Fig. 2-24-year-old previously healthy man was admitted with classical presentation of acute appendicitis. No diar- rhea was present. WBC was 16,500!mm3.
Perspective Sonography
and the Acute
Abdomen:
Practical
Considerations Julien
B. C. M. Puylaert1,
O
Friso M. van der Zant1, Arie M. Rijke2
ver the past 10 years, has gained acceptance
. .
patients
ing
with
sonography for examin-
acute
of
abdominal
27%;
and
into three
and low
abdomen
rapid,
inexpensive,
clinical
limited
in obese patients;
suspicion have an
cannot
penetrate
and readily accessible; it has some serious drawbacks. Use is
however,
more
than
other
the ultrasound
radiologic
and
ator-dependent
techniques,
requires
skill,
and experience. In this perspective,
several
of
on
using
include
pain
are
the choice
is oper-
practical
patients
puncture,
graphic
findings,
appendix
highlighted. These aspects between sonography and CT
value
the
significance
of normal
and,
commu-
on
nication
with the clinician.
a sonogram,
finally,
the threshold
for
diagnostic
sono-
negative ill-advised surgical
laparotomy
delay.
inside
prospective
study
appendicitis
showed
accepted
the
Nonetheless, hospital
of patients a negative
a high
the risks of
rate to avoid
surgical delay
have
with
A
of sonography
rate
Received June 1, 1995; accepted after revision July 23, 1
of Radiology.
AJR 1997;168:179-186
AJR:168, January
Health Sciences
0361-803X/97/1681-179
1997
be
using were
sonography, 13%,
surgical
13%,
delay.
all patients are
patients
as
in cases
of
rejected.
on clinical
man-
abdomen
is
of all
at our abdominal
abdominal
sonographic
institution, pain has
and nationbecome the
Sonography
or CT as Initial
Several
for radiologists are on call.
when
acute
easily
detected
gram.
They
abdominal
include
a ruptured
hepatic
abscesses.
provide
better results in obese retrocecal appendicitis,
institution,
in unnecesvirtually
abscess,
deeply
sematous enced
referred
for
a sonogram,
including
reliably
definitely
tions
In addition,
located
bowel
aneurysm, rupture,
CT scans
sigmoid
obstruction,
cholecystitis. hands,
diagnose in most
most
patients
acute
usually
who appendiceal
diverticulitis, gastrointestinal and emphy-
However,
the sonograrn
a an and
patients
to the retropetitoneum,
perforation
abdominal
seems
internal
closed-loop
aortic
acute pancreatitis, hernia, and perirenal
incarcerated
laparotomy
more
on a sono-
an
sig-
respectively,
are
than
an esophageal
sus-
7%,
Technique?
conditions
on a CT scan
aneurysm,
have
to go in
they
dissection,
mycotic
or subacute surgery
perpain
reason
acute
whom
25%
prac-
abdominal
of acute
most frequent to the hospital
with for
up
the acute
routine
Sonography
with
reduction
In our
institutions.
possi2).
of
findings
negative and
makes
1 and
affected
on indication
an aortic
changed the therapeutic management of patients [4]. In three independent
in experi-
can still be used abdominal
[4]. Therefore,
to
condia reason-
1996.
Department of Radiology, Westeinde Hospital. Ujnbaan 32, 2512 VA The Hague, the Netherlands.
2Department
only
sonographic
[4-61 with a concomitant
pain
a suspected
laparotomy
of sonography used
is and should
rates
studies
imaging
concept
doubt
sary
serious
is common.
diagnoand that
The impact
studies surgeons
a
is unreliable
agement of patients with an acute impressive. In a study of patients
Indications
with
that the clinical
tool
pected appendicitis,
examinations wide, acute
with a remote (Figs.
sonography
in many
had
an
surgery
has markedly
formed
treatment was of misdiagnosis
radiologic
should be low. The a helpful
nificantly in 26% Traditionally,
show abdomen
tice
as patients
surprisingly,
did not of the
In 30 patients
6 hr because
figures
Not
in the high-
group
aneurysm,
than
sis of an acute
clinical
the
findings
of indirect
of
even
of the patients whereas 5%
[2].
