Acute appendicitis in adults: Diagnostic evaluation

Authors:
Ronald F Martin, MD
Stella K Kang, MD, MS
Section Editor:
Martin Weiser, MD
Deputy Editor:
Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Dec 2019. | This topic last updated: Oct 16, 2019.

INTRODUCTIONAppendicitis is common and is seen in up to 1 in 10 individuals

over a lifetime. Most cases present between the ages of 10 and 30 years. There is a
slight male predominance among patients presenting before age 30 (male:female ratio
approximately 3:2). (See "Acute appendicitis in adults: Clinical manifestations and
differential diagnosis", section on 'Epidemiology'.)

This topic reviews the diagnostic evaluation of suspected appendicitis in nonpregnant

adults, incorporating the clinical evaluation, laboratory tests, and imaging exams.
Diagnosis of appendicitis in children and pregnant women is discussed separately, as
are the pathogenesis, clinical manifestations, differential diagnosis, and management.
(See "Acute appendicitis in children: Clinical manifestations and diagnosis" and
"Acute appendicitis in pregnancy" and "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis" and "Management of acute appendicitis in
adults".)

GENERAL APPROACHThe evaluation of patients with suspected appendicitis is

driven by the goal of identifying all patients presenting with acute appendicitis as
early in their clinical course as possible while minimizing the nontherapeutic
laparoscopy/laparotomy rate. Missed diagnosis of appendicitis, especially when
perforated, can result in severely adverse patient outcomes, while nontherapeutic
operations incur surgical morbidity without treating the underlying condition.

The Alvarado score (table 1) uses data from the history, physical exam, and
laboratory testing to describe the clinical likelihood of acute appendicitis. Those with
a low Alvarado score are triaged for evaluation of alternative diagnoses. In those with
a higher Alvarado score, imaging and surgical laparoscopic exploration are used to
improve the specificity of evaluation and to minimize the likelihood of a negative
laparotomy (algorithm 1).

The evaluation for appendicitis in nonpregnant adults can be particularly challenging

in several populations, including:

●Women of reproductive age

●Elderly and frail (eg, immunosuppressed, multiple comorbidities)

In women of reproductive age, gynecologic pathologies (eg, pelvic inflammatory
disease, adnexal torsion) can mimic appendicitis clinically. Elderly and frail patients
can present with nonclassical or nonspecific clinical features.

Negative appendectomy rate (nontherapeutic operative rate) — The negative

appendectomy rate (NAR), also referred to as the nontherapeutic operative rate, for
presumed appendicitis is defined as the proportion of all vermiform appendix
specimens submitted without pathologic evidence of acute inflammation and is
considered a quality metric in the treatment of appendicitis. Historically, the
acceptable NAR has varied depending upon patient age and gender and availability of
imaging. In young healthy males with right lower quadrant pain, an NAR less than 10
percent has been considered acceptable, while a rate that approaches 20 percent was
often seen in women of reproductive age in whom other pelvic processes can
confound the evaluation [1,2]. Observed NAR have decreased in the past decade,
which is likely attributable, in part, to the increased utilization of imaging [3].

Studies show that the addition of computed tomography (CT) or ultrasound to the
clinical evaluation of suspected appendicitis is associated with a reduction in NAR
without an associated increase in perforation rate [4-9]. In a retrospective study of
19,327 patients at 55 hospitals in Washington state over six years, the odds of
negative appendectomy for patients not imaged were 3.7 times higher than those who
received imaging (95% CI 3.0-4.4) [9]. The benefit of imaging was independent of
age, sex, and white blood cell (WBC) count. Appendiceal perforation was the same
between patients who were and were not imaged (18.8 versus 15.6 percent).

Adult women are more than twice as likely as men to have a nontherapeutic
appendectomy for suspected acute appendicitis [4,10-13]. Imaging with CT can
decrease the NAR in this population. A single-center retrospective review of 1425
consecutive patients found that adult women evaluated with a preoperative CT had a
significantly lower NAR compared with those who did not undergo CT (21 versus 8
percent) [4].

