J Gastrointest Surg (2007) 11:14171422

DOI 10.1007/s11605-007-0268-y

Computed Tomography in the Diagnosis of Acute

Appendicitis: Definitive or Detrimental?
Sandeepa Musunuru & Herbert Chen &
Layton F. Rikkers & Sharon M. Weber

Received: 21 May 2007 / Accepted: 19 July 2007 / Published online: 16 August 2007
# 2007 The Society for Surgery of the Alimentary Tract

Abstract
Objectives Utilization of computed tomography (CT) scans in patients with presumed appendicitis was evaluated at a single
institution to determine the sensitivity of this diagnostic test and its effect on clinical outcome.
Methods Adult patients (age>17 years) with appendicitis were identified from hospital records. Findings at surgery,
including the incidence of perforation, were correlated with imaging results.
Results During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of
these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before
the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients
who had preoperative imaging (8.20.3 h) compared to those who did not (5.10.2 h, p<0.001). Moreover, this possible
delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p=0.017).
Conclusions Preoperative CT scanning in patients with presumed appendicitis should be used selectively as widespread
utilization may adversely affect outcomes. The potential negative impact of CT imaging includes a delay in operative
intervention and a potentially higher perforation rate.
Keywords Appendicitis . Diagnosis . Perforation .
Imaging . CT

Introduction
Approximately 250,000 appendectomies are done per year
in the USA, making it the most common emergency
procedure performed by general surgeons. Despite such a
large number of cases, diagnosis is often difficult. Demonstrating this fact, at the time of operation, a normal
appendix is found in approximately 1520% of cases.1
Much of the uncertainty in diagnosis occurs in women of
childbearing age and in patients with atypical presentations.

This paper was presented at the SSAT Annual Meeting, May 1923,
2007.
S. Musunuru : H. Chen : L. F. Rikkers : S. M. Weber (*)
Department of Surgery, University of Wisconsin,
H4/752 Clinical Science Center, 600 Highland Avenue,
Madison, WI 53792, USA
e-mail: webers@surgery.wisc.edu

The consequences of a negative appendectomy include

development of intraabdominal adhesions, adverse effects
of anesthesia, cost, and negative effects on quality of life
from unnecessary surgery.2,3 To demonstrate the potential
negative impact on these patients, the complication rate
after a negative appendectomy may be as high as 6% and
reoperation occurs in up to 2%.4 On the other hand, in
patients with appendicitis, delaying the time to definitive
intervention may lead to negative consequences including
perforation. Appendiceal perforation is associated with a
threefold increase in complications, including an eightfold
increase in abscess formation. There are also higher rates of
reoperation, sepsis, infertility, and dehiscence associated
with perforated appendicitis, compared to simple appendicitis.1 Thus, a great deal of effort has been placed on
making an early and accurate diagnosis, as multiple
complications can occur, both in the setting of a falsenegative and a false-positive diagnosis.
Computed tomography (CT) scan is playing a larger role
in clarifying the clinical picture in patients with presumed
appendicitis, particularly over the last decade. CT was
popularized in the late 1990s after publication of a prospec-

1418

tive trial that supported the routine use of CT with rectal

contrast. This trial found that CT was 98% accurate in
diagnosing appendicitis, although the technique employed is
not commonly utilized.5 Another prospective randomized
trial in patients with atypical symptoms of appendicitis
determined that noncontrast CT scan is superior to ultrasound in diagnostic accuracy and reliability.6 Because of
these studies, the use of CT for the routine diagnosis of
appendicitis has markedly increased at our institution over
the last decade. Therefore, we sought to evaluate the
sensitivity, specificity, and positive and negative predictive
value of CT, and its effect on clinical outcome at an academic
teaching institution.

