Revista 2

Advances in Surgery 51 (2017) 11–28
ADVANCES IN SURGERY
Can the Diagnosis of

Appendicitis Be Made Without
a Computed Tomography Scan?
Yangyang R. Yu, MD, Sohail R. Shah, MD, MSHA*
Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children’s
Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA
Keywords
Appendicitis Diagnostic algorithm CT MRI Ultrasonography
Pediatric appendicitis score Alvarado score
Key points
Historically, management of appendicitis emphasized avoidance of perforation
at the expense of negative appendectomies.
Development of advanced imaging modalities led to an over-reliance on imaging
to diagnose appendicitis, particularly computed tomography (CT) scans.
Detrimental effects of radiation have led to efforts to minimize CT use in the
diagnosis of appendicitis, especially in vulnerable populations such as children
and pregnant patients.
Clinical scoring systems offer a standardized method to risk stratify patients with
suspected appendicitis.
Diagnostic algorithms combine various diagnostic modalities into a standardized
pathway for the diagnosis of appendicitis while limiting the necessity for CT
scans.
INTRODUCTION
Appendicitis is the most common surgical emergency in the adult and pediatric
populations with incidence increasing from 7.6 per 10,000 in 1993 to 9.38 per
10,000 in 2008 [1]. Children account for approximately 88,000 hospitalizations
annually compared with approximately 190,000 annual hospitalizations in
adults [1]. The burden of managing appendicitis on the nation’s health care
Disclosures: The authors have nothing to disclose.
*Corresponding author. E-mail address: sohailshahmd@gmail.com
http://dx.doi.org/10.1016/j.yasu.2017.03.002
0065-3411/17/ª 2017 Elsevier Inc. All rights reserved.
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12 YU & SHAH
system is substantial. Total hospital days spent treating appendicitis annually is

estimated at more than 1 million days, which results in almost $3 billion in hos-
pital charges [2]. Approximately $800 million annually in charges are related to
managing this condition in children and adolescents alone [3]. Lifetime risk of
appendicitis is estimated to be 9%, with highest incidence between 10 and
19 years of age [4,5]. In addition to a male preponderance (55%–60%) [6],
peak incidence in male patients occurs earlier, between 10 and 14 years of
age compared with female patients, whose peak incidence occurs at ages 15
to 19 [7].
The diagnosis of appendicitis traditionally consisted of history, physical ex-
amination, and laboratory evaluation; however, today diagnostic imaging has
become a common adjunct. The high sensitivity (87%–100%) and specificity
(89%–99%) reported with computed tomography (CT) scans has resulted in
it being among the most commonly used imaging studies to diagnose appendi-
citis across the country (Figs. 1 and 2) [8]. The percentage of patients with
appendicitis who receive a CT scan has grown from less than 7% in 1996 to
at least 70% of adults and 60% of children by 2006 [9]. Its rise in popularity
is in part due to extensive availability, rapid acquisition time, accuracy, and
ease of examination [10,11].
However, recent reports have raised concern about radiation exposure in pa-
tients undergoing CT scans. The exposure may result in an increased lifetime
risk of radiation-induced malignancies, especially in children. Some estimate
the tradeoff for avoiding 12 unnecessary appendectomies is at the risk of 1
additional death due to cancer from radiation exposure [12]. A 2012 study
from the United Kingdom reported a CT dose of 30 mGy or higher imparts
a 3.2 times greater risk of leukemia in children [13].
Fig. 1. Patient with nonperforated appendicitis diagnosed on CT. Dilated appendix with thick-
ened, hyperemic walls (arrows) on (A) transverse and (B) coronal CT views.
DIAGNOSING APPENDICITIS WITHOUT A CT SCAN? 13
Fig. 2. Patient with perforated appendicitis diagnosed on CT. (A) Dilated appendix with peri-
appendiceal inflammatory changes and abscess (arrow). (B) Dilated right lower quadrant ap-
pendix (solid arrow) with pelvic inflammatory changes and abscesses (dashed arrow).
Concerns for radiation exposure, especially its future oncologic impact on

children, have led the American College of Radiology to support campaigns
such as Image Gently, and highlight the radiation safety principle of using a
dose that is as low as reasonably achievable (ALARA) in an effort to reduce
radiation exposure [14]. In addition to decreasing the radiation doses used
[15,16] and using targeted CT scans to reduce anatomic coverage, there is
an effort to avoid CT scans altogether [11,17–20]. This article evaluates the
current literature on diagnostic tools for appendicitis to better understand if
the diagnosis of appendicitis can be made without a CT scan.
HISTORY, PHYSICAL EXAMINATION, AND LABORATORY

