International Journal of Colorectal Disease

https://doi.org/10.1007/s00384-021-03940-8

REVIEW

Classification of acute appendicitis (CAA): treatment directed new

classification based on imaging (ultrasound, computed tomography)
and pathology
Jörg C. Hoffmann 1 & Claus-Peter Trimborn 1 & Michael Hoffmann 2 & Ralf Schröder 3 & Sarah Förster 4 & Klaus Dirks 5 &
Andrea Tannapfel 4 & Matthias Anthuber 2 & Alois Hollerweger 6

Accepted: 21 April 2021

# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Purpose Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk
stratifications, “negative” appendectomies are performed in up to 30% of patients whilst the appendix perforates in others.
Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging
(ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between com-
plicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT
images and be employed in a diagnostic and therapeutic algorithm.
Methods Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores,
pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the
author’s image database.
Results Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncompli-
cated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The
imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised
reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management.
Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated
AA.
Conclusion Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA
allowing nonoperative management in selected patients with uncomplicated forms of AA.

Keywords Imaging . Complicated appendicitis . Uncomplicated appendicitis . Standardised reporting . Diagnostic algorithm .
Therapeutic algorithm

* Jörg C. Hoffmann
joerg.hoffmann@st-marienkrankenhaus.de
1
Medizinische Klinik I mit Schwerpunkt Gastroenterologie,
Diabetologie, Rheumatologie und Onkologie, St. Marien- und St.
Annastiftskrankenhaus, Salzburger Straße 15,
D67067 Ludwigshafen, Germany
2
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie,
Universitätsklinikum Augsburg, Augsburg, Germany
3
Radiologische Klinik, St. Marien- und St. Annastiftskrankenhaus
Ludwigshafen, Ludwigshafen, Germany
4
Institut für Pathologie der Ruhr-Universität Bochum,
Bochum, Germany
5
Gastroenterologie, Allgemeine Innere Medizin und Geriatrie,
Rems-Murr-Kliniken Winnenden, Winnenden, Germany
6
Abteilung für Radiologie und Nuklearmedizin Krankenhaus der
Barmherzigen Brüder Salzburg, Salzburg, Austria

