Acute Appendicitis in Adults Diagnostic

10/11/2015 Acute appendicitis in adults: Diagnostic evaluation
Official reprint from UpToDate®
www.uptodate.com ©2015 UpToDate®
Acute appendicitis in adults: Diagnostic evaluation
Author Section Editor Deputy Editor

Ronald F Martin, MD Martin Weiser, MD Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2015. | This topic last updated: Jul 24, 2014.
INTRODUCTION — The diagnosis of acute appendicitis is typically based upon the findings from the medical
history and clinical examination and is supported by the laboratory and/or imaging findings.
This topic will review the diagnostic studies, including radiographic studies and laboratory tests that can assist
in establishing the diagnosis of acute appendicitis in the adult. The clinical manifestations of acute appendicitis
and the operative and nonoperative management are reviewed as separate topics. (See "Acute appendicitis in
adults: Clinical manifestations and differential diagnosis" and "Management of acute appendicitis in adults".)
DIAGNOSIS — The diagnosis of acute appendicitis is generally made from the history and clinical
examination; the diagnosis is supported by the laboratory and/or imaging findings. The patient presenting with
acute abdominal pain should undergo a thorough physical examination, including a digital rectal examination.
Women should undergo a pelvic examination. (See "History and physical examination in adults with abdominal
pain".)
An experienced examiner can make the correct diagnosis of appendicitis without imaging [1]. Several studies
have found the diagnostic accuracy of clinical evaluation alone to be 75 to 90 percent [25]. The diagnostic
accuracy of the clinical examination may depend on the experience of the examining clinician [611]. Patients
in whom appendicitis is considered to be extremely likely after assessment by an experienced clinician should
proceed directly to appendectomy without further radiologic testing. (See "Management of acute appendicitis in
adults".)
The diagnosis of acute appendicitis can be difficult and a delay can result in perforation rates as high as 80
percent [12,13]. However, a retrospective review of 9048 adults with acute appendicitis found that the mean
time from presentation to operation (8.6 hours) was not associated with risk of perforation [14]. Factors
associated with increased risk of perforation included male gender (RR 1.24, 95% CI 1.081.43), increasing age
(RR 1.04, 95% CI 1.081.43), three or more comorbid illnesses (RR 2.8, 95% CI 1.363.49), and lack of
medical insurance coverage (RR 1.43, 95% CI 1.241.66).
The challenging clinical settings include [15]:
● Children less than 3 years of age (see "Acute appendicitis in children: Clinical manifestations and
diagnosis")
● Adults older than age 60 years (see "Management of acute appendicitis in adults", section on 'Elderly
patients')
● Women in the second and third trimesters of pregnancy, due to the displacement of the appendix by the
uterus and the resulting changes in the physical examination (see "Acute appendicitis in pregnancy")
No single feature or combination of features is a highly accurate predictor of acute appendicitis, although
prediction rules based upon combinations of features may have some clinical utility [2,1621].
Diagnostic scoring systems — Several scoring systems have been proposed to standardize the correlation of
clinical and laboratory variables.
The Alvarado score is the most widely used diagnostic aid for the diagnosis of appendicitis and has been
modified slightly since it was introduced [22,23]. However, clinical judgment remains paramount. For example,
a low modified Alvarado score (<4) is less sensitive than clinical judgement. In a prospective study of 261 adult
patients with clinically suspicious appendicitis, in whom 53 patients (20 percent) had a final diagnosis of
appendicitis, the low modified Alvarado score was less sensitive compared with unstructured clinical
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/acuteappendicitisinadultsdiagnosticevaluation?topicKey=SURG%2F96169&elapsedTimeMs=… 1/15
judgement (72 versus 93 percent sensitivity) [24]. A retrospective review of 74 patients with acute appendicitis
found that the Alvarado score was less sensitive and specific than CT imaging [25].
