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The use of barium in the diagnosis of acute appendiceal disease: A new radiological sign
Clin. RadioL (1968) 19, 410-415 THE USE OF BARIUM IN THE DIAGNOSIS OF ACUTE DISEASE: A NEW RADIOLOGICAL SIGN
APPENDICEAL
CONSTANTINE S. SOTER
From the Department of Radiology and Nuclear Medicine, Northwest Community Hospital, Arlington Heights, Illinois, U.S.A.
Accurate early diagnosis is the most important single factor in the case of the patient with appendicitis. When the clinical findings are not diagnostic, a barium enema study may demonstrate changes in the caecum and the appendix diagnostic of the disease. A series of 40 barium enema studies was performed in patients suspected of suffering from appendicitis or in order to rule out appendiceal disease when the clinical signs and findings were not conclusive. A reliable sign was found to be a reversed 3 filling defect of the caecum due to oedema of the caecal wall and mesentry. It is believed that this diagnostic sign of appendicitis has not been previously described and that it is very helpful in the differential diagnosis of the acute abdomen.
ACUTE appendicitis is a daily diagnostic problem in all age groups. From the approximate 200,000 cases registered per year in the United States, 2,000 patients die from acute appendicitis and its complications. Delayed or missed diagnosis accounts for most of the deaths. The available statistics indicate no favorable trend consistent with earlier referral for surgery, as judged by the incidence of perforated appendices at operation. Eighteen per cent of the cases of appendicitis are first seen by the surgeon after perforation has taken place and this proportion has not changed in the last 23 years. Earlier diagnosis, before the perforation develops, is our best hope to reduce the mortality and morbidity of acute appendicitis. The clinical diagnostic accuracy of acute appendicitis has been shown statistically to be 80 to 82%. The Radiologist has a role in the diagnosis of acute appendicitis when the clinical manifestations of the disease are obscure, as in the young and the elderly. The X-ray findings of the plain roentgenograms of the abdomen have been described previously and are not the subject of this presentation. Here we describe out experiences with Barium Enema examinations in cases of suspected appendicitis where the clinical and laboratory findings were not diagnostic of a specific pathologic entity.
from the Emergency Room to the Department of Radiology. A chest X-ray and an abdomen series are obtained. If both the clinical evidence and the X-ray findings are not conclusive, a barium enema examination is performed immediately. The usual technique is used with the maximum height of the barium container at 90 cm. and an effort is made to fill the terminal ileum. Serial films of the caecum are taken. After the postevacuation roentgenogram is obtained and studied, the patient may be fluoroscoped again and spot radiography of the caecum and pericaecal area is repeated. Rarely, if the findings are not conclusive, the examination may be repeated. The information obtained from the examination may be divided as follows:
(a) Position of the Cecum and Appendix.--Collings (1958) in a review of human appendices, has found the cecum and appendix to be located in the left lower quadrant in 0.03%, left upper quadrant in 0.58 ~ , right upper quadrant in 3.9 ~, and in the right lower quadrant in 96 %. When in the right lower quadrant, the appendix was located anterior to the cecum in 74 ~ and retrocaecally in 26 %; when anterior to the cecum, it was caudal in 29%, medial in 35%, and lateral in 7%. An indentation in the middle of the cecal tip and slight rotation of the cecum are very suggestive of a retrocecal position of the appendix. Demonstration of atypical position of the cecum and T E C H N I Q U E OF BARIUM E N E M A appendix may explain atypical clinical findings. (b) Patency of the Appendiceal Lumen.--Since The purpose of the Barium Enema is to visualize the caecum and the appendix. Preparation of the obstruction of the lumen of the appendix is the bowel is not neccessary; the patient comes directly outstanding prerequisite of the appendiceal inflam410
THE USE OF BARIUM IN THE DIAGNOSIS OF ACUTE A P P E N D I C E A L DISEASE
mation, demonstration of a patent appendiceal liJmen should exclude the diagnosis of acute appendicitis. (e) Demonstration of an Irregular Appendieeal Lumen.--Normal visualization of the appendix should not be assumed, unless it is certain that the tip of the appendix is visualized and the entire lumen does not show Constrictions or irregularities. Irregularities of the appendieeal lumen, with kinks, strictures, dilatations, or cut offs are usually associated with appendiceal disease. (d) Changes of the Ceeum.--In acute inflammation of the appendix, the mesoappendix and adjacent omentum becomes edematous and produce pressure upon the tip of the cecum which is shown as flattening of the cecal tip or as a persistent pressure effect with identation, single or double, adjacent to the orifice of the appendix. The wall of the cecum may become thick and edematous and the mucosa coarse, producing a form of typhlitis. (e) Changes of the Terminal Ileum.--When the terminal ileum is filled, it occasionally may show slight extrinsic pressure or spasm and irritability. CASE HISTORIES Case 1.~46 year old obese male patient admitted to the hospital because of lower abdominal pain which he experienced suddenly, 8 hours earlier at 1 a.m. Physical examination revealed only tenderness in both lower quadrants. The patient was better on the morning of the examination. The laboratory examination revealed W.B.C. 12,500; neutrophils 59700; lymphocytes 36%; hematocrit 40.5;
FIG. 1 Case 1. Spot series of the caecum. Note the persistent pressure effect upon the tip of the caecum by the oedematous mesoappendix and adjacent omentum. The mucosa is coarse due to associated typhlitis.