aortic more
[3]. These
acute
that
in the low-suspicion
ruptured
aspects
with
equivocal,
showed
group, 35% appendicitis,
inflamed
dedication,
(high,
suspicion)
patients
as an initial examining technique, the timing the sonographic examination, sonographically guided
categories
delayed
sonography
abdominal
beam
or gas; and sonography,
bone
as well
required
bility ofrequiring
Sonography
noninvasive,
therapeutic
surgery patients
pain.
is dynamic,
serious
concomitant
delay in 14% of patients who needed [1]. Another prospective study dividing
Center, University
of Virginia.
Lee St, Charlottesville,
Address
correspondence
to J. B. C. M. Puylaert
VA 22908.
© American Roentgen Ray Society
179
Puylaert
et al. Fig. 1-68-year-old
man with acute appendicitis had 2-day history of constipation and uncomfortable sensation in lower abdomen. No local or rebound tenderness and no fever were present Erythrocyte sedimentation rate was 32 mm! hr with normal leukocyte count Proposed management was conservative. A and B, Sonography showed inflamed appendix in longitudinal (A) and transverse (B) plane. Appendix was subsequently removed.
able course
of action
is to begin
with
the least
ticular
patient.
expensive and least invasive technique and proceed to a CT scan only in cases of an inconclu-
radiologist
sive sonogram.
the Technique
abdominal
patient
of all
pain is more
abdominal
organs.
involves
a sonographically
approach
to the clinical
findings.
sonographic
communication cific
than
a routine
The
examination
guided.
problem
survey
rational
of that
par-
findings
and.
sonographic Similarly.
linked
may
to
(Fig.
feature sonographic
with physical
on
palpable
mass. For example.
spe-
questions
provided
a search
corresponds
requires because
specific
information lead
structure
symptom-
patient
raise
nation
all
depending This
the
the
consider
examination
with
conversely, may
examination,
diagnoses
sonographic
Examination of the entire abdomen, from the axilla to the groin. in patients with acute
the
continuously
differential
possible
directed Examination
During should
for
by the
a specific
3).
tender
sonography cologic moid Asking
region
is closely
A dual exami-
when
may
help
conditions
to
pelvis,
in detecting in diagnosing
appendicitis
point
can be especially
out
the
important
cause localized
omental
organ
infarction
the
vaginal gynesig-
[8] (Fig. 4). most
tender
in conditions
tenderness
sonographic
or
area or
if in women
also
171or
diverticulitis patients
what
not only but
not have conspicuous mental
identifying
to the most painful is deep in the
region
that typically
examination
examination.
most
is helpful
but
19].
do
Seg-
features.
epiploic
Fig. 2-24-year-old previously healthy man was admitted with classical presentation of acute appendicitis. No diarrhea was present WBC was 16,500!mm3. Immediate appendectomy was proposed. AD, Sonography shows mucosal inflammation ofterminal 1eum in transverse (A) and longitudinal (B) planes as well as enlarged mesenteric lymph nodes (C). Appendix (arrows) was small and measured 2.1 mm during compression. Surgery was cancelled. Three days later, Salmonella paratyphi B (D) was cultured from stool. a = iliac artery , v = iliac vein.
180
AJR:168,
January
1997
Sonography
appendagitis
10), an incarcerated
f
epiga.stric
hernia,
or sigmoid
a small
On the other
hand.
at a considerable
tender
region.
with
[I I],
lower
abdomen,
track
maximum
pain
(Fig.
ureter may present the biliary
system
down
indicate
metastases
a
may
air in
obstniction
ileus,
or
liver
an underlying
with
an
malig-
appendiceal
all emphasize
the
mass. importance
of examining the entire abdomen. If the anatomy is aberrant. especially case of
an inflamed
the
point
normally marked (Fig.
appendix
where
made.
the
The
on the
skin
abdomen
compression transducer
an indelible
shortens
the
to the abnormal
to compress
bowel.
thereby
also involves
and its surrounding For instance, of gallbladder
compression
If. despite the can
positioned this manner.
extent
ventrally
the lateral
wall and the liver.
effect
of
an
Timing
with over
of
(Fig.