EVALUATION
Historically, appendicitis has been a clinical diagnosis. Many surgeons state
that a thorough history and physical examination by an experienced clinician
can often lead to the correct diagnosis. The classic history describes periumbil-
ical pain that migrates to the right lower quadrant followed by associated
nausea, vomiting, anorexia, and possibly fever. Physical examination findings
include tenderness at McBurney point (one-third the distance from the anterior
superior iliac spine to the umbilicus), focal rebound tenderness, and guarding.
Additional examination findings that demonstrate focal peritoneal irritation
include Rovsing sign (palpation of left lower quadrant elicits pain in the right
lower quadrant), psoas sign (flexion or extension of right hip elicits pain in
the right lower quadrant), and the obturator sign (flexion and internal rotation
of the hip elicits pain) [6,21]. However, multiple patient characteristics can
make reliance on history and physical examination alone a difficult task.
Age, gender, body mass index (BMI), and pregnancy can all be confounding
14 YU & SHAH
factors in the diagnosis of appendicitis by history and physical examination

alone. Children can present a unique challenge because some may not be
able to verbalize their pain and their physical examination may be unreliable.
This can often lead to a delay in diagnosis, which results in younger children
more commonly presenting with perforated appendicitis. Children younger
than 8 years old are twice as likely to have perforated appendicitis on diagnosis
[22]. Similarly, elderly patients more often have a delay in diagnosis, with
perforation rates in this cohort as high as 60% to 70% [23]. Pregnant women
also present a diagnostic challenge by history and physical examination alone.
During the second and third trimester of pregnancy the appendix may be dis-
placed leading to periumbilical and even right subcostal pain [23]. Each of these
patient cohorts presents a unique challenge to diagnosing appendicitis by his-
tory and physical examination alone. Before the era of increased use of
advanced imaging for the diagnosis of appendicitis, these challenges were ad-
dressed by weighing the risks and benefits of a negative appendectomy versus
a missed appendicitis that may lead to perforation and associated complicated
sequela. This often meant that reliance on history and physical examination
alone could result in a negative appendectomy rate of more than 20%, and
even up to 50% in pregnant women [24,25].
In an effort to increase accuracy of the diagnosis of appendicitis, laboratory
evaluation for clinical biomarkers became more commonplace. Laboratory
studies, such as white blood cell count (WBC), absolute neutrophil count
(ANC), and C-reactive protein, are common biomarkers used to supplement
the history and physical examination. However, WBC and ANC lack speci-
ficity because they can be elevated in several conditions associated with abdom-
inal pain. WBC sensitivity ranges from 70% to 80%, whereas specificity for
diagnosing appendicitis varies from 60% to 68% [10,26–28]. Similarly, ANC
sensitivity ranges from 59% to 97% and specificity from 51% to 90% [10,26,29].
Individually, these clinical biomarkers are weak discriminators for appendi-
citis; however, there is continued evaluation of combinations of these and other
novel biomarkers to create modified laboratory testing that may further
enhance clinical evaluation of appendicitis [30,31].
Historically, even combining an experienced clinician’s history, physical ex-
amination, and laboratory evaluation led to negative appendectomy rates of
20% to 25% and occasional missed appendicitis.
CLINICAL SCORING SYSTEMS

In an effort to further standardize clinical evaluation and place a validated
weight on each potential variable in the history, physical examination, and
laboratory evaluation, there have been numerous clinical scoring systems
developed. Most of the initial scoring systems used a combination of symp-
toms, physical examination findings, and laboratory values. Each of these fac-
tors were assigned a weighted score and then added for a total score, which
was compared with a recommended cut-off value for the diagnosis of
appendicitis.
One of the most commonly used clinical scoring systems is the Alvarado
score, developed in 1986 by Alfredo Alvarado [32]. The Alvarado score incor-
porates 3 symptoms, 3 physical examination signs, and 2 laboratory values in
the scoring rubric for a total score of 10. Another commonly used scoring sys-
tem is the Pediatric Appendicitis Score (PAS) developed in 2002 by Madan
Samuel [33]. This scoring system was developed specifically for use in children
and similarly incorporates 3 symptoms, 3 physical examination signs, and 2
laboratory values for a total score of 10; however, the PAS uses physical exam-
ination signs more unique to children, such as cough or percussion tenderness.
The popularity of such scoring systems has led to the development of
numerous different scoring systems. Several commonly used and recently
developed scoring systems are presented in Table 1. Although many of these
clinical scoring systems have been evaluated in various settings to investigate
their diagnostic accuracy, the results are often varied. The scoring systems
often demonstrate variable accuracy based on practice setting, patient popula-
tion, and provider interpretation [34]. A comparison of diagnostic accuracy for
selected clinical scoring systems is shown in Table 2. In a prospective evalua-
tion of clinical scoring systems, such as the Alvarado score and PAS, the au-
thors have found, like other investigators, that these clinical scoring systems
lack the positive predictive value (PPV) or negative predictive value (NPV)
necessary for use as diagnostic tools by themselves. Clinical scoring systems
are better used as tools for risk stratification in diagnosing appendicitis.
ALTERNATIVE ADVANCED IMAGING MODALITIES