411
urine examination negative. It was decided to keep the patient under observation and re-evaluate in 8 to 12 hours. The patient was referred to the Department of Radiology for examination. The actue abdomen series revealed a reflex ileus in the lower abdomen which was considered suggestive of either diverticulitis or appendicitis. Because of 2 calcific densities seen in the area of the right kidney, an Intravenous Pyelographic examination was performed which demonstrated the calcific densities to be stones in the upper calyx of the right kidney with localized chronic pyelonephritis and no obstruction. Barium enema examination. The caecum showed flattening of the apex with coarse mucosa and double pressure effect. The appendiceal lumen was not filled (Fig. 1). These changes were considered as diagnostic of acute appendicitis. In addition, in the post-evacuation roentgenogram, the caecum and right colon remained dilated suggesting incomplete obstruction in the proximal transverse colon. At operation, a ruptured appendicitis with purulent peritonitis were found. The proximal transverse colon was explored and thick pericolonic adhesions were found which accounted for the incomplete obstruction. The postoperative course was complicated by adynamic ileus and infection of the abdominal wall. The patient was discharged in good condition 28 days after admission. Case 2.--Woman aged 34, complains of intermittent low abdominal and pelvic pain for 3 to 4 days. The pain became violent during the night prior to the examination, but in the morning she improved and the pain subsided almost completely. The W.B.C. was 17,200, but she was sent home asymptomatic. Twenty-four hours later the symptoms recurred with suprapubic intermittent pain. On examination there was deep rebound suprapubic tenderness. Gynaecologic examination showed no abnormalities. The temperature was 100°F. and the W.B.C. 13,200. She was sent home on medication. Next morning the pain was
FIG. 2 Case 2. Enlarged spot view of the c a e c u m . Note the filling of the proximal appendiceal lumen with irregular narrowing and tapering into an ovoid appendiceal faecolith (arrow). The wall of the adjacent small bowel is thickened. Changes consistent with suppurative or gangrenous appendicitis.
412
C L I N I C A L RADIOLOGY
Fio. 3 Case 3. Enlarged spot view of the caecum. Note the double pressure effect on the caecum. Also the mild pressure on the terminal ileum, and the coarse mucosal folds of the caecum. The bullet-like foreign body has not cbanged position.
still present and she was referred to the Department of Radiology. Barium enema examination revealed a low pelvic caecum which was located almost in the midline. The examination was repeated immediately because of incomplete filling of the caecum. The proximal 1 cm. of the appendiceal lumen was visualized with abrupt cut off of the lumen (Fig. 2). The appendix extended medially and upward and 2 cm. distally to the lumen cut off there was evidence of a small, 1 cm. in diameter, appendiceal stone. There was also evidence of thickening of the wall of the adjacent small bowel. The findings were considered as diagnostic of acute suppurative pelvic appendicitis. At operation the patient had a caecum lying over to the left side of the midline of the pelvis, with a retrocecal appendix approximately 1 inch in diameter and 1 inch long. The base of the appendix was necrotic and slight manipulation resulted in perforation with release of a large amount of pus and 2 stones. The pathologic report was acute gangrenous appendicitis. Case 3.--Woman aged 43, admitted to the hospital with diffuse acute mid-abdominal pain which started as epigastric distress. In the past, she had had attacks of epigastric and diffuse abdominal pain associated with nausea and back pain. The roentgenologic examination of the abdomen revealed a bullet-like density in the right lower quadrant. The bariurn enema examination revealed a pressure effect on the tip of the caecum. The appendix was not visualized and the bullet-like density was closely associated with the tip of the caecum with no change of position on compression (Fig. 3). The terminal ileum showed evidence also of slight extrinsic pressure. The findings were considered as diagnostic of acute appendicitis, secondary to obstruction by a foreign body or inspissated barium. At operation a large edematous appendix was removed.
FIG. 4 Case 3. Roentgenograms of the removed appendix. Note the thick, oedematous appendiceal wall and the gas in the lumen of the appendix which moves freely by cbanging the position of the appendix. The bullet-like foreign body, obstructing the base of the appendix, was due to impacted barium. (Barium enema examination two years previously.)
The mesoappendix and the omentum were oedematous and pressing upon the tip of the caecum and terminal ileum. X-ray examination of the removed appendix (Fig. 4) revealed the obstruction of the base of the appendiceal lumen by the opaque foreign body which was proven to be inspissated barium, apparently from a barium enema examination 2 years previously. The appendix contained gas which moved freely from the tip to the base of the lumen, produced by gas-forming organisms infecting the appendix. The patient was discharged in 6 days in good condition. Case 4.--An obese man, aged 37, was admitted to the hospital because of diffuse lower abdominal pain, present for 3 days, more pronounced in the right lower quadrant. The W.B.C. was 22,150. The patient was sent to the Department of Radiology for examination. An intravenous pyelographic study showed no abnormalities. There was suggestion of an avoid faecolith in the right lower quadrant and a barium enema study was performed immediately which showed (Fig. 5) evidence of flattening and double pressure effect upon the tip of the caecum and the terminal ileum with a small indentation in the centre of the caecum where the origin of the appendiceal lumen should be and with good demonstration of an ovoid faecolith in line with the obstructed appendiceal lumen. The findings were considered diagnostic of acute gangrenous appendicitis. At operation there was evidence of a diffuse phlegmon involving the caecum, the appendix, and the adjacent omentum due to an acute, gangrenous, perforated appendicitis. Case 5 . ~ A girl aged 15 was admitted to the hospital because of pain in the right lower quadrant of 8 hours duration. The W.B.C. was 9,100. Barium enema examination upon admission (Fig. 6) revealed a pressure defect of the tip of the caecum and no visualization of the appendix. The findings were considered as diagnostic of acute appendicitis. At surgery the appendix was acutely inflammed and there was congestion in the caecum and the omentum
T H E USE OF B A R I U M I N T H E D I A G N O S I S OF A C U T E A P P E N D I C E A L
FIG. 5 Case 4. Series of spot roentgenograms of the caecum. Note the characteristic double pressure effect on the caecum. Also the incomplete filling of the base of the appendix and the ovoid faecolith at the tip of the appendix. Findings characteristic of acute gangrenous appendicitis.
