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Iran J Pediatr. In Press(In Press):e10095.
Published online 2017 June 17.
doi: 10.5812/ijp.10095.
Research Article
Evaluation of Clinical and Imaging Findings in Children with
Diagnosis of Acute Appendicitis
Aytekin Kaymakci,1Sirin Guven,2Seher Erdogan,3Ilhan Ciftci,4,* and Recai Gokcan5
1Department of Pediatric Surgery, Umraniye Trainingand Research Hospiatal, Turkey
2Department of Pediatrics, Umraniye Training and Research Hospiatal, Turkey
3Division of Pediatric Intensive Care Unite, Umraniye Training and Research Hospiatal, Turkey
4Department of Pediatric Surgery, Selcuk University Medical Faculty, Turkey
5Department of Radyology, Umraniye Trainingand Research Hospiatal, Turkey
*Corresponding author: Ilhan Ciftci, Selcuk Universitesi Tip Fakultesi, Cocuk Cerrahisi A. D. , Konya, Turkey.Tel: +90-3322415000, E-mail: driciftci@yahoo.com
Received 2016 December 19; Revised 2017 February 16; Accepted 2017 April 14.
Abstract
Objectives: This study is an evaluation of the accuracy of ultrasonography (USG), computed tomography (CT), and Alvarado score
(AS) in the diagnosis and management of acute appendicitis in children.
Methods: Records of pediatric patients admitted to the pediatric emergency department (ED) between 2008 and 2012 were eval-
uated retrospectively. Patient data from the national electronic health information system was screened and those with complete
clinical and imaging findings (AS, preoperative USG and/or CT images) and postoperative pathological diagnosis were included in
the study.
Results: Study group consisted of 449 children with diagnosis of suspected acute appendicitis aged between 3 and 15 years (mean
age: 9.20 ±2.73 years). Of the total, 428 (95.3%) patients underwent appendectomy and 21 (4.7%) cases were treated conservatively.
Mean duration of symptoms was 4.94 ±1.84 hours. Pathological evaluation results were negative (i.e., removal of normal appendix)
in 36 (8.4%) patients; histopathological diagnosis was acute appendicitis in 392 (91.6%) patients. Perforated appendix was found
in 38 (8.5%) patients. In patients with histopathologically confirmed appendicitis, sensitivity, specificity, positive predictive value
(PPV), and negative predictive value (NPV) of CT in diagnosis of acute appendicitis were 96.3%, 55.6%, 92.8%, and 71.4%, respectively.
Sensitivity, specificity, PPV, and NPV of USG were 73.5%, 22.2%, 91.1%, and 69.2%, respectively. Negative appendectomy rate was 6.4% (n
= 8) in patients who had preoperative CT scan, and 6.5% (n = 28) in patients who had USG examination.
Conclusions: CT has higher sensitivity than USG in diagnosis of acute appendicitis. USG, on the other hand, is widely accessible
method and does not use ionizing radiation. Therefore, it may be used as initial radiological imaging method in acute appendicitis.
Thin-filter, contrast-unenhanced CT scans may be preferred in cases where clinical signs and USG findings are unclear or controver-
sial.
Keywords: Alvarado score, Appendicitis, Computed tomography, Ultrasonography, Children
1. Background
Acute appendicitis is one of the most common reasons
for emergency abdominal surgery in children. Thenonspe-
cific nature of complaints and variability may delay correct
diagnosis and lead to larger number of cases with perfora-
tion.
Research on comparison of clinical scores and imag-
ing findings continues in order to decrease negative ap-
pendectomy rate (1,2). According to recent studies, Al-
varado score (AS) is a useful tool in evaluation of children
with possible appendicitis. Score of 4 or less is used to
rule out appendicitis, whereas score of 8 or higher suggests
appendicitis and need for appendectomy/surgical consul-
tation. Patients with AS of between 5 and 7 are potential
candidates for further radiological work-up. Although ap-
pendicitis score has improved clinical diagnostic accuracy
for diagnosis of appendicitis from 80% to 92%, frequency
of unnecessary appendectomies is still high, between 8.8%
and 34% (3-5).
2. Objectives
The aim of this study was to evaluate the sensitivity and
specificity of ultrasonography (USG), computed tomogra-
phy (CT) and Alvarado score (AS) in diagnosis of acute ap-
pendicitis in children.