The modified Alvarado scale assigns a score to each of the following diagnostic criteria:
● Migratory right iliac fossa pain (1 point)
● Anorexia (1 point)
● Nausea/vomiting (1 point)
● Tenderness in the right iliac fossa (2 points)
● Rebound tenderness in the right iliac fossa (1 point)
● Fever >37.5°C (1 point)
● Leukocytosis (2 points)
A low Alvarado score (<5) has more diagnostic utility to “rule out” appendicitis than a high score (≥7) does to
“rule in” the diagnosis. In a systematic review of 42 retrospective and prospective studies that included over
8300 patients with suspected acute appendicitis and/or right iliac fossa pain, overall 99 percent of patients with
acute appendicitis had a score of ≥5 [26]. However, a high score (≥7) alone had poor diagnostic predictive
utility as the overall sensitivity was 82 percent and the specificity was 81 percent. The Alvarado score was
most accurate in men but overpredicted the probability of acute appendicitis in women in all risk groups.
A management guide based upon total points includes:
● A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be
discharged with advice to return if there was no improvement in symptoms, subject to social
circumstances.
● A patient with a score of 4 to 6 would be admitted for observation and reexamination. If the score
remains the same after 12 hours, operative intervention is recommended.
● A male patient with a score of 7 to 9 would proceed to appendectomy.
● A female patient who is not pregnant with a score of 7 to 9 would undergo diagnostic laparoscopy, then
appendectomy if indicated by the intraoperative findings. The surgical management of appendicitis during
pregnancy is discussed separately. (See "Acute appendicitis in pregnancy".)
Because of the challenges of diagnosing acute appendicitis in women, some authors have advocated
diagnostic laparoscopy to minimize the high falsenegative rate in women regardless of score [23], while others
have suggested using CT scans to help with the diagnosis of patients with an equivocal clinical presentation
and a score between 4 to 6 [27]. (See "Acute appendicitis in adults: Clinical manifestations and differential
diagnosis".)
Several other scoring systems have been described as well, but none are typically in common use [2830]. A
systematic review of several published scoring systems showed a diagnostic sensitivity of 53 to 99 percent
and specificity of 30 to 99 percent [31]. As a general rule, the addition of these decision aids to clinical
judgment has the potential to improve specificity and lead to lower falsepositive rates in diagnosis of acute
appendicitis, but decision aids cannot definitively determine or exclude the possibility of appendicitis [31].
DIAGNOSTIC EVALUATION
Imaging — Imaging modalities such as computed tomography (CT) and ultrasonography (US) are increasingly
used to support the clinical diagnosis of acute appendicitis. Although some studies suggest that the increased
use of imaging has decreased the nontherapeutic appendectomy rate (NAR) for acute appendicitis [32,33],
many surgeons will and should proceed with surgical exploration, in the absence of imaging, if there is strong
clinical support for appendicitis. (See "Acute appendicitis in adults: Clinical manifestations and differential
diagnosis", section on 'Clinical manifestations'.)
Based upon prospective trials and retrospective data, imaging studies do not improve the overall diagnostic
accuracy for acute appendicitis (image 1 and image 2); the diagnostic accuracy of an experienced surgeon is
comparable to CT scan imaging in the assessment of patients with an equivocal presentation of acute
appendicitis [2,4,5,7]. However, in a retrospective review, the CT scan changed the treatment plan in 58
percent of patients [34]. Differences in studies may, in part, be due to the experience of the surgeons and the
populations being evaluated. A prospective study of 2763 patients found that the sensitivity, specificity,
positive predictive value, and negative predictive value of preoperative evaluations included [5]:
● Ultrasonography
• 99.1, 91.7, 96.5, and 97.7 percent, respectively
● Computed tomography
● Clinical examination
Diagnostic imaging is unnecessary when the clinical diagnosis of acute appendicitis is nearly certain for either
presence or absence of appendicitis. Diagnostic imaging should be performed and is most likely to alter
treatment when the diagnosis of appendicitis is clinically suspected but unclear. Diagnostic imaging may be
useful in children, elder adults, or women of childbearing age with an unclear presentation. Similarly, patients
with comorbidities such as diabetes, obesity, and immunocompromise may have a higher occurrence of
atypical presentation of acute appendicitis. These populations are more likely to present with unclear
symptoms such as vague abdominal pain. (See "Acute appendicitis in children: Diagnostic imaging" and
"Management of acute appendicitis in adults", section on 'Special considerations' and "Acute appendicitis in
pregnancy", section on 'Diagnosis'.)