DISEASE
413
FXG. 6 Case 5. Series of spot roentgenograms of the caecum. Note the persistent pressure effect on the caecum due to the oedematous omentum.
The examination revealed (Fig. 7) a high position of the caecum with considerable double pressure effect u p o n the tip of the caecum and no visualization of the appendix. The findings were considered diagnostic of acute appendicitis with possible abscess. At surgery a diffuse phlegmon involving the cecmn and the appendix was found due to an acute appendicitis. There was no perforation or abscess formation. The patient was discharged on the 4th post-operative day in good condition.
Fro. 7 Case 6. Series of spot roentgenograms of the caecum. Note the high position of the caecum and the double pressure effect simulating the " E " sign of the descending duodenum in cases of enlargement of the head of the pancreas.
adjacent to the caecum. The patient was discharged on the 4th post-operative day in good condition. Case 6 . ~ A m a n aged 55 was admitted to the hospital because of a 2-week history of intermittent abdominal pain and diarrhea. The abdomen was distended with diminished bowel sounds and tenderness in the right lower quadrant. The W.B.C. was 13,300. Because the possibility of carcinoma of the right colon was considered, a barium enema examination was performed.
DISCUSSION Acute appendicitis continues to be an important medical problem. Earlier diagnosis of the atypical acute appendicitis is the best hope to decrease the mortality rate which continues to be high when the diagnosis is delayed and perforation develops. The incidence of gangrene or perforation in the patients over 50 years of age is 66 %, which is double that found in younger persons, and the mortality rate in these cases rises to 4 % from 0.1% in inflamed, not gangerous appendicitis. The interval between the onset of symptoms and perforation is often much shorter in the extreme ages. Barium enema examination should be considered and performed in the doubtful cases instead of waiting for the patient to develop diagnostic physical signs. Filling the colon with barium is not harmful to these patients. The teaching of " n o barium enema in suspected appendicitis" should be challenged. On the contrary, it is in these cases that a barium enema examination may afford very important information. In this series there were
414
CLINICAL
RADIOLOGY TABLE 1
BARIUM ENEMA EXAMINATIONIN SUSPECTED APPENDICITIS
Barium Enema Findings No. of Cases
Age (years) -l 5
40-
15-40
i 40
17
Diagnostic of App.
Non-Diagnostic. Non-Visualized App.
Normal Visualized App. -I
i 15
~
8
25
4
11 !
Operated
Non-Operated
Acute Appendicitis
Normal App. Mesenteric Adenitis
25
5
no untoward reactions or ill effects which could have been attributed to the barium enema examination. The examination was performed in 40 patients with the results seen in Table 1. There was no case where complete, normal visualization of the appendix proved to be pathologic. As a result of this study in young children, we found the Barium Enema very useful in the differential diangosis of appendicitis versus mesenteric adenitis or gastroenteritis. When the appendiceal lumen visualized well, we considered it as evidence of a non-diseased appendix and as presumptive evidence of mesenteric adenitis or gastroenteritis. These children are discharged from the hospital early, usually within 24 hours, if their clinical condition permits it, instead of keeping them under observation at the hospital. In this series there were 2 children of 7 and 6 years of age on which the barium enema showed normal filling of their appendices. However, because of their clinical findings indicating acute appendicitis, they were operated upon and their appendices were removed and found pathologically • normal. In both cases the surgical exploration showed mesenteric adenitis. Non-visualization of the appendiceal lumen by itself is not considered of any diagnostic significance. However, the number of normal non-visualized appendices is considerably .decreased, if a determined effort is made to visualize the appendix including fluoroscopy of the colon after evacuation of the barium. Occasionally a delayed roentgenogram in 2 to 6 hours after the
" I
Clinically Improved
10
examination may show a normal filling of the appendiceal lumen. One should be careful not to mistake a partial filling of a long appendix as normal appendix. Partial visualization of the appendiceal lumen, if the lumen is irregular, may be considered as pathologic. I f the visualized part of the lumen is smooth and regular, it should be evaluated in correlation with the possible changes of the cecum and terminal ileum. The flattening of the tip of the cecum and the double pressure effect has been found to be highly diagnostic of acute appendicitis and it is produced by the vascular engorgement and edema of the meso appendix and the omentum and serosa adjacent to the cecum which are always associated with acute appendicitis and may appear even within a few hours from the onset of the disease. Edema of the wall and the mucosa of the cecum may contribute to the deformity. The deformity is similar to the reverse '3' appearance of the second part of the duodenum in cases of oedema of the head of the pacreas. This sign of the cecum has been found always diagnostic of acute appendicitis and we know of no description of it in the literature. It is possible that a tumor, or large mesenteric lymph nodes may produce extrinsic pressure on the cecum, but then the pressure defect is irregular and eccentric a n d not the reversed 3 sign of appendicitis. In doubtful cases, air contrast study will demonstrate better the extrinsic pressure and the wall of the cecum to be intact. In cases of retrocecal appendicitis, the pressure effect may be seen in the posterior or lateral aspects
