Hyde Hannah,  Tutman Jeffrey,  Blanco Ernesto

Final Pr. ID: Poster #: CR-015

Ovarian torsion is a very rare occurrence where the ovary becomes twisted, cutting off blood supply, and placing the ovary at risk of tissue death and loss of function. Appendicitis, although more common in the pediatric population, is still a relatively uncommon condition that can have grave consequences. Appendicitis secondary to ovarian torsion, in the instance where the ovary twists on its peduncle around the body of the appendix, is not only extremely rare, but puts the patient at risks for complications and consequences for both of these rare issues. This case report will tell the story of a 15-year-old girl including her initial presentation, clinical details, imaging, post-operative notes, and prognosis. Although a very atypical finding, this case highlights the importance of time and the particular dangers when dealing with two very critical diagnoses. Read More

Authors:  Hyde Hannah , Tutman Jeffrey , Blanco Ernesto

Keywords:  Appendicitis, Torsion, Ovary

Sawyer David,  Mushtaq Raza,  Vedantham Srinivasan,  Udayasankar Unni

Final Pr. ID: Paper #: 096

Acute appendicitis represents an important cause of abdominal pain in pediatric patients. Although imaging plays an increasingly important role in the rapid diagnosis and management of this condition, there is no universally accepted strategy for imaging children suspected of having acute appendicitis. Ultrasound and computed tomography have been used most commonly, but there is rising interest in the use of magnetic resonance imaging (MRI) due to its lack of ionizing radiation or need for intravenous contrast. Recent research has shown that MRI has high diagnostic performance when employed as a first-line test. However, when considering the generalizability of MRI outside of a specialized tertiary care center, the question of operator dependence arises. To determine the performance of MRI when interpreted by readers with limited experience, we performed a retrospective review of preliminary MRI interpretations rendered by radiology residents at our institution, compared with final (attending radiologist) interpretations. Read More

Authors:  Sawyer David , Mushtaq Raza , Vedantham Srinivasan , Udayasankar Unni

Keywords:  Acute appendicitis, Magnetic resonance imaging

Singh Jasmeet,  Milks Kathryn

Final Pr. ID: Poster #: EDU-033

Ultrasound carries high sensitivity in diagnosing acute appendicitis in pediatric patients and is increasingly being used as the preferred method of diagnosis since it does not use ionizing radiation. Although an enlarged diameter of the appendix and non-compressibility are the primary indicators of appendicitis, they do not have perfect specificity. Therefore, secondary features of appendicitis are crucial in supporting the diagnosis of appendicitis. The most sensitive secondary finding of appendicitis is inflammatory echogenic periappendiceal fat. Other secondary signs of appendicitis are either infrequently present, like wall hyperemia, or entirely nonspecific, like periappendiceal free fluid. Improving diagnostic accuracy of appendicitis with additional secondary supportive signs would be helpful. We have subjectively observed that appendix shape may be a helpful secondary sign of appendicitis, and that in certain cases it forms a C-shape or curved appearance when inflamed. It mimics the appearance of the letter ‘C’ and hence, we termed it, the “C sign.” Retrospective review of 999 ultrasound appendix studies that were conducted in our hospital from January 1, 2022, to March 31, 2022, with 150 sonographically positive acute appendicitis cases, we found 10 patients with the positive C sign and deemed positive by US and pathologically to be acute appendicitis. It seems by observation that this sign is not sensitive but specific when found, for acute appendicitis. One probable explanation for this configuration is loop separation that occurs when the proximal and distal ends of the appendix are separated either by inflamed fat or wall thickening. Herein, we show a few examples of the appendiceal “C-sign”, describe our observations, and suggest its potential use as an additional secondary sign of appendicitis. Read More

Authors:  Singh Jasmeet , Milks Kathryn

Keywords:  Appendicitis, Ultrasound, C sign

Bedoya Maria,  Barrera Christian,  Ho-fung Victor,  States Lisa

Final Pr. ID: Paper #: 002 (S)

