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Update in Radiology
Usefulness of ultrasonography in children with right iliac fossa pain
Utilidad de la ecografía en niños con dolor en la fosa ilíaca derecha
L. Raposo Rodrígueza,
Corresponding author
luciaraposo81@hotmail.com

Corresponding author.
, G. Anes Gonzáleza, J.B. García Hernándeza, S. Torga Sánchezb
a Servicio de Radiodiagnóstico, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
b Servicio de Radiodiagnóstico, Hospital El Bierzo, Ponferrada, León, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute pain in the RIF is common in pediatric patients&#46; Although AA and intestinal intussusception are the typical causes&#44; RIF pain can also be caused by multiple gastrointestinal and genitourinary disorders that should be considered in the differential diagnosis of AA&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">US represents the ideal diagnostic modality in children with abdominal pain&#46; Its excellent anatomic resolution in the pediatric population has helped reduce the negative appendectomy rate&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Technological advances in US allow examination of the layers of the intestinal wall and surrounding mesentery with high spatial resolution&#46; This provides new clinical applications such as the assessment of acute inflammatory activity&#44; response to treatment and complications of Crohn&#39;s disease&#44; US evaluation of acute recurrent appendicitis&#44; follow-up of intestinal involvement in Sch&#246;nlein&#8211;Henoch purpura &#40;SHP&#41;&#44; preoperative assessment of the viability in cases of ovarian torsion&#44; or support for the decision of performing a biopsy in celiac disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this study is to describe the US findings and the key diagnostic findings of those conditions that may present with acute RIF pain in children&#44; with an emphasis on AA&#44; since this is the most common disease in children requiring surgery<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> and the most common source of diagnostic errors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">The graded compression technique described by Puylaert in 1986 is based on the fact that gradual compression on the anterior abdominal wall eliminates bowel gas and intraluminal fluid from the bowel loops&#44; reduces the distance between transducer and appendix&#44; and displaces bowel loops out of the RIF&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This compression allows visualization of iliac vessels and psoas muscle&#44; since the appendix is anterior to these structures &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; In addition to be ineffective and painful&#44; fast compression may result in rupture of an appendix at risk for perforation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The exam is performed in the longitudinal and transverse planes&#46; The ascending colon appears as a nonperistaltic structure containing fluid and gas&#46; Inferiorly&#44; the terminal ileum&#44; compressible and peristaltic&#44; can be identified&#46; The cecal base&#44; where the appendix arises&#44; is 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm below the terminal ileum&#46; While the base of the appendix is at a fairly constant location&#44; its end may move freely&#44; and its location is therefore very variable&#59; however&#44; this does not translate into a statistically significant difference in the rate of appendicitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The topology of the superior mesenteric vessels and their relationship with the aorta and inferior vena cava should be systematically identified&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Normal right iliac fossa</span><p id="par0035" class="elsevierStylePara elsevierViewall">The digestive tract comprises four concentric layers that can be differentiated histologically&#46; The layers from deep to superficial are the mucosa&#8212;consisting of an epithelium with underlying lamina propria and the muscularis mucosa&#8212;&#44; the submucosa&#44; the muscularis propria and the adventitia&#46; US shows a penta-stratified pattern where the first &#40;superficial mucosa&#41;&#44; third &#40;submucosa&#41; and fifth &#40;adventitia&#41; layers are hyperechogenic&#44; and the second &#40;muscularis mucosa&#41; and fourth &#40;muscularis propria&#41; layers are hypoechoic<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In adults&#44; the thickness in any segment of the digestive tract is &#8804;3<span class="elsevierStyleHsp" style=""></span>mm&#46; In children&#44; it ranges between 1&#46;5 and 3<span class="elsevierStyleHsp" style=""></span>mm in the terminal ileum and &#60;2&#8211;3<span class="elsevierStyleHsp" style=""></span>mm in the colon&#44; depending on the age&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Valvulae conniventes are &#60;2<span class="elsevierStyleHsp" style=""></span>mm in width and 2&#8211;5<span class="elsevierStyleHsp" style=""></span>mm in length&#44; being more numerous in the jejunum &#40;two or three per cm&#41; than in the ileum &#40;two per cm&#41;&#46; Given its intestinal origin&#44; the appendix exhibits similar characteristics to the digestive tract&#44; therefore&#44; its maximum diameter should not exceed 6<span class="elsevierStyleHsp" style=""></span>mm in the transverse plane and its wall should not exceed 3<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;6&#44;9</span></a> Nonetheless&#44; histologically normal appendixes<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm can also be found in cases of accumulation of secretions in the lumen&#44; hyperplasia or fecal impaction&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The normal appendix is oval-shaped in the transverse plane and easily compressible&#46; Conversely&#44; in appendicitis&#44; the appendix walls are inflamed&#44; rigid and noncompressible&#46; Its lumen may contain air or fluid&#44; or be collapsed with adhesion of the mucosal layers&#44; giving rise to a central echogenic line&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Lastly&#44; the mesentery appears slightly echogenic&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Acute appendicitis</span><p id="par0055" class="elsevierStylePara elsevierViewall">AA is the most common condition requiring surgery in children and the one leading to more diagnostic errors&#46; Traditionally&#44; AA has been described to occur when fecal matter or appendicoliths obstruct the appendiceal lumen&#44; which is usually followed by infection&#46; However&#44; we know now that AA is not always secondary to obstruction and that several causes may lead to AA&#58; lymphoid follicular hyperplasia obstructing the cecal&#8211;appendiceal junction&#44; inflamed follicles in infectious processes&#44; foreign bodies&#44; or trauma&#46; These factors lead to inflammation and an increase in intraluminal pressure&#46; As a result&#44; the appendix enlarges and induces inflammatory changes in the surrounding tissues&#44; such as the pericecal fat and peritoneum&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Ultimately&#44; ischemia occurs and the inflamed appendix&#44; eventually&#44; perforates&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sensitivity and specificity of sonography for the diagnosis of AA vary greatly between studies &#40;up to 100 and 98&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;12</span></a> The appendiceal diameter is considered the most relevant morphologic criteria &#40;sensitivity<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>98&#37;&#41; and&#44; traditionally&#44; the threshold diameter<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm has been used for diagnosis of appendicitis&#46; On transverse images&#44; the appendix appears fixed&#44; round and noncompressible&#46; Hyperechogenicity of the pericecal fat is common&#46; This fat may increase in volume and surround the appendix&#44; which represents the inflamed omentum that migrates to the appendiceal area in case perforation occurs &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Free fluid and mesenteric lymph nodes are frequent but unspecific&#46; In up to 30&#37; of cases&#44; appendicoliths are seen in the appendiceal lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Doppler signal varies depending on the stage of the disease&#46; Although it might increase in the acute phase &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#44; it may diminish in case of appendiceal perforation&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;9</span></a> Therefore&#44; Doppler examination alone cannot reliably distinguish between normal and abnormal appendix&#46; Perforation can be suspected in the presence of an irregular contour of the appendix&#44; fluid or collections&#44; and dilated bowel loops with thickened walls<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;7&#44;10&#44;13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#46; After perforation occurs&#44; the appendix is usually decompressed and it is visible only in 30&#8211;60&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Acute pain&#44; gas and severe obesity may complicate visualization of the appendix&#46; Therefore&#44; the nonvisualization of the appendix does not allow us to rule out AA despite the fact that the first studies considered the nonvisualization on US an exclusion criterion&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For an experienced ultrasonologist&#44; nonvisualization has a negative predictive value of 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10</span></a> Since some appendicitis are limited to the appendiceal tip&#44; only the detection of a normal appendix throughout its entire length safely rules out AA&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a> The detection range of a normal appendix varies between 40 and 82&#37; of examinations&#44; and this depends on the operator experience and the physical characteristics of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recurrent acute appendicitis</span><p id="par0075" class="elsevierStylePara elsevierViewall">In 10&#37; of patients with AA&#44; the symptoms and signs subside spontaneously 12&#8211;48 after the onset but they reappear later on&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> This phenomenon&#44; known as &#8220;spontaneously resolving appendicitis&#8221;&#44; is thought to be due to the relief of obstruction&#46; In these cases&#44; US follow-up images show a gradual decrease in the appendiceal diameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> US follow-up in patients with AA&#44; performed 6&#8211;36<span class="elsevierStyleHsp" style=""></span>h after the initial examination&#44; represents a useful diagnostic tool that complements clinical follow-up and helps reduce the number of CT studies done on children&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Recurrence rate relates to the presence or absence of enlarged mesenteric lymph nodes&#46; A study carried out by Cobben et al&#46; on 60 patients showed that the subgroup of male patients with no enlarged mesenteric lymph nodes had a recurrence rate of 60&#37;&#44; which seems a clear indication for surgery&#46; Conversely&#44; the presence of enlarged mesenteric lymph nodes was associated to a lower recurrence rate&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The term used to name this entity is also controversial&#46; Some authors use the term &#8220;appendiceal disease&#8221; in patients with long-standing symptoms&#59; however&#44; to date this entity has not been satisfactorily described&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cystic fibrosis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients with cystic fibrosis &#40;CF&#41; usually show markedly distended appendixes secondary to the presence of inspissated secretions with associated pain&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> These cases are not to be confused with AA since in CF the appendix is distended but not inflamed&#46; Additionally&#44; there is no wall thickening and the concentric layer structure is intact&#44; with no inflammation of the mesenteric fat<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>E&#41;&#46; It has been postulated as a possible protective role of these secretions against AA considering the lower rate of occurrence in patients with CF &#40;1&#8211;2&#37;&#41; compared with the normal population &#40;7&#8211;8&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16</span></a> Nonetheless&#44; the rate of perforations and abscess formation is higher&#44; probably due to a delay in diagnosis because symptoms are often masked by the use of antibiotics&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Appendiceal mucocele</span><p id="par0095" class="elsevierStylePara elsevierViewall">Appendiceal mucocele is characterized by distension of the appendix secondary to intraluminal accumulation of mucus&#46; To date&#44; four pathological processes leading to appendiceal mucocele have been described&#58; obstruction at the cecal appendiceal junction&#59; mucosal hyperplasia&#59; mucinous cystadenoma and mucinous cystadenocarcinoma&#46; US shows a distended appendix with no wall thickening and no regional inflammatory signs&#44; with abundant echogenic content in the interior and the &#8220;onion skin&#8221; structure&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a> a sign considered to be characteristic of mucoid material that allows differential diagnosis with appendiceal abscesses<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lymphoid hyperplasia related to viral infections</span><p id="par0100" class="elsevierStylePara elsevierViewall">Follicular lymphoid hyperplasia is a histopathologic finding based on the enlargement of the lymphoid follicles in the lamina propria of the appendiceal mucosa&#44; without infiltration of polymorphonuclear leukocytes&#46; It is common in childhood&#44; and according to some authors&#44; it may be the cause of acute RIF pain in children&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It also relates to intestinal intussusception&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Only on rare occasions does US allow for the diagnosis of this condition&#46; In such cases&#44; US findings include dilated appendix and thickening of the appendiceal mucosa and ileocecal valve&#44; secondary to the presence of hypoechogenic nodules&#46; Mesenteric lymph nodes are a constant&#46; Cecum&#44; mesenteric echogenicity and mobility of the distal ileum are normal&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mesenteric lymphadenitis</span><p id="par0110" class="elsevierStylePara elsevierViewall">Mesenteric lymphadenitis &#40;ML&#41; is a