Perforation — A proportion of appendicitis results in perforation, which can lead to

life-threatening complications if left untreated, including intra-abdominal infection,
sepsis, intraperitoneal abscesses, and, rarely, death [14]. A few hours of delay
between patient presentation with symptoms and treatment does not appear to be
associated with an increased risk of perforation.

The perforation rate in hospital admissions for acute appendicitis in the United States
from 2001 to 2010 was 30 percent [15], but rates as high as 80 percent have been
reported in specific high-risk populations [16]. Retrospective review of 9048 adults
with acute appendicitis found the factors associated with increased risk of perforation
to be [17]:

●Male gender (risk ratio [RR] 1.24, 95% CI 1.08-1.43)

●Increasing age (RR 1.04, 95% CI 1.03-1.04)

●Three or more comorbid illnesses (RR 2.8, 95% CI 1.36-3.49)

●Lack of medical insurance coverage (RR 1.43, 95% CI 1.24-1.66)

In this study, the mean time from presentation to operation (8.6 hours) was not
associated with risk of perforation [17].

INITIAL EVALUATION

Clinical evaluation — The diagnostic accuracy of the clinical evaluation for acute

appendicitis depends on the experience of the examining physician [18-23]. The
patient presenting with acute abdominal pain should undergo a thorough physical
examination, including a digital rectal examination. Women should undergo a pelvic
examination. Women of reproductive age should be queried regarding the possibility
of pregnancy.

Clinical symptoms and signs suggestive of appendicitis include a history of central

abdominal pain migrating to the right lower quadrant, anorexia, fever, and
nausea/vomiting. On examination, right lower quadrant tenderness, along with
classical signs of peritoneal irritation (eg, rebound tenderness, guarding, rigidity,
referred pain), may be present. Other signs (eg, the psoas or obturator signs) may help
the clinician localize the inflamed appendix [24,25]. This is discussed in more detail
separately. (See "Acute appendicitis in adults: Clinical manifestations and differential
diagnosis", section on 'Clinical manifestations'.)

Importantly, a high index of suspicion for the diagnosis of appendicitis should be

maintained when evaluating the elderly and frail, who can present with nonclassical
symptoms (eg, generalized abdominal pain, lack of leukocytosis).

Laboratory tests — The laboratory evaluation of patients with suspected appendicitis

should include:

●White blood cell (WBC) count with differential

●Serum C-reactive protein (CRP)

●Serum pregnancy test in women of childbearing age

The diagnostic performance of the first two studies is moderate individually, but
sensitivity improves substantially in combination (table 2) [26]. Some limited
evidence also suggests that repeated laboratory evaluation (WBC, CRP) may boost
the sensitivity in detecting appendicitis, especially in patients who present early [27].
However, no WBC count or CRP level can safely and sufficiently confirm or exclude
the suspected diagnosis of acute appendicitis. As an example, one retrospective
multicenter study of 1024 adults with suspected appendicitis reported that with a
disease prevalence of 57 percent (580 diagnosed with appendicitis), an abnormal
cutoff value of WBC >10 x 109/L or CRP >10 mg/L yielded a positive predictive
value (PPV) of 61.5 (95% CI 58.4–64.7) and a negative predictive value (NPV) of
88.1 (95% CI 81.8–94.4) [28].

Although mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been
noted to be a marker for appendiceal perforation with sensitivity of 70 percent and a
specificity of 86 percent [29], the test is not discriminatory and generally not helpful
in the evaluation of patients suspected of acute appendicitis.

Alvarado score calculation — The Alvarado score can be used to identify patients

with a very low likelihood of acute appendicitis so as to triage them to evaluation for
other causes of abdominal pain. Patients with a high Alvarado score should be further
evaluated with imaging prior to treatment.

