Accuracy of Nonfocused Helical CT

for the Diagnosis of Acute

Appendicitis: A 5-Year Review
Steven S. Raman 1 OBJECTIVE. The clinical usefulness of routine, nonfocused helical CT was evaluated in
David S. K. Lu 1 diagnosing acute appendicitis or providing an alternative diagnosis in patients presenting to
Barbara M. Kadell 1 the emergency department with acute lower abdominal pain.
MATERIALS AND METHODS. We reviewed CT reports and clinical records of 650
Darko J. Vodopich 1
consecutive adult patients who presented between January 1996 and December 2000 with
James Sayre 1
right lower quadrant pain or lower abdominal pain and clinical findings suggestive of appen-
Henry Cryer 2 dicitis. Helical CT was performed with oral contrast material in 610 cases (93.8%) and IV
contrast in 572 cases (88.0%). Both vascular and enteric contrast media were administered in
544 cases (83.7%). Rectal contrast material was administered in 52 cases (8.0%). The abdo-
men was helically scanned from the dome of the diaphragm to the iliac crests with a collima-
tion of 7 mm, from the iliac crests to the acetabular roof at a 5-mm collimation, from the
acetabular roof to the symphysis pubis with a collimation of 5–10 mm. The surgical or clini-
cal record was used for follow-up.
RESULTS. Of the 650 patients, 552 (84.9%) had adequate clinical follow-up. There were
137 true-positive, eight false-positive, five false-negative, and 402 true-negative cases. The
sensitivity, specificity, and accuracy of nonfocused helical CT were 96.5%, 98.0%, 97.6%, re-
spectively. The positive and negative predictive values were 94.5% and 98.8%, respectively.
In patients without acute appendicitis, CT suggested an alternative diagnosis, which clinically
explained the patient’s acute abdominal pain in 266 patients (66.2%).
CONCLUSION. Nonfocused helical CT was highly accurate in diagnosing acute appen-
dicitis or suggesting an alternative diagnosis in patients with acute lower abdominal pain or
right lower quadrant pain.

I
n patients presenting to the emer- could be spared the expense and morbidity
gency department, acute appendi- of surgery by improved diagnosis with judi-
citis is one of the most common cious use of preoperative imaging. Con-
causes of acute lower abdominal pain and right versely, patients with atypical presentations
lower quadrant pain, and appendectomy is one of acute appendicitis could be spared the
of the most common surgical procedures in the morbidity associated with missed or delayed
Unitd States. However, the preoperative clini- diagnosis [4].
cal diagnosis of appendicitis remains challeng- CT has excellent reported sensitivity and
ing even for experienced surgeons in 20–30% accuracy in the preoperative diagnosis of
of the cases because myriad gastrointestinal, acute appendicitis [5–14] and acute abdomi-
Received September 28, 2001; accepted after revision genitourinary, and gynecologic conditions can nal pain [15, 16]. However, controversy per-
December 3, 2001. have similar presentations [1–3]. To avoid ad- sists about the role of CT in the diagnosis of
1
Department of Radiology, UCLA Center for the Health ditional morbidity from missed or delayed di- appendicitis and the most effective tech-
Sciences, 10833 Le Conte Ave., Los Angeles, CA 90095- agnosis of acute appendicitis, surgeons have niques of examination [17]. A variety of CT
1721. Address correspondence to S. S. Raman.
traditionally accepted that up to 20% of pa- approaches have been advocated including
2
Department of Surgery, UCLA Center for the Health tients undergoing appendectomy for suspected helical targeted or focused appendiceal tech-
Sciences, Los Angeles, CA 90095-1721.
acute appendicitis will have a normal appendix niques using rectal contrast agents (with or
AJR 2002;178:1319–1325
(negative appendectomy rate) [1]. A signifi- without oral contrast material) [5–7], unen-
0361–803X/02/1786–1319 cant number of patients without acute appendi- hanced helical techniques similar to those
© American Roentgen Ray Society citis who have equivocal clinical presentations used for the detection of renal stones [8–10],

AJR:178, June 2002 1319

 Raman et al.