J Gastrointest Surg (2007) 11:14171422

the Social Sciences (SPSS) software (SPSS Inc., version

14.0). Data are represented as mean SEM. Sensitivity was
defined as the number of cases of appendicitis correctly
diagnosed by CT divided by the total number of cases of
appendicitis. Specificity was defined as the number of cases
without appendicitis divided by the number of negative
tests obtained. Indeterminate CT scans were categorized as
negative, as they did not assist with clinical decisionmaking. Positive predictive value was calculated from the
number of positive cases of appendicitis cases diagnosed by
CT compared to the total number of positive CT scans.
Negative predictive value was calculated from the number
of negative cases of appendicitis cases diagnosed by CT
compared to the total number of negative CT scans.
Significance was defined as a p value<0.05.

Materials and Methods

Four hundred and eleven adult patients (age>17 years)
underwent emergency appendectomy for presumed appendicitis at the University of Wisconsin Hospital and Clinics over
a 3-year period from January 2002 through December 2004.
These patients were identified by ICD-9 codes. Medical
records were retrospectively reviewed to assess whether CT
scans were utilized for preoperative diagnosis. Patients were
analyzed for demographic variables such as age and gender. In
addition, each patients medical record was reviewed to
evaluate white blood cell count, time interval from emergency
room to operating room, laparoscopic versus open procedure,
operating room time (defined as incision to closure), and
presence or absence of appendiceal perforation. Pathology
results for each specimen were reviewed. Perforation was
defined as either gross perforation found at the time of
operation and/or microperforation discovered on histological
exam. This study was approved by the University of
Wisconsin Institutional Review Board.
Our policy was to utilize abdominal and pelvis CT scans
with intravenous and oral contrast. However, if patients had
renal insufficiency, patients either underwent prehydration or
the intravenous contrast was withheld. During the time of the
study, there was no institutional policy dictating which
patients received CT scans. In general, patients were first
evaluated by emergency room (ER) physicians followed by
surgical residents. CT scans may have been ordered by the ER
physician or the surgical team. Patients with negative CT
scans underwent operative intervention if there was a high
clinical suspicion of appendicitis. During the time of the study,
patients with appendicitis underwent operation at the time of
the next available operating room.

Results
Patient Demographics
Of the 411 appendectomy patients, 256 (62%) had a
preoperative CT, and the remaining 155 (38%) patients
did not have imaging before their operation. The median
age was older for the CT group compared to the non-CT
group (Table 1). The majority of the patients were male, but
a higher percentage of females underwent CT imaging. The
mean white blood cell (WBC) counts at presentation to the
emergency room (ER) were similar between the two groups
(Table 1).
Operative Results
Comparisons were made between the number of laparoscopic versus open appendectomies in each group. There
was a significant difference with more laparoscopic
procedures performed in the non-CT group (Table 2). The
mean operating time for both CT and non-CT patients was
1.2 h.
The final pathology in the corresponding groups is found
in Table 3. Overall, CT had a sensitivity of 92% (208:225)
and a specificity of 68% (21:31). The positive and negative
Table 1 Patient Demographics
Number of
Patients
256
155

Mean
Age
371
311
<0.001

Gender

WBC
(1,000)

Male

Female

127
103
0.001

129
52

Statistical Analysis

CT
No CT
p Value

Statistical analyses between groups were performed with

analysis of variance (ANOVA) using Statistical Package for

Mean SEM
NS Not significant, WBC white blood cell

13.60.3
14.40.3
NS

J Gastrointest Surg (2007) 11:14171422

1419

Table 2 Operative Results

CT
No CT
p Value

Table 4 Outcomes

OR Time (Hours)