THE USE OF BARIUM IN THE D I A G N O S I S OF ACUTE A P P E N D I C E A L DISEASE o f t h e c e c u m o r t h e a s c e n d i n g c o l o n . I n t h e s e cases, the tip of the cecum shows an indentation produced by the retrocaecal position of the appendix. T h e c h a n g e s o n t h e c e c u m are c o n s t a n t a n d reproducible on repeat examination. The barium e n e m a e x a m i n a t i o n is p a r t i c u l a r l y h e l p f u l in o b e s e p a t i e n t s w h e r e t h e p h y s i c a l e x a m i n a t i o n is difficult to evaluate. The post-appendectomy
deformity of the cecum
415
should be differentiated by the clinical history and t h e l a c k o r e d e m a o r d o u b l e p r e s s u r e effect. REFERENCES
BARNES, B. A., BEHRINGER, G. E., WHEELOCK, F. C. & WILKINS, E. W. (1962). J. Am. reed., Ass., 180, 122. BOCKUS, H. L. (1964). Gastroenterology. V o l II, 2nd Ed. Philadelphia: Saunders. CLEMENTS, N., OLSON, J. E. & POWERS, J. tt. (1965). Ann. Surg., 161,231. COLLINS, D. C. (1965). Surgery Gynec. Obstet., 101, 437. SOTEROPOULOS, C. & GILMORE, J. (1958). Radiology, 71,246.
BOOK REVIEWS Myelography. By R. SHAPIRO. Second edition. Chicago: Year Book Medical Publishers. 1968. 224s. The fact that the second edition of tbis work has appeared a relatively short time after the first is adequate testimony to its popularity, a popularity which is fully justified by the excellence of the book. The format is fairly standard. There are chapters dealing with the history of myel0graphy, contrast media, indications, technique and radiation dosage. These are followed by a short chapter on plain X-ray examination of the spine, an excellent chapter on anatomy, and sections on the normal myelogram and possible artefacts. The major part of the book is devoted to the abnormal myelogram. The various conditions are dealt with most comprehensively and with few apparent errors or omissions. Myelographic examination of the posterior fossa is included. The book ends with sections on complications and limitations, and there are chapters on intraosseous venography and discography. Recent advances since the first edition are discussed including scintillation scanning. The book is beautifully produced, with clear, concise text and excellent illustrations. There may be different views particularly as regards technique and contrast media, but the author gives his own opinions convincingly. The price may be beyond the means of many, but for value received it is certainly not overpriced. I think that it is probably the best book on the subject in the English language. LEON MORRIS
appearance in the elderly female. The observation that this is almost exclusively confined to the female sex has interested the reviewer for many years but no explanation for this is given. Illustrations are very variable in quality. Most are satisfactory but many are reproduced by the LogEtron method where 'dodging' has been pushed sufficiently to distort normal contrasts and the illustration becomes quite unlike an original radiograph. The blocks are of good standard but the press-work shows some loss of definition in many illustrations, due to 'squish'. This book is a most useful addition to the literature concerning diagnostic radiology of the chest. G. B. LOCKE. By DAVID H. TRAPNELL, M.A., M.D., M.R.C.P., F.F.R., D.M.R.D. Pp. 300, with illustrations. London: Butterworth & Co. (Publishers) Ltd. 1967. £6 10s.
Principles of X-Ray Diagnosis.
Radiological trainees frequently have difficulty in adapting themselves to the change-over from the clinical to the radiological examination of the patient. Few text-books have attempted to deal with the fundamental problems of radiodiagnosis and it is pleasing that an attempt has been made to rectify this position. It does not pretend to give a full account of all radiological conditions. The author gives an account of his own method of examination of radiographs, stressing the importance of a systematic approach before it is possible to arrive at a diagnosis. Lung Calcifications in X-ray Diagnosis. By EMANUAL There are two excellent chapters on the production of SALZMAN. Pp. 123 with 70 illustrations. Charles C. X-rays and radiographs, and thereafter each anatomical Thomas. Springfield, Illinois: t968. $7.50. system is discussed. The book has the advantages and disadvantages of having This book presents a most interesting and complete been written by a single author. It is very easy to read, is description of lung calcification which extends beyond its lavishly illustrated and most of the illustrations are of a high title to include calcifications and ossifications in lung, quality. There is much that is of value in this work but mediastinum and pleura. A very comprehensive collection of unfortunately there are a number of minor errors in the text. illustrative lesions is shown in a well classified manner and For example, not many authorities would agree that 1 0 ~ of includes several unusual and rare examples. A wide variety chronic benign gastric ulcers become malignant. In the of lnng calcifications include the granulomata, the pneumosection on the central nervous system there is a confused and conioces and parasitic diseases. Good illustrations of many muddled description of the value of arteriography in the rare lesions are shown and interesting observations are made investigation of cysts and tumours. Later in this section it is on the importance of calcification in the identification of stated that cholesteatomata characteristically have ragged lung tumours. edges. This book is up to date, with a very good example of the Despite these minor criticisms, there is much to be comcharacteristic development of calcifying nodules in "chickenmended in this book and it will form a valuable introduction pox" pneumonia. Calcifications in the main bronchi are to the study of Radiology. well demonstrated and are shown to be a normal physiological K. T. EVANS
APPENDICEAL
CONSTANTINE S. SOTER
From the Department of Radiology and Nuclear Medicine, Northwest Community Hospital, Arlington Heights, Illinois, U.S.A.