In the diagnosis of acute appendicitis, unenhanced MRI provides an efficient and comprehensive evaluation of the appendix. However, on the daily clinical basis, there are cases that generate a diagnostic dilemma with subtle/indeterminate inflammatory changes. For these questionable cases, the morphology of the appendix could play a role as an aid for the radiologist to increase the confidence diagnosing or ruling out acute appendicitis. The aim of this study is to evaluate the morphology of the appendix as an additional tool for the diagnosis of appendicitis. Read More

Authors:  Bedoya Maria , Barrera Christian , Ho-fung Victor , States Lisa

Keywords:  MRI, Appendicitis

Crido Silvina,  Bravo Monica,  Lipsich Jose,  Cermeño Claudia,  Dardanelli Esteban,  Moguillanky Slvia

Final Pr. ID: Poster #: EDU-029

To present a series of patients with pylephlebitis without a significant past medical history Read More

Authors:  Crido Silvina , Bravo Monica , Lipsich Jose , Cermeño Claudia , Dardanelli Esteban , Moguillanky Slvia

Keywords:  Pylephlebitis, portal vein thrombosis, omphalitis, appendicitis, ultrasonography

Rodriguez Takeuchi Sara,  Doria Andrea,  Sousa-plata Karen,  Man Carina,  Vidarsson Logi,  Rayner Tammy,  Mohanta Arun,  Amirabadi Afsaneh,  Schuh Suzanne

Final Pr. ID: Poster #: SCI-010

Despite being recognized as a secondary sign of appendicitis, no clear definition exists about the amount of intra-abdominal fluid considered physiologic in children. The purpose is (1) to assess the amount of intra-abdominal free fluid by US and MRI in children with suspected appendicitis, (2) to detect the performance characteristics of US for detecting free fluid, and (3) to determine the association between fluid volume and perforated appendicitis. An additional ex-vivo study was done to assess the validity of US measurement abdominal free fluid volume using phantoms. Read More

Authors:  Rodriguez Takeuchi Sara , Doria Andrea , Sousa-plata Karen , Man Carina , Vidarsson Logi , Rayner Tammy , Mohanta Arun , Amirabadi Afsaneh , Schuh Suzanne

Keywords:  Appendicitis, ascites, ultrasonography

Tung Eric,  Ayyala Rama,  Sams Cassandra,  Herliczek Thaddeus,  Baird Grayson,  Swenson David

Final Pr. ID: Paper #: 097

Rapid, non-contrast MRI has been reported as accurate for diagnosing acute appendicitis at specialized pediatric hospitals, but there remains a dearth of evidence-based, MRI-specific criteria upon which the diagnosis should be established. To our knowledge, our study comprises the largest study with the most independent readers of MRI-specific diagnostic criteria for pediatric appendicitis reported to date. Read More

Authors:  Tung Eric , Ayyala Rama , Sams Cassandra , Herliczek Thaddeus , Baird Grayson , Swenson David

Keywords:  Appendicitis, MRI

Francavilla Michael,  Mpoti Makhethe,  Vossough Arastoo

Final Pr. ID: Paper #: 092

We sought to determine factors associated with sonographic non-visualization of the appendix in patients being evaluated for appendicitis. Read More

Authors:  Francavilla Michael , Mpoti Makhethe , Vossough Arastoo

Keywords:  appendicitis, overweight, obesity

Sousae Sean,  Simmons Curtis,  Bailey Smita,  Cutler Kayci,  Youssfi Mostafa,  Reynolds Kristine,  Oliver Clay,  Pfeifer Cory

Final Pr. ID: Poster #: SCI-006

Growth in our hospital has resulted in multiple new locations opening which has resulted in staffing by ultrasound technologists lesser experienced in appendicitis imaging. Likewise, our ordering providers have increased their push to reduce CT utilization. Our aim was to improve the appendix visualization frequency by 10% over 6 months to reduce exposure to ionizing radiation, reduce cost for families, lower risk to patients, reduce length of stay in the emergency department, and shorten the time to diagnosis. Read More