Percent Laparoscopic

1.20.1
1.20.1
NS

88%
96%
0.003

CT
No CT
p Value

Mean SEM
NS Not significant, OR operating room

predictive values were 91% (208:229) and 37% (10:27),

respectively.
The negative appendectomy rate for patients diagnosed
with appendicitis on CT was 8% (19:227). For all patients
who underwent appendectomy without preoperative imaging, the negative appendectomy rate was 14% (22:155),
which was not significantly different (p=0.09). In addition,
7 of 14 patients with negative CT scans were ultimately
found to have appendicitis; thus, the negative appendectomy rate in patients with negative CT scans was 50% (p<
0.001, compared to those with CT scans positive for
appendicitis). When evaluating both negative and indeterminate scans together, the negative appendectomy rate was
37% (17:27, p<0.001).
Outcomes
The time interval from the patients first contact in the
emergency room to the operating room start time was
significantly longer in the CT group as compared to the
non-CT group (Table 4). In addition, the rate of perforation
(based on final pathology and intraoperative observation)
was significantly greater in the imaging group [17%
(43:256) versus 8% (13:155), p=0.017].
Because more patients in the CT group actually had
appendicitis [89% (225:254) versus 86% (134:155) in the
non-CT group], we compared perforation rates in those
with pathologically proven appendicitis. In this group, the
perforation rate remained significantly elevated in the CT
group [19% (42:225) versus 10% (13:133), p=0.033].

Table 3 Pathological Results

Pathology
Positive

Negative

Indeterminate

208
7
10
133

19
7
3
22

CT scan
+

+/
No CT

(+) Appendicitis, () normal appendix, (+/) indeterminate

Time from ER
to OR (Hours)

Percent
Perforation
(All specimens)

Percent Perforation
(Appendicitis only)

8.20.3
5.10.2
<0.001

17%
8%
0.017

19%
10%
0.033

Mean SEM
ER Emergency room, OR operating room

Discussion
The diagnosis of acute appendicitis is often not straight
forward. Imaging studies, including CT scans, have been
employed at increasing rates over the last decade in an
attempt to improve diagnostic accuracy. In this study, the
use of CT scan for diagnosis of appendicitis and its effect
on clinical outcome was retrospectively reviewed at our
institution. The two major findings of this investigation are
(1) there was no significant difference in the negative
appendectomy rate between those that had preoperative
imaging and those that did not and (2) there was a
significantly longer time to operation in patients who had
preoperative CT scan, and this was associated with an
increased rate of appendiceal perforation.
Although initial reports on the use of CT scans in
patients with appendicitis concluded that CT should be used
routinely in all patients suspected to have appendicitis,
more recent reports suggest that a selective approach is
likely more beneficial.1,5,6 As these more selective
approaches to preoperative imaging have been employed,
it has become clear that CT scanning is beneficial for the
diagnosis of appendicitis in patients with atypical presentations and in women of childbearing age.7 However, this is
not without increased cost, radiation exposure, and a
potential delay in time to definitive treatment. To demonstrate this, even in studies that utilized a selective approach
to imaging with the use of an institutional pathway, CT was
obtained in 529 cases but only a minority (97, 18%)
actually had appendicitis.1 It is clear that we still need to
make progress in clinically assessing patients with presumed appendicitis, and, even when CT is used selectively,
the cost of making an accurate diagnosis remains high.
Although institution of a clinical pathway in one study,
Antevil et al., led to a substantial decrease in the number of
negative appendectomies (from 16 to 4%, p<0.001), the
issue of improving patient selection for CT remains a
problem.
The negative appendectomy rate in the present study was
11% (29:256), which is consistent with the national

1420

J Gastrointest Surg (2007) 11:14171422

Table 5 Summary of Recent Prospective, Randomized Trials Evaluating Use of CT for Diagnosis of Appendicitis
Study

Type of Study

Number of
Patients

Type of
Contrast

Sensitivity
(%)

Specificity
(%)

Accuracy
(%)

Negative Appendectomy
Rate (%)

Walker15

Prospective
randomized

63

100

79

89

19

Mittal14

Prospective
randomized

94
97

100
86

96
92

5
8.3

Hong12

Prospective
randomized

No CT (PE only) OR PO and/

or IV contrast
Rectal
Triple contrast
(PO, IV, rectal)
Rectal only
None
PO, IV

88
100
91

100
73
93

92
90
92

7.7
NA
NA

65 (CT)
52
39
68
97(CT)