Accurate early diagnosis is the most important single factor in the case of the patient with appendicitis. When the clinical findings are not diagnostic, a barium enema study may demonstrate changes in the caecum and the appendix diagnostic of the disease. A series of 40 barium enema studies was performed in patients suspected of suffering from appendicitis or in order to rule out appendiceal disease when the clinical signs and findings were not conclusive. A reliable sign was found to be a reversed 3 filling defect of the caecum due to oedema of the caecal wall and mesentry. It is believed that this diagnostic sign of appendicitis has not been previously described and that it is very helpful in the differential diagnosis of the acute abdomen.
ACUTE appendicitis is a daily diagnostic problem in all age groups. From the approximate 200,000 cases registered per year in the United States, 2,000 patients die from acute appendicitis and its complications. Delayed or missed diagnosis accounts for most of the deaths. The available statistics indicate no favorable trend consistent with earlier referral for surgery, as judged by the incidence of perforated appendices at operation. Eighteen per cent of the cases of appendicitis are first seen by the surgeon after perforation has taken place and this proportion has not changed in the last 23 years. Earlier diagnosis, before the perforation develops, is our best hope to reduce the mortality and morbidity of acute appendicitis. The clinical diagnostic accuracy of acute appendicitis has been shown statistically to be 80 to 82%. The Radiologist has a role in the diagnosis of acute appendicitis when the clinical manifestations of the disease are obscure, as in the young and the elderly. The X-ray findings of the plain roentgenograms of the abdomen have been described previously and are not the subject of this presentation. Here we describe out experiences with Barium Enema examinations in cases of suspected appendicitis where the clinical and laboratory findings were not diagnostic of a specific pathologic entity.
from the Emergency Room to the Department of Radiology. A chest X-ray and an abdomen series are obtained. If both the clinical evidence and the X-ray findings are not conclusive, a barium enema examination is performed immediately. The usual technique is used with the maximum height of the barium container at 90 cm. and an effort is made to fill the terminal ileum. Serial films of the caecum are taken. After the postevacuation roentgenogram is obtained and studied, the patient may be fluoroscoped again and spot radiography of the caecum and pericaecal area is repeated. Rarely, if the findings are not conclusive, the examination may be repeated. The information obtained from the examination may be divided as follows:
(a) Position of the Cecum and Appendix.--Collings (1958) in a review of human appendices, has found the cecum and appendix to be located in the left lower quadrant in 0.03%, left upper quadrant in 0.58 ~ , right upper quadrant in 3.9 ~, and in the right lower quadrant in 96 %. When in the right lower quadrant, the appendix was located anterior to the cecum in 74 ~ and retrocaecally in 26 %; when anterior to the cecum, it was caudal in 29%, medial in 35%, and lateral in 7%. An indentation in the middle of the cecal tip and slight rotation of the cecum are very suggestive of a retrocecal position of the appendix. Demonstration of atypical position of the cecum and T E C H N I Q U E OF BARIUM E N E M A appendix may explain atypical clinical findings. (b) Patency of the Appendiceal Lumen.--Since The purpose of the Barium Enema is to visualize the caecum and the appendix. Preparation of the obstruction of the lumen of the appendix is the bowel is not neccessary; the patient comes directly outstanding prerequisite of the appendiceal inflam410
THE USE OF BARIUM IN THE DIAGNOSIS OF ACUTE A P P E N D I C E A L DISEASE
mation, demonstration of a patent appendiceal liJmen should exclude the diagnosis of acute appendicitis. (e) Demonstration of an Irregular Appendieeal Lumen.--Normal visualization of the appendix should not be assumed, unless it is certain that the tip of the appendix is visualized and the entire lumen does not show Constrictions or irregularities. Irregularities of the appendieeal lumen, with kinks, strictures, dilatations, or cut offs are usually associated with appendiceal disease. (d) Changes of the Ceeum.--In acute inflammation of the appendix, the mesoappendix and adjacent omentum becomes edematous and produce pressure upon the tip of the cecum which is shown as flattening of the cecal tip or as a persistent pressure effect with identation, single or double, adjacent to the orifice of the appendix. The wall of the cecum may become thick and edematous and the mucosa coarse, producing a form of typhlitis. (e) Changes of the Terminal Ileum.--When the terminal ileum is filled, it occasionally may show slight extrinsic pressure or spasm and irritability. CASE HISTORIES Case 1.~46 year old obese male patient admitted to the hospital because of lower abdominal pain which he experienced suddenly, 8 hours earlier at 1 a.m. Physical examination revealed only tenderness in both lower quadrants. The patient was better on the morning of the examination. The laboratory examination revealed W.B.C. 12,500; neutrophils 59700; lymphocytes 36%; hematocrit 40.5;
FIG. 1 Case 1. Spot series of the caecum. Note the persistent pressure effect upon the tip of the caecum by the oedematous mesoappendix and adjacent omentum. The mucosa is coarse due to associated typhlitis.
