Path beyond the blind end-unravel the imaging spectrum of appendiceal pathologies

The appendix is involved in a diverse spectrum of inflammatory, infectious, benign, and malignant conditions that extend far beyond acute appendicitis. Although acute appendicitis remains the most common appendiceal emergency, numerous entities-including reactive appendiceal inflammation, inflammatory bowel disease, appendiceal endometriosis, mucinous and non-mucinous neoplasms, lymphoma, post-transplant lymphoproliferative disorder, and rare mesenchymal tumors-may present with similar clinical symptoms and overlapping imaging findings. Accurate distinction among these conditions is essential because management ranges from conservative medical therapy to appendectomy, right hemicolectomy, cytoreductive surgery or systemic oncologic treatment. Furthermore, several common mimics of appendiceal disease, including mesenteric adenitis, terminal ileitis, epiploic appendagitis, cecal diverticulitis, gynecologic disorders, and ureteric calculi, can closely resemble appendiceal pathology and may lead to inappropriate treatment if not correctly recognized. This narrative imaging review provides a comprehensive multimodality imaging approach to appendiceal diseases using ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and molecular imaging techniques. Emphasis is placed on imaging features that facilitate differential diagnosis, clinicopathologic and surgical correlation, recognition of disease mimics, assessment of complications, and determination of disease extent. The review highlights how radiologists contribute not only to diagnosis but also to treatment planning, surgical decision-making, staging, surveillance, and multidisciplinary patient management. Emerging applications of dual-energy CT, radiomics, artificial intelligence, and advanced molecular imaging are also discussed. By integrating imaging findings with clinical and pathologic considerations, this review aims to improve diagnostic accuracy, guide appropriate management, and strengthen the radiologist's role in the comprehensive evaluation of appendiceal pathology.