Introduction
Acute appendicitis (AA) is one of the most common causes of
lower abdominal pain in patients presenting to the emergency
room; AA is also the leading cause of peritonitis in young adults
and children [1]. Whilst the gold standard of AA treatment is
appendectomy, the most frequent abdominal operation world-
wide, some evidence suggests that uncomplicated AA may as
well be treated nonoperatively [1–3]. Furthermore, overdiagno-
sis of AA can lead to so called “negative” appendectomies.
Delay of the correct diagnosis, on the other hand, can lead to
perforation. Therefore, both the correct diagnosis of AA in the
first place and a distinction between complicated and uncom-
plicated forms of AA are important. The European Association
of Endoscopic Surgery (EAES) defined complicated AA as
gangrenous AA with or without perforation, AA with an
intraabdominal abscess, and AA with periappendicular
contained phlegmon or purulent/free fluid [4]. Consequently,
the diagnostic workup in suspected AA is aiming at the avoid-
ance of both delayed diagnosis with perforation, e.g., in gan-
grenous AA, as well as “negative” appendectomies.
AA is microscopically defined by transmural inflammation
of the appendix either at the tip (tip AA) or as a whole [5, 6].
The earliest changes are dilatation of the serosal vessels,
oedematous swelling of the wall followed by intramural ab-
scesses and involvement of the mesoappendix. Precursors of
AA, also known as borderline AA, show only local inflam-
mation in the lumen (intraluminal), the mucosa (mucosal) or
the submucosa (submucosal). Phlegmonous appendicitis is
characterised by neutrophilic infiltrates in all layers with or
without ulceration, vascular thrombosis, and intramural ab-
scesses. If ischemia occurs the appendix becomes friable with
a purple, green or black discoloration in areas of necrosis
(gangrenous AA). Perforation is imminent. Therefore, it is
classified as complicated AA. Importantly, faecoliths can be
found in approximately 30% of cases, sometimes with obvi-
ous obstruction [7, 8]. Small faecoliths without obstruction
can be detected in normal appendices. The obstruction of the
lumen, either by a faecolith or for instance by a tumour, is an
important finding in the diagnostic workup [8, 9].
Correspondingly, obstruction by a faecolith is an independent
prognostic risk factor for treatment failure in nonoperative
treatment of uncomplicated acute appendicitis [3, 10, 11].
In recent years, several clinical scores, based on history
taking, clinical examination, and laboratory tests, were devel-
oped in order to standardise clinical workup of patients with
suspected AA. For instance, the Adult Appendicitis Score
(AAS) with a cut-off score of 8 or less had a failure rate of
3.7% in women, the Appendicitis Inflammatory Response
Score (AIRS) with a cut-off score of 2 or less had a failure
rate of 2.4% in men, and the Shera score with a cut-off score of
3 for girls and 2 for boys had a failure rate of 3.3% [12, 13]. To
this end, both the consensus statement by the EAES and the
Int J Colorectal Dis
updated guideline on the diagnosis and treatment of AA by the
World Society of Emergency Surgery (WSES) recommend
the use of clinical scores in order to exclude AA in nonpreg-
nant patients [1, 4]. At the other end of the spectrum, the
EAES and the WSES regard high scores as sufficient evidence
for the diagnosis of AA without need for further imaging.
Such recommendations do not take into account the long list
of alternative diagnoses which can cause lower abdominal
pain. Further, patients who did not have imaging studies for
suspected AA had a more than threefold increased likelihood
of “negative” appendectomies [14]. Furthermore, clinical
scores certainly do not allow a distinction of complicated
and uncomplicated AA precluding nonoperative management
[15]. To this end, some guidelines (e.g., the Dutch guideline of
2010 or the EFSUM guideline of 2019) recommend imaging
in all patients with suspected AA [16–19].
We herein propose a new classification of acute ap-
pendicitis (CAA) that is based on pathology but aims at
the best possible imaging in order to discriminate preop-
eratively between uncomplicated and complicated forms
of AA. The preferred imaging modality is US rather than
CT because of radiation protection, availability, and
costs.
Methods
Search strategy
Medline, Embase, and the Cochrane Library were searched
for the following terms: appendicitis & clinical scores; appen-
dicitis & pathology; appendicitis & ultrasound; appendicitis &
imaging; appendicitis & CT; appendicitis & classification;
appendicitis & guideline. Any study with these MeSH head-
ings published since 1970 was reviewed. Depending on the
level of evidence and relevance to appendicitis, classification
and imaging publications were included, i.e., most guidelines,
systematic reviews/metaanalyses but also high quality reviews
(e.g., with regard to pathology) or randomised, as well as
diagnostic trials.
Development of the classification of acute
appendicitis (CAA)
Based on the Classification of Diverticular disease by the
German Society of General Surgery (DGAV) and the
German Society of Gastroenterology (DGVS) [20], as well
as the TNM classification by the UICC [21], a preliminary
classification was proposed to all authors from type 0 (no
inflammation) over uncomplicated AA (type 1) to complicat-
ed, i.e., perforated, AA (type 2). This classification was re-
vised in four rounds using the comments of all authors.
Int J Colorectal Dis

Fig. 1 Classification of acute appendicitis (CAA) type 0 on US: Normal appendix. Shown is the transverse (a) and longitudinal (b) section of a normal
appendix with 5 layers and fully visualised

Selection of images

Both US and CT images were taken from the author’s

image databases. US images were taken with a Toshiba
Aplio 400, Canon Aplio i800, and General Electric Logiq
S8. CT images were taken with a Siemens Somatom
Sensation 64.