The combined search yielded 650 adult patients

Contrast Material Used in Success of Helical CT in
Helical CT of Patients with TABLE 2 Revealing Acute presenting with lower abdominal pain or right lower
TABLE 1 quadrant pain who underwent helical CT for possible
Right Lower Quadrant Pain Appendicitis
or Lower Abdominal Pain acute appendicitis. Our study population consisted of
Statistical Results a 226 men and 424 women who ranged in age from 18
Type of Contrast Patients (n = 650) 95% CI (%)
Measure % No. to 99 years; the average age was 49 years. The dic-
Material No. % tated CT reports were compared with the surgical,
Sensitivity 96.5 137/142 91.9–98.8 clinical, and pathologic records to establish clinical
Oral 610 93.8 Specificity 98.0 402/410 96.2–99.2 follow-up. Of the 650 patients, we had surgical and
IV 572 88.0 Accuracy 97.6 539/552 96.0–98.7 pathologic correlation in 191 patients (29.4%) and
Oral and IV 544 83.7 clinical correlation (clinical notes) in 361 (55.5%).
PPV 94.5 137/145 89.4–97.6
Rectal a 52 8.0 Adequate clinical follow-up could not be obtained in
NPV 98.8 402/407 97.2–99.6 98 patients (15.1%) discharged from the emergency
Oral, IV, and rectal 41 6.3
Note.—CI = confidence interval, PPV = positive predictive department because these patients failed to return for
None 10 1.5 value, NPV = negative predictive value. a follow-up clinic visit. These patients were excluded
a
a
All combinations. True-positive interpretation, n = 137; false-positive, n = 8; from the analysis. The overall population of patients
true-negative, n = 402; false-negative, n = 5. evaluated for acute abdominal pain during this time is
unknown. To our knowledge, no appendectomy was
performed in any of our nonsurgical patients with
clinical follow-up.
IV contrast-enhanced techniques with supple- our 5-year experience with routine, nonfo- All patients were scanned using a single-de-
mentary cecal air insufflation [11], and routine cused helical CT in adults presenting with tector helical scanner (HiSpeed Advantage or
contrast-enhanced (IV and oral) conventional acute lower abdominal or right lower quadrant HiSpeed CT/i; General Electric Medical Systems,
and helical CT [12, 13]. The widespread appli- pain suspected of having acute appendicitis. Milwaukee, WI). Patients generally received both
cability of some of these techniques in most Specifically, we evaluated the accuracy of rou- oral and IV contrast material. In this population, IV
practices is debated [13, 17] because some re- tine, nonfocused helical CT in confirming a di- contrast material was administered in 88.0% of
cases; poor renal function, contrast material al-
quire the active participation of radiologists for agnosis of acute appendicitis or providing a
lergy, or poor IV access precluded administration
patient triage [5, 6] and routinely subject pa- clinically relevant true alternative diagnosis in in the remainder. Oral contrast material was given
tients to invasive procedures such as rectal cath- this patient population. in 93.8% of cases; nausea or other contraindica-
eterization [5–7, 11]. In addition to confirming tions precluded use in the remainder. Both oral and
suspected acute appendicitis, CT is valuable in Materials and Methods IV contrast materials were given in 83.7% of cases.
excluding this diagnosis and in suggesting alter- With the approval from our institutional review At the discretion of the attending radiologist or on-
native diagnoses for acute abdominal pain. board, we searched the databases of our radiology, call radiology resident, rectal contrast material was
However, the rate at which CT suggests a clini- surgery, and pathology departments to select all given in 8.0% of cases. Contrast material was not
cally relevant alternative diagnosis to explain adult patients (≥18 years old) who were referred administered in 1.5% of the cases (Table 1).
acute abdominal pain varies [5–16]. The pur- with symptoms of lower abdominal pain or right In our standard protocol, patients generally drink
lower quadrant pain from January 1, 1996, through 1000 mL of flavored 5% meglumine diazotrioate (Gas-
pose of this retrospective study was to review
December 31, 2000. The indication for the examina- trografin; Bristol-Meyers Squibb, New Brunswick,
tion as listed in the CT database was cross-refer- NJ) 45–60 min before scanning to allow opacifica-
enced against each patient’s clinical chart to ensure tion of the ileum. After IV administration of 100–
the accuracy of the symptoms and satisfy the inclu- 130 mL of iohexol (Omnipaque 350; Nycomed,
sion criteria for the study. During this period, ap- Princeton, NJ) at a rate of 2–3 mL/sec and after a 60-
proximately 69% of all patients with suspected acute sec delay, the abdomen was scanned helically during
appendicitis underwent appendectomy without CT. a single breath-hold (pitch of 1.4:1, 120–140 kVp,
Approximately 31% of patients who underwent an 240–320 mAs) with a 7-mm collimation to the iliac
appendectomy for suspected acute appendicitis also crests and a 5-mm collimation from the iliac crests
underwent preoperative abdominal CT, although the to the acetabular roof. After a 3-min delay to allow
proportion steadily increased over 5 years. In gen- opacification of the ureters and bladder, the remain-
eral, most patients who underwent CT during this der of pelvis to the symphysis pubis was scanned
period were atypical in clinical presentation, be- with a 5- to 10-mm collimation.
cause patients with clinical findings highly suspi- Images were photographed, and a diagnosis
cious for appendicitis were taken to surgery without was usually rendered on the basis of soft-copy im-
undergoing preoperative imaging. We excluded pa- ages obtained using standard soft-tissue window
tients who had a history of appendectomy; patients settings (width, 400 H; level, 40 H). All interpreta-
who presented with atypical symptoms (right upper tions were performed by radiologists specializing
quadrant pain, back or flank pain, and left lower in abdominal imaging. Because of the retrospec-
quadrant pain); patients with chronic abdominal tive nature of the study, we could not accurately
Fig. 1.—True-positive interpretation in 27-year-old pain; and patients with a known diagnosis of acute account for discrepancies in interpretations be-
man with right lower quadrant pain. Axial contrast-en- pancreatitis, cholecystitis, or diverticulitis before CT. tween the on-call residents who worked after
hanced helical CT scan shows that thickened appen- We also excluded patients who underwent CT (inter- hours (7 P.M. to 7 A.M.) and the attendings. There-
dix (>6 mm in width) and periappendiceal stranding
(arrow) are present. Terminal ileum is well opacified. preted as showing normal findings), were subse- fore, the results of the dictated CT report were
Secondary findings include appendiceal mural en- quently discharged from the emergency department used as the official CT interpretation. The primary
hancement and cecal thickening. and failed to return for a follow-up visit. diagnostic criteria for acute appendicitis were vi-

