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Meta-Analysis
. 2021 Dec 14;12(12):CD012028.
doi: 10.1002/14651858.CD012028.pub2.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

Nigel D'Souza  1 , Georgina Hicks  2 , Richard Beable  3 , Antony Higginson  3 , Bo Rud  4
Affiliations
Meta-Analysis

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis

Nigel D'Souza et al. Cochrane Database Syst Rev. .

Abstract

Background: Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.

Objectives: The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective.

Selection criteria: We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies.

Data collection and analysis: We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity.

Main results: We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains.

Authors' conclusions: MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

PubMed Disclaimer

Conflict of interest statement

Nigel D'Souza: none Georgina Hicks: none Richard Beable: none Antony Higginson: none Bo Rud: none

Figures

1
1
PRISMA flow diagram
2
2
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study.
3
3
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.
1
1. Test
MRI
4
4
Flowchart of test performance in a theoretical cohort of 1000 patients with suspected appendicitis
5
5
Forest plot of MRI for appendicitis.
6
6
Summary ROC plot of MRI for appendicitis. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circle represents the summary sensitivity and specificity. This summary point is surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
7
7
Summary ROC plot: subgroup analyses in populations of adults, children, and pregnant women. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
8
8
Summary ROC plot: analysis of effect of field of view. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
9
9
Summary ROC plot: analysis of effect of slice thickness. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
10
10
Summary ROC plot: analysis of the effect of MRI sequences. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
11
11
Summary ROC plot: analysis of the effect of contrast enhancement. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line).
12
12
Summary ROC plot: analysis of the effect of scan time. The hollow symbols represent pairs of sensitivity and specificity from included studies. The symbol size is scaled according to the sample size of the study. The solid circles represent summary sensitivity and specificity. These summary points are surrounded by a 95% confidence region (dotted line) and a 95% prediction region (interrupted line). Confidence and prediction regions overlap for the 'up to 10 minutes' category due to extremely low variances of the random effects for logit sensitivity and logit specificity.
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References