Computed tomography — Based upon retrospective reviews, adult women are more than twice as likely
as men to have a nontherapeutic appendectomy for acute appendicitis [33,3538], and, therefore, women may
benefit from a preoperative CT scan if the diagnosis is uncertain (image 3 and image 4). A retrospective review
of 1425 consecutive patients undergoing an appendectomy found that adult women evaluated with a
preoperative CT scan had a significantly lower nontherapeutic appendectomy rate (NAR) compared with adult
women without a preoperative diagnostic CT scan (21 versus 8 percent) [33]. There was no reduction in NAR
for men or children.
Preoperative CT protocols for imaging include:
● Standard abdominalpelvic CT with IV and oral contrast
● Focused appendiceal CT with rectal contrast
● Noncontrast CT
In most clinical settings, if there is sufficient diagnostic concern and uncertainty to warrant a CT scan to
diagnose appendicitis, a full abdominalpelvic CT with IV and oral contrast should be performed or a decision
should be made to proceed to the operating room for abdominal exploration by laparotomy or laparoscopy.
Standard CT scan with contrast — A commonly used protocol involves a standard abdominal and
pelvic CT scan (16MDCT or higher) with intravenous and oral contrast. (See "Principles of computed
tomography of the chest".)
A number of findings suggest acute appendicitis on standard abdominal CT scanning [21,39,40]:
● Enlarged appendiceal diameter >6 mm with an occluded lumen
● Appendiceal wall thickening (>2 mm)
● Periappendiceal fat stranding
● Appendiceal wall enhancement
● Appendicolith (seen in approximately 25 percent of patients)
The sensitivity and specificity of CT with IV and oral contrast for acute appendicitis is in the range of 91 to 98
and 75 to 93 percent, respectively [2,4,19,34,4143]. Air in the appendix or a contrastfilled lumen in a normal
appearing appendix virtually excludes the diagnosis. However, a nonvisualized appendix does not rule out
appendicitis. This is particularly important to remember in patients who have had symptoms for a short
duration, since only minimal inflammatory changes may be present in the right lower quadrant.
An advantage of a complete abdominal CT scan is that it permits visualization of the entire abdomen. An
alternative diagnosis is found in up to 15 percent of patients [34]. Furthermore, a CT scan can assist in the
treatment plan for patients with a palpable abdominal mass, such as those in whom an appendiceal phlegmon
or abscess may have developed. These features are more likely in patients who present after having prolonged
symptoms (four to five days). (See "Management of acute appendicitis in adults".)
A drawback of the standard CT protocol is that it takes up to two hours to administer oral contrast. In addition,
a CT scan involves radiation exposure and intravenous contrast, with the potential for contrastinduced renal
nephropathy. Cost and availability are also considerations, particularly in resourcepoor settings.
Appendiceal CT — A focused appendiceal CT scan can be performed with rectal contrast alone and
thin cuts through the right iliac fossa. Because full oral contrast is not given, the scan can be performed within
15 minutes. Rectal contrast provides good visualization of the pericecal region without the need to wait for oral
contrast to reach the right lower quadrant, which may be an unpleasant procedure for the patient.
In a report using a limited appendiceal CT scan with rectal contrast, the sensitivity of the most common
findings for acute appendicitis were as follows [21]:
● Right lower abdominal quadrant fat stranding (100 percent sensitivity)
● Focal cecal thickening (69 percent specificity)
● Adenopathy (63 percent sensitivity)
One study reported that a focal appendiceal CT had 98 percent accuracy and sensitivity with rectal contrast
along a limited area (15 cm) of the pelvis centered 3 cm superior to the cecal tip [17,44].