CT Computed tomography group, PO oral contrast, IV intravenous contrast, NA not available

average. The negative appendectomy rate for patients

receiving CT imaging was 8% compared to the non-CT
group rate of 14%, which was not a significant difference
(p=0.09). Importantly, of the 14 patients with CT scans
determined to be negative, seven of these patients were
found to have appendicitis at surgery, resulting in a 50%
false negative rate. Thus, this reiterates the importance of
relying on clinical findings even in the setting of a negative
CT.
Although not examined in this study, it is clear that
prolonged time from first symptoms to definitive operation
increases the risk of rupture in patients with appendicitis.8,9
In fact, the risk of rupture increases approximately 5% for
each ensuing 12-h period after 36 h.8 In addition, multiple
studies, including our own, have found that utilization of
preoperative CT scan leads to a delay in definitive
treatment.8,9,1012 Some studies have found that obtaining
a CT results in a delay to operative intervention as great as

612 h compared to patients that did not have preoperative

imaging.8,13
One area not examined in this retrospective study is the
type of contrast utilized for the CT and whether the
accuracy of CT is dependent on route of contrast administration. There are conflicting opinions as to whether the
use of intravenous, oral, and/or rectal contrast will result in
the most accurate images (Table 5). The original prospective study evaluating the accuracy of CT for the diagnosis
of appendicitis utilized rectal contrast only, and other
prospective randomized trials concluded that the use of
rectal contrast only compared to triple contrast (intravenous, oral, and rectal) resulted in decreased delay to
definitive surgery, decreased perforation rate, and a decrease in contrast-related morbidity without any compromise in diagnosis.5,14 In spite of this, the routine practice
employed by many institutions is to utilize oral and
intravenous contrast for the diagnosis of appendicitis, likely

Table 6 Summary of Recent Retrospective and Prospective Nonrandomized Trials Evaluating Use of CT for Diagnosis of Appendicitis
Study

Type of Study

Number of
Patients

Type of
Contrast

Sensitivity

Specificity

Accuracy

Negative Appendectomy
Rate (%)

Torbati16

250

92%

97%

96%

7.8

198 (CT)

None, PO, IV,

rectal
PO, IV

91%

92%

91%

16

103

None

95.4%

100%

95%

NA

100

Rectal

98%

98%

98%

NA

Lee11

Prospective
nonrandomized
Prospective
nonrandomized
Prospective
nonrandomized
Prospective
nonrandomized
Retrospective

31.7
40

74.9
74.5

Retrospective

99%

96%

97%

Present
study

Retrospective

NA
NA
None
PO, IV
None
PO, IV

83
83.8

Fuchs19

766 (total)
47 (CT)
42
182
155
256 (CT)

92%

68%

88%

15.7
NA
11.9
6.3
14
8

Hershko17
int Hof18
Rao5

CT Computed tomography group, PO oral contrast, IV Intravenous contrast, NA not available

J Gastrointest Surg (2007) 11:14171422

because of the fact that this also allows for assessment of

other areas of intra-abdominal pathology. Tables 5 and 6
summarize recent studies and the sensitivity, specificity,
and accuracy for CT imaging of appendicitis.
The major limitation of our study, as well as many of the
cited studies, is its retrospective design. Another limitation
is that only patients undergoing abdominal exploration for
appendicitis were included. CT may have benefited patients
with suspected acute appendicitis but who were successfully managed non-operatively after a negative CT, or who
were found to have other intraabdominal explanations for
their abdominal pain based on findings on CT.
In conclusion, preoperative CT scanning in patients with
suspected appendicitis should be used selectively as widespread utilization may adversely affect outcomes. We believe
that CT imaging does have a role in the diagnosis of acute
appendicitis, particularly in patients with atypical presentation
and in women of childbearing age with unusual symptoms.
The routine use of CT scan to evaluate patients suspected of
having acute appendicitis will result in unnecessary exposure
to contrast and radiation in a large number of patients and delay
in operation intervention. Therefore, it should be discouraged.