Classification of acute appendicitis (CAA)

based on imaging (Table 1)

Corresponding to pathology we propose CAA into five major

types:
Fig. 2 Classification of acute appendicitis (CAA) type 0 on CT: Normal
appendix. Shown is the transverse–oblique plane of the lower abdomen Type 0: normal appendix (US images in Fig. 1, CT image
showing the normal appendix (red arrow) in full length with intraluminal in Fig. 2),
oral contrast medium
Type X: appendix not visualised,
Type 1: acute uncomplicated appendicitis (US images in
Figs. 3 and 5, CT images in Figs. 4 and 6),

Fig. 3 Classification of acute appendicitis (CAA) type 1a on US: Borderline appendicitis. Shown is a the transverse and b longitundinal section of a slightly
enlarged appendix with preserved layers without periappendiceal air or fluid nor significant periappendiceal hyperechoic tissue
 Int J Colorectal Dis

Table 1 Classification of acute appendicitis

Type Definition Surgical/ Gross pathology Histopathology Ultrasound findings Computed tomography
findings

uX not detectable appendix not found or not appendix not found or not
fully visualized fully visualized
0 normal normal appendix normal appendix normal appendix (< 6 mm, 3 normal appendix
layers, full length
visualized)
1 uncomplicated
1a borderline dilatated serosal vessels, intraluminal neutrophils diameter: increased to 6 to 8 diameter: increased to 6 to 8
dulling of the serosa and/or neutrophils within mm, local tenderness over mm, wall integretiy: no
the mucosa and/or the appendix, wall striation: defects luminal dilation:
submucosa and/or mucosal well preserved, luminal none, contrast
erosions dilation: none, enhancement: none
hypervascularity: none periappendiceal air or fluid:
periappendiceal air or none periappendiceal fat
significant fluid: none stranding: none
hyperechoic
periappendiceal tissue:
none
1b phlegmonous edematous swelling, neutrophils within the diameter: increased > 6 mm, dilated appendix (>6 mm),
dilatated and blood filled mucosa, submucosa, and local tenderness over the wall integretiy: no defects,
lumen, inflammation of muscularis propria, appendix, wall striation: luminal dilatation: none,
the mesoappendix extensive ulceration, intact but blurred, luminal contrast enhancement:
(exsudates) intramural microabscesses, dilation: none, present, periappendiceal
vascular thrombosis hypervascularity: present, air: none significant fluid:
periappendiceal air: none minimal periappendiceal fat
significant fluid: minimal stranding: mild ±
hyperechoic mesenteric
periappendiceal tissue: lymphadenopathy
mild, ± mesenteric
lymphadenopathy
2 complicated, not perforated
2a severe faecolith with marked marked transmural edema faecolith with distal luminal intraluminal faecolith with
phlegmonous obstruction, i.e. dis- tal and neutrophil infil- tration dilatation or extraluminal distal luminal dilatation or
with luminal dilatation, or plus obstructing faecolith, fluid, others as type 1b extraluminal fluid, others as
obstruction or adjacent fluid adjacent fluid type 1b
extraluminal
fluid
2b gangrenous friable appendix; purple, transmural inflammation with focal or complete loss of contrast enhancement defect
green or black areas of necrosis; extensive stratification, intramural air, of the appendiceal wall,
mucosal ulceration marked hyperechoic periappendiceal fat
periappendiceal tissue, stranding, intramural air
vascularity reduced
3 complicated, perforated
3a abscess or marked periappendiceal transmural neutrophil periappendiceal localised marked periappendiceal fat
appendiceal inflammation with infiltration of the appen- fluid, marked hyper- echoic stranding either confined to
mass surrounding fluid, dix and mesoappendix, periappendiceal tissue, ± the mesoappendix or
perforation, sealed with melting inflammation with abscess with localized beyond, intramural or
surrounding tissue, destructed architecture, appendiceal wall defect or directly extraluminal air ±
abscess and/or periappendiceal abscess inflamma- tory tumor; fluid, abscess and/or
inflammatory tumor covered with adjacent others as type 1b inflammatory tumor
tissue
3b free perforation friable, often incomplete or severe necrosis of the free fluid/air; appendix either free fluid/air, ascites, appendix
completely necrotic destructed appendix, invisible or in- complete, either invisible or
appendix, generalized neutrophils around the ileus, extraluminal faecolith incomplete, ileus,
peritonitis incomplete appendix, extraluminal faecolith
rarely totally destructed
Int J Colorectal Dis

Type 2: acute complicated appendicitis without perfora-

tion (US images in Figs. 7, 9, and 11, CT images in Figs.
8, 10, and 12) and
Type 3: acute complicated appendicitis with perforation
(US images Figs. 13, 15, and 17, CT images in Figs. 14,
16, and 18).

