In patients with suspected acute appendicitis, use clinical findings to risk-stratify patients and guide decisions about further testing and management.
In adult patients undergoing CT imaging for suspected appendicitis, there is little evidence that intravenous, oral or rectal contrast increases the sensitivity of the test.
Given the concern over exposing children to ionizing radiation, consider using ultrasound as the initial imaging modality. In cases in which the diagnosis remains uncertain aſter ultrasound, CT may be performed.
Observation of patients with a periappendiceal mass without operative intervention is a reasonable option. A recent meta-analysis found that immediate operation was associated with a higher morbidity compared to nonsurgical management. Aſter successful nonsurgical treatment, a malignant disease was detected in 1.2% or an important benign disease in 0.7% of patients. The risk of recurrent appendicitis was 7.4%.
Imaging
ÎBased upon the patient's age, history and physical findings, the surgeon may choose, with high sensitivity and specificity, to operate immediately or to exclude the diagnosis of appendicitis without further diagnostic studies.
ÎCT scanning is the initial imaging modality of choice for suspected appendicitis in adult males and non-pregnant females (B-II).
> The CT findings suggestive of appendicitis include greater than 6 mm wall thickening; right lower quadrant inflammatory changes, such as fat stranding; and the presence of appendicoliths.
ÎAll females should undergo diagnostic imaging. Those of childbearing potential should undergo pregnancy testing prior to imaging, and if in the first trimester of pregnancy should undergo ultrasound or magnetic resonance rather than exposure to ionizing radiation (B-II). If these studies do not define the pathology present, laparoscopy or limited CT scanning may be considered (B-III).
ÎImaging of all children (particularly those under 3 years of age) is performed when the diagnosis of appendicitis is less than certain. For children, CT imaging is preferred although ultrasound may be used to avoid ionizing radiation (B-III).
ÎFor patients with negative imaging studies for suspected appendicitis, clinical follow-up at 24 hours is recommended to ensure resolution of signs and symptoms, because of the low but measurable risk of false negatives (B-III).
ÎFor patients with suspected appendicitis that can neither be confirmed nor excluded by diagnostic imaging, careful follow-up is recommended. Such patients may be hospitalized if the index of suspicion is high (A-III).
