Primary epiploic appendagitis: a report of two cases

Primary epiploic appendagitis (PEA) is a rare benign self-limiting inflammatory process of the colonic epiploic appendices. Patients present with acute abdominal pain, often misdiagnosed clinically as acute appendicitis or diverticulitis. Computed tomography (CT) scan findings of this condition are characteristic and can confidently suggest the diagnosis avoiding unnecessary barium enemas and colonoscopy, biopsy, or surgery.     

Right-sided colonic diverticulitis: CT findings.

Right-sided colonic diverticulitis is an uncommon but clinically significant condition as it closely mimics other common acute right-sided abdominal conditions like acute appendicitis and cholecystitis. CT can provide a rapid and accurate diagnosis of this condition and thereby prevent unnecessary laparotomy and surgical procedures since it is essentially a benign self-limiting condition requiring medical treatment. It is the aim of this pictorial essay to describe the CT findings and increase awareness among radiologists of this condition.     

Small-bowel diverticulitis: CT findings

Three patients with subsequently proven small-bowel diverticulitis were studied with preoperative CT. In all three cases, an inflammatory mass was present, two involving the terminal ileum and cecum and one involving the jejunum. While the findings in the two cases of ileal diverticulitis simulated appendicitis, in the case of jejunal diverticulitis the diagnosis was suggested on the basis of CT findings. Small-bowel diverticulitis should be included in the differential diagnosis if an inflammatory mass involving the small bowel is demonstrated on CT.     

Diagnostic accuracy of focused appendiceal CT in clinically equivocal cases of acute appendicitis.

PURPOSE: To determine the diagnostic accuracy of modified focused appendiceal computed tomography (CT) to exclude or confirm appendicitis in patients who presented with equivocal symptoms and signs of appendicitis. MATERIALS AND METHODS: One hundred patients (age range, 14-81 years; mean age, 30.6 years) with equivocal symptoms and signs of acute appendicitis were included in this prospective study. Patients were given 30 mL of diatrizoate meglumine and diatrizoate sodium and 60 mL of sorbitol mixed in 1 L of water orally over 1 hour. CT was performed 1.5 hours after the commencement of oral contrast material administration. The criteria used for the diagnosis of appendicitis were (a) appendix greater than 6 mm in maximum diameter, (b) no contrast material in the appendiceal lumen, and (c) inflammatory changes in the periappendiceal fat. CT results were compared with histopathologic findings at appendectomy. Patients with negative CT findings were followed up by telephone or clinically. RESULTS: Of 100 cases, 30 were positive at CT and 70 were negative. There were 28 true-positive cases; two false-positive cases, one cecal diverticulitis and one pelvic peritonitis with periappendicitis; and two false-negative cases, one perforated appendix and one mucosal and submucosal inflammation of the appendix but no transmural inflammation. Sensitivity was 93%, specificity was 97%, and accuracy was 96%. CONCLUSION: Focused appendiceal CT in which oral contrast material is used alone yields high levels of accuracy in clinically equivocal cases of acute appendicitis.     

Value of abdominal CT in the emergency department for patients with abdominal pain

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted; thus, the net impact of performing CT was to obviate the need for hospital admission in 90 of 536 (17%) of patients with abdominal pain. Prior to CT, 67 of 536 (13%) of all patients would have undergone immediate surgery; however, following CT only 25 (5%) actually required immediate surgery. Among patients with the four most common pre-CT diagnoses (appendicitis, abscess, diverticulitis, and urinary tract stones) CT had the greatest impact on hospital admission and surgical management for patients with suspected appendicitis. For patients with suspected appendicitis, CT reduced the hospital admission rate in 28% (26 of 91) of patients and changed the surgical management in 40% (39 of 91) of patients. Our study demonstrates the advantage of performing abdominal CT in the ED for patients with non-traumatic abdominal pain. Electronic Publication     

Clinical and CT findings of epiploic appendagitis within an inguinal hernia

Epiploic appendagitis is a rare condition resulting from an acute inflammation of an appendix epiploica. Epiploic appendagitis is frequently misdiagnosed as either acute appendicitis or acute diverticulitis, and the diagnosis is usually made during surgery. Epiploic appendagitis is a rare, self-limiting condition, which can be easily diagnosed with computed tomography (CT). Imaging with CT may suggest the diagnosis thus preventing unnecessary surgery. Medical management of symptoms is usually sufficient. Herein, we present CT findings of an epiploic appendagitis case that developed in a left inguinal hernia, which is a very rare entity.     