The main purpose of this classification is to discrimi-

Fig. 4 Classification of acute appendicitis (CAA) type 1a on CT:
Borderline appendicitis. Shown is the coronary plane of the right iliac
fossa with a slightly enlarged appendix, without extraluminal air or fluid,
nor fat stranding. The appendiceal wall is intact
nate complicated from uncomplicated AA based on pre-
operative US or occasionally CT. Depending on the
imaging modality employed a letter is put in front of the
number, e.g., type u2 indicating US-based or type c3 in-
dicating CT. If the appendix is removed surgically, the
classification can also be used for surgical pathology,
the intraoperative appearance, and/or the histopathology
by using the letter p, e.g., type p1. Table 1 summarises
this new classification of acute appendicitis (CAA) indi-
cating surgical pathology, histopathology, US, and finally
CT findings in various types of AA.
First, AA can affect the inner appendiceal layers (mu-
cosa ± submucosa) leading to tenderness on US using
graded compression, slightly increased diameter, pre-
served layers but no indirect signs of inflammation (AA
type 1a, i.e., borderline AA) (Fig. 3, Fig. 4). If

Fig. 5 Classification of acute appendicitis (CAA) type 1b on ultrasound: Phlegmonous appendicitis. Shown is the transverse (a,c) and longitudinal
section (b,d) of an appendix with (c,d) and without colour duplex (a,b). Layers are intact but blurred; the lumen is not dilated. Increased vascularity is
seen on colour duplex sonography. Significant periappendiceal hyperechoic tissue is shown
 Int J Colorectal Dis

Fig. 7 Classification of acute appendicitis (CAA) type 2a on ultrasound:

Severe phlegmonous appendicitis with microperforation. Shown is the
longitundinal section of an enlarged appendix with a small hypoechoic
lesion (red arrows) with marked fat stranding (e.g., hyperechoic
periappendiceal tissue, yellow arrow)

Fig. 6 Classification of acute appendicitis (CAA) type 1b on CT:

Phlegmonous appendicitis. Shown is the oblique plane of the right iliac
fossa with an enlarged appendix, as well as intact appendiceal wall struc-
tures. Periappendiceal fat stranding can be seen.

Fig. 8 Classification of acute appendicitis (CAA) type 2a on CT: Severe

phlegmonous appendicitis with microperforation. Shown is the transverse
plane of the lower abdomen demonstrating an enlarged appendix (red
arrows) with an adjacent small hypodense lesion (small turquoise ar-
rows). Marked fat stranding around the appendix

Fig. 9 Classification of acute appendicitis (CAA) type 2a on ultrasound: a small faecolith (turquoise big arrow) and marked distal dilatation due to
Severe phlegmonous appendicitis with obstruction. Shown is the obstruction. The white line indicates the level of the transverse section (b)
longitundinal (a) and transverse (b) section of an enlarged appendix with as indicated by the long turquoise arrow
Int J Colorectal Dis
Fig. 10 Classification of acute appendicitis (CAA) type 2a on CT: Severe
phlegmonous appendicitis with obstruction. Shown is the coronary plane
of a dilated appendix (red arrow) with an obstructing faecolith (turquoise
arrow) at the base of the appendix. Mild surrounding fat stranding
Fig. 11 Classification of acute appendicitis (CAA) type 2b on ultrasound:
Gangrenous appendicitis. Shown is the transverse (a,b,d) and longitudi-
nal section (c) of an appendix with intact (a,c) and destroyed (c,b,d)
layers. Decreased vascularity is seen on colour duplex sonography (d).
uncomplicated AA is more severe (type 1b, phlegmonous
AA) the appendiceal layers are blurred, the diameter is
increased (usually >8 mm), imaging shows
hypervascularity, no or minimal extraluminal fluid and
mild hyperechoic periappendiceal tissue (Fig. 5, Fig. 6).
In contrast to uncomplicated AA complicated AA is
characterised by either perforation (type 3) or either pend-
ing perforation or high likelihood of recurrence (type 2).
The latter is caused by microperforation or gangrene. The
key imaging feature is marked hyperechoic tissue on US
or marked fat stranding on CT. Marked but still localised
periappendiceal fluid (Fig. 7, Fig. 8) or obstruction (Fig.
9, Fig. 10) is seen in severe phlegmonous AA (type 2a).
Gangrenous AA (type 2b) is characterised by either intra-
mural air and/or loss of the echogenic submucosal layer
(Fig. 11, Fig. 12). Some authors have classified severe
phlegmonous AA (type 2a) and even gangrenous AA
(type 2b) as uncomplicated AA [22] supposedly because
they defined complications purely by means of the pres-
ence of frank perforation. Multiple studies have, however,
shown that a faecolith with obstruction, marked
periappendiceal inflammation, and a gangrene indicate
imminent perforation or high likelihood of recurrence af-
ter nonoperative management [3, 7, 8, 23–26]. We, there-
fore, propose that these types should be classified as
The level of transverse sections of a and b,d is indicated in the longitu-
dinal section by white lines and turquoise arrows. Strongly hyperechoic,
periappendiceal tissue is marked by red arrows