3. Methods
The study group consisted of children who were ad-
mitted to pediatric emergency department of Umraniye
training and research hospital between August 2008 and
April 2012 for abdominal pain of less than 5 days’ duration
Copyright © 2017, Iranian Journal of Pediatrics. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
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Kaymakci A et al.
and with clinical diagnosis of acute appendicitis. Demo-
graphic data, clinical findings, laboratory values, preoper-
ative USG and/or CT imaging findings, and postoperative
pathological findings were obtained from electronic na-
tional health information system (NHIS) medical records.
AS and duration of symptoms were recorded for each pa-
tient. AS was calculated as follows: Presence of fever ≥
37.3°C (1 point), rebound tenderness (1 point), right-lower-
quadrant tenderness (2 points), anorexia (1 point), nau-
sea and/or vomiting (1 point), migration of pain (1 point),
leukocytosis > 10,000 cells/mm3(2 points), and polymor-
phonuclear neutrophils > 7500 cells/mm3(1 point). Pa-
tients were then divided into 3 groups: Group 1 was made
up of patients with high (> 8) AS, Group 2 consisted of pa-
tients with intermediate (5-7) AS and Group 3 comprised
patients with low (< 4) AS. Preoperative USG and/or CT im-
age findings and postoperative pathological report find-
ings were also recorded. Pathological evaluation results
were negative (removal of normal appendix), acute ap-
pendicitis, or perforated appendix. USG studies were per-
formed in emergency department following physical ex-
amination and during observation period for acute appen-
dicitis. CT was performed only for patients with clinical
findings of acute appendicitis and negative USG image.
USG and only CT findings were recorded as negative or pos-
itive for appendicitis. CT scan was performed without con-
trast, equivocal non-contrast CT results and repeated CT
scans were not reported in our patient records. USG ex-
amination was performed using Aplio MX (Toshiba medi-
cal systems corp., Otawara-shi, Japan) color Doppler ultra-
sonography device, equipped with convex and linear trans-
ducers. Findings supportive of diagnosis of appendicitis
included pain; aperistaltic, noncompressible, dilated ap-
pendix (> 6 mm outer diameter); presence of appendi-
colith (calcified deposit within the appendix); and promi-
nent echogenic pericecal fat. CT evaluation was conducted
using spiral tomography scanner (GE medical system, op-
tima CT 660,128 Slice USA). Presence of dilated appendix
with distended lumen (> 6 mm diameter), thickened wall,
and periappendiceal inflammation with stranding of ad-
jacent fat and thickening of lateroconal fascia were con-
sidered signs of appendicitis (Figure 1). USG and CT im-
ages were interpreted by radiologists. Percentage of cases
of pathologically proven negative or acute appendicitis in
children who had USG without CT examination was com-
pared with that of children who had USG and CT examina-
tion. Patients who did not undergo surgery were clinically
observed in emergency department (ED).
3.1. Statistical Analyses
SPSS Statistics 22.0 (IBM Corp., Armonk, NY, USA) was
used for statistical analyses. Data were analyzed using
Figure 1. Unenhanced Axial CT Image: Increased Diameter of Appendix(11 mm) and
Inflammation in Periappendiceal Mesentery
descriptive statistical methods (i.e., mean, SD, frequency).
Comparisons between study groups were performed using
Mann-Whitney U test for continuous variables. McNemar’s
test was applied to test difference between paired propor-
tions. Sensitivity, specificity, positive predictive value (PPV)
and negative predictive value (NPV) of diagnostic modali-
ties were calculated. Level of statistical significance was set
at P < 0.05.
4. Results
Study included 449 children with suspected diagnosis
of acute appendicitis. Mean age of the patients was 9.20 ±
2.73 years. There were 208 (46.3%) female patients and 241
(53.7%) male patients. There was evidence of perforation
in 38 (8.5%) patients. Of the total, 428 (95.3%) patients had
appendectomy and 21 (4.7%) patients were managed con-
servatively. Mean duration of symptoms was 4.94 ±1.84
hours, with median duration of 4 hours. Pathological re-
sults were negative (i.e., removal of normal appendix) in
36 (8.4%) patients, whereas histopathology was consistent
with acute appendicitis in 392 (91.6%) patients. Pathologi-
cal and imaging findings are summarized in Table 1.