Ultrasonography
Transabdominal compression ultrasonography (US) for the evaluation of acute
appendicitis was first introduced in 1986 by Puylaert [35]. There are several
advantages to US as an imaging modality for appendicitis. It is a noninvasive,
fast, and inexpensive adjunct. Patients do not require any sedation and are not
exposed to contrast agents or ionizing radiation. However, it is greatly limited
by its dependence on individual operator experience. Additionally, many insti-
tutions lack the availability of US during certain hours (often nights and week-
ends). Use of US to evaluate the appendix is also especially challenging in cases
of severe pain, which limits the ability of the technician to perform an adequate
examination, and in obese patients, in which it may be difficult to locate the
appendix. Keller and colleagues [36] prospectively studied 106 subjects be-
tween 4 and 30 years of age and found obese (BMI >85% percentile) and older
patients to be independent predictors of nondiagnostic ultrasounds for appen-
dicitis. Thus, US is most commonly used in children, thin adults, and women
of child-bearing age with possible gynecologic conditions (Fig. 3) [37].
Children
US should be the default imaging study to evaluate appendicitis in the pediatric
population. The American College of Emergency Physicians issued a level B
recommendation for the use of US in confirming the diagnosis of appendicitis
16
Table 1
Selected appendicitis clinical scoring systems
Heidelberg
Alvarado AIR Lintula appendicitis Tzanakis
score [32] PAS [33] RIPASA [34] score [67] MESH [63] score [68] score [69] score [70]
Age ranges developed in 4–80 y 4–15 y All ages 10–86 y >17 y 4–15 y 0–16 y 15–86 y
Gender
Male gender — — 1 — — 2 — —
Female gender — — 0.5 — — — — —
Age
Age <39.9 y — — 1 — — — — —
Age >40 y — — 0.5 — — — — —
Symptoms
Duration
<48 h — — 1 — — — — —
>48 h — — 0.5 — — — — —
Nausea or vomiting 1 1 1 — — 2 — —
Vomiting — — — 1 — — — —
Anorexia 1 1 1 — — — — —
RLQ pain — — 0.5 — — — — —
Migration of pain 1 1 0.5 — 2 4 — —
Signs
Continuous pain — — — — — — 1 —
Pain or tenderness in RLQ 2 2 1.0 1 — 4 1 4
Guarding — — 2 — — 4 — —
Rebound tenderness 1 — 1 — — 7 1 3
Light — — — 1 — — — —
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Medium — — — 2 — — — —
Strong — — — 3 — — — —
Cough or percussion tenderness — 2 — — — — — —
DIAGNOSING APPENDICITIS WITHOUT A CT SCAN?

Rovsing sign — — 2 — — — — —
Heel drop test — — — — 3 — — —
Pain intensity — — — — — 2 — —
Decreased bowel sounds — — — — — 4 — —
Pyrexia — 1 — — — — — —
Body temperature >37.0 C — — 1 — — 3 — —
Body temperature >37.5 C 1 — — — — — — —
Body temperature 38.5 C — — — 1 — — — —
Laboratory tests
Urinalysis negative — — 1 — — — — —
Polymorphonuclear neutrophilia (>75%) 1 1 — — 2 — — —
70%–74% — — — 1 — — — —
75%–84% — — — 1 — — — —
85% — — — 2 — — — —
WBC elevation — — 1 — — — — —
>10.0 109/L 2 1 — 1 3 — — —
>12.0 109/L — — — — — — — 2
>15.0 109/L — — — 2 — — — —
C-reactive protein
10–49 g/L — — — 1 — — — —
50 g/L — — — 2 — — — —
Positive ultrasounda — — — — — — 1 6
Foreign NRIC — — 1 — — — — —
Total score 10 10 17.5 12 10 32 4 15
Cut-offs for appendicitis 7 6 7.5 5 5 16 3 8
Abbreviations: AIR, appendicitis inflammatory response; MESH, pain migration, elevated WBC >10K, shift to left, positive heel drop; NRIC, National Registration Identity Card;
RIPASA, Raja Isteri Pengiran Anak Saleha Appendicitis; RLQ, right lower quadrant.
a
Appendix diameter >6 mm, surrounding echogenic inflamed fat and hyperemia in the wall on color Doppler.
17
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Table 2
Diagnostic accuracy of selected appendicitis clinical scoring systems
Sensitivity (%) Specificity (%) NPV (%) PPV (%) Accuracy (%)
Alvarado [32], 1986 72–90 44–81 46–87 39–92 56–82
PAS [33] 82–100 56–92 88–99 44–96 63–71
mAS [71] 83 37 83 37 51
mPAS [71] 87 30 85 36 47
Lintula et al [68], 2005 59–100 80–88 82–100 57–83 73
Tzanakis et al [70], 2005 95 97 94–97 72–97 97
Heidelberg [69] 91 94 95 89 —
AIR [67] 96 73 97 64 97
RIPASA [34] 88 67 53 93 —
Abbreviations: mAS, modified Alvarado score; mPAS, modified PAS; NPV, negative predictive value; PPV,
positive predictive value.
in children [38]. Additionally, the American College of Radiology recommends