1320 AJR:178, June 2002

 Helical CT of Acute Appendicitis

tient did not undergo either an appendectomy or suspected clinically and treated medically with
percutaneous drainage of a periappendiceal ab- IV antibiotics because of comorbid conditions or
scess or if the surgeon clinically excluded acute refusal of surgery. Follow-up imaging was not
appendicitis, the case was categorized as a false- performed in these patients. Acute appendicitis
positive. For a case to be categorized as a true-neg-
was correctly excluded prospectively in 402 pa-
ative, the CT report must state that the scans were
tients (specificity, 98.0%). The overall accuracy
interpreted as showing either normal findings or
findings that suggested an alternative diagnosis for
was 97.6% for diagnosing acute appendicitis.
acute abdominal pain, and acute appendicitis was No clinically relevant discrepancies in radiologic
not included in the differential diagnosis. In the findings between the dictated CT reports and re-
false-negative category, we listed all cases for view of the studies were recorded.
which CT was interpreted as showing normal or Of the eight false-positives, five patients
nondiagnostic findings and the patient had surgi- were discharged after the presenting symp-
cally proven appendicitis. We reviewed the scans toms resolved, and three underwent surgery
for all cases categorized as true-positive, false- for suspected acute appendicitis. In one pa-
Fig. 2.—False-positive interpretation in 20-year-old positive, and false-negative to check for overcalled tient, both a thickened appendix and periap-
man with right lower quadrant pain. On axial contrast- or missed findings. In patients without CT or clini-
pendiceal stranding were present, but the
enhanced helical CT scan, thickened appendix and cal evidence of acute appendicitis (true-negatives),
mild adjacent stranding (arrow) are present. Patient’s patient’s symptoms and physical examina-
we compared the suggested alternative CT diagno-
symptoms resolved after medical therapy, and he was
sis with the clinical diagnosis in the computerized
tion findings resolved and the patient was
discharged. subsequently discharged (Fig. 2). In the four
chart to determine whether the suggested CT diag-
nosis proved to be clinically relevant in explaining other patients, fluid and various degrees of
the patient’s abdominal pain. pericecal stranding were present in the right
sualization of a thickened appendix (distended ap- lower quadrant without a discrete appendix
pendix [width, >6 mm] with or without mural identified either prospectively or retrospec-
thickening and enhancement) and periappendiceal Results tively. However, the symptoms resolved in
stranding (Fig. 1). Secondary diagnostic criteria Overall, acute appendicitis was present in these patients, and they were discharged. In
included appendicolith, periappendiceal abscess, 142 (21.8%) of the 650 patients. Acute appendi- these four cases, acute appendicitis was in-
small-bowel obstruction, and mural thickening of cluded in the differential diagnosis listed in
citis was correctly diagnosed prospectively in
the cecum. Cecal signs such as the cecal bar and
137 of 142 patients using routine helical CT the dictated CT report. In the first of three
cecal arrowhead were not evaluated because most
patients did not receive rectal contrast material.
(sensitivity, 96.5%) (Table 2). An appendec- patients who underwent surgery, pericecal
For a case to be categorized as one with true-posi- tomy was performed in 130 of 137 patients. Of stranding was present on CT, and a promi-
tive findings, the conclusion of the radiology re- the remainder, five patients with periappen- nent right cecal diverticulum was misinter-
port had to be the unequivocal diagnosis of acute diceal abscesses were treated with percutaneous preted as a thickened appendix (Fig. 3). The
appendicitis without offering a differential diagno- drainage without a follow-up appendectomy. In second patient, a young woman with a surgi-
sis. If acute appendicitis was reported and the pa- the other two patients, acute appendicitis was cally confirmed ruptured ovarian cyst, had