controversial entity&#44; and we frequently resort to this diagnosis in patients in whom normal appendices have been removed&#46; The term is used to refer to enlargement of some mesenteric lymph nodes&#44; with or without ileitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; some papers describe the presence of enlarged &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>mm in the short axis&#41; mesenteric nodes in asymptomatic children&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Increased color Doppler signal in the mesenteric vessels and minimal amount of free fluid may be seen &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>E&#41;&#46; The nonvisualization of the inflamed appendix is more indicative of ML than AA&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Acute gastroenteritis</span><p id="par0115" class="elsevierStylePara elsevierViewall">Acute gastroenteritis &#40;AGE&#41; is the most common inflammatory disease in children&#46; It usually has a viral origin and the iliocecal region is the most frequently affected&#46; The classic presentation of AGE does not require imaging studies&#46; US shows dilated&#44; hyperperistaltic fluid-filled small bowel loops with thin walls&#44; where it is not uncommon to see transient intussusception<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>E&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Infectious ileitis or iliocecitis</span><p id="par0120" class="elsevierStylePara elsevierViewall">Some bacteria&#8212;such as <span class="elsevierStyleItalic">Salmonella</span>&#44; <span class="elsevierStyleItalic">Campylobacter jejuni</span>&#44; <span class="elsevierStyleItalic">Yersinia</span> and&#44; more rarely&#44; <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#8212;have a strong affinity for the lymphoid tissue of the terminal ileum and give rise to enteritis whose symptoms may simulate those of AA&#46; US findings include intestinal wall thickening and hypogenicity&#8212;usually with intact wall layers&#8212;&#44; transmural or mucosal hypervascularity and enlargement of mesenteric lymph nodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In contrast to AA&#44; the mesentery is normal and the thickened bowel loops do not form a conglomerate around the appendix&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Tuberculous ileitis is rare in developed countries&#46; It appears as asymmetrical&#44; non-stratified thickening of the ileocecal walls<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#46; Its clinical course is similar to that of chronic diseases with US findings similar to those of Crohn&#39;s disease&#44; but always with considerable involvement of the cecum&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The microorganism induces an inflammatory process that eventually leads to ulcer formation with subsequent healing&#44; as well as extensive infiltration of peritoneum&#44; omentum and mesentery associated with centrally hypodense lymph nodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> There are no pathognomonic findings&#46; Biopsy during colonoscopy and culture of lesions is the diagnostic technique of choice&#44; while negative histologic results do not preclude tuberculosis&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Crohn&#39;s disease</span><p id="par0130" class="elsevierStylePara elsevierViewall">In 25&#37; of cases&#44; Crohn&#39;s disease &#40;CD&#41; begins in childhood&#44; with involvement of the iliocecal region in 55&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Acute abdominal symptoms simulating AA are not unusual&#46; CD causes transmural inflammation that extends to the surrounding mesentery&#46; On US this translates into circumferential wall thickening that may be segmental or multifocal&#44; and finally&#44; loss of wall stratification&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10&#44;27&#44;28</span></a> The wall appears hypoechoic with an echogenic central line that represents the superficial mucosa &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A and B&#41;&#46; The mesentery is hyperechogenic and there is no motion of bowel loops with transducer pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Enlarged lymph nodes are found in approximately 15&#37; of CD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">CD is associated with intestinal neovascularization&#46; In contrast with what happens in areas of fibrotic scarring&#44; in active disease there is mesenteric hypervascularity and &#8220;comb sign&#8221;&#44; indicative of increased blood flow in the vasa recta &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46; This finding may help differentiate CD from infectious or eosinophilic ileitis or ileitis associated with SHP&#44; where vascular proliferation is less conspicuous&#46; Vessel density&#44; assessed by Doppler US in affected bowel loops&#44; correlates with disease activity and is used as a non-invasive technique for monitoring the course of the disease and the response to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;28&#44;30</span></a> Vessel density is classified as low&#44; moderate and high if there are 0&#8211;2&#44; 3&#8211;5&#44; or more than 5 Doppler signals per cm&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Appendiceal involvement appears in 23&#37; of patients with CD&#44; manifesting as appendiceal hyperemia similar to that of AA&#46; However&#44; thickening<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm and hyperemia of the terminal ileum support the diagnosis of CD&#46; US findings in cecum and appendix are similar in both entities and therefore cannot be used for differentiation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sch&#246;nlein&#8211;Henoch purpura</span><p id="par0145" class="elsevierStylePara elsevierViewall">SHP is a small-vessel vasculitis that may affect the intestinal tract&#46; In some patients &#40;10&#8211;30&#37;&#41;&#44; the intestinal involvement may precede skin lesions&#44; simulating AA&#46; The episodes of paroxysmal pain are secondary to edema in the subserosa and submucosa and hemorrhagic infiltration&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;31</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Characteristic US findings include diffuse&#44; circumferential thickening of the bowel wall&#44; with focal intramural hematomas that appear as hyperechogenic areas&#44; giving an irregular appearance to the thickened wall&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8&#44;31</span></a> Associated mesenteric adenopathy and free fluid are common&#46; The duodenum and jejunum are the initially involved sites but&#44; with recurrent episodes&#44; the disease extends to the ileum&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Celiac disease</span><p id="par0155" class="elsevierStylePara elsevierViewall">Up to 25&#37; of children with celiac disease initially present with acute abdomen&#46; US may help make an initial diagnosis and institute an early treatment&#46; Characteristic findings include abnormally dilated fluid-filled bowel loops and reversal of the jejuno-ileal fold pattern&#46; There is hyperperistalsis and minimal ascites in 82&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Intestinal intussusception is a common complication and the presence of underlying celiac disease should be investigated in case of recurrent intussusception&#46; Ulcerative