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Invited Commentary

Douglas S. Katz, MD, Vladimir Merunka, BS, John J. Hines, MD* and Evan M. Meiner, MD

Department of Radiology, Winthrop-University Hospital, Mineola, New York
Department of Radiology, School of Medicine, State University of New York at Stony Brook
*Department of Radiology, Long Island Jewish Medical Center, New Hyde Park, New York
Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Acute appendicitis in a 23-year-old woman, 31 weeks pregnant, who presented with acute RLQ pain. The appendix could not be identified at US performed earlier in the day. Axial single-shot fast SE images show a dilated appendix containing intraluminal fluid and gas (arrows). The intraluminal ovoid low-signal-intensity filling defect (arrowhead in b) is consistent with an appendicolith. Acute appendicitis was confirmed at surgery. C = cecum, F = fetus. (See also Figs E1 and E2 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Acute appendicitis in a 23-year-old woman, 31 weeks pregnant, who presented with acute RLQ pain. The appendix could not be identified at US performed earlier in the day. Axial single-shot fast SE images show a dilated appendix containing intraluminal fluid and gas (arrows). The intraluminal ovoid low-signal-intensity filling defect (arrowhead in b) is consistent with an appendicolith. Acute appendicitis was confirmed at surgery. C = cecum, F = fetus. (See also Figs E1 and E2 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Normal appendix in a 30-year-old woman who was 19 weeks pregnant and presented with acute right-sided abdominal pain. The appendix was not visualized at US. Axial fat-suppressed single-shot fast SE image shows the appendix (arrows) with a normal diameter. There is no periappendiceal edema. AF = amniotic fluid. (See also Figs E3 and E4 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Normal appendix in a 37-year-old woman in the second trimester of pregnancy who had RLQ pain. F = fibroid. (a) Axial single-shot fast SE image shows a prominent appendix (arrows) with a diameter of 8 mm; however, the lumen is gas filled, and there is no wall thickening or periappendiceal edema. Two large fibroids are noted, including a subserosal myoma that protrudes off the uterine fundus into the RLQ. (b) Steady-state free precession (FIESTA) image obtained with fat suppression shows the lack of wall thickening more clearly (small arrows). A small amount of free fluid is present in the right pelvis (large arrow). The patient’s pain resolved without surgery or other intervention and was assumed to be due to the fibroids. (See also Figs E5 and E6 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Normal appendix in a 37-year-old woman in the second trimester of pregnancy who had RLQ pain. F = fibroid. (a) Axial single-shot fast SE image shows a prominent appendix (arrows) with a diameter of 8 mm; however, the lumen is gas filled, and there is no wall thickening or periappendiceal edema. Two large fibroids are noted, including a subserosal myoma that protrudes off the uterine fundus into the RLQ. (b) Steady-state free precession (FIESTA) image obtained with fat suppression shows the lack of wall thickening more clearly (small arrows). A small amount of free fluid is present in the right pelvis (large arrow). The patient’s pain resolved without surgery or other intervention and was assumed to be due to the fibroids. (See also Figs E5 and E6 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Right ovarian vein branch mimicking a normal appendix in a 44-year-old woman with right-sided abdominal pain and leukocytosis. Axial single-shot fast SE (a) and steady-state free precession (FIESTA) (b) images show a tortuous tubular structure (arrows in a, solid arrows in b) medial to the right colon that mimics the appendix. However, this structure courses toward the midline, posterior to the right kidney (K), an appearance consistent with the course of a branch of the right ovarian vein. On the steady-state free precession image, the high signal intensity of the structure is similar to that of the right ovarian vein (open arrow in b) and inferior vena cava (arrowhead in b), thus confirming that the structure is an ovarian vein branch. (See also Figs E9 and E10 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Right ovarian vein branch mimicking a normal appendix in a 44-year-old woman with right-sided abdominal pain and leukocytosis. Axial single-shot fast SE (a) and steady-state free precession (FIESTA) (b) images show a tortuous tubular structure (arrows in a, solid arrows in b) medial to the right colon that mimics the appendix. However, this structure courses toward the midline, posterior to the right kidney (K), an appearance consistent with the course of a branch of the right ovarian vein. On the steady-state free precession image, the high signal intensity of the structure is similar to that of the right ovarian vein (open arrow in b) and inferior vena cava (arrowhead in b), thus confirming that the structure is an ovarian vein branch. (See also Figs E9 and E10 at http://radiographics.rsnajnls.org/cgi/content/full/27/3/743/DC1.)

