Open Access Original

Article DOI: 10.7759/cureus.48154

Up-to-Date Diagnostic CT Standards for Acute

Appendicitis: Wall Thickness and Intraluminal
Review began 10/20/2023
Fluid Thickness
Review ended 10/29/2023
Published 11/02/2023 Mohammad Wazzan 1 , Ahmed Abduljabbar 1 , Huda Khizindar 1 , Aghnar Alzahrani 2 , Renad M. Aljohani 3 ,
Rana Nahas 4 , Rahf Aman 5 , Shouq Tawfiq 6 , Arwa Aldajani 7
© Copyright 2023
Wazzan et al. This is an open access article
distributed under the terms of the Creative 1. Department of Radiology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU 2. Department of Medicine
Commons Attribution License CC-BY 4.0., and Surgery, Albaha University, Baha, SAU 3. Department of Medicine, King Saud Bin Abdulaziz University for Health
which permits unrestricted use, distribution, Sciences College of Medicine, Riyadh, SAU 4. Department of Medicine, Faculty of Medicine, Ibn Sina National College,
and reproduction in any medium, provided
Jeddah, SAU 5. Department of Medicine and Surgery, Batterjee Medical College, Jeddah, SAU 6. Department of
the original author and source are credited.
Medicine and Surgery, King Faisal University, Jeddah, SAU 7. Department of Medicine and Surgery, Alfaisal University
College of Medicine, Riyadh, SAU

Corresponding author: Mohammad Wazzan, mawazzan@[Link]

Abstract
Acute appendicitis is a prevalent condition that requires accurate and timely diagnosis and management to
avoid potential complications. Classically, the diagnosis of appendicitis is made using the appendicular
outer-to-outer wall diameter. In this study, we examined the sensitivity and specificity of computed
tomography (CT) scans for diagnosing acute appendicitis using wall thickness and lumen thickness rather
than diameter.

This study included data from 350 patients who presented to the emergency department with clinically
suspected acute appendicitis. All patients underwent a CT scan, and 62 radiologically positive patients
underwent surgery. A radiological diagnosis was made using the conventional outer-to-outer wall diameter
with a cut-off of 6 mm for a positive diagnosis. These 62 positive CT scans were reviewed and compared
with surgical results.

The study showed that a threshold of 2.25 mm for appendicular lumen thickness is an excellent diagnostic
tool for acute appendicitis, demonstrating a high sensitivity of 96.4% and a lower specificity of 67%. In
contrast, 1.6 mm wall thickness indicates acute appendicitis, with 81.8% sensitivity and 84% specificity.
However, the wall thickness remains inferior to the conventionally used measurement of 6.75 mm for
appendicular diameter, with a sensitivity of 87.5% and a specificity of 100%.

Categories: Radiology
Keywords: diagnostic accuracy, sensitivity and specificity, ct scan, lumen thickness, wall thickness, acute
appendicitis

Introduction
Appendicitis is one of the most common causes of acute abdomen in adults and has a lifetime risk of 6%-7%
[1]. It is defined as inflammation of the vermiform appendix, an acute condition that presents within 24
hours [2].

Multiple imaging modalities, including abdominal computed tomography (CT), ultrasonography, and
magnetic resonance imaging (MRI), aid in the clinical diagnosis of appendicitis [2]. Recently, CT scans with
high accuracy have been widely used in acute settings [2]. Moreover, CT scans provide high-resolution
images that better evaluate potential complications, eliminate differential diagnoses, and limit unnecessary
surgical explorations [3,4]. Consequently, the number of unnecessary appendectomies has significantly
decreased owing to the use of CT scans. Further, the perforation rate decreases in parallel.

The primary criteria for a CT scan to diagnose acute appendicitis are appendicular swelling, defined as an
appendicular diameter greater than 6 mm, and periappendiceal inflammatory alterations. Nevertheless,
normal appendices with a diameter >6 mm are frequently encountered in daily practice [5]. In contrast, we
occasionally encounter patients with appendicitis who do not exhibit significant periappendiceal
inflammation [5].

There are no reports describing the differences observed in CT parameters between a normal appendix of
more than 6 mm and an inflamed appendix that does not exhibit periappendicular fat stranding.
Differentiation between these entities may be challenging, especially without a clear clinical presentation,
such as in cases of vague abdominal pain.

How to cite this article

Wazzan M, Abduljabbar A, Khizindar H, et al. (November 02, 2023) Up-to-Date Diagnostic CT Standards for Acute Appendicitis: Wall Thickness
and Intraluminal Fluid Thickness. Cureus 15(11): e48154. DOI 10.7759/cureus.48154
 In this study, we evaluated the accuracy of measuring appendicular wall thickness and intraluminal fluid
thickness as supportive methods for CT scans in diagnosing acute appendicitis.

Materials And Methods

Study design
This study is a retrospective cross-sectional study conducted at King Abdulaziz University Hospital, Jeddah,
Saudi Arabia. The study analyzed data from 350 CT scans of patients who presented to the emergency
department with clinically suspected acute appendicitis and correlated it with the final diagnosis by
reviewing the emergency room notes and progress notes in the surgical notes. Sixty-two patients were
positive for CT scan criteria and underwent surgery. The CT scans of these 62 patients were reviewed for
lumen thickness and wall thickness and compared with the surgical results of the patients.