jejuno-ileitis should be suspected in adult patients with celiac disease and acute abdomen&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">US findings may confirm the need for biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Typhlitis</span><p id="par0170" class="elsevierStylePara elsevierViewall">Typhlitis occurs more typically in patients with hematologic malignancies who are neutropenic as a result of chemotherapy&#46; In the pediatric population&#44; typhlitis is more frequently seen in pre-adolescent children with acute myeloid leukemia&#46; The most commonly affected portions are the ascending colon and the cecum&#8212;hence the term typhlitis&#8212;although any segment of the intestinal tract may be involved&#46; For this reason&#44; the term &#8220;neutropenic enterocolitis&#8221; seems more appropriate&#46; Histologic examination reveals bowel wall necrosis and hemorrhage&#44; without inflammatory or tumoral infiltration&#46; Imaging features include asymmetrical thickening of the cecal wall &#40;&#62;3<span class="elsevierStyleHsp" style=""></span>mm&#41; that is usually hyperechogenic and heterogeneous with areas of different echogenicity secondary to necrosis or hemorrhage&#44; and redundant mucosa &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; In most cases&#44; Doppler US shows hypervascularity and surrounding inflammatory changes&#44; as well as free fluid&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">In same patients&#44; in addition to the findings compatible with typhlitis&#44; there might also be thickening of the appendix&#44; possibly due to the same causative factors of typhlitis&#44; and surgery may therefore not be indicated&#46; This&#44; combined with the fact that pediatric patients are not good candidates for surgery&#44; makes the surgical management of these children&#44; who present with appendiceal thickening and RIF pain&#44; controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Intussusception</span><p id="par0180" class="elsevierStylePara elsevierViewall">Intussusception involves invagination of a segment of intestine into the lumen of an immediately distal segment&#46; Intussusception is usually idiopathic&#44; associated with lymphoid hyperplasia&#44; secondary to viral infections&#46; Approximately 90&#37; of patients with intussusception are younger than two years&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Findings on abdominal radiograph may be non-specific and the use of conventional enema to make the diagnosis is no longer justified&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> US is the test of choice because it provides a diagnostic accuracy of 97&#8211;100&#37;&#44; allows for the detection of the causes and predictive factors of irreducibility&#44; and can be used for follow-up and assessment of response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Approximately 90&#37; of intussusceptions are ileocolic&#46; The diagnostic image of intussusception is located at the receptor bowel loop&#44; which would explain why the lesion is not detected in the RIF&#44; but in the subhepatic region &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>E&#41;&#46; The &#8220;doughnut&#8221; sign refers to the transverse section of the intussusception that shows a thick hypoechoic ring and an echogenic center&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;41</span></a> The target sign consists of concentric hypo- and hyperechogenic rings&#44; whose number varies depending on the extension of the edema &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; The pseudokidney sing refers to the kidney-like appearance of the loop inside the receptor loop&#44; in the longitudinal section &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>E&#41;&#44; usually exceeding 5<span class="elsevierStyleHsp" style=""></span>cm in length&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> The main prognostic indicators for irreducibility and ischemia on US include presence of liquid trapped inside the intussusception&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> absence of flow on Doppler US&#44; enlarged lymph nodes&#44; thickening of the outer ring of the doughnut and presence of gas in the intussusceptum&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;44</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Meckel diverticulum</span><p id="par0190" class="elsevierStylePara elsevierViewall">Meckel diverticulum&#44; related to a persistent omphalomesenteric duct&#44; occurs on the antimesenteric border of the ileum&#46; Meckel diverticulum is a true diverticulum composed of all layers of the intestinal wall&#46; It should be suspected in children with inflammatory signs of RIF in whom a normal appendix and a lesion connected to the terminal ileum with similar appearance to that of AA are visualized&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;10&#44;45</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right-sided diverticulitis</span><p id="par0195" class="elsevierStylePara elsevierViewall">Right-sided diverticulitis is an unusual inflammatory condition that can mimic AA&#46; It should be considered in young patients with RIF pain and normal appendix&#46; Right-side diverticula are true diverticula&#44; composed of all intestinal layers&#44; and are usually congenital and solitary&#46; US findings of right-sided diverticulitis include direct visualization of the diverticulum in the right wall of the colon&#44; focal thickening of the colonic wall at the diverticulum site and inflammation of the adjacent fat&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25&#44;11&#44;46</span></a> This condition is usually self-limited and does not require surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Enteric duplication cysts</span><p id="par0200" class="elsevierStylePara elsevierViewall">Enteric duplication cysts are congenital abnormalities that result in duplication of a normal bowel loop&#46; They normally occur on the mesenteric border of the bowel&#44; usually on the ileum&#46; The walls are composed of all intestinal layers and most lesions do not communicate with the lumen of the digestive tract&#46; They may contain ectopic gastric mucosa or lymphoid tissue&#46; US examination shows a well-defined&#44; fluid-filled mass with tubular or spherical shape and an echogenic inner mucosal layer<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; In some cases&#44; the content is heterogeneous as a result of hemorrhage or thick material in the interior&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Burkitt lymphoma</span><p id="par0205" class="elsevierStylePara elsevierViewall">Burkitt lymphoma is the most common intraabdominal tumor in children aged 5&#8211;12&#46; It usually occurs in the terminal ileum and US demonstrates bowel wall thickening with transmural involvement with loss of stratification and markedly hypoechogenic&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Ascites and enlarged mesenteric lymph nodes are frequent&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epiploic appendagitis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Epiploic appendagitis &#40;EA&#41; is an unusual cause of acute abdomen in children&#46; It is a benign and self-limited condition occurring secondary to torsion or spontaneous venous thrombosis of the draining veins of the epiploic appendages&#46; As a result&#44; ischemic necrosis of the