9).
be applied
pain.
the
to the
transducer the flank.
acute
tendency
organ
gas continues examination,
of the Sonographic
Many
identification
always
located
abdominal
It is also
as assessment
to minimize
be scanned
or gas-containing (Fig. 10). With the
decubitus position, free be looked for between
mittent
posterolaterally
bowel loops can be avoided
patient in a left lateral air should specifically
however,
compression. sonographic
hamper
the
fluid-filled abscesses
can be compressed.
should
manner
14).
Compression
appendicitis
in
urinary tract infec-
A, Sonography showed thickened small-bowel loops (b) with interloop fistula (black arrows). Adjacent bladder wall was locally irregular (white arrows). B, Small amount of air was found in dome of bladder (arrowhead). Only on specific questioning did patient recall episode of urinating air. She was diagnosed with Crohns disease with fistulization to bladder.
allows as well
rigidity
in a graded
patient
tissues
hydrops
appendiceal Finally,
images.
compression
of recurrent
gas-containing
the disturbing the
[
from
and allows
probe.
determining
graded
palpation
distance structure
gas on the sonographic
an acute
with
or displace
reducing
is
be
woman with 10-year history of abdominal pain complained
tions.
pencil
with
performed
the use of a high-frequency used
incision
should
to gentle
similar
Compression
Fig. 3-67-year-old in the removed
gridiron
in patients be
should
far
appendix with
8). Sonography
the distal
pain,
bowel
gallstone
indicate
nancy in patients These examples
from in the
flank
small
pare-
may cause
distance
with only
because
the right
7), a stone
with
ulcer
pain
obstruction
at a marked
of obstruction
be
a patient
duodenal
quadrant
small-bowel
can
the pain is some-
lower
contents
colic gutter.
signs
from the most
a perforated
right
the gastric
diagnostic distance
in the
that causes
from
Abdomen
or
hematoma
In appendicitis.
times diffuse may present
may
Acute
(Figs. 5 and 6).
found
site
the
[ I 2, 13j are a few such
diverticulitis
conditions
spigelian
rectus
and
toward
gas in partially
may
symptoms
toms
resolve.
recurs,
the symptoms
This
and
scenario disease.
recur
a
the
Inter-
are pre-
obstruction. the sympobstruction
reappear.
is seen
in
appendicitis. hernia,
later. pain
cases of is relieved, when
show
resolution;
of abdominal
dominantly seen in When the obstruction
stone
Examination conditions
spontaneous
episodes
incarcerated In
abdominal
and
biliary
and
urinary
intussusception, small-bowel
obstruc-
tion from adhesions. Sonographic findings during an episode of pain may differ significantly
Fig. 4.-25-year-old woman complained of lower abdominal pain in pelvic region for 1 day. Transabdominal sonography
was normal.
Transvaginal
sonography
revealed inflamed appendix (arrow).
Fig. 5.-Infarcted epiploic appendix. 40-year-old man had severe pain on pressure in left lower quadrant, suspect for sigmoid diverticulitis. Erythrocyte sedimentation rate was 36 mm!hr. A, At point of maximum tenderness, sonography showed 2.5-cm ovoid area of inflamed fat (arrowheads). B, CT scan confirmed diagnosis of infarcted epiploic appendix
(arrowheads).
AJR:168,
January
1997
181
Puylaert
et al. Fig. 6.-Otherwise healthy middle-aged woman presented with severe localized pain in right lower quadrant. She was suspected of having appendicitis. A, Sonography showed small, impalpable rectus hematoma (arrowheads). B, Rectus hematoma (arrowheads) was confirmed by CT scan. Appendectomy was cancelled.