The relevance of focal appendiceal imaging is questionable outside of large medical centers, as this technique
requires personnel to administer rectal contrast and a radiologist on site for the verification of positioning. In
addition, an appendiceal CT scan only evaluates the appendix, and the images may be unrevealing in the
presence of other abdominal pathology.
Unenhanced CT — The administration of contrast for imaging adds time, expense, and risk of an
allergic reaction. A number of studies have suggested that adequate imaging can be obtained without contrast.
In various reports, unenhanced CT had a sensitivity of 88 to 96 percent, specificity of 91 to 98 percent, and
diagnostic accuracy of 94 to 97 percent for appendicitis, with the added advantage of total exam time of 5 to 15
minutes [7,45,46].
Test characteristics may depend, at least in part, upon the patient's body habitus [2]. Some radiologists
maintain that if the BMI exceeds 25 that the CT is less accurate and therefore oral contrast is necessary.
An important limitation of unenhanced CT is the diminished ability to diagnose other abdominal pathology,
potentially diminishing the role of the examination in patients in whom there is diagnostic uncertainty (eg, elder
patients, women, atypical presentation).
Unenhanced CT may be of some value in patients who have renal failure or clinical instability. However, for
most patients where there is sufficient diagnostic uncertainty to warrant a CT scan for appendicitis, a full
abdominalpelvic CT with IV and oral contrast should be performed or a decision should be made to proceed to
the operating room for abdominal exploration.
Ultrasonography — Ultrasound (US) is reliable to confirm the clinical diagnosis of acute appendicitis, but
is not reliable to exclude the diagnosis (image 5 and image 6) [47]. Accuracy is diminished in obese patients.
At least eight sonographic findings suggestive of internal inflammatory changes of the appendix have been
described [4850]. The most accurate ultrasound finding for acute appendicitis is an appendiceal diameter of >6
mm with a sensitivity, specificity, negative predictive value, and positive predictive value of 98 percent [49,50].
In various reports, the sensitivity and specificity by US in the diagnosis of appendicitis ranged from 35 to 98
percent and 71 to 98 percent, respectively [2,7,33,36].
Advantages of US compared with CT imaging include:
● Results may be obtained more efficiently (institution and practitioner dependent)
● No radiation exposure
● No use of intravenous or intestinal contrast agents
Disadvantages of US compared with CT imaging include:
● Less diagnostic accuracy
● Less likely to reveal an accurate alternative diagnosis
● Accuracy is operator dependent
● Technical challenges: Patients with a large body habitus and/or a large amount of overlying bowel gas
Imaging costs — The use of preoperative imaging studies in the diagnosis of acute appendicitis has
increased with time, from 32 percent (1995 through 1999) to 95 percent (2001 through 2008), at one
representative academic institution [33]. The increase in the use of CT scanning for the diagnosis of
appendicitis has been largely justified by the assumption that it decreases the rates of perforated appendicitis
as well as nontherapeutic appendectomies [51,52]. In two studies that performed cost analysis, one showed
that the cost of a nontherapeutic appendectomy was 16 times more expensive than a focused appendiceal CT
scan, while another reported that an appendectomy was 22 times more expensive than nonenhanced CT
scanning, implying cost savings if a reduction in nontherapeutic appendectomy rates could be achieved
[46,53]. However, in one retrospective review, most patients undergoing a nontherapeutic appendectomy had a
preoperative CT scan, and more than 50 percent of those patients had CT interpretations that were positive for,
or could not exclude, acute appendicitis [33].
Several studies have failed to demonstrate a significant reduction in the overall institutional rates for
nontherapeutic appendectomies despite the increased use of CT scan over time [19,34,35,37,41,5456].
Results of studies that included analysis of perforated appendicitis are mixed. One study showed an observed
rate of appendiceal perforation of 9 percent in patients who underwent routine CT imaging compared with 25
percent in patients in whom CT scanning was not used [37]. Other studies have demonstrated a fairly constant
rate of perforated appendix over time despite the increased use of CT scan [33,35,56].