fatty tissue with associated peritoneal irritation occurs&#46; US images show a noncompressible hyperechoic ovoid mass usually 1&#46;5&#8211;5<span class="elsevierStyleHsp" style=""></span>cm in diameter that is surrounded by a thin hypoechogenic rim and is adherent to the colon &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;50&#8211;52</span></a> Color Doppler US shows absence of central blood flow&#44; unlike the increase in blood flow normally detected in appendicitis&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Omental infarction</span><p id="par0215" class="elsevierStylePara elsevierViewall">Omental infarction is a rare cause of abdominal pain in children&#46; It may be primary or secondary to omental torsion&#44; trauma&#44; vasculitis or hypercoagulability&#46; US findings show an ovoid noncompressible hyperechogenic mass in the right flank immediately beneath the rectus abdominis&#46; This mass is larger than that in AE&#44; not connected to the colon and without halo&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Both AE and omental infarctions are self-limited processes that usually do not require surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;52</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lymphangioma</span><p id="par0220" class="elsevierStylePara elsevierViewall">Lymphangiomas are benign cystic tumors&#44; usually multiloculated that arise from the endothelium of lymphatic vessels and are filled with serous or chylous fluid&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;53</span></a> Mesenteric lymphangiomas are rare and usually discovered incidentally&#46; Acute abdominal symptoms may occur as a result of rupture&#44; torsion&#44; infection or hemorrhage &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>E&#41;&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ovarian torsion</span><p id="par0225" class="elsevierStylePara elsevierViewall">Ovarian torsion is the most frequent alternative diagnosis to AA in girls with RIF pain&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is usually unilateral and with right-sided preference&#46; Although it may result from excessive mobility of the ovary&#44; it may be associated with ovarian tumors or cyss &#40;in girls&#44; benign teratomas&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53&#8211;55</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">US&#44; CT and MRI show similar non-specific findings that vary depending on the duration of the torsion and the presence of an underlying mass &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>A&#8211;C&#41;&#46; The most constant finding is an enlarged ovary that appears heterogeneous due to edema and hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;56</span></a> In 74&#37; of cases&#44; US examination demonstrates multiple small cysts in the periphery of the ovary&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a> This finding alone is not indicative of torsion since it can also be seen in polycystic ovaries and even in normal ovaries in the fertile woman&#59; but it can be indicative of torsion in the setting of pain with unilateral ovarian enlargement&#46; The presence of fluid-blood level has been described as a pathognomonic sign of ovarian torsion&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55&#44;57</span></a> Other findings include thickened fallopian tube&#44; fluid in the pouch of Douglas&#44; ipsilateral deviation of the uterus and thickening of the coexisting mass wall&#44; if present&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55&#44;58</span></a></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Sometimes&#44; color Doppler US has a limited diagnostic utility&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Although it may show absence of arterial flow&#44; up to 60&#37; of ovarian torsions show normal arterial waveforms<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> because the symptoms of venous thrombosis appear before the arterial obstruction occurs&#46; Additionally&#44; the arterial flow persists because of the dual ovarian blood supply from the ovarian artery and the ovarian branches from the uterine artery&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> The most common finding is a decreased or absent venous flow&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> The main use of color Doppler is to the preoperative assessment of the viability of the ovary&#44; associated with the presence of central venous flow&#44; while absence of flow is associated with non-viability&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;60</span></a> The whirlpool sign is the identification of the twisted vascular pedicle at color Doppler US&#46; This sign is not always visible&#44; but its presence suggests that the ovary is still viable&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;61</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hemorrhagic ovarian cyst</span><p id="par0240" class="elsevierStylePara elsevierViewall">Ovarian cysts may cause pain due to hemorrhage or rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Classically they appear as avascular complex cystic lesions&#44; with a thin reticular pattern&#44; fluid-detritus levels and&#47;or hyperechogenic areas in relation to coagulated blood &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>E&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The absence of involvement of the adjacent fat helps differentiate it from an abscess&#46; The presence of free peritoneal fluid is common&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ovarian tumors</span><p id="par0245" class="elsevierStylePara elsevierViewall">Most ovarian tumors in girls are benign and painless but&#44; on occasions&#44; they may cause pain due to compression of adjacent structures or increase in size&#46; Cystic teratoma is the most common ovarian tumor&#46; US shows a complex solid-cystic mass with echogenic or hypoechogenic component depending on the amount of fat&#44; fluid or calcium &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;62</span></a> The rest of benign ovarian tumors are usually cystadenomas that usually present as large unilocular cystic lesions with thin septa that may show solid poles&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Acute pyelonephritis</span><p id="par0250" class="elsevierStylePara elsevierViewall">In most cases of acute pyelonephritis&#44; US findings are normal&#44; but there might be focal or generalized renal enlargement&#44; areas of hypo- or hyperechogenicity &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>E&#41;&#44; loss of corticomedullary differentiation&#44; thickening of the pelvic and&#47;or ureteral urothelium&#44; and&#47;or perinephric inflammatory changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;63</span></a> Color Doppler US shows cortical hypoperfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Urachal anomalies</span><p id="par0255" class="elsevierStylePara elsevierViewall">Urachal anomalies are caused by incomplete persistence of patency of the urachus&#46; Urachal sinus refers to the persistence of the urachus at the umbilical end&#46; At US&#44; the persistent urachus and the urachal sinus are small-caliber tubular structures&#44; which appear as a fluid-filled long tube or as an echogenic cord &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41;&#46; Diverticulum and cyst are fluid-filled