While several scoring systems have been proposed to standardize the clinical and
laboratory assessment for acute appendicitis [30-32], the modified Alvarado score is
the most widely used [33,34].

The modified Alvarado scale assigns a score to each of the following diagnostic
criteria (table 1):

●Migratory right lower quadrant pain (1 point)

●Anorexia (1 point)

●Nausea or vomiting (1 point)

●Tenderness in the right lower quadrant (2 points)

●Rebound tenderness in the right lower quadrant (1 point)

●Fever >37.5°C (>99.5°F) (1 point)

●Leukocytosis of WBC count >10 x 109/L (2 points)

The score is obtained by summing the components. Higher values indicate higher
probability of appendicitis. The maximum total score is 9. The original Alvarado
score included left shift as an additional factor, resulting in a total score of 10 [33].

Scores of <4 and <5 have both been assessed as a cutoff for low risk of acute
appendicitis in the literature and have resulted in an overall similarly low likelihood
of acute appendicitis with either cutoff score [35,36]. For the purposes of triage, the
score of <4 is selected for its potential to rule out appendicitis with greater certainty,
given reported variability in the prevalence of acute appendicitis in patients with a
score of 4 [35-37]. Initial triage in the diagnostic workup of appendicitis using
Alvarado score is as follows (algorithm 1):

●Patients with a score of 0 to 3 are unlikely to have appendicitis and should be

evaluated for other possible diagnoses. (See "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis", section on 'Differential diagnosis' and
"Causes of abdominal pain in adults", section on 'Lower abdominal pain syndromes'.)

●Patients with a score of ≥4 should be evaluated further for appendicitis. Surgical

evaluation and imaging, if readily available, should be pursued.
A low Alvarado score (<4) has more diagnostic utility to "rule out" appendicitis than a
high score (≥7) does to "rule in" the diagnosis [26]. The accuracy of the score in
women of reproductive age is equivalent to that in all adults [26]. In a systematic
review of 42 retrospective and prospective studies that included over 8300 patients
with suspected acute appendicitis and/or right lower quadrant pain, overall, 99 percent
of patients with acute appendicitis had a score of >4 [35]. In contrast, a high score
(≥7) alone had poor diagnostic utility as the overall specificity was 81 percent.

IMAGING

Selection of modality — Imaging is used mainly to increase the specificity of the

diagnostic evaluation for appendicitis and to decrease the negative appendectomy
rate. Computed tomography (CT) is the preferred modality, with ultrasound and
magnetic resonance imaging (MRI) reserved for radiosensitive populations such as
pregnant women and children. CT demonstrates the highest diagnostic accuracy and
lowest rates of nondiagnostic exams (ie, nonvisualization of the appendix). However,
as expedited workup is a priority in suspected appendicitis, the choice of imaging is
subject to the availability of the scanner technology and radiologist expertise (table 3)
[38]. In a contemporary worldwide observational study of over 4000 patients
suspected of acute appendicitis, 21.2 percent underwent abdominal CT, 43.3 percent
underwent abdominal ultrasound (US), 6.7 percent underwent both CT and US, and
28.8 percent did not undergo any radiological investigation [39].

Computed tomography — Abdominopelvic CT is recommended as the preferred test

in the imaging evaluation of suspected appendicitis in adults (image 1 and image 2)
[38]. If available, low radiation dose image acquisition protocols should be used as
they do not compromise diagnostic accuracy [40,41]. Intravenous contrast is
recommended, although CT without contrast is an acceptable alternative when
intravenous contrast is contraindicated. The use of oral or rectal contrast varies greatly
among individual practices due to the tradeoffs that exist in diagnostic expediency,
diagnostic confidence, and patient tolerability of the exam (see below).