Fig. 12 Classification of acute appendicitis (CAA) type 2b on CT:
Gangrenous appendicitis. Shown is the sagittal plane of the right iliac
fossa with a small faecolith (yellow arrow) at the base of an enlarged
appendix (red arrow) with blurred margins, intramural air (turquoise ar-
row) and marked periappendiceal fat stranding (black arrow)
Fig. 13 Classification of acute appendicitis (CAA) type 3a on ultrasound
(localised, perforated AA): Appendicitis with sealed perforation. Shown
is the proximal transverse (a) and distal transverse (b, white arrow) sec-
tion of an enlarged appendix with a faecolith (turquoise arrow), localised
Int J Colorectal Dis
Fig. 14 Classification of acute appendicitis (CAA) type 3a on CT (local-
ised, perforated AA): Appendicitis with sealed perforation. Shown is a
coronary plane of the abdomen with a slightly enlarged appendix (red
arrow) and a large extraluminal hypodense lesion indicating a sealed
abscess (>2 cm, red arrow) with surrounding fat stranding
defect of the appendiceal wall (b, yellow arrow) and extraluminal
hypoechoic lesion indicating a sealed abscess (>2 cm, red arrow) with
surrounding hyperechoic tissue
Int J Colorectal Dis
Fig. 15 Classification of acute appendicitis (CAA) type 3a on ultrasound
(localised, perforated AA): Appendicitis with appendiceal mass. Shown
is the longitudinal section of an enlarged appendix with an
Fig. 16 Classification of acute appendicitis (CAA) type 3a on CT (local-
ised, perforated AA): Appendicitis with appendiceal mass. Shown is a
transverse plane of the abdomen with a slightly enlarged appendix with a
perforation (red arrow) and an adjacent inhomogenous, hypodense, and
inflammatory tumour (turquoise arrow), as well as the surrounding fat
stranding
Fig. 18 Classification of acute appendicitis (CAA) type 3b on CT:
Appendicitis with free perforation. Shown is a transverse plane of the
lower abdomen with free fluid, air and marked fat stranding indicating
free perforation due to a necrotic, destroyed, and therefore undetectable
appendix
inhomogenous, inflammatory tumour, as well as the surrounding
hyperechoic tissue. Colour duplex sonography shows vascular structures
inside the “tumour”
Fig. 17 Classification of acute appendicitis (CAA) type 3b on ultrasound:
Appendicitis with free perforation. Shown is the right iliac fossa with
hypoechoic, inhomogeneous fluid and echogenic dots (air bubbles) indi-
cating free perforation due to a necrotic, destroyed, and therefore unde-
tectable appendix
complicated AA in accordance with the consensus state-
ment by the EAES [4].
If perforation is detected this can present as sealed perfora-
tion (type 3a, Fig. 13 and Fig. 14) with an abscess or as free
perforation with free fluid, air, and pus in the abdominal cavity
(type 3b, Fig. 17 and Fig. 18). Occasionally, an appendiceal
mass involving surrounding small or large bowel loops can be
found which is also a more localised form of perforation, i.e.,
type 3a (Fig. 15 and Fig. 16) [27]. A more detailed description
of the surgical pathology, histology, US, and CT findings can
be found in Table 1.
Diagnostic and therapeutic algorithm
for suspected AA based on CAA
State of the art AA management requires not only the cor-
rect diagnosis but also the distinction between complicated
 Int J Colorectal Dis