that a CT should not be done for the evaluation of suspected appendicitis in
children until US has been performed [39]. However, even in children, the re-
ported diagnostic accuracy of US varies widely with sensitivities ranging from
44% to 94% and specificities ranging from 47% to 95% [40–45]. These varia-
tions in diagnostic accuracy are often due to operator experience, individual
practice use (a potential indirect correlate to experience), and standardized re-
porting (the use of templates to decrease indeterminate reports).
Adults
There are no current guidelines for the use of US in adult patients with suspected
appendicitis. A meta-analysis of 17 studies, encompassing 3358 adults, showed
overall US sensitivity and specificity to be 85% and 92%, respectively [46].
Fig. 3. Patient with acute appendicitis diagnosed on US. Characteristics of acute appendicitis
on this image include thickened, noncompressible appendix with thickened and hyperemic
walls. Dashed line measures appendiceal thickness at 1.4 cm.
Pregnancy
Diagnosing appendicitis during pregnancy can be challenging due to the
anatomic displacement of the appendix. Delayed diagnosis in this population
can have significant impact on maternal and fetal complications [47]. US during
pregnancy for suspected appendicitis has reported sensitivity and specificity
ranges from 67% to 100% and 83% to 96%, respectively [48]. In a recent
case-control study comparing the use of US in pregnant and nonpregnant
women, Segev and colleagues [49] report a PPV of 94% and 91%, respectively,
and an NPV of 40% and 43%, respectively. Based on these results, they sug-
gested that US diagnostic for appendicitis during pregnancy is highly accurate;
however, a negative US should prompt additional work-up. With similar re-
sults in nonpregnant women, this practice may be safe for all women who
have US for the diagnosis of appendicitis.
Effect of use and reporting on US reliability
Two factors that may increase reliability on US for the diagnosis of appendicitis
are increased use of US within a practice, and standardized result reporting.
Mittal and colleagues [50] reported hospitals with greater use of US had higher
sensitivity in diagnosing appendicitis when it was present. Sensitivity was 78%
at hospitals with at least 90% US use compared with 35% sensitivity in hospi-
tals with less than 10% use. Additionally, the use of a standardized US report-
ing template increases the sensitivity of US from 67% to 92% [51]. Standardized
reporting allows better communication between radiologists and clinicians, and
it can increase accuracy [52]. Table 3 compares 3 recently published US report-
ing templates. In patients with equivocal US findings, between 44% to 76%
were found to have appendicitis [51,53,54]. However, use of a standardized
US scoring rubric still demonstrated overall improvement in the sensitivity
and specificity for the diagnosis of appendicitis (Table 4).
MRI
MRI is another alternative for imaging appendicitis that offers some distinct
advantages over other advanced imaging modalities. Similar to CT scans,
an MRI is excellent for soft tissue evaluation and offers cross-sectional im-
ages; however, MRI has the added advantage of eliminating ionizing radia-
tion exposure when compared with CT. MRI also eliminates the operator
dependence of US. However, MRI availability is not as ubiquitous as CT
scanners and US. MRI availability may also be limited based on practice
setting or timing (nights and weekends). Other potential disadvantages to
the use of MRI in diagnosing appendicitis is the length of time it takes to com-
plete the study, which sometimes may necessitate the use of sedation in
young children, and potential cost differences compared with CT and US.
However, the use of MRI in the diagnosis of appendicitis is increasing with
novel improvements. New fast-sequence MRI imaging has been described,
which allows complete evaluation of the appendix with a median time of 5 mi-
nutes. These enhancements have led to decreased costs and need for sedation
in younger children [55].
20
Table 3
Comparison of 3 ultrasonography scoring templates and percentages of confirmed appendicitis within each category
Ultrasound scoring templates
Fallon Nielsen
et al [53] et al [51] Larson et al [54]
2015, 2015, 2015,
categories, % % categories, % % categories, % %
n ¼ 686 Description Total Appendicitis n ¼ 2031 Description Total Appendicitis n ¼ 1357 Description Total Appendicitis
1 Completely 40 1 1 Normal 38 1 Normal Appendix 30 .5
visualized appendix visualized and
normal- normal
appendix
2 Partially 3 0 2 Appendix not 43 3 Not visualized, Appendix not 48 4
visualized visualized or no secondary visualized and
normal- partially findings no findings to
appearing visualized support a
appendix without diagnosis of
3 Nonvisualized 23 10 secondary appendicitis
appendix signs of
without appendicitis
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ancillary
findings to
suggest
appendicitis
DIAGNOSING APPENDICITIS WITHOUT A CT SCAN?