Data collection
Emergency room notes, surgical notes, and progress notes were obtained from the hospital information
system and thoroughly reviewed. All data were secured by the principal author.

Inclusion criteria
The study included all positive CT scans for acute appendicitis that were confirmed positive after surgery. A
radiological diagnosis of acute appendicitis was made using the conventional outer-to-outer wall diameter
with a cut-off of 6 mm for a positive diagnosis. Patients who underwent appendectomy, percutaneous
drainage, or received antibiotics were categorized as confirmed positives after confirmation from the
surgeon's operation notes.

Exclusion criteria
All CT scans negative for acute appendicitis have been excluded.

Reference standard
Patients who underwent appendectomy and the surgeon’s operation note documented a normal or non-
inflamed appendix or had alternate diagnoses and managed accordingly and did not present with similar
complaints to our hospital within our research study time frame were categorized as confirmed negative.

Statistical analysis
IBM SPSS software, version 25 (IBM Corp., Armonk, NY), was used for statistical analysis. Descriptive
analysis was performed using the quantitative variables’ mean and standard deviation (SD). For qualitative
variables, we calculated the frequencies and percentages. We calculated accuracy measures, including
sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC). Statistical
significance was set at a confidence interval (CI) of 95% and a margin of error of < 0.05.

Data collection
The measurements of the appendix, including the diameter, wall thickness, and lumen thickness, were
obtained on the axial images of the CT scan. It was obtained by a senior radiology resident and reviewed by a
senior radiologist.

Ethical approval
Per institutional policies and regulations, this research study did not require Institutional Review Board
(IRB) approval due to the nature of the data and methods used.

Results
The study analyzed data from 350 CT scans; 62 were positive by CT scans and confirmed positive after
appendectomy. Our findings revealed that males accounted for 57.1% (32) of the positive scans, and females
accounted for 42.9% (24). Additionally, patients with positive scans were more likely to have appendicoliths,
fat stranding, and free fluids. These features are indicators of inflammation, infection, and appendiceal
obstruction. In contrast, patients with negative scans had an equal distribution of males and females, were
less likely to have any of the abovementioned features, and were likely to have intraluminal air. The mean
age of the patients was 33 years. The mean appendiceal length was 7 cm, the mean diameter was 8.8 mm, the
mean lumen thickness was 9.5 mm, and the mean wall thickness was 2.3 mm (Tables 1, 2).

2023 Wazzan et al. Cureus 15(11): e48154. DOI 10.7759/cureus.48154 2 of 6

 Variable Confirmed positive Confirmed negative

Male 32 57.1% 3 50.0%

Sex
Female 24 42.9% 3 50.0%

Positive 13 23.2% 3 50.0%

Intraluminal air
Negative 43 76.8% 3 50.0%

Positive 14 25.0% 0 0.0%

Appendicolith
Negative 42 75.0% 6 100.0%

Positive 56 100.0 0 0.0

Fat stranding
Negative 0 0.0 6 100.0

Positive 24 42.9% 0 0.0%

Free fluid
Negative 32 57.1% 6 100%

Positive 3 5.4% 0 0.0%

Abscess/Phlegmon
Negative 53 94.6% 6 100%

TABLE 1: Descriptive analysis of the qualitative study variables

This table presents the descriptive analysis of the study variables for 62 CT examinations.

Variable Mean±SD Minimum–Maximum

Age (year) 33.98±16.8 9–83

Length (cm) 7.0±1.7 3–13

Diameter (mm) 9.7±2.9 5.2–19

Lumen thickness (mm) 5.2±2.0 1.5–10

Wall thickness (mm) 2.3±0.80 1–4

TABLE 2: Descriptive analysis of the quantitative study variables

These measurements help confidently diagnose acute appendicitis, considering that an enlarged appendix
with thickened walls reflects a state of inflammation and infection.

Applying the 1.6 mm wall thickness measurement alone to diagnose acute appendicitis resulted in 81.8%
sensitivity and 84% specificity. When utilizing a luminal thickness of 2.25 mm to diagnose acute
appendicitis, the highest sensitivity was 96.4%, and the specificity was 67% (Table 3).

2023 Wazzan et al. Cureus 15(11): e48154. DOI 10.7759/cureus.48154 3 of 6

 95% CI
Variable Size (mm) Sensitivity Specificity AUC
Lower Upper

Wall thickness 1.6 81.8% 84% 0.883 0.774 0.992

Lumen thickness 2.25 96% 67% 0.915 0.811 1.00

Appendix diameter 6.75 87.5% 100% 0.887 0.805 0.969

TABLE 3: Accuracy of wall thickness, lumen thickness, and appendix diameter in CT scans for the
diagnosis of acute appendicitis
AUC: area under the receiver operating characteristic curve; CI: confidence interval

However, other studies have reported lower sensitivity and specificity. For example, Alshebromi et al. (2019)
reported a specificity of only 16.7% [1]. A more recent study by Eurboonyanun et al. (2021) reported a
sensitivity of 80.7% and a specificity of 86.7% for non-enhanced CT scans [4], which are lower than those of
other studies that used enhanced contrast CT. These differences may be due to variations in the study
population, imaging protocols, or interpretation criteria [6].