411
urine examination negative. It was decided to keep the patient under observation and re-evaluate in 8 to 12 hours. The patient was referred to the Department of Radiology for examination. The actue abdomen series revealed a reflex ileus in the lower abdomen which was considered suggestive of either diverticulitis or appendicitis. Because of 2 calcific densities seen in the area of the right kidney, an Intravenous Pyelographic examination was performed which demonstrated the calcific densities to be stones in the upper calyx of the right kidney with localized chronic pyelonephritis and no obstruction. Barium enema examination. The caecum showed flattening of the apex with coarse mucosa and double pressure effect. The appendiceal lumen was not filled (Fig. 1). These changes were considered as diagnostic of acute appendicitis. In addition, in the post-evacuation roentgenogram, the caecum and right colon remained dilated suggesting incomplete obstruction in the proximal transverse colon. At operation, a ruptured appendicitis with purulent peritonitis were found. The proximal transverse colon was explored and thick pericolonic adhesions were found which accounted for the incomplete obstruction. The postoperative course was complicated by adynamic ileus and infection of the abdominal wall. The patient was discharged in good condition 28 days after admission. Case 2.--Woman aged 34, complains of intermittent low abdominal and pelvic pain for 3 to 4 days. The pain became violent during the night prior to the examination, but in the morning she improved and the pain subsided almost completely. The W.B.C. was 17,200, but she was sent home asymptomatic. Twenty-four hours later the symptoms recurred with suprapubic intermittent pain. On examination there was deep rebound suprapubic tenderness. Gynaecologic examination showed no abnormalities. The temperature was 100°F. and the W.B.C. 13,200. She was sent home on medication. Next morning the pain was
FIG. 2 Case 2. Enlarged spot view of the c a e c u m . Note the filling of the proximal appendiceal lumen with irregular narrowing and tapering into an ovoid appendiceal faecolith (arrow). The wall of the adjacent small bowel is thickened. Changes consistent with suppurative or gangrenous appendicitis.
412
C L I N I C A L RADIOLOGY
Fio. 3 Case 3. Enlarged spot view of the caecum. Note the double pressure effect on the caecum. Also the mild pressure on the terminal ileum, and the coarse mucosal folds of the caecum. The bullet-like foreign body has not cbanged position.
still present and she was referred to the Department of Radiology. Barium enema examination revealed a low pelvic caecum which was located almost in the midline. The examination was repeated immediately because of incomplete filling of the caecum. The proximal 1 cm. of the appendiceal lumen was visualized with abrupt cut off of the lumen (Fig. 2). The appendix extended medially and upward and 2 cm. distally to the lumen cut off there was evidence of a small, 1 cm. in diameter, appendiceal stone. There was also evidence of thickening of the wall of the adjacent small bowel. The findings were considered as diagnostic of acute suppurative pelvic appendicitis. At operation the patient had a caecum lying over to the left side of the midline of the pelvis, with a retrocecal appendix approximately 1 inch in diameter and 1 inch long. The base of the appendix was necrotic and slight manipulation resulted in perforation with release of a large amount of pus and 2 stones. The pathologic report was acute gangrenous appendicitis. Case 3.--Woman aged 43, admitted to the hospital with diffuse acute mid-abdominal pain which started as epigastric distress. In the past, she had had attacks of epigastric and diffuse abdominal pain associated with nausea and back pain. The roentgenologic examination of the abdomen revealed a bullet-like density in the right lower quadrant. The bariurn enema examination revealed a pressure effect on the tip of the caecum. The appendix was not visualized and the bullet-like density was closely associated with the tip of the caecum with no change of position on compression (Fig. 3). The terminal ileum showed evidence also of slight extrinsic pressure. The findings were considered as diagnostic of acute appendicitis, secondary to obstruction by a foreign body or inspissated barium. At operation a large edematous appendix was removed.
FIG. 4 Case 3. Roentgenograms of the removed appendix. Note the thick, oedematous appendiceal wall and the gas in the lumen of the appendix which moves freely by cbanging the position of the appendix. The bullet-like foreign body, obstructing the base of the appendix, was due to impacted barium. (Barium enema examination two years previously.)
The mesoappendix and the omentum were oedematous and pressing upon the tip of the caecum and terminal ileum. X-ray examination of the removed appendix (Fig. 4) revealed the obstruction of the base of the appendiceal lumen by the opaque foreign body which was proven to be inspissated barium, apparently from a barium enema examination 2 years previously. The appendix contained gas which moved freely from the tip to the base of the lumen, produced by gas-forming organisms infecting the appendix. The patient was discharged in 6 days in good condition. Case 4.--An obese man, aged 37, was admitted to the hospital because of diffuse lower abdominal pain, present for 3 days, more pronounced in the right lower quadrant. The W.B.C. was 22,150. The patient was sent to the Department of Radiology for examination. An intravenous pyelographic study showed no abnormalities. There was suggestion of an avoid faecolith in the right lower quadrant and a barium enema study was performed immediately which showed (Fig. 5) evidence of flattening and double pressure effect upon the tip of the caecum and the terminal ileum with a small indentation in the centre of the caecum where the origin of the appendiceal lumen should be and with good demonstration of an ovoid faecolith in line with the obstructed appendiceal lumen. The findings were considered diagnostic of acute gangrenous appendicitis. At operation there was evidence of a diffuse phlegmon involving the caecum, the appendix, and the adjacent omentum due to an acute, gangrenous, perforated appendicitis. Case 5 . ~ A girl aged 15 was admitted to the hospital because of pain in the right lower quadrant of 8 hours duration. The W.B.C. was 9,100. Barium enema examination upon admission (Fig. 6) revealed a pressure defect of the tip of the caecum and no visualization of the appendix. The findings were considered as diagnostic of acute appendicitis. At surgery the appendix was acutely inflammed and there was congestion in the caecum and the omentum
T H E USE OF B A R I U M I N T H E D I A G N O S I S OF A C U T E A P P E N D I C E A L
FIG. 5 Case 4. Series of spot roentgenograms of the caecum. Note the characteristic double pressure effect on the caecum. Also the incomplete filling of the base of the appendix and the ovoid faecolith at the tip of the appendix. Findings characteristic of acute gangrenous appendicitis.