In 25 (5.6%) patients, AS was < 4, and these patients
were not evaluated with CT scan. One patient with AS
of 3 had muscular defense during physical examination.
This patient also had normal USG examination, but sub-
sequently had surgery and was diagnosed histopatholog-
ically as appendicitis.
CT scan was performed on 125 patients, of whom 111
(89 %) had positive CT findings. Eight (6.4%) patients had
histopathological diagnosis of negative for appendicitis.
Fourteen (11.2%) patients had negative CT findings; how-
ever, 4 (3.2%) of them were histopathologically diagnosed
2Iran J Pediatr. In Press(In Press):e10095.
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Kaymakci A et al.
Table1. The Distribution of USG, CT and Histopathological Results in Patients
n %
USG (n = 449)
Positive 316 70.4
Negative 133 29.6
CT (n = 125)
Positive 111 88.8
Negative 14 11.2
Histopathology (n = 428)
Appendicitis 392 91.6
Normal 36 8.4
as appendicitis (Figure 3). There were 316 (73.8%) patients
with positive USG findings; however, 28 (6.5%) of them were
histopathologically normal. Of 112 (26.2%) patients with
negative USG results, 104 (24.3%) were subsequently diag-
nosed as appendicitis.
There were 308 (68.6%) patients with AS of between 5
and 7, CT scan was performed on 79 of these patients. There
were 116 (25.8%) patients with AS of ≥8. CT scan was per-
formed on 46 patients; 80 (69%) patients with AS of ≥8 had
been diagnosed histopathologically as appendicitis and 36
(31%) had normal histopathology. Sensitivity, PPV, and ac-
curacy of CT scan in diagnosing acute appendicitis were
each 100% in patients with AS of 8 or above. For all patients
with histopathologically confirmed appendicitis, sensitiv-
ity of CT was 96.26% and specificity was 55.56%; sensitivity
of USG in that group of patients was 73.47% and specificity
22.22%. USG findings, CT results, and AS of histopatholog-
ically confirmed appendicitis cases are provided in Table
2. A statistically significant difference was not found be-
tween USG-positive and USG-negative patients with respect
to AS (P > 0.05; P = 0.113). AS of CT-positive patients, on
the other hand, was significantly higher than that of CT-
negative patients (P < 0.01; P = 0.001). AS of patients diag-
nosed histopathologically as appendicitis was also signif-
icantly higher than score of patients with histopathologi-
cally negative diagnosis (P < 0.01; P = 0.001) (Figure 2).
5. Discussion
Negative appendectomy rate varies significantly by pa-
tient sex. Primary reason is overlap with symptoms of
acute gynecological diseases, making clinical symptoms
unreliable. Overall negative appendectomy rate (8.6%) of
the present study is similar to rates reported in the rele-
vant literature (6,7). Although intravenous iodinated con-
trast agents may have serious side effects and CT scan itself
is costly, CT may provide evidence of early stage of appen-
dicitis and its complications (8). Non-contrast-enhanced,
thin-section CT is faster and safer alternative to enhanced
CT scan, and is preferred as standard technique at our in-
stitution. According to Malone and Wolf (9), non-contrast,
thin section helical CT technique has 97% specificity and
87% sensitivity in patients with acute pain in right lower
quadrant. Kim et al. (10) evaluated 891 young adults with
suspected appendicitis and compared low-dose CT (one-
quarter of standard dose) to high-dose CT. Rate of negative
appendectomy in 2 groups was similar and no difference
was seen in terms of perforation rate. In a retrospective
study conducted by Martin and Vollman (11), use of USG
to evaluate suspected appendicitis decreased from 20% in
1998 to 7% in 2001. Meanwhile, CT orders increased from
17.6% to 51.3%. Negativeappendectomy rate was 22% for USG
and 18% for CT. According to Garcia Pena et al. (12), negative
appendectomy rate was 6% for patients who had preoper-
ative CT examination and 12% for patients without prior
CT examination. In the present study, negative appendec-
tomy rate of patients who had positive CT (6.4%) was simi-
lar to that of studies summarized above. Negative appen-
dectomy in our patients who had positive USG rate (6.5%)
was found to be lower than reported in these studies. We
did not find a difference in negative appendectomy rates
based on imaging scan. Karakas et al. (13) reported higher
rate of perforation in children who had only CT (54%), or CT
and USG (71%), than in children who underwent only USG
(23%). They explained their observation with delay in man-
agement due to lengthy CT request to report cycle. In our
study, perforated appendix was found in 38 (8.5%) patients.