Authors:  Sousae Sean , Simmons Curtis , Bailey Smita , Cutler Kayci , Youssfi Mostafa , Reynolds Kristine , Oliver Clay , Pfeifer Cory

Keywords:  Appendicitis, Quality Improvement, Ultrasound

Layton Katherine,  Rayne Florence,  Cao Wen,  Bulas Dorothy

Final Pr. ID: Paper #: 168

General Emergency Departments (ED) continue to have a high usage of CT for the diagnosis of appendicitis in children. Purpose of this project was to see if an interdisciplinary approach in a small community ED could increase the usage of US for the evaluation of appendicitis in children. Read More

Authors:  Layton Katherine , Rayne Florence , Cao Wen , Bulas Dorothy

Keywords:  appendicitis, ultrasound, community hospital

Dougherty Ryne,  Alves Timothy

Final Pr. ID: Poster #: EDU-022

Abdominal pain is common presentation to the pediatric emergency department, and appendicitis remains the most common pediatric surgical emergency. While the imaging workup of pediatric appendicitis typically begins with ultrasound, MRI is increasingly being used for problem-solving and to further evaluate equivocal ultrasound results. With increased utilization, more and more mimics of appendicitis are being encountered on MRI. The purpose of this educational exhibit is to familiarize the practicing pediatric radiologist with these mimics through a case-based review in order to improve diagnostic accuracy and patient care. Read More

Authors:  Dougherty Ryne , Alves Timothy

Keywords:  Appendicitis, Emergency, MRI

Mcclure Meghan,  Abdessalam Shahab,  Powers Andria

Final Pr. ID: Poster #: EDU-030

Omental infarction and epiploic appendagitis are subtypes of a broader entity of abdominal fat necrosis known as intraperitoneal focal fat infarction (IFFI). IFFI is an uncommon cause of acute abdominal pain in children, and a known mimicker of acute appendicitis. The CT appearance of IFFI is well described, but the appearance is less familiar on MRI and is a potential imaging pitfall. Familiarity with the MRI appearance of IFFI is particularly timely, given the growing use of MRI in the evaluation of right lower quadrant pain in children. The purpose of this educational exhibit is to review the clinical history, pathologic appearance and treatment of IFFI, and describe MRI features that will allow the radiologist to make the correct diagnosis. Read More

Authors:  Mcclure Meghan , Abdessalam Shahab , Powers Andria

Keywords:  omental infarction, epiploic appendagitis, appendicitis

Jackson Dana,  Gould Sharon,  Choudhary Arabinda,  Epelman Monica

Final Pr. ID: Poster #: EDU-082

Acute onset pelvic pain in a pubertal girl has many possible etiologies. Reproductive, urinary and gastrointestinal pathology all can underlie acute onset pelvic pain in this age group and may have similar presentations. We present a series of six cases in which MRI was utilized for further evaluation of US findings and either confirmed the need for surgical intervention, or established the cause of pain and eliminated the need for surgery. Read More

Authors:  Jackson Dana , Gould Sharon , Choudhary Arabinda , Epelman Monica

Keywords:  Pelvic pain, Ovarian torsion, Appendicitis

Kosaraju Sriya,  Errampalli Eric,  Illimoottil Mathew,  Priya Lakshmi,  Orscheln Emily