Cost analysis for studies such as these is complicated by the value of CT scanning in patients in whom
therapeutic appendectomy was performed; as a result, the cost savings depend upon an absolute rate
reduction for nontherapeutic appendectomies [34,57]. Additionally, cost calculations depend upon local
institutional variables and surgeon variables; selected institutional observations may not be applicable to all
practices.
Laboratory tests — Laboratory tests serve a supportive role in the diagnosis of appendicitis. No single
laboratory test or combination of tests is an absolute marker for appendicitis [49,54].
A complete blood count (CBC) with a differential should be obtained, but cannot be used to confirm or exclude
the diagnosis of appendicitis. A mild leukocytosis and a left shift (increase in total white blood cell count,
bands [immature neutrophils], and neutrophils) can be present in acute appendicitis as well as other acute
etiologies of abdominal pain.
A pregnancy test should be performed for all women of childbearing age.
Although mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been noted to be a marker for
appendiceal perforation with a sensitivity of 70 percent and a specificity of 86 percent [58], the test is not
discriminatory and generally not helpful in the evaluation of patients suspected of acute appendicitis.
Exploratory laparotomy/laparoscopy — The acceptable nontherapeutic appendectomy rate (NAR) varies
depending upon the age and sex of the patient. For example, in young healthy males with right lower quadrant
pain, the negative appendectomy rate (NAR) should be less than 10 percent, while a rate that approaches 20
percent is reasonable in young women in whom other pelvic processes can make accurate diagnosis more
difficult (eg, pelvic inflammatory diseases, tuboovarian abscess) [45,59].
No significant difference in NAR was noted in comparing laparoscopic and open appendectomy [33]. A low
NAR has been achieved in some centers that use close inhospital observation [60].
SUMMARY
● The constellation of findings from history, physical examination, and laboratory studies will usually lead
an experienced examiner to the correct diagnosis of appendicitis without diagnostic imaging (see
'Diagnosis' above). A clinical diagnosis can be more challenging in women, who may benefit from the
addition of radiologic imaging when the diagnosis is unclear.
● The patient presenting with acute abdominal pain should undergo a thorough physical examination,
including a digital rectal examination. Women should undergo a pelvic examination. (See 'Diagnosis'
above and "History and physical examination in adults with abdominal pain".)
● Based upon prospective trials and retrospective data, imaging studies do not improve the overall
diagnostic accuracy for acute appendicitis (image 1 and image 2); the diagnostic accuracy of an
experienced surgeon is comparable to CT scan imaging in the assessment of patients with an equivocal
presentation of acute appendicitis. (See 'Imaging' above.)
● Diagnostic imaging is advised when the diagnosis of appendicitis is suspected but unclear (eg, elderly
patients, patients with comorbid illnesses, women of childbearing age). In this clinical setting, we perform
a standard abdominal CT scan with intravenous and oral contrast. (See 'Standard CT scan with contrast'
above.)
● Ultrasound (US) is reliable to confirm the clinical diagnosis of acute appendicitis, but is not reliable to
exclude the diagnosis (image 5 and image 6). (See 'Ultrasonography' above.)
● Laboratory tests serve a supportive role in the diagnosis of appendicitis. No single laboratory test or
combination of tests is an absolute marker for appendicitis. However, a complete blood count and a
pregnancy test in premenopausal women should be obtained in patients with acute abdominal pain, but
cannot confirm or exclude a diagnosis of acute appendicitis. (See 'Laboratory tests' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Andersson RE. Metaanalysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;
91:28.
2. 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; 136:556.
3. Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984; 200:567.
4. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus
computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003; 4:231.
5. Park JS, Jeong JH, Lee JI, et al. Accuracies of diagnostic methods for acute appendicitis. Am Surg
2013; 79:101.
6. Kosloske AM, Love CL, Rohrer JE, et al. The diagnosis of appendicitis in children: outcomes of a
strategy based on pediatric surgical evaluation. Pediatrics 2004; 113:29.