Fig. 3.—False-positive interpretation in 71-year-old man with right lower quadrant pain. On axial contrast-en- Fig. 4.—False-positive interpretation in 42-year-old man
hanced helical CT scan, we misinterpreted cecal diverticulum (arrow) as thickened appendix. Cecal diverticulitis with right lower quadrant pain and surgically confirmed
was confirmed at surgery. right-sided diverticulitis. Axial contrast-enhanced helical
CT scan reveals focal region of stranding (arrow) adja-
cent to ascending colon. Appendix was not visualized,
and acute appendicitis was included in differential diag-
nosis along with right-sided diverticulitis.

AJR:178, June 2002 1321

 Raman et al.

124 (90.5%) of 137 patients. No significant

contrast material–related complications oc-
curred in our study population.
Of the true-negative cases, the alternative
diagnosis based on CT findings agreed with
the final clinical diagnosis in 266 (66.2%) of
402 patients without acute appendicitis
(Figs. 8 and 9) (Table 3). Neither CT nor
clinical findings explained the cause of acute
abdominal pain in 108 (26.9%) of 402 pa-
tients. The CT diagnosis disagreed with the
clinical impression in 28 patients (6.9%).
Overall, a clinically relevant diagnosis for
acute lower abdominal pain was provided in
403 (73%) of the 552 patients with adequate
clinical follow-up. In the 98 patients with in-
Fig. 5.—False-negative interpretation in 34-year- Fig. 6.—False-negative interpretation in 21-year-old woman
old woman with lower abdominal pain. On axial with lower abdominal pain. On axial contrast-enhanced CT adequate clinical follow-up, all CT findings
contrast-enhanced CT scan, appendix (arrow ) is scan, appendix (arrow), which was identified only retro- were reported as unequivocal negative find-
at upper limits of normal range in size without spectively, is at upper limits of normal range in thickness ings for appendicitis.
periappendiceal infiltration. Appendix was not with minimal periappendiceal fat stranding. This study was
identified prospectively, and study was inter- initially interpreted as showing no evidence for appendicitis.
preted as showing no evidence for appendicitis. Acute appendicitis was confirmed at pathology.
Discussion
In performing this study, we found that non-
mild pericecal stranding on CT. No discrete tified prospectively or retrospectively. In focused contrast-enhanced helical CT of the
appendix was identified. CT of the third pa- these four patients, the pathologic cross-sec- abdomen and pelvis achieved high diagnostic
tient revealed a normal appendix and no find- tional diameter ranged between 6 and 8 mm. accuracy in a large population of adult patients
ings to explain right lower quadrant pain In the final patient with a false-negative with acute lower abdominal pain or right lower
(Fig. 4). At histopathology, “fibrous oblitera- finding, a high-grade small-bowel obstruction quadrant pain and an average prevalence of
tion of the appendix” was noted in the report. was identified prospectively. However, an ap- acute appendicitis. Furthermore, we provided
False-negative CT findings were reported pendiceal abscess, which was confirmed at an alternate, clinically relevant explanation for
in five patients. In two patients, the appendix surgery, had been misinterpreted prospec- acute abdominal pain in 66.2% of patients
was within the upper limits of the normal tively on CT as the unopacified cecal base. without appendicitis.
range of thickness, and marginal periappen- However, even in retrospect, the abscess is Other studies have shown that CT is
diceal stranding was identified retrospectively difficult to detect (Fig. 7). highly accurate in the evaluation of acute ap-
(Figs. 5 and 6). Scans of both patients were A thickened appendix was visualized in 126 pendicitis, although debate continues about
interpreted as showing “no evidence of acute (92%) of the 137 patients with prospectively which technique is optimal [5–14, 17]. Be-
appendicitis,” according to the CT report. diagnosed appendicitis and likely in one of fore the report by Kamel et al. [13] was pub-
The terminal ileum was not well opacified eight false-positive cases. Periappendiceal fat lished, the best overall results were reported
in either patient. In two other patients, nei- stranding was present in 135 (98.5%) of 137, by Rao et al. [5, 6]; these researchers used
ther primary nor secondary signs were iden- and the combination of findings was present in focused CT of the lower abdomen after ad-
ministration of a combination of oral and co-
lonic contrast material [5] or colonic contrast
material alone [6]. The two studies by Rao et
al. were performed in a closely selected pa-
tient population who were actively triaged by
experienced attending emergency radiolo-
gists. One study [6] included both children
and adults with a strong clinical suspicion of
acute appendicitis, and the researchers used
sonography to exclude a large group of
Fig. 7.—False-negative interpretation women with gynecologic disorders. In our
in 89-year-old woman with right lower study, all patients were adults who were re-
quadrant pain. On axial contrast-en-
hanced CT scan, numerous asymmet-
ferred at the discretion of emergency physi-
rically dilated small-bowel loops are cians or surgeons. At our center, most
visible. Terminal ileum and cecum are patients (69%) with strong clinical suspicion
poorly filled with contrast material. Pe- of acute appendicitis underwent an appen-
riappendiceal abscess (arrows) was
present but misinterpreted as base of dectomy without preoperative CT. We im-
unopacified cecum. aged only 31% of all patients who underwent