Final Pr. ID: Poster #: EDU-046

Appendicitis is an important cause of abdominal pain and is the leading reason for emergent surgery in children. Prompt and accurate diagnosis is important because delayed diagnosis increases the risk of rupture and false positive diagnosis may result in unnecessary surgery. While it can occur at any age, it most frequently occurs in pediatric patients. Further, the rate of perforation is higher in younger children. However, the differential diagnosis for pediatric abdominal pain is broad and includes many non-surgical diagnoses. Localization of pain can also be more difficult in children, posing an additional challenge. In this educational exhibit, we will discuss some clinical mimics of appendicitis and characteristic imaging findings to help differentiate them. Topics covered include omental infarct, typically a self-limited condition, but a cause of abdominal pain that has been identified in 0.024 to 0.1% of cases of surgery for appendicitis. In the rare cases that do require surgery, the surgical approach differs from that for appendicitis. In addition, we will discuss epiploic appendagitis, yet another self limiting condition in which proper diagnosis prevents unnecessary surgery. We will discuss Meckel’s diverticulum, which when inflamed may mimic acute appendicitis very closely in imaging appearance as well as clinical presentation. However, these entities can be differentiated if the inflamed structure can be identified as arising from the ileum rather than the cecum. Finally, we will also discuss other clinical appendicitis mimics such as mesenteric adenitis, inflammatory bowel disease, ileocolic intussusception, and ovarian torsion, and we will contrast the imaging appearance of lymphoid hyperplasia of the appendix with acute appendicitis. Read More

Authors:  Kosaraju Sriya , Errampalli Eric , Illimoottil Mathew , Priya Lakshmi , Orscheln Emily

Keywords:  appendicitis, omental infarct, abdomen

Lee Megan,  Eutsler Eric,  Sheybani Elizabeth,  Khanna Geetika

Final Pr. ID: Poster #: SCI-011

Postoperative abscess is the most common complication of perforated appendicitis in children with an incidence of 3-25%. Though the imaging algorithms for diagnosis of pediatric appendicitis have evolved to magnetic resonance imaging (MRI), the use of MRI for post-operative evaluation of these children remains in its infancy.
The purpose of our study was to evaluate our experience with a rapid non-contrast MR protocol for evaluation of post-appendectomy cases with concern for abscess. Read More

Authors:  Lee Megan , Eutsler Eric , Sheybani Elizabeth , Khanna Geetika

Keywords:  MRI, appendicitis, abscess

Tong Jane,  Luo Yu

Final Pr. ID: Poster #: CR-007

Although acute appendicitis is thought to be result from luminal obstruction of the appendix, rarely it may develop following abdominal trauma. Traumatic appendicitis is thought to occur through direct injury to the appendix, or as a response to other abdominal organ injury. On the other hand, in patients with other organ injury, some distension of the appendix can occur with surrounding free fluid secondary to trauma, mimicking appendicitis. While the clinical presentation of traumatic appendicitis is similar to that of traditional appendicitis, differentiation between reactive appendiceal changes in the setting of traumatic injury to other intra-abdominal organs is important, as the latter will not require appendectomy. We present two pediatric patients in whom following initial suspicion of acute appendicitis, ultrasonography (US) identified mildly enlarged fluid-filled and hyperemic appendix with out of proportion complex fluid, raising the suspicion of previously unsuspected abdominal trauma. Upon further examination, injury to other abdominal solid organs was discovered as the primary cause of patient's presentation and appendiceal findings were reactive to abdominal solid organ injury. In cases of suspected appendicitis, visualization of significant free fluid with dense debris on ultrasonography (US) calls for more careful examination to assess clues of other abdominal injury.
Read More

Authors:  Tong Jane , Luo Yu

Keywords:  reactive appendicitis, abdominal trauma, ultrasound

Alhashmi Ghufran,  Yang Joseph,  Amirabadi Afsaneh,  Aquino Michael

Final Pr. ID: Paper #: 091

Background: Prior studies have shown significant discrepancy between the initial radiologist and pediatric radiologist interpretation of imaging exams performed on pediatric patients. Studies specifically focused on the rate of discrepancy of ultrasound (US) exams for suspected appendicitis and intussusception are deficient.
Objective: To determine the agreement and discrepancy rates, and the clinical impact of discrepancies in the diagnosis of appendicitis and ileocolic intussusception between initial US performed at referring community hospitals and second (2^nd) opinion US performed at an academic pediatric tertiary care hospital. Read More