masses&#44; with or without communication with the bladder&#44; respectively&#46; Internal echoes result from infection&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">In addition to acute pyelonephritis and urachal anomalies&#44; other urinary disorders such as ureterohydronephrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>E&#41; and vesicoureteral reflux may also cause acute and intermittent abdominal pain&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> For this reason&#44; the urinary system must also be assessed during US examination&#46;</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0265" class="elsevierStylePara elsevierViewall">US is a useful technique for the evaluation of acute RIF pain in children&#46; Multiple conditions may cause RIF pain &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; The high spatial resolution of US in children&#44; even better than that of CT&#44; provides relevant information regarding these disorders and may help confirm or rule out AA&#44; or establish an alternative diagnosis&#44; without the need of invasive techniques&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Authorship</span><p id="par0270" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study &#40;original idea of the study&#41;&#58; GAG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Conception of the study&#58; GAG&#44; LRR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Design of the study&#58; LRR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Acquisition of data&#58; GAG&#44; JBGH&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Analysis and interpretation of data&#58; LRR&#44; GAG&#44; JBGH&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; N&#47;A&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Bibliographic search&#58; LRR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Drafting of the paper&#58; LRR&#44; STS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Critical review with intellectually relevant contributions&#58; GAG&#44; JBGH and STS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; LRR&#44; GAG&#44; JBGH&#44; STS&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0325" class="elsevierStylePara elsevierViewall">The authors declare not having any conflict of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "identificador" => "xpalclavsec109207"
          "titulo" => "Keywords"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Normal right iliac fossa"
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          "identificador" => "sec0020"
          "titulo" => "Acute appendicitis"
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        8 => array:2 [
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          "titulo" => "Recurrent acute appendicitis"
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          "titulo" => "Cystic fibrosis"
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        10 => array:2 [
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          "titulo" => "Appendiceal mucocele"
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        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Lymphoid hyperplasia related to viral infections"
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        12 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Mesenteric lymphadenitis"
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        13 => array:3 [
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          "titulo" => "Acute gastroenteritis"
          "secciones" => array:1 [
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              "titulo" => "Infectious ileitis or iliocecitis"
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          "titulo" => "Crohn&#39;s disease"
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              "titulo" => "Sch&#246;nlein&#8211;Henoch purpura"
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          "titulo" => "Celiac disease"
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          "titulo" => "Typhlitis"
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        17 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Intussusception"
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        18 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Meckel diverticulum"
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        19 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Right-sided diverticulitis"
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          "titulo" => "Enteric duplication cysts"
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        21 => array:2 [
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          "titulo" => "Burkitt lymphoma"
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        22 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Epiploic appendagitis"
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          "titulo" => "Omental infarction"
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        24 => array:2 [
          "identificador" => "sec0115"
          "titulo" => "Lymphangioma"
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        25 => array:2 [
          "identificador" => "sec0120"
          "titulo" => "Ovarian torsion"
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        26 => array:2 [
          "identificador" => "sec0125"
          "titulo" => "Hemorrhagic ovarian cyst"
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        27 => array:2 [
          "identificador" => "sec0130"
          "titulo" => "Ovarian tumors"
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        28 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Acute pyelonephritis"
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          "identificador" => "sec0140"
          "titulo" => "Urachal anomalies"
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        30 => array:2 [
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          "titulo" => "Conclusion"
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          "titulo" => "Authorship"
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          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-02-14"
    "fechaAceptado" => "2011-05-23"
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          "identificador" => "xpalclavsec109208"
          "palabras" => array:6 [
            0 => "Ecograf&#237;a abdominal"
            1 => "Fosa il&#237;aca derecha"
            2 => "Pediatr&#237;a"
            3 => "Abdomen agudo"
            4 => "Apendicitis"
            5 => "Enfermedad de Crohn"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute pain in the right iliac fossa &#40;RIF&#41; is common in children&#46; It can arise from a wide variety of gastrointestinal and genitourinary processes that make up the differential diagnosis with acute appendicitis &#40;AA&#41;&#46; In this article&#44; we describe the most representative findings of these processes on ultrasonography &#40;US&#41;&#46; We emphasize the characteristics that enable these processes to be differentiated from AA&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El dolor agudo en la fosa il&#237;aca derecha es un cuadro frecuente en la infancia&#46; Su origen puede ser secundario a un amplio abanico de procesos gastrointestinales y genitourinarios que constituyen el diagn&#243;stico diferencial de la apendicitis aguda&#46; En el presente art&#237;culo se describen los hallazgos ecogr&#225;ficos m&#225;s representativos de tales procesos&#44; insistiendo en las caracter&#237;sticas que permiten diferenciarlos de la apendicitis aguda&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Raposo Rodr&#237;guez L&#44; et al&#46; Utilidad de la ecograf&#237;a en ni&#241;os con dolor en la fosa il&#237;aca derecha&#46; Radiolog&#237;a&#46; 2012&#59;54&#58;137&#8211;48&#46;</p>"