CT demonstrates higher diagnostic accuracy than ultrasound or MRI (table 2). Other
advantages of CT include less variability in diagnostic performance than ultrasound or
MRI. CT demonstrates the lowest rates of nondiagnostic tests as the normal appendix
is visualized in almost all cases (table 3). When compared with MRI, CT scanners and
radiologist expertise are more readily available, and the exam is better tolerated by
most patients. As CT imaging usually includes the abdomen and pelvis, the exam
evaluates for other pathologies should the patient prove to not have appendicitis. The
disadvantages of CT are patient exposure to ionizing radiation and iodinated contrast.

The estimated effective radiation dose of abdominopelvic CT is 8 to 10 mSv with

standard dose and 2 to 4 mSv with low dose techniques [40]. To put these numbers
into context, the effective dose from annual background radiation is 3.1 mSv and from
plain abdominal radiography is 0.7 mSv. (See "Radiation-related risks of imaging".)

Intravenous contrast administration is recommended in CT exams performed for the

diagnosis of appendicitis. Contraindications to contrast administration are [42]:
●Renal insufficiency (estimated glomerular filtration rate [eGFR] <30 mL/minute per
1.73 m2)

●History of hypersensitivity reaction to iodinated contrast

Noncontrasted CT is an acceptable alternative if intravenous contrast is

contraindicated. While reasonably high diagnostic accuracy is seen with noncontrast
CT [43,44], intravenous contrast improves the exam value in other ways. In patients
with appendiceal perforation where CT is used not only for diagnosis but also for
treatment planning, contrast improves the delineation of the phlegmon or abscess. In
one study, an alternative diagnosis was made in 42 percent (893 out of 2122) of
patients without appendicitis, and the pathologic diagnosis was better characterized
with intravenous contrast administration [45].

The use of oral or rectal contrast varies greatly among individual practices. The
advantage of enteral contrast is that it distends the bowel, improving appendix
visualization. Oral contrast administration delays scanning by one to two hours.
Rectal contrast avoids this delay but is not well tolerated.

The imaging features of acute appendicitis on abdominopelvic CT are [46-48]:

●Enlarged appendiceal double-wall thickness (>6 mm)

●Appendiceal wall thickening (>2 mm)

●Periappendiceal fat stranding

●Appendiceal wall enhancement

●Appendicolith (seen in a minority of patients)

Diagnosing appendicitis based on a single criterion is not advised. As an example,

while appendiceal diameter is larger in patients with appendicitis, more than 20
percent of patients without appendicitis have an appendiceal diameter >7 mm [49].

A meta-analysis of 72 studies on the ability of CT to diagnose appendicitis in adults

reported a sensitivity of 95 percent (95% CI 95 to 97 percent) and a specificity of 96
percent (95% CI 93 to 97 percent). On subgroup analysis, diagnostic performance in
the elderly and in women of reproductive age was similar to that seen in the entire
cohort, although specificity demonstrated wider confidence intervals [26]. CT
performed with low radiation dose techniques demonstrates comparable diagnostic
performance to standard dose CT [50]. Nonvisualization of the appendix
(nondiagnostic result) occurs in 10 to 20 percent of exams and decreases but does not
eliminate the likelihood of a positive diagnosis of appendicitis [51-53].

A positive CT result indicates that treatment for appendicitis should be initiated,

whereas a negative result indicates that a normal appendix has been visualized and
appendicitis is highly unlikely as the diagnosis. A nondiagnostic result does not rule
out appendicitis, and continued evaluation is warranted (algorithm 1).
Ultrasound — An abdominal ultrasound focused on the right lower quadrant is the
preferred imaging exam in children and pregnant women and is recommended over
CT in these populations. In other populations, ultrasound represents an alternative to
CT if the latter is not readily available (eg, within three hours) (image 3 and image 4).
(See "Acute appendicitis in children: Clinical manifestations and diagnosis" and
"Acute appendicitis in pregnancy".)

