients with suspected appendicitis. However, the overall frequency with which US enables establishment of alternative diagnoses in children with suspected appendicitis is only about 60% (8). Gynecobogic diseases, gastrointestinal abnormalities, and urinary tract diseases account for the majority of these alternative diagnoses. Findings in recent studies have shown
that
color
Doppler
US
associated
with
scale
US alone.
Color
tis in four
Doppler
US did
provide a simple means to confirm the gray-scale US findings, with no
cyst.
Longitudi-
blood
flow.
Normal
in the iliac artery
blood
and vein
(ar-
of our
33 patients
and
sup-
ported the possibility of other causes of acute abdominal pain. This is important because, as noted earlier, the sensitivity of gray-scale US for enabling detection in children of causes of acute abdominal pain other than appendicitis is only about 60% (8). Our promising results indicate that, where available, color Doppler US is a useful adjunct to conventional US in assessment of suspected appendicitis in children. A larger prospective study
to confirm
be undertaken.
our
findings
should
#{149}
References 1. 2. 3.
4. 5.
Jones PF. Active observation in management of acute abdominal pain in childhood. Br Med J 1976; 2:551-553. Winsey HS. Acute adominalpain in childhood: analysis of a year’s admissions. Br Med 1967; 1:653-655. Abu-YousefMM, BleicherJJ, MaherjW, Urdaneta LF, Franken EAJr, Metcalf AM. Highresolution sonography of acute appendicitis. AJR 1987; 149:5-58. Puylaert JCBM. Acute appendicitis: US evaluation using graded compression. Radiology 1986; 158:3-360. PuylaertJCBM, Rutgers RB, Lalisang RI, et al. A prospective study of ultrasonography in the diagnosis of appendicitis. N Englj Med 1987; 317:666-669.
6. 7. 8. 9.
appendicitis.
The addition of color Doppler US did not increase the sensitivity of the cxamination for detecting appendicitis compared with the sensitivity of gray-
in-
appreciable increase in examination time (average, 1-2 minutes) or in cost (when using instruments already equipped for Doppler imaging). Indeed, it is our impression that use of color Doppler US made interpretation of these studies easier and increased observer confidence. In this preliminary study, there were no false-negative or false-positive diagnoses of appendicitis with color Doppler US. Additionally, the results of color Doppler US helped to exclude appendici-
is a reli-
abbe technique for enabling detection of increased blood flow accompanying certain inflammatory processes, such as epididymo-orchitis (10,11). In this preliminary study, we have shown that color Doppler US can also demonstrate the expected hyperperfusion
DISCUSSION
for 20%-36%,
and
the mucosa.
demonstrates a complex mass increased sound transmission
increased
flow is seen rowheads).
(arrows)
within
mesenteric
nal sonogram (arrows) with and
wall
flow centrally
10. 11.
Jeffrey RB, Laing FC, Lewis FR. Acute appendicitis: high-resolution real-time US findings. Radiology 1987; 163:11-14. Jeffrey RB, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167:327-329. Siegel MJ, Card CC, Surratt S. Ultrasonography of acute abdominal pain in children. JAMA 1991; 266:1987-1989. Vinault F, Filiatrault D, Brandt ML, Garel L, Grignon A, Ouimet A. Acute appendicitis in children: evaluation with US. Radiology 1990; 176:501-504. Foley WD, Erickson SJ. Color Doppler flow imaging. AIR 1991; 156:3-13. Middleton WD, Siegel BA, Melson GL, Yates CK, Andriole GL. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 1990; 177:177-181.
Radiology
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