4 Equivocal 5 44 3 Appendix not 3 76 Intermediate Appendix 5 26
visualized or likelihood visualized with
partially intermediate
visualized with likelihood of
secondary appendicitis
signs of Not visualized, Appendix not 4 39
appendicitis secondary visualized but
findings secondary
present findings of
acute
appendicitis
present
5a Acute 25 92 4 Acute 16 93 Positive Appendix 13 93
appendicitis appendicitis visualized with
without findings
perforation consistent with
acute
appendicitis
5b Perforated 5 100 — — — — — — — —
appendicitis
21
22 YU & SHAH
Table 4
Comparison of diagnostic accuracy of 3 ultrasonography scoring systems
Sensitivity (%) Specificity (%) NPV (%) PPV (%)
Fallon et al [53] 2015, Appy Score 93 93 85 97
Nielsen et al [51] 2015, Ultrasound 92 98 98 90
report template
Larson et al [54] 2015, Ultrasound 86 99 97 97
categories
Children
A recent meta-analysis of 11 pediatric studies with a total of 1698 subjects
found pooled sensitivity of 97%, specificity of 96%, PPV of 92%, and NPV
of 98% [56]. These results are comparable to the diagnostic accuracy of CT
and better than the diagnostic accuracy of US at many centers.
Adults
Similar results regarding MRI accuracy have been found in adults. A meta-
analysis of MRI in adults that included 9 studies and 363 subjects demonstrated
a sensitivity of 97% and specificity of 95% [57].
Pregnancy
Pregnant patients, similar to children, are another population in which there
has been a focus on the evaluation of the use of MRI for the diagnosis of appen-
dicitis to decrease exposure to ionizing radiation. During pregnancy, US and
MRI are recommended as initial imaging modalities [58]. In a multicenter retro-
spective review of 714 pregnant subjects, Burke and colleagues [59] found MRI
to have a sensitivity of 97%, specificity of 99%, diagnostic accuracy of 99%,
PPV of 92%, and NPV of 100%. Other reports also indicate shorter hospital
length of stay, decreased hospital charges, and greater cost-effectiveness
when using MRI for the evaluation of appendicitis during pregnancy [60,61].
DIAGNOSTIC ALGORITHMS
Similar to the use of clinical scoring systems, diagnostic algorithms are
becoming increasingly popular for the diagnosis of appendicitis. These algo-
rithms combine a variety of available diagnostic modalities (history, physical
examination, laboratory evaluation, clinical scoring systems, and advanced im-
aging modalities) to create a standardized pathway for the diagnosis of appen-
dicitis. In fact, recent guidelines by the Surgical Infection Society and the
Infectious Diseases Society of America recommended implementation of clin-
ical pathways to standardize diagnosis of appendicitis. These diagnostic algo-
rithms should be created by a multidisciplinary team of providers who are
involved in the care of patients with suspected appendicitis [62,63].
Children
Saucier and colleagues [64] recently reported that a clinical pathway combining
PAS and US resulted in increased sensitivity and specificity for the diagnosis of
pediatric appendicitis than PAS alone. However, during their prospective eval-
uation they were unable to assess the impact of the clinical pathway on CT use.
The authors created a diagnostic algorithm through a multidisciplinary quality
improvement initiative with the objective of decreasing CT use for the diag-
nosis of appendicitis in an academic children’s hospital emergency department.
This diagnostic algorithm used the PAS for risk stratification and then relied on
early surgical consultation for patients with a high probability of appendicitis
and prioritized US imaging over CT scans in all patients (Fig. 4). After imple-
mentation of the algorithm, CT use decreased from 75.4% to 24.2% (P<.0001)
and diagnostic accuracy remained high. The diagnostic pathway had a sensi-
tivity of 99% and specificity of 94% [65].
Adults
Various diagnostic algorithms for the evaluation of appendicitis have also been
proposed for adults. Poletti and colleagues [66] assessed the value of a diag-
nostic algorithm that uses US and a low-dose CT protocol. This algorithm
demonstrated a sensitivity of 99%, specificity of 97%, PPV of 97%, and
NPV of 99%.
DISCUSSION
The clinical evaluation of appendicitis with history, physical examination, and
laboratory studies may still serve a role in a straightforward patient presenta-
tion; however, the increased risk of a negative appendectomy or missed appen-
dicitis remains for many patients. In an era in which diagnostic adjuncts are
routinely available, it is difficult to expect clinicians to consistently rely on clin-
ical evaluation alone and accept these associated risks. Therefore, it is impor-
tant that clinicians are familiar with available diagnostic adjuncts and their
potential role in a specific practice setting or patient population.
Clinical scoring systems (ie, the Alvarado score and PAS) offer the potential
benefit of risk stratification and standardization of the initial diagnostic workup
between various providers; however, these tools are not accurate enough to be
used alone for the diagnosis of appendicitis. Additionally, many of the scoring
systems incorporate subjective assessments that may change from provider to
provider.
Advanced imaging modalities offer some distinct advantages for diagnosing
appendicitis; however, each of them also has limitations. US should be the
initial imaging modality of choice in all children and pregnant patients. The
use of US in adults shows great promise and should still be considered in
most adults. The limitations created by operator dependence are real; however,
this should be addressed through additional training and standardization of
technique and reporting. The most difficult limitation of US to overcome is
an obese patient population that may require additional imaging. MRI is a diag-
nostic test that should ultimately replace CT as the imaging modality reserved
for an indeterminate US. MRI has the same advantages as CT, with cross-
sectional imaging that allows excellent evaluation of the soft tissues, but it
24 YU & SHAH
Fig. 4. Diagnostic algorithm for suspected appendicitis, using PAS for risk stratification. Alt,
alternative. D/C, discharge; RLQ, right lower quadrant. (From Shah SR, Sinclair KA, Theut
SB, et al. Computed tomography utilization for the diagnosis of acute appendicitis in children
decreases with a diagnostic algorithm. Ann Surg 2016;264:475; with permission.)
eliminates the radiation exposure. Limitations often discussed include cost,