Multi-slice spiral CT in routine diagnosis of suspected acute left-sided colonic diverticulitis: a prospective study of 120 patients

This prospective study evaluated the use of multi-slice CT (MSCT) for detection of clinically suspected left-sided colonic diverticulitis with regard to diagnosis, complications and alternative diagnoses. One hundred twenty patients with clinically suspected acute left-colonic diverticulitis underwent MSCT of the lower abdomen with IV contrast after rectal application of iodic contrast. The MSCT results were compared with histopathological and intraoperative findings or other radiological or endoscopic methods and clinical outcome. Acute diverticulitis was proven in 67 of the 120 (55.8%) patients, which was detected by MSCT with an accuracy of 98% (sensitivity 97%, specificity 98%). Contained perforation or abscess formation were detected with an accuracy of 96% (sensitivity 100%, specificity 91%) and 98% (sensitivity 100%, specificity 97%), respectively. In 31 of 120 (25.8%) patients diagnoses other than diverticulitis caused abdominal pain, which was correctly diagnosed by MSCT in 71%. The MSCT as well as other concurrently performed diagnostic methods showed normal findings and no causes for the patients symptoms in 22 of the 120 (18.4%) patients. Multi-slice CT is reliable in detecting diverticulitis, including extracolic complications, and often reveals other diagnoses; therefore, MSCT is recommended as standard diagnostic procedure in suspected acute diverticulitis.     

CT findings in duodenal diverticulitis

OBJECTIVE: Duodenal diverticulitis is a rare complication of duodenal diverticulosis. It is often clinically misdiagnosed because it has no pathognomonic signs or symptoms and its CT findings may mimic other intraabdominal processes. We describe two patients with duodenal diverticulitis who presented with abdominal pain, nausea, and leukocytosis. At the time of initial presentation, only one of the two patients was diagnosed correctly. In the first case, which was initially misdiagnosed as acute pancreatitis, the correct diagnosis was evident only after the disease process had become more quiescent and a follow-up CT scan using orally and i.v.-administered contrast agents was performed. In the second case, the coronal reformatted images confirmed the diagnosis suggested by the axial images. CONCLUSION: Duodenal diverticulitis can be a difficult CT diagnosis to make; however, maintaining it in the differential diagnosis of duodenal and pancreatic inflammatory processes and masses as well as defining the anatomy with nonaxial imaging including coronal images may be helpful in confirming the diagnosis.     

非对比增强CT对临床疑诊急性阑尾炎的诊断准确性（附74例分析）

目的评价非对比增强CT对1临床疑诊急性阑尾炎的诊断准确性。方法74例临床疑诊急性阑尾炎患者均经非对比增强的腹盆部（从L1椎体水平至耻骨联合上缘）螺旋CcT扫描。用于诊断急性阑尾炎的标准为阑尾直径大于6mm和阑尾周围脂肪的炎性改变。最终的CT诊断经手术或临床随访证实。结果74例临床疑诊急性阑尾炎患者中,CT诊断25例真阳性,42例真阴性,4例假阴性和3例假阳性,敏感性为86．2％,特异性为93．3％,准确性为90．5％,阳性预测值为89．3％,阴性预测值为91．3％。结论非对比增强CT对诊断或排除急性阑尾炎具有较高的准确性,并能大幅度地降低阴性阑尾的切除率和不必要的延期观察。     

Right lower quadrant pain: Imaging with computed tomography

Computed tomography (CT) is a fast and accurate way to evaluate patients with acute right lower abdominopelvic pain. In the emergency setting, appendicitis is the most common etiology. A tailored CT examination can visualize the normal or abnormal appendix with accuracy, confirming or excluding appendicitis in 90–95% of cases. If the appendix is normal, CT often identifies an alternative etiology for the pain. This exhibit reviews the CT appearance of the normal appendix, usual and unusual presentations of appendicitis and complicated appendicitis, and pitfalls in diagnosis. The CT appearance of other conditions included in the differential diagnosis of acute right lower quadrant pain and clinically mimicking appendicitis is also presented, including disorders arising from the gastrointestinal tract, genitourinary tract, and vascular and musculoskeletal systems.     