Table 2 Standardised ultrasound reporting for suspected appendicitis

Category Parameter Subgroup Detailed description

General Location [pelvic; subcecal; retroileal; retrocecal; ectopic; preileal]

Visualisation [complete; incomplete; not visualised]
Local tenderness [yes; no; unclear]
Appendix Compressibility [yes; no]
Total diameter [in mm]
Lumen diameter [in mm]
air (hyperechoic dot) [present; absent]
faecolith (echogenic) [none; present, no distal dilatation; present with distal dilatation]
Wall diameter [in mm]
layers [preserved stratification; blurred stratification; localised loss of stratification; generalised
loss of stratification]
vascularity [normal; increased within the appendix; locally reduced; reduced in the whole appendix]
perforation [none; localised/small; complete/large]
intramural air [present; absent]
(hyperechoic dot)
Surrounding Periappendiceal fat [normal; slightly increased hyperechoic tissue; markedly increased hyperechoic tissue]
Mesenteric lymph nodes [not visible; visible, normal; visible, enlarged, reactive; visible, enlarged, likely neoplastic]
Fluid (hypoechoic or [minute periappendiceal (< 5 mm); little periappendiceal (5-20 mm); large, localised (> 2
echofree) cm); free ascites]
Air (hyperechoic dot, [outside the wall; within a localised fluid collection (abscess); within free fluid (free
extramural) perforation)]
Special features Inflammatory [present; absent]
tumour/mass
Ileal blowel loops [normal; dilated, no peristalsis; dilated, increased peristalsis]
Caecal tumor [present; absent]
Others [present; absent]

Summary: e.g. acute appendicitis type u1b according to CAA (phlegmonous appendicitis without obstruction)

Table 3 Standardised computed tomography reporting for suspected appendicitis

Category Parameter Subgroup Detailed description

General Location [pelvic; subcecal; retroileal; retrocecal; ectopic; preileal]

Visualisation [complete; incomplete; not visualised]
Local tenderness [yes; no; unclear]
Appendix Total diameter [in mm]
Lumen diameter [in mm]
air (black dot) [present; absent]
faecolith (bright) [none; present, no distal dilatation; present with distal dilatation]
Wall diameter [in mm]
vascularity [normal; enhanced contrast; locally reduced; overall reduced]
perforation [none; localised/small; complete/large]
intramural air (hyperechoic [present; absent]
dot)
Surrounding Periappendiceal fat [normal; slight fat stranding; marked fat stranding]
Mesenteric lymph [not visible; visible, normal; visible, enlarged, reactive; visible, enlarged, likely neoplastic]
nodes
Fluid (dark grey) [minute periappendiceal (< 5 mm); little periappendiceal (5-20 mm); large, localised (> 2 cm);
free ascites]
Air (black) [outside the wall; within a localised fluid collection (abscess); within free fluid (free
perforation)]
Special features Inflammatory tumour/mass [present; absent]
Ileal blowel loops [normal; dilated, no peristalsis; dilated, increased peristalsis]
Caecal tumor [present; absent]
Others [present; absent]