availability, and the length of time necessary to complete an MRI, which
may necessitate sedation in young children. However, many of these limita-
tions have been eliminated by the use of fast-sequence MRI, and selective
use after an indeterminate US has already become the standard at some insti-
tutions around the country. There is need to further evaluate the selective use
of fast-sequence MRI on different patient populations in various practice set-
tings, and findings should be disseminated rapidly, allowing for more wide-
spread adoption of successful techniques.
Diagnostic algorithms demonstrate great promise in combining numerous
diagnostic modalities into a standardized pathway to effectively diagnose
appendicitis. However, a single diagnostic algorithm will not meet the needs
of all patient populations and every practice setting. Instead, diagnostic algo-
rithms should be modified and validated by a multidisciplinary team to meet
the needs of different practice settings based on resources available.
Ultimately, the diagnosis of appendicitis can be made in most patients
without a CT scan. This can be accomplished by individual institutions estab-
lishing multidisciplinary diagnostic algorithms incorporating a standardized
clinical workup, risk stratification of patients, and selective imaging of patients.
Advanced imaging will have a necessary role in the algorithm; however, CT
should have a limited role only after the consideration of other imaging modal-
ities based on resources available.
References
[1] Buckius MT, McGrath B, Monk J, et al. Changing epidemiology of acute appendicitis in the
United States: study period 1993-2008. J Surg Res 2012;175:185–90.
[2] Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in
the United States in 1997. Surg Infect (Larchmt) 2004;5:160–5.
[3] Owens P, Thompson J, Elixhauser A, et al. Care of children and adolescents in U.S. Hospi-
tals. Rockville (MD): Agency for Healthcare Research and Quality; 2003. HCUP Fact Book
No. 4; AHRQ Publication No. 04-0004. Available at: https://archive.ahrq.gov/data/
hcup/factbk4/factbk4.pdf. Accessed April 22, 2017.
[4] Anderson JE, Bickler SW, Chang DC, et al. Examining a common disease with unknown eti-
ology: trends in epidemiology and surgical management of appendicitis in California,
1995-2009. World J Surg 2012;36:2787–94.
[5] Bhangu A, Soreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of path-
ogenesis, diagnosis, and management. Lancet 2015;386:1278–87.
[6] Rentea RM, Peter SD, Snyder CL. Pediatric appendicitis: state of the art review. Pediatr Surg
Int 2017;33(3):269–83.
[7] Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendec-
tomy in the United States. Am J Epidemiol 1990;132:910–25.
[8] Hernanz-Schulman M. CTand US in the diagnosis of appendicitis: an argument for CT. Radi-
ology 2010;255:3–7.
[9] Tsze DS, Asnis LM, Merchant RC, et al. Increasing computed tomography use for patients
with appendicitis and discrepancies in pain management between adults and children:
an analysis of the NHAMCS. Ann Emerg Med 2012;59:395–403.
[10] Glass CC, Rangel SJ. Overview and diagnosis of acute appendicitis in children. Semin Pe-
diatr Surg 2016;25:198–203.
[11] Goske MJ, Applegate KE, Boylan J, et al. The ‘Image Gently’ campaign: increasing CT ra-
diation dose awareness through a national education and awareness program. Pediatr Ra-
diol 2008;38:265–9.
[12] Rogers W, Hoffman J, Noori N. Harms of CT scanning prior to surgery for suspected appen-
dicitis. Evid Based Med 2015;20:3–4.
26 YU & SHAH
[13] Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and
subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet
2012;380:499–505.
[14] Golden SK, Harringa JB, Pickhardt PJ, et al. Prospective evaluation of the ability of clinical
scoring systems and physician-determined likelihood of appendicitis to obviate the need for
CT. Emerg Med J 2016;33:458–64.
[15] Callahan MJ, Anandalwar SP, MacDougall RD, et al. Pediatric CT dose reduction for sus-
pected appendicitis: a practice quality improvement project using artificial gaussian
noise–part 2, clinical outcomes. AJR Am J Roentgenol 2015;204:636–44.
[16] Berlin SC, Weinert DM, Vasavada PS, et al. Successful dose reduction using reduced tube
voltage with hybrid iterative reconstruction in pediatric abdominal CT. AJR Am J Roentgenol
2015;205:392–9.
[17] Goske MJ, Applegate KE, Boylan J, et al. Image Gently(SM): a national education and
communication campaign in radiology using the science of social marketing. J Am Coll Ra-
diol 2008;5:1200–5.
[18] Bulas DI, Goske MJ, Applegate KE, et al. Image gently: why we should talk to parents about
