Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children

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To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain.

Study design

We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted.


Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal ultrasound imaging had computed tomography imaging confirming appendicitis. There were 51 patients with a partially visualized appendix. The segment of appendix that could be seen was normal in 34 patients, none of whom had appendectomy. The remaining 17 had appendectomy, in whom the appendix seemed to be inflamed in 13 and equivocal in 4, all with histologically confirmed appendicitis. Overall, 232 children underwent appendectomy; 58 had no ultrasound imaging done, and 5 had a histologically normal appendix (overall negative appendectomy rate, 2.2%). Only 35 of 1359 patients (0.03%) had computed tomography scans.


In patients with a nonvisualized appendix on ultrasound imaging and no evidence of secondary inflammatory changes, the likelihood of appendicitis is less than 2%. Generous use of ultrasonography as an adjunct to clinical examination can achieve low negative appendectomy rates without underdiagnosis of acute appendicitis.

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