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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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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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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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REFERENCES
1. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;
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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;
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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. Pittman-Waller 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), McGraw-Hill Health Pub. Division, New York 2005.
17. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: prospective
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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.
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51. Romero J, Sanabria A, Angarita M, Varn JC. Cost-effectiveness 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 reproductive-age women with right
lower quadrant abdominal pain: does its use reduce negative appendectomy rates and healthcare costs?
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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, Holland-Letz 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
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Topic 96169 Version 5.0
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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.
Graphic 83554 Version 2.0
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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.
Graphic 83555 Version 1.0
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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.
Graphic 83460 Version 2.0
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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.
Graphic 83459 Version 2.0
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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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