Advantages of ultrasound include the lack of ionizing radiation and intravenous

contrast. Unlike CT or MRI, ultrasound can be performed at the bedside (table 3).
However, an important disadvantage is that ultrasound demonstrates lower diagnostic
accuracy than CT or MRI (table 2). The test performance is highly variable and
depends on patient-specific (eg, body habitus, discomfort and alertness, appendix
location relative to overlying bowel) and operator-specific (eg, experience) variables.
Rates of indeterminate exams are high, with 50 to 85 percent of normal appendices
not visualized [54,55]. Finally, graded compression of the appendix, integral to the
ultrasound exam, can cause significant patient discomfort in patients with
appendicitis.

Imaging features of acute appendicitis on ultrasound include [56-58]:

●Noncompressible appendix with double-wall thickness diameter of >6 mm

●Focal pain over appendix with compression

●Appendicolith

●Increased echogenicity of inflamed periappendiceal fat

●Fluid in the right lower quadrant

A meta-analysis of 38 studies on the ability of ultrasound to diagnose appendicitis

reported a sensitivity of 85 percent (95% CI 79 to 90 percent) and a specificity of 90
percent (95% CI 93 to 95 percent) [59,60].

A positive ultrasound result indicates that treatment for appendicitis should be

initiated, whereas a negative result indicates that a normal appendix has been
visualized and appendicitis is highly unlikely as the diagnosis. Importantly, a
nondiagnostic result does not rule out appendicitis, and continued evaluation is
warranted (algorithm 1).

Magnetic resonance imaging — MRI of the abdomen should be used in the imaging

evaluation of suspected appendicitis in (image 5 and image 6) [61]:

●Pregnant women (see "Acute appendicitis in children: Clinical manifestations and

diagnosis")

●Older children who can cooperate with the exam (see "Acute appendicitis in
children: Clinical manifestations and diagnosis")
MRI is recommended over CT in these populations as minimizing ionizing radiation
exposure is a priority. If readily available, MRI may also be substituted for CT in
young women (age <30 years) in whom gynecologic diagnoses remain in the
differential diagnosis after the initial clinical evaluation and exam. However, lesser
overall experience with MRI evaluation for acute appendicitis contributes to greater
variability in its test performance characteristics compared with CT.

An advantage of MRI over CT is that it does not expose the patient to ionizing
radiation or intravenous iodinated contrast (table 3). Intravenous contrast can be
administered to improve accuracy if images without contrast prove nondiagnostic.
Diagnostic accuracy is comparable to CT and is better than ultrasound (table 2). A
meta-analysis of seven studies on the MRI diagnosis of appendicitis reported a
sensitivity of 95 percent (95% CI 88 to 98 percent) and a specificity of 92 percent
(95% CI 87 to 95 percent) [62].

The rate of nondiagnostic exams is higher than that reported with CT but lower than
that with ultrasound, with 20 to 40 percent of normal appendices not visualized [63].
Similar to CT, MRI allows for detection of alternative diagnoses should the patient
not have appendicitis. However, the exam itself is less well tolerated than ultrasound
or CT. The patient is usually required to lie still in a magnet for >10 minutes; this can
be very uncomfortable for those who are claustrophobic, very young, or elderly and
those with significant pain. Common relative contraindications include cardiac
pacemakers and implanted metallic surgical hardware. (See "Patient evaluation for
metallic or electrical implants, devices, or foreign bodies before magnetic resonance
imaging", section on 'Assessing implants, devices, or foreign bodies for MRI' and
"Patient evaluation for metallic or electrical implants, devices, or foreign bodies
before magnetic resonance imaging".)

Plain radiography — Plain radiography is not recommended in the diagnostic workup

of suspected appendicitis, nor do findings on plain radiograph change the level of
suspicion for appendicitis. The exam does not visualize the appendix.

SURGICAL EXPLORATIONIn a minority of patients, surgical exploration may be

warranted if clinical suspicion for appendicitis is high but imaging studies are either
negative, nondiagnostic, or unavailable. In such patients, appendicitis can only be
diagnosed intraoperatively or pathologically. (See "Management of acute appendicitis
in adults", section on 'Open versus laparoscopic'.)