References
1. Antevil JL, Rivera L, Langenberg BJ, Hahm G, Favata MA,
Brown CVR. Computed tomography-based clinical diagnostic
pathway for acute appendicitis: Prospective validation. J Am Coll
Surgeon 2006;203:849856.
2. Bendeck SE, Nino-Murcia M, Berry GJ, Jeffery RB. Imaging for
suspected appendicitis: negative appendectomy and perforation
rates. Radiology 2002;225:131136.
3. Old JA, Dusing RW, Yap W, Dirks J. Imaging for suspected
appendicitis. Am Fam Phys 2005;71:7178.
4. Bijnen, CL, van den Broek, WT, Bijnen, AB, de Ruiter, P,
Gouma, DJ. Implications of removing a normal appendix. Dig
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5. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ.
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patients and use of hospital resource. N Engl J Med 1998;338:
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6. Horton MD, Counter SF, Florence MG, Hart MJ. A prospective
trial of computed tomography and ultrasonography for diagnosing
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7. McGory ML, Zingmond DS, Nanayakkara D, Maggard MA,
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risk of rupture in appendicitis. J Am Coll Surgeon 2006;202:
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9. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay
appendectomy in adults with acute appendicitis? Ann Surg
2006;244:656660.
10. Lee, SL, Walsh, AJ, Ho, HS. Computed tomography and
ultrasonography do not improve and may delay the diagnosis
and treatment of acute appendicitis. Arch Surg 2001;136:
556562.

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11. Hong, JJ, Cohn, SM, Ekeh, AP, Newman, M, Salama, M,
Leblang, SD. A prospective randomized study of clinical
assessment versus computed tomography for the diagnosis of
acute appendicitis. Surg Infect 2004;5:223224.
12. Fuchs JR, Schlamberg JS, Shortsleeve MJ, Schuler JG. Impact of
abdominal CT imaging on the management of appendicitis: an
update. J Surg Res 2002;106:131136.
13. Menes TS, Aufses AH, Rojas M, Bickell NA. Increased use of
computed tomography does not harm patients with acute
appendicitis. Am Surgeon 2006;4:326329.
14. Mittal VK, Goliath J, Sabir M, Patel R, Richards BF, Alkalay I,
ReMine S, Edwards M. Advantages of focused helical computed
tomographic scanning with rectal contrast only vs triple contrast
in the diagnosis of clinically uncertain acute appendicitis. Arch
Surg 2004;139:495500.
15. Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilland T. The
value of limited computed tomography with rectal contrast in the
diagnosis of acute appendicitis. Am J Surg 2000;180:450455.
16. Torbati SS, Guss DA. Impact of helical computed tomography on
the outcomes of emergency department patients with suspected
appendicitis. Acad Emerg Med 2003;10:823829.
17. Hershko DD, Sroka G, Bahouth H, Ghersin E, Mahajna A,
Krausz MM. The role of selective computed tomography in the
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Surgeon 2002;68:10031007.
18. int Hof KH, van Lankeren W, Krestin GP, Bonjer HJ, Lange JF,
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DISCUSSION
Attila Nakeeb, M.D. (Indianapolis, IN): Thanks for a very
elegant presentation and for the opportunity to review your
manuscript. I think it has become clear that in many hospitals
in the United States nobody goes to the operating room for an
appendectomy without a CAT scan. Your study shows that a
CT scan doesn't really help and it may actually be detrimental
to your patients. A high index of suspicion and a good
clinical exam seem to be more important in treating patients
in a timely fashion and hopefully preventing perforations.
Understanding the limitations of a retrospective study,
do you have any information on how many patients had
CT scans in your institution to rule out appendicitis? What
is your overall denominator in these patients and how
many of those patients were never seen by a surgeon?
Also, you have clearly shown in your study that the
sensitivity is about 90%, the specificity is less than 70%,
and your negative predictive value is less than 40% for
CT scans in your hands. You did your scans with both
oral and IV contrast. In the literature, using rectal contrast
alone, you get about a 95% accuracy rate. Have you
discussed changing your CT protocol to rectal contrast for
patients who are specifically being evaluated to rule out
appendicitis.