Although the present study also indicates higher perfora-
tion rate in patients who underwent CT scan, time metrics
regarding request to report time were not recorded, and
such an inference cannot be confidently established. Ac-
cording to previous studies (14,15), most diagnostic delay
is rooted in delayed presentation of patient; delays due to
hospital procedures are not significant contributors to in-
cidence of perforation. Perforation is a serious complica-
tion of acute appendicitis, and is observed 20% more fre-
quently in children and elderly patients (16,17). Time from
onset of symptoms to emergency admission was 4.94 ±
1.84 hours. Relatively low rate of perforation in this study
may be due to short interval between onset of symptoms
and admission.
In a recent study, sensitivity and specificity of CT and
USG in diagnosing appendicitis in 211 children were similar
for cases with an AS of 6 or less, When AS was ≥6, and USG
findings conflicted with clinical findings, sensitivity and
specificity of CT was higher (18). In the present study, speci-
ficity of CT was 93.4% in patients with AS of between 5 and
7 and 100% in patients with AS of 8 or more. No significant
Iran J Pediatr. In Press(In Press):e10095. 3
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Kaymakci A et al.
0
1
2
3
4
5
6
7
8
9
Pozitive Negative Pozitive Negative APP Normal
USG CT Pathology
Mean ± SD
Alvarado Score
Figure 2. Alvarado Score According to the USG, CT and Histopathology
Performed CT scans
n = 125
Positive CT scans
n = 111(89%)
Negative CT scans
n = 14 (11.2%)
Negative Histopathology
n = 8 (6.4%)
Positive Histopathology
n = 103 (92.8%)
Negative Histopathology
n = 10 (71.4%)
Positive Histopathology
n = 4 (3.2%)
Figure 3. The Distribution of CT Results in Patients
difference was found between patients with negative and
positive USG findings with regard to AS. However, patients
with positive CT finding and histopathological confirma-
tion had significantly higher AS. In a systematic review con-
4Iran J Pediatr. In Press(In Press):e10095.
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Kaymakci A et al.
Table2. USG and CT results in Histopathological Confirmed Appendicitis Patients According to Alvarado Scores
Sensitivity Specificity PPV NPV Accuracy
All cases
CT 96.26 55.56 92.79 71.43 90.4
USG 73.47 22.22 91.14 7.14 69.2
Alvarado score 5 - 7
CT 93.44 55.56 87.69 71.43 84.8
USG 79.27 24.24 89.71 12.31 73.4
Alvarado score ≥8
CT 100 - 100 - 100
USG 60.34 - 100 0 60.3
ducted previously, sensitivity and specificity of USG in di-
agnosis of acute appendicitis were reported as 83.7% and
95.9%, respectively (19,20). Contrary to these results, we
found sensitivity and specificity of USG to be 73.4% and
22.2%, respectively. PPV of USG was 91.14%, NPV 71.4%, and ac-
curacy 69.2%. Sensitivity of USG was 79.2% in patients with
AS of between 5 and 7, and 60.4% in patients with AS of 8 or
more.
Similar to our study, Schuh et al reported a suboptimal
accuracy rate (60%) of screening with ultrasound scanning
for appendicitis (21). Recent study showed that the serial
US has a higher diagnostic accuracy than initial US (22).
First reason for our lower specificity and accuracy may be
due to using only initial US in ED. Second reason may be
that even though US was performed by experienced radiol-
ogists at ED, the time for evaluation was not enough.
In conclusion, when compared with USG, CT has
greater sensitivity in diagnosis of acute appendicitis. How-
ever, USG must still be initial imaging study ordered due
to ease of use, and use of non-ionizing radiation. Thin-
section, non-enhanced CT can be ordered if clinical signs
and USG findings are contrary. Contrast-enhanced CT may
be preferred if the appendix cannot be visualized with USG
in patients with equivocal clinical findings.
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