DISEASE
413
FXG. 6 Case 5. Series of spot roentgenograms of the caecum. Note the persistent pressure effect on the caecum due to the oedematous omentum.
The examination revealed (Fig. 7) a high position of the caecum with considerable double pressure effect u p o n the tip of the caecum and no visualization of the appendix. The findings were considered diagnostic of acute appendicitis with possible abscess. At surgery a diffuse phlegmon involving the cecmn and the appendix was found due to an acute appendicitis. There was no perforation or abscess formation. The patient was discharged on the 4th post-operative day in good condition.
Fro. 7 Case 6. Series of spot roentgenograms of the caecum. Note the high position of the caecum and the double pressure effect simulating the " E " sign of the descending duodenum in cases of enlargement of the head of the pancreas.
adjacent to the caecum. The patient was discharged on the 4th post-operative day in good condition. Case 6 . ~ A m a n aged 55 was admitted to the hospital because of a 2-week history of intermittent abdominal pain and diarrhea. The abdomen was distended with diminished bowel sounds and tenderness in the right lower quadrant. The W.B.C. was 13,300. Because the possibility of carcinoma of the right colon was considered, a barium enema examination was performed.
DISCUSSION Acute appendicitis continues to be an important medical problem. Earlier diagnosis of the atypical acute appendicitis is the best hope to decrease the mortality rate which continues to be high when the diagnosis is delayed and perforation develops. The incidence of gangrene or perforation in the patients over 50 years of age is 66 %, which is double that found in younger persons, and the mortality rate in these cases rises to 4 % from 0.1% in inflamed, not gangerous appendicitis. The interval between the onset of symptoms and perforation is often much shorter in the extreme ages. Barium enema examination should be considered and performed in the doubtful cases instead of waiting for the patient to develop diagnostic physical signs. Filling the colon with barium is not harmful to these patients. The teaching of " n o barium enema in suspected appendicitis" should be challenged. On the contrary, it is in these cases that a barium enema examination may afford very important information. In this series there were
414
CLINICAL
RADIOLOGY TABLE 1
BARIUM ENEMA EXAMINATIONIN SUSPECTED APPENDICITIS
Barium Enema Findings No. of Cases
Age (years) -l 5
40-
15-40
i 40
17
Diagnostic of App.
Non-Diagnostic. Non-Visualized App.
Normal Visualized App. -I
i 15
~
8
25
4
11 !
Operated
Non-Operated
Acute Appendicitis
Normal App. Mesenteric Adenitis
25
5
no untoward reactions or ill effects which could have been attributed to the barium enema examination. The examination was performed in 40 patients with the results seen in Table 1. There was no case where complete, normal visualization of the appendix proved to be pathologic. As a result of this study in young children, we found the Barium Enema very useful in the differential diangosis of appendicitis versus mesenteric adenitis or gastroenteritis. When the appendiceal lumen visualized well, we considered it as evidence of a non-diseased appendix and as presumptive evidence of mesenteric adenitis or gastroenteritis. These children are discharged from the hospital early, usually within 24 hours, if their clinical condition permits it, instead of keeping them under observation at the hospital. In this series there were 2 children of 7 and 6 years of age on which the barium enema showed normal filling of their appendices. However, because of their clinical findings indicating acute appendicitis, they were operated upon and their appendices were removed and found pathologically • normal. In both cases the surgical exploration showed mesenteric adenitis. Non-visualization of the appendiceal lumen by itself is not considered of any diagnostic significance. However, the number of normal non-visualized appendices is considerably .decreased, if a determined effort is made to visualize the appendix including fluoroscopy of the colon after evacuation of the barium. Occasionally a delayed roentgenogram in 2 to 6 hours after the
" I
Clinically Improved
10
examination may show a normal filling of the appendiceal lumen. One should be careful not to mistake a partial filling of a long appendix as normal appendix. Partial visualization of the appendiceal lumen, if the lumen is irregular, may be considered as pathologic. I f the visualized part of the lumen is smooth and regular, it should be evaluated in correlation with the possible changes of the cecum and terminal ileum. The flattening of the tip of the cecum and the double pressure effect has been found to be highly diagnostic of acute appendicitis and it is produced by the vascular engorgement and edema of the meso appendix and the omentum and serosa adjacent to the cecum which are always associated with acute appendicitis and may appear even within a few hours from the onset of the disease. Edema of the wall and the mucosa of the cecum may contribute to the deformity. The deformity is similar to the reverse '3' appearance of the second part of the duodenum in cases of oedema of the head of the pacreas. This sign of the cecum has been found always diagnostic of acute appendicitis and we know of no description of it in the literature. It is possible that a tumor, or large mesenteric lymph nodes may produce extrinsic pressure on the cecum, but then the pressure defect is irregular and eccentric a n d not the reversed 3 sign of appendicitis. In doubtful cases, air contrast study will demonstrate better the extrinsic pressure and the wall of the cecum to be intact. In cases of retrocecal appendicitis, the pressure effect may be seen in the posterior or lateral aspects
THE USE OF BARIUM IN THE D I A G N O S I S OF ACUTE A P P E N D I C E A L DISEASE o f t h e c e c u m o r t h e a s c e n d i n g c o l o n . I n t h e s e cases, the tip of the cecum shows an indentation produced by the retrocaecal position of the appendix. T h e c h a n g e s o n t h e c e c u m are c o n s t a n t a n d reproducible on repeat examination. The barium e n e m a e x a m i n a t i o n is p a r t i c u l a r l y h e l p f u l in o b e s e p a t i e n t s w h e r e t h e p h y s i c a l e x a m i n a t i o n is difficult to evaluate. The post-appendectomy
deformity of the cecum
415
should be differentiated by the clinical history and t h e l a c k o r e d e m a o r d o u b l e p r e s s u r e effect. REFERENCES
BARNES, B. A., BEHRINGER, G. E., WHEELOCK, F. C. & WILKINS, E. W. (1962). J. Am. reed., Ass., 180, 122. BOCKUS, H. L. (1964). Gastroenterology. V o l II, 2nd Ed. Philadelphia: Saunders. CLEMENTS, N., OLSON, J. E. & POWERS, J. tt. (1965). Ann. Surg., 161,231. COLLINS, D. C. (1965). Surgery Gynec. Obstet., 101, 437. SOTEROPOULOS, C. & GILMORE, J. (1958). Radiology, 71,246.