1422

Finally in terms of the higher perforation rate in patients

undergoing CT scans and the subsequent delay in getting to
the OR, have you looked at your outcomes in those patients
in regards to increases in complications, pelvic abscess, or
increase in the length of stay?
I really enjoyed the paper. Thanks.
Sandeepa Musunuru, M.D. (Madison, WI): We do
not have information regarding the number of patients
evaluated with abdominal pain in the emergency room, or
if these patients were seen by a surgical resident or
attending. This is a weakness of our study due to its
retrospective nature.
Regarding the second question regarding the use of
rectal contrast, based on a prospective randomized study
by Mittal et al., randomizing points to triple contrast vs.
rectal only, there was no difference in the negative
appendectomy rate.
As far as follow-up of patients for complications and
length of stay, this was not included in this study.
David W. Butsch, M.D. (Barre, VT): I enjoyed your
paper. I believe you said that you used the indeterminate
group to be put into the negatives so that when you get
your final results that might make your false negative rate
higher. Did you have to take that group out and then give
the rate of success of the ones that were read as positive?
Dr. Musunuru: The indeterminate scans were included
in the negative scan category for statistical analysis since
they did not enhance clinical decision making.
Jose M. Velasco, M.D. (Chicago, IL): I realize that it is
a retrospective study. Thank you for bringing the paper and
this issue to us. It is a source of frustration for all of us.
Do you have any idea as to who made the decision to
obtain a CT scan? Was it before a clinical evaluation or
afterwards? We are trying to encourage our residents to see
the patients before a CT scan is done. Two, there are some
issues as to whether a patient with a perforated appendix
should be operated upon or should be treated nonoperatively. Did you look at the CT scans on those patients
that had perforation? Were you able to correlate whether

J Gastrointest Surg (2007) 11:14171422

the CT scan really was ordered because of a high suspicion

for perforation and then it would be indicated? And I
wouldn't include those patients. And the specificity in your
study is really very low, and when you look at the series
that have been published, it is much higher. Any idea why?
Is it maybe technique?
Thank you. I really enjoyed it.
Dr. Musunuru: The first question was who ordered the
CT scan. We do not have specific numbers of who ordered
the CT scan. However at our institution, a majority of
patients with acute appendicitis present to the emergency
room and therefore, an emergeny medicine physician will
evaluate and order the CT scan. However, if a surgical
consult is requested prior to obtaining a CT scan, a surgical
resident will conduct a history and physical exam and
determine if imaging is necessary.
Dr. Velasco: If the person evaluated the patient clinically,
did he have any idea of how frequently did the CT scan
change the clinical evaluation? In other words, what is the
impact of a CT scan on a patient that has clinically been
evaluated?
Dr. Musunuru: The CT scan should be a tool that
enhances decision making, especially in cases of atypical
presentation and women of childbearing age, because of the
larger differential diagnosis. Unfortunately we did not
evaluate how often CT scans changed decision making. We
specifically looked at patients that were operated on for
presumed appendicitis, not patients with abdominal pain who
were being evaluated. These are two very different patient
populations, and different questions are being asked.
Dr. Velasco: The final question was, were you able to
identify those patients that had a perforation and did you
review the CT scan findings and how good was the CT
scan in identifying those patients that had a perforation?
Dr. Musunuru: Perforations were identified based on
pathology and visualization in the operating room since a
majority of perforations were micro perforations not
identified on CT imaging.

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