      ]
    ]
    "multimedia" => array:11 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; US image of the normal right iliac fossa showing the psoas muscle and iliac vessels&#46; &#40;B&#41; Axial US of the appendix shows the correlation between the normal pentastratified pattern and the corresponding histological layers&#46; Hyperechogenic layers correspond to the superficial mucosa &#40;m&#41;&#44; submucosa &#40;sb&#41; and adventitia &#40;a&#41;&#44; while hypoechoic layers correspond to the mucosa and &#40;mm&#41; and muscularis propria &#40;mc&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 768
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            "Tamanyo" => 184677
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Appendicitis&#58; &#40;A&#41; Transversal US image shows inflamed appendix with enlarged diameter and wall thickening&#44; and hyperechogenicity of periappendiceal fat&#46; &#40;B&#41; Longitudinal color Doppler US image shows inflamed appendix with hyperemic wall&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1040
            "Ancho" => 996
            "Tamanyo" => 135623
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mucocele&#46; Hypoechoic mass arising from the cecum&#44; with &#8220;skin onion&#8221; structure &#40;&#42;&#41;&#44; thin walls and no associated inflammatory changes&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 941
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            "Tamanyo" => 180049
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Patient with tuberculosis and pain in right iliac fossa&#46; &#40;A&#41; Chest radiograph shows patchy lesions of alveolar characteristics with bilateral distributions and diffuse secondary to tuberculous bronchopneumonia&#46; &#40;B&#41; US images of the right flank show diffuse hypoechoic thickening&#44; with loss of normal stratification&#44; secondary to tuberculous ileitis&#46; Note the similarity to the characteristic thickening of Crohn&#39;s disease &#40;see <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A and B&#41;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 838
            "Ancho" => 2000
            "Tamanyo" => 212195
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Crohn&#39;s disease&#46; &#40;A&#41; Color Doppler US shows marked wall thickening of the terminal ileum mainly due to a hyperechogenic submucosa&#44; a finding characteristic of Crohn&#39;s disease&#44; and mural hypervascularity&#46; &#40;B&#41; Presence of multiple enlarged lymph nodes of inflammatory appearance &#40;&#42;&#41; and mesenteric hyperechogenicity and hypervascularity&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 639
            "Ancho" => 999
            "Tamanyo" => 104898
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Typhlitis in an 8-year-old child treated for leukemia&#44; with RIF pain and fever&#46; Axial US image of the RIF shows abnormal thickening of the wall of the cecum &#40;thick arrows&#41;&#44; with loss of stratification&#44; and of the terminal ileum to a lesser extent &#40;i&#41;&#46; Appendiceal caliber appears normal &#40;arrow&#41;&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 893
            "Ancho" => 999
            "Tamanyo" => 103112
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Axial US image of an ileocolic intussusception shows three layers of loops and the mesentery&#46; The outer layer is the receptor loop or <span class="elsevierStyleItalic">intussuscipiens</span>&#44; which contains the central entering limb of the <span class="elsevierStyleItalic">intussusceptum</span> &#40;i&#41;&#44; located at the center of the intussusception next to the mesentery &#40;M&#41; dragging some lymph nodes &#40;&#42;&#41;&#46; The receptor loop also contains the everted returning limb of the <span class="elsevierStyleItalic">intussusceptum</span>&#44; which is thicker&#44; constituting the outer hypoechoic ring of the doughnut &#40;arrows&#41;&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 982
            "Ancho" => 996
            "Tamanyo" => 100535
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ileal duplication cyst&#46; Transversal view of the RIF shows hypoechoic mass with an inner echogenic layer corresponding to the mucosa&#44; surrounded by an outer hypoechoic layer corresponding to the muscle wall&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 588
            "Ancho" => 2000
            "Tamanyo" => 140849
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#8211;C&#41; Ovarian torsion&#46; &#40;A&#41; Axial US image of the RIF in a newborn shows a cystic structure with fluid&#8211;fluid level &#40;arrows&#41;&#44; very suggestive of ovarian torsion secondary to the presence of a complicated cyst&#46; Bladder &#40;V&#41;&#46; &#40;B&#41; T2 weighted images of MRI study&#44; with and without fat suppression&#44; performed the following day cannot identify the right ovary but the cystic lesion is observed in the left flank&#46; The mobility of the lesion suggests ovarian origin&#44; which was subsequently confirmed at surgery&#46; &#40;C&#41; The left ovary showed normal morphology and a normal location in the pelvis &#40;arrow&#41;&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 979
            "Ancho" => 1600
            "Tamanyo" => 217515
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Persistent urachus&#46; Child with abdominal pain&#44; fever and mictional syndrome&#46; Echogenic tubular structure connected to the umbilicus &#40;&#42;&#41; in contact with the bladder dome &#40;v&#41;&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "fig0055"
        "etiqueta" => "Figure 11"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr11.jpeg"
            "Alto" => 1878
            "Ancho" => 2659
            "Tamanyo" => 349354
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diagram depicting the anatomy of RIF and the possible disorders arising from its structures&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:65 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Imaging of acute appendicitis&#58; US as the primary imaging modality"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;A&#46; Hern&#225;ndez"
                            1 => "L&#46;E&#46; Swischuk"
                            2 => "C&#46;A&#46; &#193;ngel"
                            3 => "R&#46; Chandler"
                            4 => "S&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Radiol"
                        "fecha" => "2005"
                        "volumen" => "35"
                        "paginaInicial" => "392"
                        "paginaFinal" => "395"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15635471"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current concepts in imaging of appendicitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;V&#46; Rybkin"
                            1 => "R&#46;F&#46; Thoeni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rcl.2007.04.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiol Clin North Am"