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Early appendicitis in a 30-year-old woman with twins of 28 weeks gestational age who presented with right upper quadrant pain. She underwent an initial CT examination due to technical inability to perform an MR imaging examination. CT was performed without intravenous contrast material and limited to the area of pain to reduce the amount of radiation to the fetuses. (a, b) Axial (a) and coronal reformatted (b) unenhanced CT images show a nondistended appendix (arrows) next to the gravid uterus. The results were interpreted as negative for appendicitis because of the size of the appendix (<6 mm) and lack of periappendiceal inflammation. After resolution of the technical issues, MR imaging was performed 2 hours after the initial CT because of continued clinical concern despite the negative CT results. (c, d) Axial (c) and coronal (d) T2-weighted single-shot fast SE images obtained at the same level show a fluid-filled thick-walled appendix (arrow) that is normal in size (<6 mm in diameter). Periappendiceal inflammation was absent at fat-saturated imaging. The MR images were interpreted as consistent with early appendicitis, which was confirmed at laparotomy and pathologic analysis.

View larger version (64K): [in this window] [in a new window] [Download PPT slide]   Early appendicitis in a 30-year-old woman with twins of 28 weeks gestational age who presented with right upper quadrant pain. She underwent an initial CT examination due to technical inability to perform an MR imaging examination. CT was performed without intravenous contrast material and limited to the area of pain to reduce the amount of radiation to the fetuses. (a, b) Axial (a) and coronal reformatted (b) unenhanced CT images show a nondistended appendix (arrows) next to the gravid uterus. The results were interpreted as negative for appendicitis because of the size of the appendix (<6 mm) and lack of periappendiceal inflammation. After resolution of the technical issues, MR imaging was performed 2 hours after the initial CT because of continued clinical concern despite the negative CT results. (c, d) Axial (c) and coronal (d) T2-weighted single-shot fast SE images obtained at the same level show a fluid-filled thick-walled appendix (arrow) that is normal in size (<6 mm in diameter). Periappendiceal inflammation was absent at fat-saturated imaging. The MR images were interpreted as consistent with early appendicitis, which was confirmed at laparotomy and pathologic analysis.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Early appendicitis in a 30-year-old woman with twins of 28 weeks gestational age who presented with right upper quadrant pain. She underwent an initial CT examination due to technical inability to perform an MR imaging examination. CT was performed without intravenous contrast material and limited to the area of pain to reduce the amount of radiation to the fetuses. (a, b) Axial (a) and coronal reformatted (b) unenhanced CT images show a nondistended appendix (arrows) next to the gravid uterus. The results were interpreted as negative for appendicitis because of the size of the appendix (<6 mm) and lack of periappendiceal inflammation. After resolution of the technical issues, MR imaging was performed 2 hours after the initial CT because of continued clinical concern despite the negative CT results. (c, d) Axial (c) and coronal (d) T2-weighted single-shot fast SE images obtained at the same level show a fluid-filled thick-walled appendix (arrow) that is normal in size (<6 mm in diameter). Periappendiceal inflammation was absent at fat-saturated imaging. The MR images were interpreted as consistent with early appendicitis, which was confirmed at laparotomy and pathologic analysis.

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Early appendicitis in a 30-year-old woman with twins of 28 weeks gestational age who presented with right upper quadrant pain. She underwent an initial CT examination due to technical inability to perform an MR imaging examination. CT was performed without intravenous contrast material and limited to the area of pain to reduce the amount of radiation to the fetuses. (a, b) Axial (a) and coronal reformatted (b) unenhanced CT images show a nondistended appendix (arrows) next to the gravid uterus. The results were interpreted as negative for appendicitis because of the size of the appendix (<6 mm) and lack of periappendiceal inflammation. After resolution of the technical issues, MR imaging was performed 2 hours after the initial CT because of continued clinical concern despite the negative CT results. (c, d) Axial (c) and coronal (d) T2-weighted single-shot fast SE images obtained at the same level show a fluid-filled thick-walled appendix (arrow) that is normal in size (<6 mm in diameter). Periappendiceal inflammation was absent at fat-saturated imaging. The MR images were interpreted as consistent with early appendicitis, which was confirmed at laparotomy and pathologic analysis.