BOOK REVIEWS Myelography. By R. SHAPIRO. Second edition. Chicago: Year Book Medical Publishers. 1968. 224s. The fact that the second edition of tbis work has appeared a relatively short time after the first is adequate testimony to its popularity, a popularity which is fully justified by the excellence of the book. The format is fairly standard. There are chapters dealing with the history of myel0graphy, contrast media, indications, technique and radiation dosage. These are followed by a short chapter on plain X-ray examination of the spine, an excellent chapter on anatomy, and sections on the normal myelogram and possible artefacts. The major part of the book is devoted to the abnormal myelogram. The various conditions are dealt with most comprehensively and with few apparent errors or omissions. Myelographic examination of the posterior fossa is included. The book ends with sections on complications and limitations, and there are chapters on intraosseous venography and discography. Recent advances since the first edition are discussed including scintillation scanning. The book is beautifully produced, with clear, concise text and excellent illustrations. There may be different views particularly as regards technique and contrast media, but the author gives his own opinions convincingly. The price may be beyond the means of many, but for value received it is certainly not overpriced. I think that it is probably the best book on the subject in the English language. LEON MORRIS
appearance in the elderly female. The observation that this is almost exclusively confined to the female sex has interested the reviewer for many years but no explanation for this is given. Illustrations are very variable in quality. Most are satisfactory but many are reproduced by the LogEtron method where 'dodging' has been pushed sufficiently to distort normal contrasts and the illustration becomes quite unlike an original radiograph. The blocks are of good standard but the press-work shows some loss of definition in many illustrations, due to 'squish'. This book is a most useful addition to the literature concerning diagnostic radiology of the chest. G. B. LOCKE. By DAVID H. TRAPNELL, M.A., M.D., M.R.C.P., F.F.R., D.M.R.D. Pp. 300, with illustrations. London: Butterworth & Co. (Publishers) Ltd. 1967. £6 10s.
Principles of X-Ray Diagnosis.
Radiological trainees frequently have difficulty in adapting themselves to the change-over from the clinical to the radiological examination of the patient. Few text-books have attempted to deal with the fundamental problems of radiodiagnosis and it is pleasing that an attempt has been made to rectify this position. It does not pretend to give a full account of all radiological conditions. The author gives an account of his own method of examination of radiographs, stressing the importance of a systematic approach before it is possible to arrive at a diagnosis. Lung Calcifications in X-ray Diagnosis. By EMANUAL There are two excellent chapters on the production of SALZMAN. Pp. 123 with 70 illustrations. Charles C. X-rays and radiographs, and thereafter each anatomical Thomas. Springfield, Illinois: t968. $7.50. system is discussed. The book has the advantages and disadvantages of having This book presents a most interesting and complete been written by a single author. It is very easy to read, is description of lung calcification which extends beyond its lavishly illustrated and most of the illustrations are of a high title to include calcifications and ossifications in lung, quality. There is much that is of value in this work but mediastinum and pleura. A very comprehensive collection of unfortunately there are a number of minor errors in the text. illustrative lesions is shown in a well classified manner and For example, not many authorities would agree that 1 0 ~ of includes several unusual and rare examples. A wide variety chronic benign gastric ulcers become malignant. In the of lnng calcifications include the granulomata, the pneumosection on the central nervous system there is a confused and conioces and parasitic diseases. Good illustrations of many muddled description of the value of arteriography in the rare lesions are shown and interesting observations are made investigation of cysts and tumours. Later in this section it is on the importance of calcification in the identification of stated that cholesteatomata characteristically have ragged lung tumours. edges. This book is up to date, with a very good example of the Despite these minor criticisms, there is much to be comcharacteristic development of calcifying nodules in "chickenmended in this book and it will form a valuable introduction pox" pneumonia. Calcifications in the main bronchi are to the study of Radiology. well demonstrated and are shown to be a normal physiological K. T. EVANS