RLQ Pain: CT scan; ultrasound first in the pregnant

patient.
CT Abdomen and Pelvis
In a nonpregnant adult with RLQ pain and suspected appendicitis, a CT scan with oral and IV
contrast has become the imaging modality of choice. Before the advent of CT, the negative
appendectomy rate could be as high as 20% to 35%, which was considered acceptable because
removing a normal appendix was less likely to cause morbidity than removing a perforated one.
CT scan has dramatically reduced the negative appendectomy rate and is the study of choice with
a sensitivity of 92% to 97% and a specificity of 88% to 94%. It also allows the clinician to
differentiate other structures and possibly establish an alternate diagnosis when there is no
appendicitis.

Ultrasound
When approaching a pregnant patient with RLQ pain, it is important to consider studies that
will minimize radiation exposure to the fetus. As such, ultrasound with graded compression is
the first study of choice. This is highly operator-dependent, and in experienced hands it can have
a sensitivity of 85% and a specificity of 90%. Some sources advocate MRI as the next study of
choice for less radiation exposure and better accuracy, but this has not been sufficiently studied.
CT scan with IV and oral contrast is an excellent tool even in the pregnant patient, as the
cumulative radiation dose is below that which is considered dangerous for fetal exposure.