7. Morris KT, Kavanagh M, Hansen P, et al. The rational use of computed tomography scans in the
diagnosis of appendicitis. Am J Surg 2002; 183:547.
8. Liu CC, Lu CL, Yen DH, et al. Diagnosis of appendicitis in the ED: comparison of surgical and
nonsurgical residents. Am J Emerg Med 2001; 19:109.
9. Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the
diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med 2003;
10:296.
10. Kharbanda AB, Fishman SJ, Bachur RG. Comparison of pediatric emergency physicians' and surgeons'
evaluation and diagnosis of appendicitis. Acad Emerg Med 2008; 15:119.
11. Yen K, Karpas A, Pinkerton HJ, Gorelick MH. Interexaminer reliability in physical examination of
pediatric patients with abdominal pain. Arch Pediatr Adolesc Med 2005; 159:373.
12. Daehlin L. Acute appendicitis during the first three years of life. Acta Chir Scand 1982; 148:291.
13. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly. Am J Surg 1990; 160:291.
14. Drake FT, Mottey NE, Farrokhi ET, et al. Time to appendectomy and risk of perforation in acute
appendicitis. JAMA Surg 2014; 149:837.
15. PittmanWaller VA, Myers JG, Stewart RM, et al. Appendicitis: why so complicated? Analysis of 5755
consecutive appendectomies. Am Surg 2000; 66:548.
16. Jaffe, BM, Berger, DH. The Appendix. In: Schwartz Principles of Surgery, 8th ed, Schwartz, SI,
Brunicardi, CF (Ed), McGrawHill Health Pub. Division, New York 2005.
17. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis:
prospective evaluation of a focused appendix CT examination. Radiology 1997; 202:139.
18. Hale DA, Molloy M, Pearl RH, et al. Appendectomy: a contemporary appraisal. Ann Surg 1997; 225:252.
19. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on
the results to diagnose an acute appendicitis? Curr Surg 2006; 63:464.
20. Townsend, CM, Beauchamp, RD, Evers, BM, Mattox, KL. Sabiston Textbook of Surgery, 18th ed,
Saunders Elsevier, Philadelphia, PA 2007.
21. Rao PM, Rhea JT, Novelline RA. Sensitivity and specificity of the individual CT signs of appendicitis:
experience with 200 helical appendiceal CT examinations. J Comput Assist Tomogr 1997; 21:686.
22. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15:557.
23. Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of
acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994; 76:418.
24. Meltzer AC, Baumann BM, Chen EH, et al. Poor sensitivity of a modified Alvarado score in adults with
suspected appendicitis. Ann Emerg Med 2013; 62:126.
25. Ozkan S, Duman A, Durukan P, et al. The accuracy rate of Alvarado score, ultrasonography, and
computerized tomography scan in the diagnosis of acute appendicitis in our center. Niger J Clin Pract
2014; 17:413.
26. Ohle R, O'Reilly F, O'Brien KK, et al. The Alvarado score for predicting acute appendicitis: a systematic
review. BMC Med 2011; 9:139.
27. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform
computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007; 25:489.
28. Horzić M, Salamon A, Kopljar M, et al. Analysis of scores in diagnosis of acute appendicitis in women.
Coll Antropol 2005; 29:133.
29. Ohmann C, Franke C, Yang Q. Clinical benefit of a diagnostic score for appendicitis: results of a
prospective interventional study. German Study Group of Acute Abdominal Pain. Arch Surg 1999;
134:993.
30. Enochsson L, Gudbjartsson T, Hellberg A, et al. The FenyöLindberg scoring system for appendicitis
increases positive predictive value in fertile womena prospective study in 455 patients randomized to
either laparoscopic or open appendectomy. Surg Endosc 2004; 18:1509.
31. Liu JL, Wyatt JC, Deeks JJ, et al. Systematic reviews of clinical decision tools for acute abdominal
pain. Health Technol Assess 2006; 10:1.
32. SCOAP Collaborative, Cuschieri J, Florence M, et al. Negative appendectomy and imaging accuracy in
the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008; 248:557.