1322 AJR:178, June 2002

 Helical CT of Acute Appendicitis

surgery for acute appendicitis, generally

those presenting with acute lower abdominal
pain but with a less certain clinical presenta-
tion of acute appendicitis. The overall preva-
lence of acute appendicitis was 53% in the
study by Rao et al. [6] compared with 21% in
our study population, a result that more
closely reflects the expected prevalence of
acute appendicitis in patients with acute
lower abdominal pain [1, 2]. We included
only adults, most of whom were female.
Based on our experience, diagnosis of acute
appendicitis in this subgroup causes the most
clinical confusion, and CT is often requested
for clarification. Despite the use of a general
technique, a lack of patient selection, active
triage, and inclusion of a majority of females,
we achieved a diagnostic accuracy (97.6%)
that is almost identical to that reported by Rao
et al. (98%) [6]. Indeed, when applied to more
Fig. 8.—True-negative interpretation in 68-year-old woman with lower abdominal pain. On helical CT scan obtained
typical referral cases in a community hospital
using IV and oral contrast media, well-defined filling defect (arrow) is present in ileum. Lesion was confirmed on
setting with general board-certified radiolo- subsequent small-bowel barium examination. High-grade focal B-cell lymphoma was diagnosed at surgery.
gists, the reported performance of focused he-
lical CT techniques was similar to those of
other CT techniques [7].
One strength of the focused helical CT
technique is the rate of detection of the ap-
pendix, reported to be as high as 100% [6].
In our series, the appendix was identified
prospectively as being abnormal in 126
(92%) of the 137 patients with acute appen-
dicitis. The appendix was identified as ab-
normal only on retrospective analysis in one
of eight false-positive cases. We believe that
in this patient, acute appendicitis may have
been present and treated adequately with IV
antibiotics. In the remaining seven patients,
only various degrees of pericecal inflamma-
tion and fluid were present. A normal appen-
dix was diagnosed in two of three patients
who underwent surgery. In two patients, in-
flamed cecal diverticula were misinterpreted
as acute appendicitis. Of the five false-nega-
tive cases, an appendix of normal width with
minimal periappendiceal stranding was visu-
alized retrospectively in two thin young
women. In both patients, the pathology re-
ports described early or minimal appendici-
tis. In two other patients, no findings were
present to suggest acute appendicitis. Even
on retrospective review, it is unclear whether
thin-section CT would have added useful di-
agnostic information in these two false-nega-
tive cases or in the seven false-positive cases.
In our series, colonic contrast material was
used in only 8.0% of the cases, generally to
Fig. 9.—True-negative interpretation in 28-year-old woman with lower abdominal pain and fever. On contrast-en-
better define cecal anatomy. In our retrospec- hanced CT scan, patchy enhancement is visible bilaterally. Differential diagnosis included pyelonephritis, which
tive review, the additional use of rectal contrast was confirmed clinically.