Fig. 1.-Incarcerated obturator hernia. 86-year-old woman presented with small-bowel obstruction. A, Left-sided groin sonography revealed small, impalpable herniated bowel loop (asterisk) behind pectineus muscle. B, T2-weighted MR imaging confirms incarcerated obturator hernia (asterisk). Also note contralateral asymptomatic
Fig. 8.-Inflamed appendix in unusually high position. A, Sonogram shows inflamed appendix in right upper quadrant. B. In view of its unusual position, location of appendix was drawn C. This location influenced site, size, and direction of incision.
182
on skin with indelible
hernia.
a
=
femoral
artery,
v
=
femoral
vein.
pencil.
AJR:168, January
1997
Sonography from
findings
sode
and
immediately
such
an episode.
from
For
examined
during
sonogram
may show
gallbladder
after
the findings an
wall,
such
several
instance, episode
and
the
Acute
Abdomen
an epi-
days
after
if a patient is of biliary colic, a
hydrops,
thickening
a sonographic
of the
Murphy’s
sign,
and an impacted stone. A few days later, when the symptoms have subsided, all that is found is a morphologically ing
a
should
normal
mobile
stone.
gallbladder
be correlated
always
contain-
Sonographic with
findings the course
appendix may the obstruction.
quickly However, the
disappear
associated
changes
tion
often
days
or weeks
long
since
remain
appendicitis
of obstrucvisible
when
cally in a patient the sonogram
the symptoms
These
residual
impressive
can
or
sonographically
subsided. an
bowel,
after relief of inflammatory
with the process
even
why
explain
of
due to an
the symptoms in time. Dilatation obstruction ofthe gallbladder, kidney,
for
have changes
cholecystitis
be documented free ofsymptoms
or
sonographiat the time of
16](Fig. I 1).
Preferably, the examination should be done during an episode of pain for two reasons. Not only is the chance of a diagnostic sonographic finding greater but it also guarantees optimal timing of possible surgery. In case of intennirtent episodes ofpain, the patient should be warned to seek immediate medical attention during the next episode so that sonography, and possibly surgery, can be performed without delay (Fig. 12).
Sonographically In patients
with
Guided
Puncture
an acute
abdomen,
Fig. 9.-Acute gallbladder hydrops. A and B, On compression of gallbladder, in longitudinal (A) and transverse (B) plane mild bulging (arrowheads) of anterior abdominal wall was noted, indicating hydrops with high pressure in lumen. No gallstones were visualized. At surgery, 3-mm obstructing stone in distal cystic duct was found.
Indirect fluid,
however,
cally
guided
a small
blood, tory
pus,
malignant
Fig. 10.-Small-bowel obstruction with partially gas-filled loops. A and B, Ventral scanning yielded only air(A), whereas posterolateral
January
1997
carries
rapid
differentiation
and
investigation
between
gastric ascites
be helpful.
puncture
risk and allows
amount of free fluid may occur in both surgical and nonsurgical conditions and, as such, is nonspecific. Identifying the nature of the
AJR:168,
can
bile,
and can
fluid, (Fig.
Sonographivirtually
additional distinguish
pancreatic 13).
Many no
between laborafurther fluid,
and
scanning clearly showed dilated loops (B).
Sonographic sonographic
dicitis, renal straightfoaward
findings
such as appen-
colic, or cholecystitis and can be made
dence. However, tion is not well, sonography.
Findings diagnoses
are fairly with confi-
sometimes the primary condior not at all, recognizable by
In such
cases,
indirect
sonographic
may be of help.
Fig. 11.-50-year-oldwomanwith classic signs of cholecystitis 2 days earlier was completely free of symptoms when this sonogram was obtained. Gallbladder still showed considerable residual changes. 183
Puylaert
et al.
primary
bowel
ocolitis.