Summary: e.g. acute appendicitis type 1b according to CAA (phlegmonous appendicitis without obstruction)
Int J Colorectal Dis
Fig. 19 Diagnostic algorithm for patients with suspected acute appendicitis (AA). *According to clinical score, laboratory and US; # HR, high risk; IR,
intermediate risk; LR, low risk; US, ultrasound; CT, computer tomography
and uncomplicated forms of AA. Therefore, history taking,
clinical examination and emergency laboratory analysis
must be supplemented with abdominal US including so-
phisticated visualisation of the appendix. The US tech-
nique has been described elsewhere with visualisation in
up to 95% of cases and sensitivities of up to 99% [16, 19,
28–31]. Particularly, the anatomical variations need to be
considered in order to keep the proportion of nonvisualised
appendices as low as possible [32, 33]. In order to accom-
plish the best possible imaging results, it has been shown
that standardised reporting leads to better diagnostic results
for both US and CT [34–38]. Therefore, Table 2 shows a
standardised reporting scheme for US of the appendix and
Table 3 for CT scans. If a CT scan is used it is recommend-
ed to limit the range and the dose in order to reduce radi-
ation [35, 39, 40]. The not completely visualised appendix
can either be reexamined by US later (particularly in low
risk or young intermediate risk patients) or can be evaluat-
ed further by CT, particularly in high-risk patients and
patients over 40 years of age. Importantly, delaying sur-
gery because of nonvisualisation of the appendix does not
lead to increased perforation rates when looking at all pa-
tients with AA, even if they are pregnant [41–43]. It must
be emphasised that visualisation of the complete appendix
including the tip is very important. If the appendix cannot
be fully visualised both clinical scores and the patient’s age
can help to make a decision how to proceed. If the situation
remains unclear, diagnostic laparoscopy is also a good op-
tion to proceed although one randomised trial did not show
a benefit when comparing laparoscopy to active clinical
observation [44–46].
Figure 19 summarises the recommended diagnostic
workup in suspected AA leading either to discharge from
the emergency room or further treatment based on the new
Classification of AA (see Fig. 20). Once AA is diagnosed
the new CAA allows differentiating between uncomplicat-
ed and complicated forms of AA. Free perforation (type
3b) and gangrenous AA (type 2b) require an emergency
operation. Highly inflamed, phlegmonous AA, as well as
phlegmonous AA with obstruction (both type 2a), is un-
likely to be cured upon sole antibiotic treatment and is,
therefore, no candidate for nonoperative management [3,
7, 8, 23, 25, 26]. Patients with abscesses/sealed perforation
or an appendiceal mass (both type 3a) can be treated by
US- or CT-guided drainage and/or antibiotics depending
on their size, usually followed by elective surgery later on

Fig. 20 Therapeutic algorithm for patients with confirmed acute appendicitis (AA). * microperforation; # HR, high risk; IR, intermediate risk; LR, low
risk; Sx, surgery; PAA, phlegmonous AA; US, ultrasound; CT, computer tomography; u, based on US; c, based on CT; AB, antibiotics; h, hours
[1]. Some data even suggest that appendiceal masses
might not even need later surgery at all [27]. Finally, un-
complicated AA can either be treated nonoperatively, e.g.,
in borderline cases possibly even without antibiotics but
with US and clinical follow-up [47] or, possibly, in mild
forms of phlegmonous AA provided there is no high risk
situation [2, 3]. Whilst no data is available about the re-
currence rate of borderline AA upon nonoperative treat-
ment the recurrence of uncomplicated AA (type 1b) was
39.1% of patients within 5 years in well characterised pa-
tients [48]. Since the postoperative complication rate of
appendectomy is low when looking at patients with un-
complicated AA (type 1b) the threshold to operate should
be rather low unless significant comorbidity is present
[49]. Still, a population-based study from Ontario showed
up to 25.2% postoperative complications (including read-
mission, emergency room visits, and prolonged hospital
stays) [50]. When looking at patients with nonperforated
forms of AA without obstruction a recent randomised trial
detected AA recurrence in still 25% of patients within 90
days [3]. However, severe phlegmonous types of appendi-
citis (type 2a), as well as gangrenous types of AA (type
2b), were counted as uncomplicated AA in this study.
Importantly, just 3.5% had an “US only” diagnostic ap-
proach compared to 79.6% a “CT only” reflecting possible
improvements with regard to radiation protection.
Acknowledgement We thank M. Knörzer for secretarial assistance and
A. De Forrest, MD, and M.W. Hoffmann, MD PhD, for critical reading of
the manuscript.
Int J Colorectal Dis
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