AJR:178, June 2002 1323

 Raman et al.

Clinically Confirmed
cal mesentery. In the study by Kamel et al. variable CT experience often provide initial
Alternate Diagnosis [13], if the researchers had restricted imaging interpretations of images obtained of pa-
TABLE 3 Suggested by Helical CT in to the right lower quadrant, they would have tients presenting after hours.
Patients Without Acute significantly decreased the rate of alternative We acknowledge several limitations to our
Appendicitis diagnoses, especially those requiring imme- study. Our study is retrospective, and the types
Patients (n = 402) diate surgery. of helical scanners, scan collimation, and con-
Diagnosis In studies advocating unenhanced imag- trast agents varied. However, we believe that
No. %
ing, reported accuracy for diagnosing acute this variability reflects the true clinical situa-
Colon appendicitis has ranged from 93% for con- tion in most large radiology practices. We were
Colitis 42 45.7 ventional CT [8] to 94–99% for helical CT unable to provide the true denominator of all
Diverticulitis 32 34.8 [9, 10]. Although these studies have stressed patients evaluated for acute lower abdominal
Fecal impaction 6 6.5 the benefits of helical CT, which include pain. We also could not obtain follow-up in 98
Other 12 13 lower cost and increased throughput, the patients who were not diagnosed with acute
rates of providing true alternative diagnoses appendicitis after CT and were discharged
Total 92 22.9
were significantly lower (35–36%) [9, 10] from the emergency department. We could not
Small bowel than in our study and other studies that— accurately account for discrepant interpreta-
Small-bowel obstruction 38 52.1 with vascular or bowel contrast material or tions between the on-call residents and those
Inflammatory bowel disease 15 20.5 both—reported rates ranging from 54% to given by experienced abdominal imaging staff
Ischemia or infarction 6 8.2 95% [5–7, 11–16]. In our study, most pa- members for examinations performed at night.
Other 14 19.1 tients received oral and IV contrast media, Because the interpretations were those of ex-
Total 73 18.2
and we were able to provide a relevant alter- perienced abdominal radiologists, widespread
native diagnosis for abdominal pain in general applicability may be somewhat lim-
Gynecologic 66.2% of patients without appendicitis (Ta- ited. Also, the scans with true-negative find-
Ruptured adnexal cyst 14 51.2 ble 3). This rate compares favorably with a ings were not retrospectively reviewed.
Adnexal mass 9 33.3 rate of 56% reported by Kamel et al. [13]. In In summary, we found that routine contrast-
Tuboovarian abscess 2 7.4 our experience and those of other research- enhanced helical CT is an excellent diagnostic
Other 2 7.4 ers, the use of IV and oral contrast media is test to define the cause of acute lower abdomi-
Total 27 6.7 important to establish a diagnosis in patients nal pain in adult patients with suspected acute
with suspected acute abdomen [13, 15, 17]. appendicitis. The study cohort was large, unse-
Acute cholecystitis 19 4.7
The administration of contrast material in lected, and likely reflects the population of a
Acute pancreatitis 13 3.2 thin patients, particularly women, is needed large radiology practice. We also advocate the
Renal calculi passing 12 3.0 to clearly identify the terminal ileum, small- judicious use of routine contrast-enhanced CT
Retroperitoneal hemorrhage 10 2.5 bowel loops, and blood vessels. We present (oral and IV media) to help establish a diagno-
Other 20 5.0 two cases in which the use of IV or oral con- sis in adults with an equivocal clinical presen-
Total 266 66.2 trast material helped to identify an alterna- tation of acute appendicitis.
tive diagnosis (Figs. 8 and 9). We agree with
Federle [17] that limited or focused studies References
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 Helical CT of Acute Appendicitis

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