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Appendicitis in adults".)

SUMMARY

●The evaluation of patients with suspected appendicitis is driven by the goal of

identifying all patients presenting with acute appendicitis while minimizing the
negative appendectomy rate (nontherapeutic operative rate). Missed diagnosis of
appendicitis, especially when perforated, can result in severely adverse patient
outcomes. (See 'General approach' above.)
●The diagnostic evaluation of children and pregnant women differs from that of
nonpregnant adults and is discussed separately. (See "Acute appendicitis in
pregnancy" and "Acute appendicitis in children: Clinical manifestations and
diagnosis".)

●Clinical symptoms and signs suggestive of appendicitis include a history of central

abdominal pain migrating to the right lower quadrant, anorexia, fever, and
nausea/vomiting. (See 'Clinical evaluation' above and "Acute appendicitis in adults:
Clinical manifestations and differential diagnosis".)

●The initial physical examination of patients with suspected appendicitis should

include a digital rectal examination. Women should also undergo a pelvic
examination. (See 'Clinical evaluation' above and "Acute appendicitis in children:
Clinical manifestations and diagnosis".)

●The laboratory evaluation of suspected appendicitis should include white blood cells
(WBC) with differential and serum C-reactive protein (CRP). A serum pregnancy test
should be performed for women of childbearing age. (See 'Laboratory tests' above.)

●The Alvarado score can be used to identify patients with a very low likelihood of
acute appendicitis so as to triage them to evaluation for other causes of abdominal
pain (table 1). (See 'Alvarado score calculation' above.)

•Patients with a score of 0 to 3 are unlikely to have appendicitis and should be

evaluated for other possible diagnoses. (See "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis", section on 'Differential diagnosis' and
"Causes of abdominal pain in adults", section on 'Lower abdominal pain syndromes'.)

•Patients with a score of ≥4 should be evaluated further for appendicitis. Surgical

evaluation and imaging, if readily available, should be pursued.

●For most patients with suspected appendicitis, we recommend abdominopelvic

computed tomography (CT) with intravenous contrast. Low radiation dose techniques,
if available, should be used for image acquisition. If readily available, magnetic
resonance imaging (MRI) is acceptable as a substitute for CT in young women (age
<30 years) in whom gynecologic diagnoses are still included in the differential
diagnosis after the initial clinical evaluation. (See 'Computed tomography' above and
'Magnetic resonance imaging' above.)

●If CT is not readily available (<3 hours), we recommend an abdominal ultrasound.

Ultrasound demonstrates lower diagnostic accuracy and higher rates of nondiagnostic
exams than CT or MRI. (See 'Ultrasound' above.)

●In a minority of patients, surgical exploration may be warranted if clinical suspicion

for appendicitis is high but imaging studies are either negative, nondiagnostic, or
unavailable. In such patients, appendicitis can only be diagnosed intraoperatively or
pathologically. (See 'Surgical exploration' above.)