Authors:  Alhashmi Ghufran , Yang Joseph , Amirabadi Afsaneh , Aquino Michael

Keywords:  Second Opinion, Appendicitis, intussusception

Essenmacher Alex,  Kao Simon,  Sato T Shawn

Final Pr. ID: Poster #: EDU-019

The management of acute appendicitis is most often surgical with appendectomy; the blind-ending, inflamed appendix is removed, usually laparoscopically. There is growing awareness of the potential for a delayed complication if only the tip or otherwise subtotal length is removed. A remnant portion of the base of the appendix, referred to as a stump, if long enough can become obstructed and symptomatic similar to the etiology of acute appendicitis. In cases of recurrent right lower quadrant pain in a patient with a surgical history of appendectomy, appendicitis remains on the differential diagnosis alongside non-appendiceal causes such a colitis and epiploic appendagitis. Imaging diagnosis by computed tomography or ultrasound of stump appendicitis is similar to acute appendicitis with right lower quadrant inflammation and stump distension and wall thickening. In this educational exhibit we will review the imaging features of stump appendicitis as well as developments in surgical techniques relevant to this delayed complication. Relevant anatomy and differential diagnosis for right lower quadrant pain will also be summarized. Read More

Authors:  Essenmacher Alex , Kao Simon , Sato T Shawn

Keywords:  appendix, surgery, appendicitis

Hubbard Caroline,  Hill Jeanne,  Russell William,  Cina Robert

Final Pr. ID: Poster #: SCI-010

A multi-disciplinary team of physicians developed a clinical practice guideline (CPG) in June
2010 to standardize the diagnosis and management of suspected appendicitis in pediatric patients (< 18 years) who
presented to a single institution’s emergency room. This study evaluated the utilization and efficacy of the CPG,
comprised of Pediatric Appendicitis Score (PAS) and staged ultrasound (US) and computed tomography (CT)
imaging, from 1/1/13-12/31/16. Using baseline data from the first year after implementation, we hypothesized that
increased US and PAS utilization would result in improved US performance and a concomitant decrease in CT
utilization without loss of diagnostic accuracy. Read More

Authors:  Hubbard Caroline , Hill Jeanne , Russell William , Cina Robert

Keywords:  Appendicitis, Imaging, Clinical Pathway

Jackson Dana,  Gould Sharon,  Reichard Kirk,  Epelman Monica

Final Pr. ID: Poster #: EDU-059

Tubo-ovarian abscesses are uncommon and are usually associated with pelvic inflammatory disease secondary to sexually transmitted disease; however, there has been a small number of reported cases occurring in non-sexually active girls. A series of six virginal girls with tubo-ovarian abscesses is presented for discussion of the clinical circumstances, imaging findings and diagnostic difficulties encountered in this uncommon diagnosis. Read More

Authors:  Jackson Dana , Gould Sharon , Reichard Kirk , Epelman Monica

Keywords:  Tubo-ovarian, adnexal, abscess, appendicitis

Tomlinson Amanda,  Lowe Nicole

Final Pr. ID: Poster #: CR-001 (R)

Purpose or Case Report: Ultrasound Diagnosis of Perforated Appendicitis in Pediatric Patients. Acute appendicitis is the most common condition requiring emergency surgery in children. In a pediatric setting, it is common for clinicians to request an ultrasound as the imaging modality of choice when there is a clinical concern for appendicitis. Therefore, it is important to differentiate a perforated appendicitis from a nonperforated appendicitis. Treatment of nonperforated appendicitis requires immediate surgical intervention while perforated appendicitis can be managed conservatively. Our purpose is to describe the sonographic appearance of a perforated appendicitis. We will characterize the two main appearances of perforated appendicitis seen on ultrasound. These appearances include: 1.) Visualization of the appendix with loss of the echogenic submucosal layer, the presence of an intraluminal appendicolith, or a large amount of periappendiceal echogenic fat. 2.) Non-visualization of the appendix but the sonographic appearance of an abscess formation can be associated with perforation. Read More

Authors:  Tomlinson Amanda , Lowe Nicole

Keywords:  perforated appendicitis

Steinberg Zach,  Rein Julia,  Scanlan James,  Carlson Alex,  Weinsheimer Robert,  Finch Lisa