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Abdeen 2019 {published data only}
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    1. Harringa J, Kinner S, Riedesel E, Gill K, Ziemlewicz T, Robbins J, Kitchin D, Pickhardt P, Reeder S, Repplinger M. Prospective comparison of contrast-enhanced magnetic resonance imaging versus contrast-enhanced computed tomography for suspected appendicitis in children and young adults. Annals of Emergency Medicine 2016;68(4):S147-8.
Harringa 2019 {published data only}
    1. Harringa J, Bracken R, Davis J, Mao L, Kitchin D, Robbins J. Prospective evaluation of MRI compared with CT for the etiology of abdominal pain in emergency department patients with concern for appendicitis. Journal of Magnetic Resonance Imaging 2019;50(5):1651-8. - PMC - PubMed
Herliczek 2012 {published data only}
    1. Herliczek T, Swenson D. MRI of right lower quadrant pain in pediatric patients with inconclusive appendix us: Initial experience. Pediatric Radiology 2012;42:S244-5.
Hormann 2002 {published data only}
    1. Hormann M, Puig S, Prokesch S, Partik B, Helbich T. MR imaging of the normal appendix in children. European Radiology 2002;12(9):2313-6. - PubMed
How 2014 {published data only}
    1. How R, Wikiel KJ, Hamad GG. Right lower quadrant pain during pregnancy. JAMA Surgery 2014;149(5):489-90. - PubMed
Hutton 2015 {published data only}
    1. Hutton MDC, Strugnell M, Hopkins I, Murray IA. Gastrointestinal: An abnormal MRI. Remember the history. Journal of Gastroenterology and Hepatology 2015;30(4):647. - PubMed
Inci 2011a {published data only}
    1. Inci E, Hocaoglu E, Aydin S, Palabiyik F, Cimilli T, Turhan AN, Aygün E. Efficiency of unenhanced MRI in the diagnosis of acute appendicitis: comparison with Alvarado scoring system and histopathological results. European Journal of Radiology 2011;80(2):253-8. - PubMed
Inoue 2020 {published data only}
    1. Inoue A, Furukawa A, Nitta N, Takaki K, Ohta S, Murata K. Optimization of pulse sequences in ultrafast magnetic resonance imaging for the diagnosis of acute abdominal pain caused by gastrointestinal disease. Acta Radiologica Open 2020;9(8):2058460120949246. - PMC - PubMed
Kearl 2014 {published data only}
    1. Kearl L, Claudius I, Behar S, Hardasmalani M, Rose E, Santillanes G. Magnetic resonance imaging for the diagnosis of pediatric appendicitis. Annals of Emergency Medicine 2014;64(4):S104-5.
Kelly 2017 {published data only}
    1. Kelly D, Patel F, Gill M, Bhowmick A. Appendicectomy: The case for pre-operative imaging. Colorectal Disease 2017;19:60.
Koning 2014a {published data only}
    1. Koning JL, Naheedy JH, Kruk PG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. Pediatric Radiology 2014;44(8):948-55. - PubMed
Koning 2014b {published data only}
    1. Koning J, Naheedy J, Kruk P, Hauschildt J. Contrast enhanced magnetic resonance evaluation of acute appendicitis in the pediatric population: efficacy of a novel imaging protocol. In: Pediatric Radiology. Vol. 44. 2014:948-55.
Kruger 2019 {published data only}
    1. Krüger PC, Mentzel HJ. Radiological evaluation of acute abdomen in children. Der Radiologe 2019;59(2):146-153. - PubMed
Leeuwenburgh 2013 {published data only}
    1. Leeuwenburgh MM, Wiarda BM, Wiezer MJ, Vrouenraets BC, Gratama JW, Spilt A, Richir MC, Bossuyt PM, Stoker J, Boermeester MA, OPTIMAP Study Group. Comparison of imaging strategies with conditional contrast-enhanced CT and unenhanced MR imaging in patients suspected of having appendicitis: a multicenter diagnostic performance study. Radiology 2013;268(1):135-43. - PubMed
Lescheid 2015 {published data only}
    1. Leschied J, Dillman J, Smith E, Strouse P, Gadapelli S, N Sroufe N. Suspected acute appendicitis in children: MRI appearances, alternative diagnoses, and lessons learned. In: Pediatric Radiology. Vol. 45. 2015:S186.
Long 2011 {published data only}
    1. Long SS, Long C, Lai H, Macura KJ. Imaging strategies for right lower quadrant pain in pregnancy. American Journal of Roentgenology 2011;196(1):4-12. - PubMed
Lyons 2017 {published data only}
    1. Lyons GR, Renjen P, Askin G, Giambrone AE, Beneck D, Kovanlikaya A. Diagnostic utility of intravenous contrast for MR imaging in pediatric appendicitis. Pediatric Radiology 2017;47(4):398-403. - PubMed
Martin 2016 {published data only}
    1. Martin JF, Mathison DJ, Mullan PC, Otero HJ. Applicability of emergent MRI for suspected pediatric appendicitis with equivocal ultrasound results. In: Pediatric Radiology. Vol. 46. 2016:S127.
Meesa 2011a {published data only}
    1. Meesa IR, Mammen L. MRI of pregnant women with abdominal pain and suspected appendicitis: Diagnostic accuracy and outcomes. In: American Journal of Roentgenology. Vol. 196 (5S). 2011:A176.
Mittal 2019 {published data only}
    1. Mittal M. Appendicitis: role of MRI. Paediatric Emergency Care 2019;35(1):63-6. - PubMed
Modgil 2006 {published data only}
    1. Modgil G, Cooke DI, Newbury L. Appendiceal appearances: the great imitator. Archives of Disease in Childhood 2006;91(4):333. - PMC - PubMed
Naz 2018 {published data only}