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REFERENCES
1. Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are
no longer acceptable. Am J Surg 1997; 174:723.
2. 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.
3. Lu Y, Friedlander S, Lee SL. Negative Appendectomy: Clinical and Economic
Implications. Am Surg 2016; 82:1018.
4. 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.
5. 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.
6. Horton MD, Counter SF, Florence MG, Hart MJ. A prospective trial of
computed tomography and ultrasonography for diagnosing appendicitis in the
atypical patient. Am J Surg 2000; 179:379.
7. Güller U, Rosella L, McCall J, et al. Negative appendicectomy and perforation
rates in patients undergoing laparoscopic surgery for suspected appendicitis.
Br J Surg 2011; 98:589.
8. Coursey CA, Nelson RC, Patel MB, et al. Making the diagnosis of acute
appendicitis: do more preoperative CT scans mean fewer negative
appendectomies? A 10-year study. Radiology 2010; 254:460.
9. Drake FT, Florence MG, Johnson MG, et al. Progress in the diagnosis of
appendicitis: a report from Washington State's Surgical Care and Outcomes
Assessment Program. Ann Surg 2012; 256:586.
10. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis
and the use of diagnostic imaging. J Am Coll Surg 2005; 201:933.
11. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of
appendicitis decreased over time? A population-based analysis. JAMA 2001;
286:1748.
12. Jones K, Peña AA, Dunn EL, et al. Are negative appendectomies still
acceptable? Am J Surg 2004; 188:748.
13. Wilson EB. Surgical evaluation of appendicitis in the new era of radiographic
imaging. Semin Ultrasound CT MR 2003; 24:65.
14. Parks NA, Schroeppel TJ. Update on imaging for acute appendicitis. Surg Clin
North Am 2011; 91:141.
15. Barrett ML, Hines AL, Andrews RM. Trends in rates of perforated appendix,
2001–2010: Statistical brief #159. Healthcare Cost and Utilization Project
(HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare
Research and Quality (US). 2006-2013.
16. Horattas MC, Guyton DP, Wu D. A reappraisal of appendicitis in the elderly.
Am J Surg 1990; 160:291.
17. Drake FT, Mottey NE, Farrokhi ET, et al. Time to appendectomy and risk of
perforation in acute appendicitis. JAMA Surg 2014; 149:837.
18. 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.
19. 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.
20. 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.
21. 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.
22. Kharbanda AB, Fishman SJ, Bachur RG. Comparison of pediatric emergency
physicians' and surgeons' evaluation and diagnosis of appendicitis. Acad
Emerg Med 2008; 15:119.
23. 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.
24. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of
appendicitis. Br J Surg 2004; 91:28.
25. Bundy DG, Byerley JS, Liles EA, et al. Does this child have appendicitis?
JAMA 2007; 298:438.
26. Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of right lower quadrant
pain and suspected acute appendicitis [Internet]. AHRQ Comparative
Effectiveness Reviews 2015; Report No: 15(16)-EHC025-EF.
27. Dayawansa NH, Segan JD, Yao HH, et al. Incidence of normal white cell
count and C-reactive protein in adults with acute appendicitis. ANZ J Surg
2016.
28. Atema JJ, Gans SL, Beenen LF, et al. Accuracy of White Blood Cell Count
and C-reactive Protein Levels Related to Duration of Symptoms in Patients
Suspected of Acute Appendicitis. Acad Emerg Med 2015; 22:1015.
29. 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.
30. Horzić M, Salamon A, Kopljar M, et al. Analysis of scores in diagnosis of
acute appendicitis in women. Coll Antropol 2005; 29:133.
31. 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.
32. Enochsson L, Gudbjartsson T, Hellberg A, et al. The Fenyö-Lindberg scoring
system for appendicitis increases positive predictive value in fertile women--a
prospective study in 455 patients randomized to either laparoscopic or open
appendectomy. Surg Endosc 2004; 18:1509.
33. Alvarado A. A practical score for the early diagnosis of acute appendicitis.
Ann Emerg Med 1986; 15:557.
34. 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.
35. 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.
36. Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the