33. Wagner PL, Eachempati SR, Soe K, et al. Defining the current negative appendectomy rate: for whom is
preoperative computed tomography making an impact? Surgery 2008; 144:276.
34. Schuler JG, Shortsleeve MJ, Goldenson RS, et al. Is there a role for abdominal computed tomographic
scans in appendicitis? Arch Surg 1998; 133:373.
35. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A
populationbased analysis. JAMA 2001; 286:1748.
36. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic
imaging. J Am Coll Surg 2005; 201:933.
37. Jones K, Peña AA, Dunn EL, et al. Are negative appendectomies still acceptable? Am J Surg 2004;
188:748.
38. Wilson EB. Surgical evaluation of appendicitis in the new era of radiographic imaging. Semin Ultrasound
CT MR 2003; 24:65.
39. Whitley S, Sookur P, McLean A, Power N. The appendix on CT. Clin Radiol 2009; 64:190.
40. Choi D, Park H, Lee YR, et al. The most useful findings for diagnosing acute appendicitis on contrast
enhanced helical CT. Acta Radiol 2003; 44:574.
41. Perez J, Barone JE, Wilbanks TO, et al. Liberal use of computed tomography scanning does not improve
diagnostic accuracy in appendicitis. Am J Surg 2003; 185:194.
42. Gaitini D, BeckRazi N, MorYosef D, et al. Diagnosing acute appendicitis in adults: accuracy of color
Doppler sonography and MDCT compared with surgery and clinical followup. AJR Am J Roentgenol
2008; 190:1300.
43. Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and
ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004; 141:537.
44. Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only
through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol 1997; 169:1275.
45. Ege G, Akman H, Sahin A, et al. Diagnostic value of unenhanced helical CT in adult patients with
suspected acute appendicitis. Br J Radiol 2002; 75:721.
46. Lane MJ, Katz DS, Ross BA, et al. Unenhanced helical CT for suspected acute appendicitis. AJR Am J
Roentgenol 1997; 168:405.
47. Lee SL, Ho HS. Ultrasonography and computed tomography in suspected acute appendicitis. Semin
Ultrasound CT MR 2003; 24:69.
48. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337.
49. Kessler N, Cyteval C, Gallix B, et al. Appendicitis: evaluation of sensitivity, specificity, and predictive
values of US, Doppler US, and laboratory findings. Radiology 2004; 230:472.
50. Jeffrey RB Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases.
Radiology 1988; 167:327.
51. Romero J, Sanabria A, Angarita M, Varón JC. Costeffectiveness of computed tomography and
ultrasound in the diagnosis of appendicitis. Biomedica 2008; 28:139.
52. Morse BC, Roettger RH, Kalbaugh CA, et al. Abdominal CT scanning in reproductiveage women with
right lower quadrant abdominal pain: does its use reduce negative appendectomy rates and healthcare
costs? Am Surg 2007; 73:580.
53. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of
patients and use of hospital resources. N Engl J Med 1998; 338:141.
54. Johansson EP, Rydh A, Riklund KA. Ultrasound, computed tomography, and laboratory findings in the
diagnosis of appendicitis. Acta Radiol 2007; 48:267.
55. Rao PM, Rhea JT, Rattner DW, et al. Introduction of appendiceal CT: impact on negative appendectomy
and appendiceal perforation rates. Ann Surg 1999; 229:344.
56. DeArmond GM, Dent DL, Myers JG, et al. Appendicitis: selective use of abdominal CT reduces negative
appendectomy rate. Surg Infect (Larchmt) 2003; 4:213.
57. Lin KH, Leung WS, Wang CP, Chen WK. Cost analysis of management in acute appendicitis with CT
scanning under a hospital global budgeting scheme. Emerg Med J 2008; 25:149.
58. Sand M, Bechara FG, HollandLetz T, et al. Diagnostic value of hyperbilirubinemia as a predictive factor
for appendiceal perforation in acute appendicitis. Am J Surg 2009; 198:193.
59. Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are no longer acceptable. Am
J Surg 1997; 174:723.
60. White JJ, Santillana M, Haller JA Jr. Intensive inhospital observation: a safe way to decrease
unnecessary appendectomy. Am Surg 1975; 41:793.
Topic 96169 Version 5.0
GRAPHICS
CT scan equivocal appendicitis
The patient is a 56yearold male who presents with right lower quadrant pain. The CT scan
of the lower abdomen in the axial plane (A) and the magnified view of the appendix (B)
show a normal sized appendix with surrounding induration (red arrow). The periappendiceal
induration raises the possibility of appendicitis. The associated thickening of the posterior
peritoneum (orange arrow) suggests an acute process in the right lower quadrant. However,
the epicenter of induration (yellow arrow in A and B) in the region of the tip of the liver (L)
and ascending colon (C) suggests that the process likely originates in that region. Thus the
process around the appendix is secondary and not primary to the appendix.
Graphic 83554 Version 1.0
Ultrasound equivocal appendicitis
The gray scale ultrasound of the appendix is projected in the longitudinal (A) and transverse
planes (B). The appearance of the appendix is near normal except for a diameter that
measures 7.6 mm in the long axis, and a diameter that measures between 7 and 9 mm in
the transverse plane. Since this diameter should be 6 mm or less, the diagnosis of
appendicitis is entertained. There is no loculated fluid around the appendix and no free fluid
present in the peritoneal cavity. The echogenic line of the mucosa and submucosa is intact
and the lumen is distended with complex material (arrow). The findings of the enlarged
diameter with no other specific pathognomonic features make the diagnosis of acute
appendicitis equivocal.
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/acuteappendicitisinadultsdiagnosticevaluation?topicKey=SURG%2F96169&elapsedTimeMs… 10/15
CT scan normal appendix
CT scan depicts a normal appendix. The figure on the left shows an appendiceal lumen
containing air and wall thickness of 3 mm (yellow arrow). The figure on the right shows the
tip of the normal appendix (green arrow) that measures 6 mm and no associated induration.
CT scan acute appendicitis
The CT scan was obtained using oral and intravenous contrast from a patient who presented
with right lower quadrant abdominal pain. These figures show an inflammed appendix that
measures 21 mm in diameter and contains an appendicolith and fluid that is likely purulent.
(A) Shows an appendicolith in the appendix using a white arrow.
(B) Shows the appendicolith, an overlay of orange to show fluid inside the appendix, and a
yellow arrow indicates free fluid.
(C) Shows the enlarged appendix and fluid without an overlay.
(D) Shows a colored overlay: red circle depicts the enhancing appendiceal wall; orange
depicts the intraappendiceal fluid; yellow depicts the free fluid.
Normal appendix on ultrasound
Ultrasound image of a normal appendix (red arrow and markers). The
appendix is located at the confluence of the taenia coli (white arrows)
and is seen in relationship to the cecum (COE). Fluid filled small
bowel (DD) and iliac vessels (VI) are also indicated.
Courtesy of Christoph F Dietrich, MD.
Doppler ultrasound of appendicitis
In this doppler ultrasound image of appendicitis, the appendix appears
edematous (9 x 8 mm) and hypervascular. The layers of the wall are
still detectable. Continued inflammation may be followed by localized
ischemia (which may be visualized by color Doppler imaging) and
necrosis. Sonographic findings were confirmed at surgery.
Courtesy of Christoph F Dietrich, MD.
Disclosures
Disclosures: Ronald F Martin, MD Nothing to disclose. Martin Weiser, MD Nothing to disclose. Wenliang Chen, MD, PhD Nothing
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multilevel review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Acute Appendicitis in Adults Diagnostic

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Acute Appendicitis in Adults Diagnostic

Enviado por

Direitos autorais:

Formatos disponíveis

10/11/2015 Acute appendicitis in adults: Diagnostic evaluation

Author Section Editor Deputy Editor

Você também pode gostar