Acute flank pain: comparison of unenhanced helical CT and ultrasonography in detecting causes other than ureterolithiasis

Several conditions can clinically mimic renal colic. We assessed the accuracy of non-contrast-enhanced helical CT and of ultrasonography (US) in offering an alternative explanation for flank pain. In a 3-year period, 181 patients with acute flank pain underwent US and non-contrast-enhanced helical CT in a blinded sequence. Their efficacy in detecting both alternative causes of pain and additional findings unrelated to the pain was assessed in 160 cases with a confirmed diagnosis. An alternative cause was found in 23 cases (14%). US gave 4 false-negative results (1 acute appendicitis, 1 ovarian cyst torsion, 1 diverticulitis, and 1 papillary necrosis) and 2 false-positive results (1 acute pyelonephritis and 1 diverticulitis), with a 78% sensitivity and a 98% specificity for nonlithiasic causes. CT gave 5 false-negative results (1 complicated ovarian cyst, 1 pleuritis, 1 epididymitis, 1 acute pyelonephritis, and 1 papillary necrosis) and 1 false-positive (1 simple ovarian cyst described as a complicated lesion), resulting in a 74% sensitivity and a 99% specificity for diagnosing alternative causes. There were 130 additional US findings in 68 patients and 151 additional CT findings in 77 patients. A wide spectrum of findings can be identified in subjects imaged for flank pain. Non-contrast-enhanced helical CT and US have comparable accuracy in diagnosing causes other than stone disease. Electronic Publication     

A comparison of the Accuracy of Ultrasound and Computed Tomography in common diagnoses causing acute abdominal pain

Objectives

Head-to-head comparison of ultrasound and CT accuracy in common diagnoses causing acute abdominal pain.

Materials and methods

Consecutive patients with abdominal pain for >2 h and <5 days referred for imaging underwent both US and CT by different radiologists/radiological residents. An expert panel assigned a final diagnosis. Ultrasound and CT sensitivity and predictive values were calculated for frequent final diagnoses. Effect of patient characteristics and observer experience on ultrasound sensitivity was studied.

Results

Frequent final diagnoses in the 1,021 patients (mean age 47; 55% female) were appendicitis (284; 28%), diverticulitis (118; 12%) and cholecystitis (52; 5%). The sensitivity of CT in detecting appendicitis and diverticulitis was significantly higher than that of ultrasound: 94% versus 76% (p?p?=?0.048), respectively. For cholecystitis, the sensitivity of both was 73% (p?=?1.00). Positive predictive values did not differ significantly between ultrasound and CT for these conditions. Ultrasound sensitivity in detecting appendicitis and diverticulitis was not significantly negatively affected by patient characteristics or reader experience.

Conclusion

CT misses fewer cases than ultrasound, but both ultrasound and CT can reliably detect common diagnoses causing acute abdominal pain. Ultrasound sensitivity was largely not influenced by patient characteristics and reader experience.     

Acute epiploic appendagitis: CT findings in 33 cases

Acute epiploic appendagitis (AEA) is a benign self-limiting process presenting with acute abdominal pain often misdiagnosed clinically as either diverticulitis or appendicitis, but which has a pathognomonic CT appearance. The CT findings in 33 adult patients diagnosed by CT over a 33-month period as having AEA were retrospectively reviewed. The study group included 24 men and 9 women, with a mean age of 44.6 years. The mean age of the male patients was lower than that of the female patients, 40.9 vs 54.7 years. All patients presented with acute abdominal pain, mainly in the left (n=21) and right (n=9) lower quadrants, with localized tenderness in all patients and peritoneal irritation in 15 of them. Low-grade fever was found in 8 patients and mild leukocytosis in 16. Characteristic CT findings of an oval fatty mass with central streaky densities and surrounded by mesenteric stranding adjacent to the serosal surface of the colon were seen in all cases. Additional findings included mural thickening of the juxtaposed colon in 16 patients and peritoneal fluid in 7. One patient underwent surgery on the basis of an erroneous diagnosis of acute appendicitis. As CT is often used nowadays to evaluate various acute abdominal complaints, it may be the first imaging modality by which AEA is diagnosed. AEA should be included in the differential diagnosis in young male patients with localized left lower abdominal pain and tenderness. Electronic Publication     

Appendiceal diverticulitis: diagnosis and differentiation from usual acute appendicitis using computed tomography