Crohn’s
wall diseases disease,
as infectious
ile-
I 15).
or ischemia
Other useful indirect findings are associated with abscesses, which occur when a gastrointestinal sealed
perforation
off.
Often
appendicitis,
is not
the
diverticulitis,
a malignancy-can be cases of large, gas-containing may
abscessogram
done
neous
cause-
Crohn’s
disease,
determined. abscesses,
or
determination
effectively
underlying
be difficult
In this
I 16, 17). An
some days after percutaand a repeated sonogram
drainage
may, as yet, reveal
the underlying
condition.
Another indirect sonographic sign related to free perforation. If the process sealing
has been completely
the bowel
fective and the bowel contents into the peritoneal cavity. first then Fig. 12.-Over 3 months, 59-year-old woman suffered from severe colicky attacks lasting 1-2 hr. Two earlier sonographic examinations performed during symptom-free intervals showed no abnormalities. Present examination, performed during attack, revealed intussusception.
a generalized
ileus
will
fluid-filled
peritonitis
ensue.
The
bowel
loops
sis is an important
clue
inef-
are spilling a local and with
presence with
paralytic of
dilated
absent
and.
peristal-
in most
cases,
indicates a gastrointestinal perforation ing surgical treatment (Fig. 15). The most helpful to gastrointestinal occur in appendicitis, ease,
peptic
indirect findings are related pertration. such as may diverticulitis.
all of these conditions,
omentum, site
of
attempt
contents
inesenteiy, imminent to seal
offand
protective and bowel
perThration prevent
into the peritoneal
ing, inflamed fatty mesentery recognized as amorphous choic,
noncompressible
fat is usually
Crohn’s
ulcer disease, and bowel
concentrated
of howel
The
around
migrat-
omentum
are
of hypere-
This
inflamed
the diseased
feature
of inflamed
intermittent
graded
compression fat,
Inflamed
attenuating
streaky
by applying with the trans-
especially
in advanced
on a CT scan as hyper-
(dirty)
areas
in the abdomi-
nal fat(dirtyfat)(Fig. 14). Secondary
boring citis,
bowel is another
be confusing
mural
thickening
loops,
such
indirect
and
may
Normal
of
as seen
sign.
This
be interpreted
Sonographic
It is not
fat is its noncom-
is best observed
is well recognized
can easily
The most con-
which
cases,
in
prominent,
pressibility, ducer.
masses tissue.
spicuous
an
spillage
and
In
often
on a sonogram.
be overlooked
migration of loops to the occurs
cavity.
dis-
cancer.
organ and, although
unusual
abnormalities acute
sonographic
occurs
as such
sonographic
with
requiring
with
an
a low clinical
surgery, can
a negabe
usually
taken as confirmation that no condition requiring surgery exists. lf however, clinical findings
finding
can
no
in patients
examination
and laboratory tests ity, further workup
neigh-
find
In patients
in appendi-
the
to
of disease
suspicion tive
requir-
Findings
whatsoever
abdomen.
is of
frequently
appendicitis
suggest
a serious
is required. in young
women
must be differentiated
abnormal-
This
problem in
whom
from adnexi-
Fig. 13.-61-year-old woman was admitted with rapidly increasing pain over entire abdomen. She had suffered no trauma. A and B, Sonograms show free fluid around liver and inhomogeneous spleen. C, Sonography-guided puncture yielded blood. Surgery confirmed spontaneously ruptured spleen.
184
AJR:168, January
1997
Sonography
and
the
Acute
Abdomen
unnecessary
laparotomy.
may provide
ney
Two
other and
creatitis
is usually
amylase
in
by
both
ischemia,
urine
in a patient
upper
quadrant
severe
symptoms, cause
of pulmonary
the first embolism
If,
in
be fluid
consolidation
or early
pneumonia with
both
findings
should
a patient
symptoms,
study
patient
(Fig.
normal.