                        "fecha" => "2007"
                        "volumen" => "45"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound evaluation of acute abdominal emergencies in infants and children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Vasavada"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rcl.2004.01.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiol Clin North Am"
                        "fecha" => "2004"
                        "volumen" => "42"
                        "paginaInicial" => "445"
                        "paginaFinal" => "456"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15136027"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "When appendicitis is suspected in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Sivit"
                            1 => "M&#46; Siegel"
                            2 => "E&#46; Kimberly"
                            3 => "K&#46; Applegate"
                            4 => "K&#46; Newman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiographics.21.1.g01ja17247"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiographics"
                        "fecha" => "2001"
                        "volumen" => "21"
                        "paginaInicial" => "247"
                        "paginaFinal" => "262"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11158659"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Optimizing US examination to detect the normal and abnormal appendix in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Peletti"
                            1 => "M&#46; Baldisserotto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00247-006-0305-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Radiol"
                        "fecha" => "2006"
                        "volumen" => "36"
                        "paginaInicial" => "1171"
                        "paginaFinal" => "1176"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17004079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagn&#243;stico ecogr&#225;fico de la apendicitis aguda&#46; A prop&#243;sito de 226 casos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46; Sandoval"
                            1 => "J&#46;M&#46; Alonso"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Radiolog&#237;a"
                        "fecha" => "1998"
                        "volumen" => "40"
                        "paginaInicial" => "299"
                        "paginaFinal" => "306"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Valor diagn&#243;stico de la ecograf&#237;a en la apendicitis del ni&#241;o"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Galindo"
                            1 => "S&#46; Calleja"
                            2 => "M&#46;A&#46; Nieto"
                            3 => "B&#46; Fadrique"
                            4 => "A&#46;M&#46; Gonz&#225;lez"
                            5 => "J&#46; Manzanares"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Esp Pediatr"
                        "fecha" => "1998"
                        "volumen" => "48"
                        "paginaInicial" => "28"
                        "paginaFinal" => "32"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9542224"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasonography of Crohn disease in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Alison"
                            1 => "A&#46; Kheniche"
                            2 => "R&#46; Azoulay"
                            3 => "S&#46; Roche"
                            4 => "G&#46; Sebag"
                            5 => "N&#46; Belarbi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00247-007-0559-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Radiol"
                        "fecha" => "2007"
                        "volumen" => "37"
                        "paginaInicial" => "1071"
                        "paginaFinal" => "1082"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17899062"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Color Doppler US of children with acute lower abdominal pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Quillin"
                            1 => "M&#46; Siegel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/radiographics.13.6.8290724"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiographics"
                        "fecha" => "1993"
                        "volumen" => "13"
                        "paginaInicial" => "1281"
                        "paginaFinal" => "1293"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8290724"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasonography of the acute abdomen&#58; gastrointestinal conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Puylaert"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiol Clin North Am"
                        "fecha" => "2003"
                        "volumen" => "41"
                        "paginaInicial" => "1227"
                        "paginaFinal" => "1242"
                        "link" => array:1 [
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Article information
ISSN: 21735107
Original language: English
DOI:10.1016/j.rxeng.2011.05.001
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2021 June 0 3 3
2021 May 0 9 9
2021 April 0 24 24
2021 March 0 18 18
2021 February 0 4 4
2021 January 0 4 4
2020 December 0 4 4
2020 November 0 5 5
2020 October 0 1 1
2020 September 0 4 4
2020 May 0 3 3
2020 April 0 4 4
2020 March 0 8 8
2020 February 0 9 9
2020 January 0 1 1
2019 December 0 5 5
2019 November 0 6 6
2019 October 0 4 4
2019 September 0 9 9
2019 August 0 10 10
2019 July 0 9 9
2019 June 0 14 14
2019 May 0 16 16
2019 April 0 30 30
2019 March 0 4 4
2019 February 0 6 6
2019 January 0 23 23
2018 December 0 7 7
2018 November 0 3 3
2018 May 38 7 45
2018 April 202 27 229
2018 March 184 28 212
2018 February 92 22 114
2018 January 161 11 172
2017 December 170 15 185
2017 November 148 21 169
2017 October 152 21 173
2017 September 121 32 153
2017 August 109 53 162
2017 July 111 26 137
2017 June 144 65 209
2017 May 173 35 208
2017 April 98 68 166
2017 March 186 101 287
2017 February 90 39 129
2017 January 77 25 102
2016 December 95 42 137
2016 November 112 54 166
2016 October 129 89 218
2016 September 147 54 201
2016 August 157 54 211
2016 July 157 15 172
2016 June 154 96 250
2016 May 142 124 266
2016 April 128 108 236
2016 March 169 117 286
2016 February 130 106 236
2016 January 139 96 235
2015 December 134 91 225
2015 November 156 78 234
2015 October 172 82 254
2015 September 132 88 220
2015 August 150 55 205
2015 July 276 56 332
2015 June 168 32 200
2015 May 174 49 223
2015 April 221 58 279
2015 March 345 33 378
2015 February 215 29 244
2015 January 66 18 84
2014 December 78 18 96
2014 November 68 15 83
2014 October 67 21 88
2014 September 63 10 73
2014 August 95 19 114
2014 July 75 14 89
2014 June 62 11 73
2014 May 70 13 83
2014 April 48 7 55
2014 March 312 25 337
2014 February 251 19 270
2014 January 295 10 305
2013 December 250 22 272
2013 November 234 20 254
2013 October 282 14 296
2013 September 205 35 240
2013 August 213 24 237
2013 July 135 17 152
2013 June 124 23 147
2013 May 130 32 162
2013 April 129 24 153
2013 March 86 24 110
2013 February 104 18 122
2013 January 66 10 76
2012 December 13 8 21
2012 November 1 1 2
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