Discussion
Appendicitis is a medical condition characterized by appendiceal inflammation. It most commonly presents
as an acute condition that manifests suddenly and severely, often within 24 hours of onset [7]. The classic
symptoms of appendicitis include vague periumbilical pain, anorexia, nausea, vomiting, migration of pain to
the right lower quadrant, and low-grade fever [8].

All patients suspected of having acute appendicitis should undergo laboratory testing, including total white
blood cell count, percentage of neutrophils, and measurement of C-reactive protein concentration, before
proceeding to further diagnostic steps [9].

The mean age of the participants was 34 years. The appendix had a mean length of 7 cm and a mean
diameter of 8.8 mm. The mean lumen thickness of the appendix was 9.5 mm, and the mean wall thickness of
the appendix was 2.3 mm.

Among the patients with surgically proven positivity, males accounted for 57.1% (32) of the positive scans,
and females accounted for 42.9% (24). In addition, positive cases were less likely to have intraluminal air;
however, they demonstrated appendicoliths, fat stranding, and free fluids. These features can indicate
inflammation, infection, or obstruction of the appendix. In contrast, negative cases had an equal distribution
between males and females, demonstrated intraluminal air, and were less likely to have any of the features
above.

Appendicular diameter is commonly used in daily clinical practice for diagnosing acute appendicitis on CT.
When we evaluated the accuracy of this method, we found that the 6.75 mm appendicular diameter had a
sensitivity of 87.5% and a specificity of 100%. This result is compatible with prior findings in the literature,
suggesting that CT is a highly accurate method for diagnosing acute appendicitis. Eng et al. reported
sensitivity and specificity of 94.9% and 92.4%, respectively [3]. Yun et al. reported a sensitivity of 96.40%
and a specificity of 92.17% for standard-dose CT scans [10]. Doan et al. reported a higher sensitivity (97.4%)
and accuracy (96.6%) [2].

However, other studies have reported conflicting results with lower sensitivity and specificity. Alshebromi
et al. reported a specificity of only 16.7% [1]. Eurboonyanun et al. reported a sensitivity of 80.7% and a
specificity of 86.7% for non-enhanced CT, which is lower than that of other studies that used enhanced
contrast CT [4]. These differences may be due to variations in the study population, imaging protocols, or
interpretation criteria [10].

Our proposed method suggests the application of lumen thickness and luminal thickness measurements to
diagnose acute appendicitis. The results showed that 2.25 mm lumen thickness had a high sensitivity (96%)
but a low specificity (67%), with an area under the ROC curve of 0.915. However, when applying 1.6 mm wall
thickness, it showed a lower sensitivity of 81.8% but a higher specificity of 84%.

Overall, these results suggest that appendicular lumen thickness and wall thickness measurements on CT
are important predictors of the likelihood of positive CT results in acute appendicitis. An increase in the
lumen thickness was associated with a significantly higher likelihood of a positive CT result, which may aid

2023 Wazzan et al. Cureus 15(11): e48154. DOI 10.7759/cureus.48154 4 of 6

 in diagnosing acute appendicitis.

One limitation of this study is the relatively small sample size, which may limit the generalizability of the
findings. Therefore, the results of this study should be interpreted with caution. Further validation studies
with larger sample sizes are required to confirm our findings.

Conclusions
The study included 62 confirmed positive CT scans. The appendicular lumen thickness of 2.25 mm is an
excellent diagnostic tool for acute appendicitis, demonstrating a high sensitivity of 96.4% but a lower
specificity of 67%. On the other hand, 1.6 mm wall thickness has 81.8% sensitivity and 84% specificity,
which is inferior to the conventional appendicular thickness, yielding a sensitivity of 87.5% and a specificity
of 100%.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Mohammad Wazzan, Huda Khizindar, Aghnar Alzahrani , Renad M. Aljohani, Rana
Nahas, Rahf Aman, Shouq Tawfiq , Arwa Aldajani , Ahmed Abduljabbar

Acquisition, analysis, or interpretation of data: Mohammad Wazzan, Huda Khizindar, Aghnar Alzahrani
, Renad M. Aljohani, Rana Nahas, Rahf Aman, Shouq Tawfiq , Arwa Aldajani , Ahmed Abduljabbar

Drafting of the manuscript: Mohammad Wazzan, Huda Khizindar, Aghnar Alzahrani , Renad M. Aljohani,
Rana Nahas, Rahf Aman, Shouq Tawfiq , Arwa Aldajani , Ahmed Abduljabbar

Critical review of the manuscript for important intellectual content: Mohammad Wazzan, Huda
Khizindar, Aghnar Alzahrani , Renad M. Aljohani, Rana Nahas, Rahf Aman, Shouq Tawfiq , Arwa Aldajani ,
Ahmed Abduljabbar

Supervision: Mohammad Wazzan, Huda Khizindar, Ahmed Abduljabbar

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All
authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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