Ece ZENGİN, Elif Çiğdem KARATAYLI, Mehmet Emir ÇEVİK, Hatice Kübra ÖZDEMİR, Tuğba ÇAVİŞ
Advanced Radiology and Imaging - 2026;3(2):25-31
Objectives: Accurate preoperative differentiation between perforated and uncomplicated appendicitis in children remains challenging, but is essential for appropriate management. This study evaluated the diagnostic performance of predefined ultrasonographic signs and inflammatory markers at admission for differentiating perforated from uncomplicated appendicitis. Methods: This retrospective diagnostic accuracy study included 174 pediatric patients who were evaluated with ultrasonography for suspected acute appendicitis. Final reference diagnoses were: no appendicitis (normal appendix) (n=55), simple appendicitis (n=82), and perforated appendicitis (n=37). The sonographic variables included loculated periappendiceal fluid, appendicolith, complex free fluid, periappendiceal fat echogenicity, distribution of free fluid in five abdominal regions, and periportal echogenicity. Leukocyte count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were recorded at admission. Diagnostic performance was calculated for perforated versus simple appendicitis. Results: Children with perforated appendicitis were younger than those with simple appendicitis or no appendicitis/normal appendix. ESR and CRP levels were highest in the perforated group (p<0.001). Loculated periappendiceal fluid was observed in 18 of 37 perforated cases and 7 of 82 simple cases, yielding 48.6% sensitivity and 91.5% specificity (p<0.001). Complex free fluid had a sensitivity of 51.4% and a specificity of 87.8% (p<0.001). Echogenic periappendiceal fat occurred frequently in both appendicitis groups and was not specific to perforation. Conclusion: Loculated periappendiceal fluid and complex free fluid are specific but incompletely sensitive sonographic signs of perforated appendicitis in children. CRP and ESR reflect the severity of inflammation and should be interpreted together with ultrasound findings, rather than as isolated diagnostic tests.
