Perforated appendicitis: an underappreciated mimic of intussusception on ultrasound.
BACKGROUND
We encountered multiple cases in which the US appearance of ruptured appendicitis mimicked intussusception, resulting in diagnostic and therapeutic delay and multiple additional imaging studies.


OBJECTIVE
To explore the clinical and imaging discriminatory features between the conditions.


METHODS
Initial US images in six children (age 16 months to 8 years; 4 boys, 2 girls) were reviewed independently and by consensus by three pediatric radiologists. These findings were compared and correlated with the original reports and subsequent US, fluoroscopic, and CT images and reports.


RESULTS
All initial US studies demonstrated a multiple-ring-like appearance (target sign, most apparent on transverse views) with diagnostic consensus supportive of intussusception. In three cases, US findings were somewhat discrepant with clinical concerns. Subsequently, four of the six children had contrast enemas; two were thought to have partial or complete intussusception reduction. Three had a repeat US examination, with recognition of the correct diagnosis. None of the US examinations demonstrated definite intralesional lymph nodes or mesenteric fat, but central echogenicity caused by debris/appendicolith was misinterpreted as fat. All showed perilesional hyperechogenicity that, in retrospect, represented inflamed fat "walling off" of the perforated appendix. There were four CTs, all of which demonstrated a double-ring appearance that correlated with the US target appearance, with inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis.


CONCLUSIONS
Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.
Department of Radiology, Stanford University, Lucile Packard Children's Hospital, 725 Welch Road, MC 5913, Stanford, CA, 94305, USA, bevn@stanford.edu.
Beverley
B
Newman
Matthew
M
Schmitz
Rakhee
R
Gawande
Shreyas
S
Vasanawala
Richard
R
Barth
D001064:Appendicitis / Q000000981:diagnostic imaging*; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007223:Infant; D007443:Intussusception / Q000000981:diagnostic imaging*; D008297:Male; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography / Q000379:methods