Improved Sonographic Visualization of the Appendix With a Saline Enema in Children With Suspected Appendicitis

Abstract

Objective. To determine whether abdominal sonography after a saline enema can identify the appendix that is not visualized at graded compression sonography in children with suspected appendicitis. Methods. High-frequency compression sonography was prospectively performed in 120 consecutive children with suspected appendicitis; the appendix was not identified in 27 of these patients. Among the 27 patients with a nonvisualized appendix, abdominal sonography after a saline enema was performed in 12 to identify the appendix. Results. Abdominal sonography after the saline enema revealed the appendix in all 12 children in whom the appendix was not visualized at graded compression sonography. A normal appendix was found in 11 children, and acute appendicitis confined to the appendiceal tip was found in 1. The appendix was located in the pelvis (n = 5), posterior to the cecum (n = 4), posterior to the ileum (n = 2), and anterior to the ileum (n = 1). The appendix could be identified by using a window of the saline-filled sigmoid colon (n = 5), saline-filled cecum (n = 4), and saline-filled terminal ileum (n = 2). Conclusions. Abdominal sonography after a saline enema is a helpful technique for depiction of the appendix that is not visible at graded compression sonography in children with suspected appendicitis.

Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US

“…Sources of heterogeneity among primary studies in our meta-analysis include variations in the institution type (eg, pediatric hospital, academic hospital, and community hospital), characteristics of the imaging modality, experience of sonographers, experience of imaging reviewers, handling of equivocal results, and criteria for diagnosis of appendicitis. Of note, five of nine studies (56%) on second-line US (32,33,35,37,38), 12 of 20 studies (60%) on CT (26,37,41,43,45,46,(48)(49)(50)(52)(53)(54), and six of 11 studies (55%) on MRI (24,56,59-62) did not state how equivocal results were handled. The remaining studies used a variety of strategies such as the use of a Likert scale, considering all equivocal results to be false-positive findings or false-negative findings, or excluding equivocal results from the 2 3 2 contingency table.…”

“…When grouped by modality, there were nine articles on US, composed of six articles on 548 children (9,11,(32)(33)(34)(35) and three articles on 169 adults (36)(37)(38); 20 articles on CT, composed of nine articles on 1498 children (9,26,(39)(40)(41)(42)(43)(44)(45) and 11 articles on 1027 adults (25,37,(46)(47)(48)(49)(50)(51)(52)(53)(54); and 11 articles on MRI, composed of five articles on 287 children (39,(55)(56)(57)(58), one article on 223 adults (59), and five articles on 204 pregnant women (for a total of 427 patients) (24,(60)(61)(62)(63). Figure 1 shows the article selection process.…”

Imaging of Acute Appendicitis for Adult Patients

“…Bladder repletion is not necessary to allow optimal examination of appendix ( Figure 1) [22]. Some authors have shown improved visualization of the appendix using saling colonic enema: this option is however not applicable and commonly used in clinical routine [23].…”