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Official reprint from UpToDate


www.uptodate.com 2016 UpToDate

Acute appendicitis in adults: Diagnostic evaluation


Author
Ronald F Martin, MD

Section Editor
Martin Weiser, MD

Deputy Editor
Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2016. | 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.
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 [2-5]. The diagnostic
accuracy of the clinical examination may depend on the experience of the examining clinician [6-11]. 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 1.08-1.43), increasing age (RR 1.04,
95% CI 1.08-1.43), three or more comorbid illnesses (RR 2.8, 95% CI 1.36-3.49), and lack of medical insurance
coverage (RR 1.43, 95% CI 1.24-1.66).
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 [2,16-21].
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 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].

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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 >37.5C (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 over-predicted 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 re-examination. 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 false-negative 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 [28-30]. 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 false-positive 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

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99.1, 91.7, 96.5, and 97.7 percent, respectively


Computed tomography
96.4, 95.4, 95.6, and 96.3 percent, respectively
Clinical examination
99.0, 76.1, 88.1, and 97.6 percent, respectively
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 [33,35-38], 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 abdominal-pelvic 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 abdominal-pelvic 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 (16-MDCT 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 [2,4,19,34,41-43]. Air in the appendix or a contrast-filled 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".)

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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 contrast-induced renal
nephropathy. Cost and availability are also considerations, particularly in resource-poor 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 [48-50]. 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

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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 [19,34,35,37,41,54-56]. 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, tubo-ovarian 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 in-hospital 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.)

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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.)
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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 in-hospital observation: a safe way to decrease unnecessary
appendectomy. Am Surg 1975; 41:793.
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GRAPHICS
CT scan equivocal appendicitis

The patient is a 56-year-old 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 (arrowhead). The periappendiceal
induration raises the possibility of appendicitis. The associated thickening of the posterior
peritoneum (dashed arrow) suggests an acute process in the right lower quadrant. However,
the epicenter of induration (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.
CT: computed tomography.
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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.
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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 (arrow). The figure on the right shows the tip of the
normal appendix (arrowhead) that measures 6 mm and no associated induration.
CT: computed tomography.
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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 an 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 intra-appendiceal fluid; yellow depicts the free fluid.
CT: computed tomography.
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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.
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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.
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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
multi-level 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

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