    1. Naz F, Abdeen N. Rapid non-contrast MR protocol for evaluation of abdominal and pelvic abscesses in children. Pediatric Radiology 2018;48:S166-7.
Nitta 2005a {published data only}
    1. Nitta N, Takahashi M, Furukawa A, Murata K, Mori M, Fukushima M. MR imaging of the normal appendix and acute appendicitis. Journal of Magnetic Resonance Imaging 2005;21(2):156-65. - PubMed
Olympia 2016 {published data only}
    1. Olympia RP, Hariharan N, Chen BY. Implementation of a MRI program for the evaluation of pediatric right lower quadrant abdominal pain: Effect on emergency department length of stay in adolescent females. Annals of Emergency Medicine 2016;68(4):S36.
Orth 2013 {published data only}
    1. Orth RC, Guillerman RP, Zhang W, Masand P, Bisset GS. Prospective comparison of MRI and ultrasound for the diagnosis of pediatric appendicitis. Pediatric Radiology 2013;43:S298-9.
Oto 2009 {published data only}
    1. Oto A, Ernst RD, Ghulmiyyah LM, Nishino TK, Hughes D, Chaljub G, Saade G. MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdominal Imaging 2009;34(2):243-50. - PubMed
Pedrosa 2009a {published data only}
    1. Pedrosa I, Lafornara M, Pandharipande PV, Goldsmith JD, Rofsky NM. Pregnant patients suspected of having acute appendicitis: effect of MR imaging on negative laparotomy rate and appendiceal perforation rate. Radiology 2009;250(3):749-57. - PubMed
Repplinger 2014 {published data only}
    1. Repplinger MD, Pickhardt PJ, Kitchin D, Robbins J, Ziemlewicz T, Reeder SB. Direct comparison of a magnetic resonance imaging protocol with contrast-enhanced computed tomography to diagnose appendicitis. Annals of Emergency Medicine 2014;64(4):S21.
Repplinger 2015 {published data only}
    1. Repplinger M, Pickhardt P, Kitchin D, Robbins J, Ziemlewicz T, Reeder S. Prospective evaluation of contrast-enhanced magnetic resonance imaging for suspected appendicitis. Academic Emergency Medicine 2015;22:S402-3.
Rosenbaum 2017 {published data only}
    1. Rosenbaum DG, Askin G, Beneck DM, Kovanlikaya A. Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging. Pediatric Radiology 2017;47(11):1483-90. - PubMed
Saunders 2016 {published data only}
    1. Saunders D, Tolan D, Lambie H. Could MRI become the first-line investigation in suspected appendicitis? American Journal of Roentgenology. 2016;207(5):W103. - PubMed
Shin 2018 {published data only}
    1. Shin I, Chung YE, An C, Lee HS, Kim H, Lim JS, Kim MJ. Optimisation of the MR protocol in pregnant women with suspected acute appendicitis. European Radiology 2018;28(2):514-21. - PubMed
Singh 2007 {published data only}
    1. Singh A, Danrad R, Hahn PF, Blake MA, Mueller PR, Novelline RA. MR imaging of the acute abdomen and pelvis: acute appendicitis and beyond. Radiographics 2007;27(5):1419-31. - PubMed
Spalluto 2012 {published data only}
    1. Spalluto LB, Grand DJ. MRI of acute appendicitis in the pregnant patient. Medicine & Health Rhode Island 2012;95(2):39-40. - PubMed
Steinkeler 2008 {published data only}
    1. Steinkeler JA, Woodfield CA. MR imaging of acute appendicitis in pregnancy. Medicine & Health Rhode Island 2008;91(6):196. [PMID: ] - PubMed
Steinkeler 2017 {published data only}
    1. Steinkeler JA, Lee KS. MRI in pregnancy: gastrointestinal and genitourinary pathology. Applied Radiology 2017;46(5):23-8.
Stiefelhagen 2009 {published data only}
    1. Stiefelhagen P. Difficult differential diagnosis. Appendicitis or right quadrant diverticulitis? MMW Fortschritte der Medizin 2009;151(46):18. [PMID: ] - PubMed
Stoker 2008 {published data only}
    1. Stoker J. Magnetic resonance imaging and the acute abdomen. British Journal of Surgery 2008;95(10):1193-4. - PubMed
Theilen 2014 {published data only}
    1. Theilen L, Mellnick V, Longman R, Macones G, Cahill A. Rate of and risk factors for non-visualization of the appendix with magnetic resonance imaging (MRI) in pregnant women with suspected appendicitis. American Journal of Obstetrics & Gynecology 2014;210(1):S105-6.
Thompson 2015 {published data only}
    1. Thompson G, Martin DA, Killam R, Eccles R, Brindle M, Gupta P. Magnetic resonance imaging provides useful diagnostic information following equivocal ultrasound in children with suspected appendicitis. Academic Emergency Medicine 2015;22:S325. - PubMed
Trout 2015 {published data only}
    1. Trout A, Wallihan D, Towbin A, Depinet H, Von Allmen D, Podberesky D. MR as a rapid secondary assessment for suspected appendicitis following equivocal sonography: Feasibility and patient preference assessment. Pediatric Radiology 2015;45:S100.
Tseng 2018 {published data only}
    1. Tseng J, Cohen T, Melo N, Alban RF. Imaging utilization affects negative appendectomy rates in appendicitis: An ACS-NSQIP study. American Journal of Surgery 2018;217(6):1094-8. - PubMed
Warner 2020 {published data only}
    1. Warner J, Desoky S, Tiwari HA, Morello F, Gilbertson D, Udayasankar U. Unenhanced MRI of the abdomen and pelvis in the comprehensive evaluation of acute atraumatic abdominal pain in children. American Journal of Roentgenology 2020;215(5):1218-28. - PubMed
Wolfe 2007 {published data only}
    1. Wolfe G, Oto A. MR evaluation of acute abdominal pain in pregnant patients. Applied Radiology 2007;36(9):20.

