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Acute appendicitis in adults: Diagnostic evaluation

Authors: Ronald F Martin, MD, Stella K Kang, MD, MS

Section Editor: Martin Weiser, MD
Deputy Editors: Wenliang Chen, MD, PhD, Susanna I Lee, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Jun 01, 2017.

INTRODUCTION Appendicitis 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 APPROACH The 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 1.08-1.43)
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).
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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 58.464.7) and a negative
predictive value (NPV) of 88.1 (95% CI 81.894.4) [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 >37.5C (>99.5F) (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].

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 [39].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 [39]. 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 studies".)

Intravenous contrast administration is recommended in CT exams performed for the diagnosis of appendicitis. Contraindications to contrast administration are
[40]:

Renal insufficiency (estimated glomerular filtration rate [eGFR] <30 mL/minute per 1.73 m2)
History of hypersensitivity reaction to iodinated contrast

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Noncontrasted CT is an acceptable alternative if intravenous contrast is contraindicated. While reasonably high diagnostic accuracy is seen with noncontrast CT
[41,42], 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 [43].

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 [44-46]:

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)

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]. 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 [47-49].

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 [50,51]. 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 [52-54]:

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) [55,56].

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) [57]:

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) [58].

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 [59]. 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 "Principles of magnetic resonance imaging" and "Principles of magnetic resonance imaging", section on 'Precautions'.)

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 EXPLORATION 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 "Management of acute
appendicitis in adults", section on 'Laparotomy versus laparoscopy'.)

[26,34]

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.)

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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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50. Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic appearance of the normal appendix in adults. J Ultrasound Med 2007; 26:37.
51. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007; 24:359.
52. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337.
53. 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.
54. Jeffrey RB Jr, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167:327.
55. 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.
56. 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.
57. Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria right lower quadrant pain--suspected appendicitis. J Am Coll Radiol 2011; 8:749.
58. 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.
59. 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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GRAPHICS

Modified Alvarado score for diagnosis of appendicitis

Feature Point

Migratory right lower quadrant pain 1

Anorexia 1

Nausea or vomiting 1

Tenderness in the right lower quadrant 2

Rebound tenderness in the right lower quadrant 1

Fever >37.5C (>99.5F) 1

Leukocytosis of white blood cell count >10 x 10 9/liter 2

Total 9

Score of 0 to 3 indicates appendicitis is unlikely and other diagnoses should be pursued. Score of 4 indicates that the patient should be further evaluated for appendicitis.

C: centigrade; F: fahrenheit.

Modified from: Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15:557.

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Algorithm: Diagnostic evaluation of suspected appendicitis

CT: computed tomography; MRI: magnetic resonance imaging.

* Experienced clinicians may use clinical judgment in place of the Alvarado score.
Imaging available in <3 hours.
Perform imaging if it becomes available during observation period.
Intravenous contrast and, if available, low radiation dose image acquisition protocols recommended. If readily available, MRI can substitute for CT in women <30 years when gynecologic
conditions are a diagnostic consideration.
Women of reproductive age should undergo laparoscopic exploration to look for other causes of abdominal pain. Appendectomy is performed at the time of laparoscopy. Most other
patients can proceed with appendectomy directly without diagnostic laparoscopy.

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Test performance for diagnosis of appendicitis

Test Sensitivity (95% CI) Specificity (95% CI)

WBC 0.84 (0.73 to 0.92) 0.67 (0.50 to 0.81)

CRP 0.81 (0.74 to 0.87) 0.54 (0.42 to 0.64)

WBC & CRP 0.93 (0.86 to 1.00) 0.62 (0.37 to 0.86)

CT 0.96 (0.95 to 0.97) 0.96 (0.93 to 0.97)

US 0.85 (0.79 to 0.90) 0.90 (0.83 to 0.95)

MRI 0.95 (0.88 to 0.98) 0.92 (0.87 to 0.95)

CI: confidence intervals; WBC: white blood cell count; CRP: C-reactive protein; CT: computed tomography; US: ultrasound; MRI: magnetic resonance imaging.

Data from: Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of Right Lower Quadrant Pain and Suspected Acute Appendicitis. Comparative Effectiveness Review No. 157.
(Prepared by the Brown Evidence-based Practice Center under Contract No. 290-2012-00012-I.) AHRQ Publication No. 15(16)-EHC025-EF. Rockville, MD: Agency for Healthcare
Research and Quality; December 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

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Imaging modalities for diagnosis of appendicitis

Advantages Disadvantages

US No ionizing radiation Lower diagnostic accuracy than CT or MRI

Widely available, including at the bedside Patient- and operator-dependent variability in diagnostic performance

High rates of indeterminate exams with 50 to 85% of normal

appendices not visualized [1,2]

CT High diagnostic accuracy Ionizing radiation

Lowest rates of indeterminate exams with 80 to 90% of normal Intravenous iodinated contrast needed for optimum diagnostic
appendix visualized [3,4,5] performance

MRI No ionizing radiation Limited availability

High diagnostic accuracy Requires patient lie still in an enclosed scanner for 10 to 30 minutes

Moderates rates of nondiagnostic exams with 20 to 30% normal

appendices not visualized [6]

US: ultrasound; CT: computed tomography; MRI: magnetic resonance imaging.

References:
1. Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic appearance of the normal appendix in adults. J Ultrasound Med 2007; 26:37.
2. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007; 24:359.
3. Benjaminov O, Atri M, Hamilton P, Rappaport D. Frequency of visualization and thickness of normal appendix at nonenhanced helical CT. Radiology 2002; 225:400.
4. 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.
5. 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.
6. 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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CT normal appendix

Normal appendix. Images of the pelvis from a CT with intravenous and oral
contrast shows an appendix (arrow) that is air-filled with double-layer wall
thickness of <6 mm.

CT: computed tomography.

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CT acute appendicitis

Acute appendicitis. Images of the pelvis (A and B) from a CT with intravenous and oral contrast
shows an thickened appendix (arrow) containing an appendicolith and surrounding fluid
indicating inflammation.

CT: computed tomography.

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Ultrasound normal appendix

Normal appendix. Image from an abdominal ultrasound shows an appendix

(thick red arrow) measuring <6 mm in double-layer thickness (calipers)
originating from the cecal base (thin, white arrow). Surrounding normal
structures include the cecum (COE), small bowel (DD), and iliac vessels (VI).

Courtesy of Christoph F Dietrich, MD.

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Ultrasound acute appendicitis

Acute appendicitis. Image from an abdominal ultrasound with Doppler shows a

thickened appendix (calipers) with hypervascular wall. Diagnosis was surgically
confirmed.

Courtesy of Christoph F Dietrich, MD.

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MRI normal appendix

Normal appendix. MR T2-weighted images (A and B) of the pelvis in a pregnant

patient shows the appendix (arrow) that is <6 mm double-layer wall thickness
originating from the cecum (asterisk).

MRI: magnetic resonance imaging; MR: magnetic resonance.

Courtesy of Susanna I Lee, MD, PhD.

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MRI appendicitis

Acute appendicitis. MR sagittal T2-weighted image of the pelvis shows a

thickened appendix (arrow) with surrounding edema originating from the cecum
(asterisk).

MRI: magnetic resonance imaging; MR: magnetic resonance.

Courtesy of Stella K Kang MD, MS.

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Contributor Disclosures
Ronald F Martin, MD Nothing to disclose Stella K Kang, MD, MS Nothing to disclose Martin Weiser, MD Nothing to disclose Wenliang Chen, MD,
PhD Nothing to disclose Susanna I Lee, 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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