Alvarado and Pediatric Appendicitis Scores? A systematic review. Ann Emerg
Med 2014; 64:365.
37. Tan WJ, Acharyya S, Goh YC, et al. Prospective comparison of the Alvarado
score and CT scan in the evaluation of suspected appendicitis: a proposed
algorithm to guide CT use. J Am Coll Surg 2015; 220:218.
38. Smith MP, Katz DS, Lalani T, et al. ACR Appropriateness Criteria® Right
Lower Quadrant Pain--Suspected Appendicitis. Ultrasound Q 2015; 31:85.
39. Sartelli M, Baiocchi GL, Di Saverio S, et al. Prospective Observational Study
on acute Appendicitis Worldwide (POSAW). World J Emerg Surg 2018;
13:19.
40. Yun SJ, Ryu CW, Choi NY, et al. Comparison of Low- and Standard-Dose CT
for the Diagnosis of Acute Appendicitis: A Meta-Analysis. AJR Am J
Roentgenol 2017; 208:W198.
41. LOCAT Group. Low-dose CT for the diagnosis of appendicitis in adolescents
and young adults (LOCAT): a pragmatic, multicentre, randomised controlled
non-inferiority trial. Lancet Gastroenterol Hepatol 2017; 2:793.
42. American College of Radiology (ACR) Committee on Drugs and Contrast
Media. ACR manual on contrast media, version 10.1, 2015. Available at:
http://www.acr.org/~/media/37D84428BF1D4E1B9A3A2918DA9E27A3.pdf
(Accessed on August 17, 2016).
43. Dearing DD, Recabaren JA, Alexander M. Can computed tomography scan be
performed effectively in the diagnosis of acute appendicitis without the added
morbidity of rectal contrast? Am Surg 2008; 74:917.
44. Hershko DD, Awad N, Fischer D, et al. Focused helical CT using rectal
contrast material only as the preferred technique for the diagnosis of suspected
acute appendicitis: a prospective, randomized, controlled study comparing
three different techniques. Dis Colon Rectum 2007; 50:1223.
45. Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ. Diagnostic performance of
multidetector computed tomography for suspected acute appendicitis. Ann
Intern Med 2011; 154:789.
46. 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.
47. Whitley S, Sookur P, McLean A, Power N. The appendix on CT. Clin Radiol
2009; 64:190.
48. 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.
49. Moskowitz E, Khan AD, Cribari C, Schroeppel TJ. Size matters: Computed
tomographic measurements of the appendix in emergency department scans.
Am J Surg 2019; 218:271.
50. Yoon HM, Suh CH, Cho YA, et al. The diagnostic performance of reduced-
dose CT for suspected appendicitis in paediatric and adult patients: A
systematic review and diagnostic meta-analysis. Eur Radiol 2018; 28:2537.
51. Benjaminov O, Atri M, Hamilton P, Rappaport D. Frequency of visualization
and thickness of normal appendix at nonenhanced helical CT. Radiology
2002; 225:400.
52. Nikolaidis P, Hwang CM, Miller FH, Papanicolaou N. The nonvisualized
appendix: incidence of acute appendicitis when secondary inflammatory
changes are absent. AJR Am J Roentgenol 2004; 183:889.
53. Johnson PT, Horton KM, Kawamoto S, et al. MDCT for suspected
appendicitis: effect of reconstruction section thickness on diagnostic accuracy,
 rate of appendiceal visualization, and reader confidence using axial images.
AJR Am J Roentgenol 2009; 192:893.
54. Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic appearance of
the normal appendix in adults. J Ultrasound Med 2007; 26:37.
55. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute
appendicitis in pregnancy. Emerg Med J 2007; 24:359.
56. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000;
215:337.
57. 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.
58. Jeffrey RB Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic
criteria based on 250 cases. Radiology 1988; 167:327.
59. Keyzer C, Zalcman M, De Maertelaer V, et al. Comparison of US and
unenhanced multi-detector row CT in patients suspected of having acute
appendicitis. Radiology 2005; 236:527.
60. Kaewlai R, Lertlumsakulsub W, Srichareon P. Body mass index, pain score
and Alvarado score are useful predictors of appendix visualization at
ultrasound in adults. Ultrasound Med Biol 2015; 41:1605.
61. Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria® right
lower quadrant pain--suspected appendicitis. J Am Coll Radiol 2011; 8:749.
62. 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.
63. Nikolaidis P, Hammond N, Marko J, et al. Incidence of visualization of the
normal appendix on different MRI sequences. Emerg Radiol 2006; 12:223.

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