the most
is
a
is obese
phy in other
CT
useful
scan,
with
between
Understandably,
ogy has
c&tsed
Radiologist
role of the erythrocyte
sedimentation
rate must
be present
be emphasized, because in adnexitis it is usually high at the time of admission. If the etythrocyte sedimentation
rate
is
markedly
young and not too obese woman sonographic findings. adnexitis favored. erythrocyte
The reasoning sedimentation
AJR:168, January
1997
is as follows:
elevated
with is
in
normal strongly
if the high
rate had been
caused
that would
during sonography. Another condition a
not have
gone
in which
no sonographic
in the presence
however,
is usually
cal presentation. a condition
rate
It can, however,
requiting
surgery
ofa
lead
as
to an
good
communica-
should speak such
as
acorn-
“phlegmon”,
“walled-offperforation”,
and
“pseudoa-
mean differentthings
a radiologist
a morphologic
should
In
difficult
to
cases,
of the intni-
description
be avoided.
ln such
ings
cases,
the radiolo-
to be present
at the
sonographic
find-
examination.
In the
on clini-
masquerade and
and
and “ileus”can
sonographic
is pyelonephritis;
made
a good relarelationship starts have
A good
gisi should ask the surgeon
high
ad-
and
abdominal situation based on the sonographic findings should be given, and a single-term diagnosis
abnormalities are found erythrocyte sedimentation this diagnosis
unnoticed
the
and confusion
must
Tenns
“perforation”,
therefore,
would
man-
abdomen.
viewed
excitement
and surgeon
language.
mon
a surgeon extensive
acute
have
radiologists
tionship with surgeons. with mutual confidence
neulysm”,
and
an
in this field with caution
both
[20}; therefore,
changes
in their
conservative
and
surgeons
been
have
impression
even some distrust. The realization that astuteness is being challenged by technol-
perhaps
clinical
conspicuous
surgeons
with
vance ofsonography
tion.
the
the Clinician
surgery
of patients
agement
if
for sonogra-
respects.
to rely on their clinical
decision
periappendiceal
be is
complemen-
especially
For mote than a century, taught
appendicitis,
16). abdominal laboratory
a psychogenic
or is not suitable
Communication
inflammatory
be
of pulmonary
or functional bowel disorder should suspected. If the sonographic examination not conclusive,
by
or a
cause
tary
sonographic findings do not exclude or adnexitis. In this context, the
con-
may
severe and
sonographic
are repeatedly
or inf-
of pleural
to the diagnosis
clue
are
epigastric
a myocardial
A subtle amount
region
tis. Normal appendicitis
serum.
be a diag-
can
abnormalities
with
or a pulmonary
sidered.
Fig. 15.-i 1-year-old girl presented with right lower quadrant pain. A and B, Sonograms show dilated fluid-filled bowel loops over entire abdomen with complete absence of penstalsis during 10 mm of examination. No other abnormality was shown. Surgery by median incision showed generalized purulent peritonitis from perforated appendicitis.
Pan-
elevated
and
however,
no sonographic
found arction
B
an
nightmare.
When
A
are pan[19).
ischemia
diagnosed
level
Mesenteric
Fig. 14.-Inflamed fat in sigmoid diverticulitis. A, Sonogram shows wall thickening of contracted sigmoid (5) and diverticulum surrounded by large areas of hyperechoic, noncompressible tissue (asterisks). B, This tissue represents fatty mesentery and migrated omentum, which was confirmed by CT scan.
findings
mesenteric
pye-
[ I 8J. do not give
that initially
sonographic
creatitis
nostic
ofthe
over the kid-
to the diagnosis
clues
diseases
to abnormal
rise
Thickening
wall and local tenderness
localiceal
final
should
report, be
history,
physical
as well
as the
integrated signs,
results
the
with
and
the
patient’s
laboratory
of a possible
data CT
scan
185
Puylaert
et al. Fig. 16.-2O-year-old woman presented with severe right upper quadrant pain and marked leukocytosis. Patient was suspected of having cholecystitis or generalized pelvic inflammatory disease. A, Sonographically.
abdomen
was normal.