CT in children. AJR Am J Roentgenol 2009;192:1176–8.
[19] Callahan MJ, Kleinman PL, Strauss KJ, et al. Pediatric CT dose reduction for suspected
appendicitis: a practice quality improvement project using artificial Gaussian noise–part
1, computer simulations. AJR Am J Roentgenol 2015;204:W86–94.
[20] Bachur RG, Levy JA, Callahan MJ, et al. Effect of reduction in the use of computed tomogra-
phy on clinical outcomes of appendicitis. JAMA Pediatr 2015;169:755–60.
[21] Drake FT, Flum DR. Improvement in the diagnosis of appendicitis. Adv Surg 2013;47:
299–328.
[22] Pearl RH, Hale DA, Molloy M, et al. Pediatric appendectomy. J Pediatr Surg 1995;30:
173–8 [discussion: 8–81].
[23] Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA
1996;276:1589–94.
[24] Neumayer L, Kennedy A. Imaging in appendicitis: a review with special emphasis on the
treatment of women. Obstet Gynecol 2003;102:1404–9.
[25] Soreide K. The research conundrum of acute appendicitis. Br J Surg 2015;102:1151–2.
[26] Kharbanda AB, Cosme Y, Liu K, et al. Discriminative accuracy of novel and traditional bio-
markers in children with suspected appendicitis adjusted for duration of abdominal pain.
Acad Emerg Med 2011;18:567–74.
[27] Siddique K, Baruah P, Bhandari S, et al. Diagnostic accuracy of white cell count and C-
reactive protein for assessing the severity of paediatric appendicitis. JRSM Short Rep
2011;2:59.
[28] Beltran MA, Almonacid J, Vicencio A, et al. Predictive value of white blood cell count and C-
reactive protein in children with appendicitis. J Pediatr Surg 2007;42:1208–14.
[29] Bundy DG, Byerley JS, Liles EA, et al. Does this child have appendicitis? JAMA 2007;298:
438–51.
[30] Gonzalez Del Castillo J, Ayuso FJ, Trenchs V, et al. Diagnostic accuracy of the APPY1 Test in
patients aged 2-20 years with suspected acute appendicitis presenting to emergency de-
partments. Emerg Med J 2016;33(12):853–9.
[31] Benito J, Acedo Y, Medrano L, et al. Usefulness of new and traditional serum biomarkers in
children with suspected appendicitis. Am J Emerg Med 2016;34:871–6.
[32] Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med
1986;15:557–64.
[33] Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;37:877–81.
[34] Chong CF, Adi MI, Thien A, et al. Development of the RIPASA score: a new appendicitis
scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010;51:220–5.
[35] Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology
1986;158:355–60.
[36] Keller C, Wang NE, Imler DL, et al. Predictors of nondiagnostic ultrasound for appendicitis. J
Emerg Med 2017;52(3):318–23.
[37] Pinto Leite N, Pereira JM, Cunha R, et al. CTevaluation of appendicitis and its complications:
imaging techniques and key diagnostic findings. AJR Am J Roentgenol 2005;185:406–17.
[38] Howell JM, Eddy OL, Lukens TW, et al. Clinical policy: critical issues in the evaluation and
management of emergency department patients with suspected appendicitis. Ann Emerg
Med 2010;55:71–116.
[39] American College of Radiology. 2012. Available at: http://www.choosingwisely.org/
societies/american-college-of-radiology. Accessed April 22, 2017.
[40] Ramachandran P, Sivit CJ, Newman KD, et al. Ultrasonography as an adjunct in the diag-
nosis of acute appendicitis: a 4-year experience. J Pediatr Surg 1996;31:164–7 [discus-
sion: 7–9].
[41] Sivit CJ, Newman KD, Boenning DA, et al. Appendicitis: usefulness of US in diagnosis in a
pediatric population. Radiology 1992;185:549–52.
[42] Vignault F, Filiatrault D, Brandt ML, et al. Acute appendicitis in children: evaluation with US.
Radiology 1990;176:501–4.
[43] Crady SK, Jones JS, Wyn T, et al. Clinical validity of ultrasound in children with suspected
appendicitis. Ann Emerg Med 1993;22:1125–9.
[44] Wong KK, Cheung TW, Tam PK. Diagnosing acute appendicitis: are we overusing radio-
logic investigations? J Pediatr Surg 2008;43:2239–41.
[45] Rubin SZ, Martin DJ. Ultrasonography in the management of possible appendicitis in child-
hood. J Pediatr Surg 1990;25:737–40.
[46] Orr RK, Porter D, Hartman D. Ultrasonography to evaluate adults for appendicitis: decision
making based on meta-analysis and probabilistic reasoning. Acad Emerg Med 1995;2:
644–50.
[47] Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam Med
2006;19:621–6.
[48] Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in preg-
nancy. Emerg Med J 2007;24:359–60.
[49] Segev L, Segev Y, Rayman S, et al. The diagnostic performance of ultrasound for acute
appendicitis in pregnant and young nonpregnant women: a case-control study. Int J Surg
2016;34:81–5.
[50] Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of