OBJECTIVE: To describe the computed tomographic findings of appendiceal diverticulitis. METHODS: Computed tomography (n = 20) and clinical findings in 23 patients with appendiceal diverticulitis were retrospectively reviewed and compared with those in 23 patients with usual acute appendicitis. RESULTS: Computed tomography visualized the inflamed diverticula (up to 4 per patient) mostly as small (median, 7.5 mm) round cystic outpouchings at the distal appendix with contrast enhancement at the cyst wall in 16 (80%) patients with appendiceal diverticulitis. In 50% of appendiceal diverticulitis patients, computed tomographic diagnosis of accompanying appendicitis was false positive. Appendicolith was rarely observed in the appendiceal diverticulitis group (5% vs 48%, P = 0.002). No significant difference was observed in the clinical findings except for the patient age (median, 45 vs 31 years; P = 0.001). CONCLUSIONS: Most appendiceal diverticulitis can be differentiated from usual acute appendicitis at computed tomography by visualization of the inflamed diverticulum.     

多排螺旋CT对肠梗阻诊断的临床价值

目的探讨多排螺旋CT对肠梗阻诊断的临床价值。方法回顾性分析41例经临床保守治疗或手术证实的肠梗阻的螺旋CT影像资料,并将其诊断结果与手术、病理结果进行对照分析。结果多排螺旋CT诊断肠梗阻的准确性100%,对肠梗阻部位判断的准确性及病因判断有着独特的优势。其中肠肿瘤15例,粘连性肠梗阻21例（包括阑尾炎脓肿形成1例,肠憩室炎1例）,闭孔疝1例,腹股沟疝2例,肠系膜血管栓塞1例,后腹膜恶性纤维组织细胞瘤侵犯肠壁1例。结论多排螺旋CT在显示肠梗阻的存在与否、确定肠梗阻部位以及梗阻原因判断方面具有很高的临床价值。     

MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome

Elderly adults are at increased risk for complications related to both delayed diagnosis of appendicitis and to unnecessary appendectomy. We assessed the diagnostic performance of computed tomography (CT) in a consecutive elderly cohort with clinically suspected appendicitis. CT findings and clinical outcomes were analyzed for 262 consecutive adult patients age 65 and older (mean 75.6 ± 7.5 years; range 65–94; M/F 111:151) referred for clinically suspected appendicitis at a single medical center between January 2000 and December 2009. The overall prevalence of proven acute appendicitis in this elderly cohort with clinically suspected appendicitis was 16.8% (44/262). CT sensitivity, specificity, PPV, and NPV for acute appendicitis were 100% (44/44), 99.1% (216/218), 95.7% (44/46), and 100.0% (216/216), respectively. The negative appendectomy rate was 2.3% (1/43). The perforation rate was 40.9% (18/44). There were no false-negative and two false-positive CT interpretations. All patients with appendicitis suspected on CT were hospitalized (44/44), with an average stay of 5.7 ± 3.2 days, and 93.5% (43/46) underwent appendectomy. Overall surgical complication rate was 34.9% (15/43). Compared with younger adults over the same period, elderly patients had higher rates of perforation and surgical complications, and longer hospital stays (p < 0.003). CT is highly accurate for the evaluation of clinically suspected appendicitis in elderly patients. Prompt diagnosis is important given the higher rates perforation and surgical complications relative to younger adults.     

Inter-observer agreement for abdominal CT in unselected patients with acute abdominal pain

The level of inter-observer agreement of abdominal computed tomography (CT) in unselected patients presenting with acute abdominal pain at the Emergency Department (ED) was evaluated. Two hundred consecutive patients with acute abdominal pain were prospectively included. Multi-slice CT was performed in all patients with intravenous contrast medium only. Three radiologists independently read all CT examinations. They recorded specific radiological features and a final diagnosis on a case record form. We calculated the proportion of agreement and kappa values, for overall, urgent and frequently occurring diagnoses. The mean age of the evaluated patients was 46 years (range 19–94), of which 54% were women. Overall agreement on diagnoses was good, with a median kappa of 0.66. Kappa values for specific urgent diagnoses were excellent, with median kappa values of 0.84, 0.90 and 0.81, for appendicitis, diverticulitis and bowel obstruction, respectively. Abdominal CT has good inter-observer agreement in unselected patients with acute abdominal pain at the ED, with excellent agreement for specific urgent diagnoses as diverticulitis and appendicitis.     