Final Pr. ID: Poster #: SCI-055

In the past Computed Tomography (CT), has been the preferred diagnostic modality in appendicitis diagnosis. Due to increasing radiation and cancer concerns, ultrasound (US) has been promoted as a safer alternative. Despite the US benefits, some pediatric providers have reluctance to use US due to its lower appendicitis sensitivity. Attempting to increase the use and efficacy of US in suspected appendicitis, our US department performed three annual interventions consisting of lectures and hands-on sonographer training during 2012-2014. Additionally, a clinical pathway for appendicitis diagnosis was developed in 2014 to promote US as the primary diagnostic modality in acute appendicitis evaluation. Read More

Authors:  Steinberg Zach , Rein Julia , Scanlan James , Carlson Alex , Weinsheimer Robert , Finch Lisa

Keywords:  Appendicitis, Ultrasound, Computed Tomography

Adams Janet,  Gramke Michelle,  Hekler Lindsey

Final Pr. ID: Poster #: EDU-031

Timely sonographic diagnosis of appendicitis can be critical for pediatric patients, as perforation rate is inversely related to the child’s age, and atypical signs and symptoms can commonly obscure the clinical diagnosis.¹ In experienced hands, pediatric sonography for appendicitis has a high sensitivity and specificity and spares the child radiation.² Our educational poster entitled “Unusual Appendicitis Presentations” has been authored by experienced sonographers and will cover the following:
1. Scanning protocols and techniques used at our institution
2. Helpful tips that go beyond routine imaging to detect difficult appendicitis findings
3. Uncommon cases including neonatal, duplicated, mucinous, gangrenous, and disrupted appendicitis involving the bladder wall
4. Images from each case as well as patient symptoms, imaging findings and surgically confirmed diagnosis

1 McAbee G, Donn S, Mendelson R, McDonnell W, Gonzalez J, Ake J: Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. J Amer Acad Pediatrics 2008;122(6):1282–1286.
2 Krishnamoorthi R, Ramarajan N, Wang N, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259(1):231–239. Read More

Authors:  Adams Janet , Gramke Michelle , Hekler Lindsey

Keywords:  appendicitis

Szymanski Kathryn,  Wang Lucas,  Arnold Cerys,  Pfeifer Cory

Final Pr. ID: Poster #: EDU-043

Appendicitis is a common cause of acute abdominal pain requiring surgery in the pediatric population. For this reason, urgent and accurate diagnosis is critical. While ultrasound is the first line diagnostic modality, MRI has emerged as an important adjunct. The purpose of this presentation is to review the use of MRI for appendicitis in Children's hospitals from the perspectives of both the radiology departments and ordering providers using existing literature. Read More

Authors:  Szymanski Kathryn , Wang Lucas , Arnold Cerys , Pfeifer Cory

Keywords:  Appendicitis, MRI

Kennedy Thomas,  Thompson Amy,  Choudhary Arabinda,  Schenker Kathleen,  Depiero Andrew

Final Pr. ID: Poster #: SCI-011

Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values. The secondary objective was to determine the test characteristics of the fast, non-contrast MRI protocol used for suspected appendicitis. Read More

Authors:  Kennedy Thomas , Thompson Amy , Choudhary Arabinda , Schenker Kathleen , Depiero Andrew

Keywords:  Appendicitis, MRI, ultrasound

Moredock Elisabeth,  Coleman Jay,  Chang Alice,  Pfeifer Cory,  Kwon Jeannie

Final Pr. ID: Poster #: SCI-012

Ultrasound is often the initial imaging modality in evaluation for pediatric appendicitis, but there is concern that the increasing prevalence of pediatric obesity may affect both the sensitivity of ultrasound and the interpretation of an equivocal result. We hypothesized that higher BMI percentile would correlate with lower ultrasound sensitivity, higher equivocal rate, and higher rate of CT acquisition.
Read More

Authors:  Moredock Elisabeth , Coleman Jay , Chang Alice , Pfeifer Cory , Kwon Jeannie

Keywords:  Appendicitis, Obesity, Ultrasound