appendicitis in children in a multicenter cohort. Acad Emerg Med 2013;20:697–702.
[51] Nielsen JW, Boomer L, Kurtovic K, et al. Reducing computed tomography scans for appen-
dicitis by introduction of a standardized and validated ultrasonography report template.
J Pediatr Surg 2015;50:144–8.
[52] Godwin BD, Simianu VV, Drake FT, et al. Is there a need to standardize reporting terminol-
ogy in appendicitis? Ultrasound Q 2015;31:92–4.
[53] Fallon SC, Orth RC, Guillerman RP, et al. Development and validation of an ultrasound
scoring system for children with suspected acute appendicitis. Pediatr Radiol 2015;45:
1945–52.
[54] Larson DB, Trout AT, Fierke SR, et al. Improvement in diagnostic accuracy of ultrasound of the
pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roent-
genol 2015;204:849–56.
[55] Johnson AK, Filippi CG, Andrews T, et al. Ultrafast 3-T MRI in the evaluation of children with
acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol
2012;198:1424–30.
[56] Moore MM, Kulaylat AN, Hollenbeak CS, et al. Magnetic resonance imaging in pediatric
appendicitis: a systematic review. Pediatr Radiol 2016;46:928–39.
[57] Barger RL Jr, Nandalur KR. Diagnostic performance of magnetic resonance imaging in the
detection of appendicitis in adults: a meta-analysis. Acad Radiol 2010;17:1211–6.
28 YU & SHAH
[58] Hawkins JD, Thirlby RC. The accuracy and role of cross-sectional imaging in the diagnosis of
acute appendicitis. Adv Surg 2009;43:13–22.
[59] Burke LM, Bashir MR, Miller FH, et al. Magnetic resonance imaging of acute appendicitis in
pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 2015;213:693.e1-6.
[60] Fonseca AL, Schuster KM, Kaplan LJ, et al. The use of magnetic resonance imaging in the
diagnosis of suspected appendicitis in pregnancy: shortened length of stay without increase
in hospital charges. JAMA Surg 2014;149:687–93.
[61] Kastenberg ZJ, Hurley MP, Luan A, et al. Cost-effectiveness of preoperative imaging for
appendicitis after indeterminate ultrasonography in the second or third trimester of preg-
nancy. Obstet Gynecol 2013;122:821–9.
[62] Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-
abdominal infection in adults and children: guidelines by the Surgical Infection Society and
the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010;11:79–109.
[63] Ahn S, Lee H, Choi W, et al. Clinical importance of the heel drop test and a new clinical
score for adult appendicitis. PLoS One 2016;11:e0164574.
[64] Saucier A, Huang EY, Emeremni CA, et al. Prospective evaluation of a clinical pathway for
suspected appendicitis. Pediatrics 2014;133:e88–95.
[65] Shah SR, Sinclair KA, Theut SB, et al. Computed Tomography utilization for the diagnosis of
acute appendicitis in children decreases with a diagnostic algorithm. Ann Surg 2016;264:
474–81.
[66] Poletti PA, Platon A, De Perrot T, et al. Acute appendicitis: prospective evaluation of a diag-
nostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT.
Eur Radiol 2011;21:2558–66.
[67] Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the
diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg
2008;32:1843–9.
[68] Lintula H, Pesonen E, Kokki H, et al. A diagnostic score for children with suspected appen-
dicitis. Langenbecks Arch Surg 2005;390:164–70.
[69] Boettcher M, Breil T, Gunther P. The Heidelberg appendicitis score simplifies identification of
pediatric appendicitis. Indian J Pediatr 2016;83:1093–7.
[70] Tzanakis NE, Efstathiou SP, Danulidis K, et al. A new approach to accurate diagnosis of
acute appendicitis. World J Surg 2005;29:1151–6 [discussion: 7].
[71] Khanafer I, Martin DA, Mitra TP, et al. Test characteristics of common appendicitis scores
with and without laboratory investigations: a prospective observational study. BMC Pediatr
2016;16:147.

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Advances in Surgery 51 (2017) 11–28

Can the Diagnosis of

Disclosures: The authors have nothing to disclose.

*Corresponding author. E-mail address: sohailshahmd@gmail.com

system is substantial. Total hospital days spent treating appendicitis annually is

Concerns for radiation exposure, especially its future oncologic impact on

HISTORY, PHYSICAL EXAMINATION, AND LABORATORY

factors in the diagnosis of appendicitis by history and physical examination

CLINICAL SCORING SYSTEMS

ALTERNATIVE ADVANCED IMAGING MODALITIES

DIAGNOSING APPENDICITIS WITHOUT A CT SCAN?

in children [38]. Additionally, the American College of Radiology recommends

DIAGNOSING APPENDICITIS WITHOUT A CT SCAN?

eliminates the radiation exposure. Limitations often discussed include cost,

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