References to studies awaiting assessment

Covelli 2019 {published data only}
    1. Covelli JD, Madireddi SP, May LA, Costello JE, Lisanti CJ, Carlson CL. MRI for pediatric appendicitis in an adult-focused general hospital: A clinical effectiveness study-challenges and lessons learned. American Journal of Roentgenology 2019;212(1):180-7. - PubMed
Davis 2020 {published data only}
    1. Davis J, Chima M, Kasmire K. Radiation-free diagnosis of pediatric appendicitis: accuracy of point-of-care ultrasonography and magnetic resonance Imaging. Pediatric Emergency Care 2020:Epub ahead of print. [PMID: ] - PubMed
Donlon 2019 {published data only}
    1. Donlon NE, Kelly ME, Davern M, Sheppard A, Nugent T, Durand M. Should MRI be the imaging modality of choice in suspected appendicitis during pregnancy? Irish Medical Journal 2019;112(10):1018. [PMID: ] - PubMed
Heye 2020 {published data only}
    1. Heye P, Saavedra JSM, Victoria T, Laje P. Accuracy of unenhanced, non-sedated MRI in the diagnosis of acute appendicitis in children. Journal of Pediatric Surgery 2020;55(2):253-6. - PubMed
James 2020 {published data only}
    1. James, Karl, Duffy, Patrick, Kavanagh, Richard G. Fast acquisition abdominal MRI study for the investigation of suspected acute appendicitis in paediatric patients. Insights into Imaging 2020;11(1):78. - PMC - PubMed
Jung 2021 {published data only}
    1. Jung JY, Na JU, Han SK, Choi PC, Lee JH, Shin DH. Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients. World Journal of Emergency Medicine 2018-03-15;9(1):26-32. - PMC - PubMed
Kalimullina 2019 {published data only}
    1. Kalimullina DS, Egorova EA, Lezhnev DA, Bazhin AV, Merkusheva MM. Magnetic resonance imaging for diagnosis of acute appendicitis in pregnant women in multi-field hospital. Khirurgiia (Mosk) 2019;(7):45-51. - PubMed
Kashmire 2020 {published data only}
    1. Kashmire K, Davis J, Chima M. Accurate, radiation-free evaluation of pediatric appendicitis. Academic Emergency Medicine 2020;27(S1):S7-S316.
Kennedy 2019 {published data only}
    1. Kennedy TM, Thompson AD, Choudhary AK, Caplan RJ, Schenker KE, DePiero AD. Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis. American Joural of Emergency Medicine 2019;37(9):1723-8. - PMC - PubMed
Lukenaite 2020 {published data only}
    1. Lukenaite B, Luksaite-Lukste R, Mikalauskas S, Strupas K, Poskus T. MRI reduces the rate of diagnostic laparoscopy in pregnant patients with suspected acute appendicitis. Gastroenterology 2020;158(6):S1535. - PMC - PubMed
Marie 2019 {published data only}
    1. Marie E, Alhashmi G, Ricci A, Man C, Doria A. How can criteria for interpretation of MRI examinations of appendicitis influence diagnostic accuracy? Pediatric Radiology 2019;49(1):1-245.
Mushtaq 2019 {published data only}
    1. Mushtaq R, Desoky SM, Morello F, Gilbertson-Dahdal D, Gopalakrishnan G, Leetch A, Vedantham S, Kalb B, Martin DR, Udayasankar UK. First-line diagnostic evaluation with MRI of children suspected of having acute appendicitis. Radiology 2019;291(1):170-7. - PubMed
Roh 2019 {published data only}
    1. Roh, Albert T, Xiao, Zhibo, Cheng, Joseph Y. Conical ultrashort echo time (UTE) MRI in the evaluation of pediatric acute appendicitis. Abdominal Radiology 2019;44(1):22-30. - PMC - PubMed
Sincavage 2019 {published data only}
    1. Sincavage J, Buonpane C, Benyamen B, Benya E, Lautz T, Helenowski I. Alvarado scores predict additive value of magnetic resonance imaging in workup of suspected appendicitis in children. Journal of Surgical Research 2019;244:42-9. - PubMed

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