CT of appendicitis in children

Appendicitis is the most common condition requiring intraabdominal surgery in infancy and childhood. Yet, despite its common occurrence, accurate diagnosis remains challenging. Acute appendicitis may be missed at initial clinical examination in 28%-57% of children aged 12 years and younger and in nearly 100% of children under the age of 2 years. Diagnostic imaging has an ever-increasing role in the prompt and accurate diagnosis of acute appendicitis in the pediatric population. At the authors' institution, helical computed tomography (CT) is the primary tool for diagnosing or excluding appendicitis in children. Since its inception in 1998, helical CT with rectally administered contrast material has been shown to reduce the total number of inpatient observation days, laparotomies with negative findings, and per-patient cost. Helical CT is a highly sensitive and specific tool for diagnosing pediatric appendicitis and has resulted in a beneficial change in patient care in 68.5% of all patients seen in the authors' emergency department for suspected appendicitis. This includes both those patients who receive an eventual diagnosis of appendicitis and those who do not have the disease. Major strengths of limited helical CT with rectal contrast material include producing uniformly high published sensitivity and specificity values for diagnosis of appendicitis and enabling diagnosis of alternative conditions of acute abdominal pain in children. In contrast, limitations of graded-compression ultrasonography in children include highly operator-dependent sensitivity and specificity values and relative infrequency with which the normal appendix can be visualized in this population. Although there have been many exciting diagnostic advancements for the diagnosis of acute appendicitis in the pediatric population, the role of helical CT is far from clear. The purpose of this article is to describe a helical CT approach to imaging in children suspected of having acute appendicitis at a large urban pediatric teaching hospital and its effects on patient outcomes and hospital costs.     

Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations

Purpose

Appendiceal diverticulitis is relatively rare and is difficult to distinguish clinically and radiologically from acute appendicitis. The aim of this study was to describe the computed tomography (CT) findings of acute appendiceal diverticulitis.

Materials and methods

Among the 1329 patients who underwent appendectomy at our institution between January 2010 and July 2015, 28 were diagnosed pathologically with appendiceal diverticulitis, including 24 patients who were evaluated by preoperative CT. The control group consisted of 38 patients without diverticulitis. Average age of patients, ratio of males to females, appendiceal diameter, presence of a diverticulum, diverticular enhancement, peri-appendiceal fat stranding, peri-appendiceal loculated fluid and perforation, and the presence of appendicolith were evaluated retrospectively.

Results

Peri-appendiceal fat stranding (p < 0.005), appendiceal diameter (p < 0.005), and peri-appendiceal loculated fluid differed significantly between the diverticulitis and non-diverticulitis groups (p < 0.005).

Conclusion

Although relatively uncommon, appendiceal diverticulitis should be included in the differential diagnosis of acute appendicitis. It differs from typical acute appendicitis by the presence of an inflamed diverticulum, seen on CT. These patients are also more likely to have peri-appendiceal extra-luminal loculated fluid, peri-appendiceal fat stranding, and a larger diameter of the appendix. The latter finding is likely due to the increased intraluminal pressure.

     

A simple MRI protocol in patients with clinically suspected appendicitis: results in 138 patients and effect on outcome of appendectomy

To establish the value of breathhold magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis. Over a 14-month period, 138 patients clinically suspected of having appendicitis were evaluated prospectively with MRI and comprised the study group. Fast turbo spin-echo breathhold T1, T2 and T2 fat suppression sequences were used in coronal and axial planes. The imaging results were recorded separately and subsequently correlated with clinical, radiological and histopathological follow-up. The effect of imaging strategies in patients suspected of appendicitis on hospital resources was calculated. Sixty-two of the 138 patients had a histopathologically proven appendicitis. MRI determined appendicitis in 63 patients, with one examination being false positive. The resulting sensitivity and specificity were 100% and 99%, respectively. MRI showed an alternative diagnosis in 41 of the 75 remaining patients. In 22 of the remaining 34 patients, a normal appendix was depicted with MRI. In two patients, where MRI showed no appendicitis, an alternative diagnosis or normal appendix, an unnecessary appendectomy was performed. The overall effect of using MRI in patients suspected of appendicitis on the use of hospital resources could have been a net saving between € 55,746 and € 72,534. MRI has a high accuracy in detecting and excluding appendicitis, an alternative diagnosis or showing the normal appendix, and can be a valuable and cost-effective tool in the workup of patients clinically suspected of having appendicitis.