Only abnormalities observed were some echolucent areas above diaphragm. B, On lateral chest radiograph, small posterobasal consolidation wasfound. Final diagnosis was right-sided basal pneumonia.
and other radiologic examinations. Liberal use and a clinical approach are the key points in sonography of the acute abdomen. Sonography
is
a valuable
tool
to
lower
both
number of unnecessary laparotomies technique related to surgical delay.
and
the the
I. Pieper R. Kager L, Nesman P. Acute appendicitis: a clinical study of 1028 cases of emergency appendectomy. Acw Chir Scand 1982; 140:51-62 WB,
Wicktrup
B, Rothmund
M, Rus-
choffi. Ultrasonography in the diagnosis of acute appendicitis: a prospective study. Gastroenterol-
1989:97:630-639 3. Marston WA, Ahlquist ogv
J VascSurg 4. Puylaert prospective
R, Johnson
G, Meyer
study
Rutgers
PH. Lalisang
of ultrasonography
RI, et al. A in the diag-
nosis of appendicitis. N Engi J Med 317:666-669 5. Braun B, Blank W. Ultraschall-Diagnostik
186
AA.
1992:16:17-22 JBCM.
JBCM.
Puylaert JSurg
Ultraschall
Kang
1987; der
PJ,
1989: 10: 17()-l76 Koumans RKJ,
and appendicitis.
findings.
J
C/in
segmental CT
findings.
as appendicitis:
omental Radiol-
US
Dis Colon
acute colonic diverticulitis: Rectum
a prospective 1992:35:1077-1084
of the
and
in the diagcolon.
AiR
Acute
graded
appendicitis:
compression.
US evalua1986:
Radiology
158:355-360 L, Koumans
Ri, Van der WerfSDJ,
RKJ.
graphic diagnosis of bacterial ading as appendicitis. Lrnicet
16. Jeffrey
Incidence
and sono-
ileocaecitis l989:ii:84-86
masquer-
RB. The pancreas. In: Jeffrey RB. of the acute abdomen,
and
sonographv
New
York:
17. Balthazar
Raven.
El.
CT
ed.
1St ed.
1989:111-148 RB. CT of appendicitis.
Gordon
Semin Ultrasound CT MR 1989; 10:326-340 18. Avni EF. Van Gansheke D, Thona Y. et al. US demonstration of pyelitis and ureteritis in children. Pediatr 19. Jeffrey RB. inflammatory
CT diagnosis. Abdom Imaging 1995:20:152-154 12. Schwerk WB, Schwarz 5, Rothmund M. Sonogin
JBCM.
tion using
for
EG. Puylaert JBCM. Herrectus sheath hematoma
masquerading
of sonography
diverticulitis
1990:154:1199-1202
Doornhos
P. Coerkamp E. Nonpalpable
study.
acute
IS. Puylaert JBCM. Vermeijden
Ultrasound
10. Rioux M, Langis P. Primary epiploic appendicitis: clinical, US and CT findings in 14 cases. Radiolog% 1994:191:523-526
raphy
of
14. Puylaert
9. Puylaert JBCM. Rightsided infarction: clinical, US and Og) 1992;l84: 169-172
clinically
SR. The value
nosis
BAMW, Puylaert JBCM, Van Dessel diverticulitis in the female: transvagi-
8. Puylaert JBCM. Transvaginal sonography appendicitis (letter). AJR 1994:163:746
I I . Lohle mans
I 3. Wilson
Br
18
1991:78:315-3
7. Broekman 1. Sigmoid
You
Ultrasound
nal sonographic 1993; 2 1:393-395
References
2. Schwerk
Akuten Appendizitis. 6. Ooms HWA. Ho
20.
Radio! 1988:18:134-139 Management of the periappendical
mass.
Seinin
Ultrasound
1989;10:341-347 Schwartz SI. Tempering
the technological
ofappendicius.
Med
N EnglJ
CT
MR
diagnosis
1987:317:703-704
AJR:168, January
1997