Acute appendicitis in adults: Diagnostic evaluation

Author
Ronald F Martin, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer
review process is complete.
Literature review current through: Dec 2015. | This topic last updated: Jul
24, 2014.
INTRODUCTION The diagnosis of acute appendicitis is typically based
upon the findings from the medical history and clinical examination and is
supported by the laboratory and/or imaging findings.
This topic will review the diagnostic studies, including radiographic studies
and laboratory tests that can assist in establishing the diagnosis of acute
appendicitis in the adult. The clinical manifestations of acute appendicitis
and the operative and nonoperative management are reviewed as separate
topics. (See "Acute appendicitis in adults: Clinical manifestations and
differential diagnosis" and "Management of acute appendicitis in adults".)
DIAGNOSIS The diagnosis of acute appendicitis is generally made from
the history and clinical examination; the diagnosis is supported by the
laboratory and/or imaging findings. The patient presenting with acute
abdominal pain should undergo a thorough physical examination, including
a digital rectal examination. Women should undergo a pelvic examination.
(See "History and physical examination in adults with abdominal pain".)
An experienced examiner can make the correct diagnosis of appendicitis
without imaging [1]. Several studies have found the diagnostic accuracy of
clinical evaluation alone to be 75 to 90 percent [2-5]. The diagnostic
accuracy of the clinical examination may depend on the experience of the
examining clinician [6-11]. Patients in whom appendicitis is considered to be
extremely likely after assessment by an experienced clinician should
proceed directly to appendectomy without further radiologic testing. (See
"Management of acute appendicitis in adults".)
The diagnosis of acute appendicitis can be difficult and a delay can result in
perforation rates as high as 80 percent [12,13]. However, a retrospective

review of 9048 adults with acute appendicitis found that the mean time
from presentation to operation (8.6 hours) was not associated with risk of
perforation [14]. Factors associated with increased risk of perforation
included male gender (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 1.363.49), and lack of medical insurance coverage (RR 1.43, 95% CI 1.24-1.66).
The challenging clinical settings include [15]:
Children less than 3 years of age (see "Acute appendicitis in children:
Clinical manifestations and diagnosis")
Adults older than age 60 years (see "Management of acute appendicitis in
adults", section on 'Elderly patients')
Women in the second and third trimesters of pregnancy, due to the
displacement of the appendix by the uterus and the resulting changes in
the physical examination (see "Acute appendicitis in pregnancy")
No single feature or combination of features is a highly accurate predictor of
acute appendicitis, although prediction rules based upon combinations of
features may have some clinical utility [2,16-21].
Diagnostic scoring systems Several scoring systems have been proposed
to standardize the correlation of clinical and laboratory variables.
The Alvarado score is the most widely used diagnostic aid for the diagnosis
of appendicitis and has been modified slightly since it was introduced
[22,23]. However, clinical judgment remains paramount. For example, a low
modified Alvarado score (<4) is less sensitive than clinical judgement. In a
prospective study of 261 adult patients with clinically suspicious
appendicitis, in whom 53 patients (20 percent) had a final diagnosis of
appendicitis, the low modified Alvarado score was less sensitive compared
with unstructured clinical judgement (72 versus 93 percent sensitivity) [24].
A retrospective review of 74 patients with acute appendicitis found that the
Alvarado score was less sensitive and specific than CT imaging [25].
The modified Alvarado scale assigns a score to each of the following
diagnostic criteria:

Migratory right iliac fossa pain (1 point)

Anorexia (1 point)
Nausea/vomiting (1 point)
Tenderness in the right iliac fossa (2 points)
Rebound tenderness in the right iliac fossa (1 point)
Fever >37.5C (1 point)
Leukocytosis (2 points)
A low Alvarado score (<5) has more diagnostic utility to rule out
appendicitis than a high score (7) does to rule in the diagnosis. In a
systematic review of 42 retrospective and prospective studies that included
over 8300 patients with suspected acute appendicitis and/orright iliac fossa
pain, overall 99 percent of patients with acute appendicitis had a score of
5 [26]. However, a high score (7) alone had poor diagnostic predictive
utility as the overall sensitivity was 82 percent and the specificity was 81
percent. The Alvarado score was most accurate in men but over-predicted
the probability of acute appendicitis in women in all risk groups.
A management guide based upon total points includes:
A patient with a score of 0 to 3 could be considered to have a low risk of
appendicitis and would be discharged with advice to return if there was no
improvement in symptoms, subject to social circumstances.
A patient with a score of 4 to 6 would be admitted for observation and reexamination. If the score remains the same after 12 hours, operative
intervention is recommended.
A male patient with a score of 7 to 9 would proceed to appendectomy.
A female patient who is not pregnant with a score of 7 to 9 would undergo
diagnostic laparoscopy, then appendectomy if indicated by the
intraoperative findings. The surgical management of appendicitis during
pregnancy is discussed separately. (See "Acute appendicitis in pregnancy".)

Because of the challenges of diagnosing acute appendicitis in women, some

authors have advocated diagnostic laparoscopy to minimize the high falsenegative rate in women regardless of score [23], while others have
suggested using CT scans to help with the diagnosis of patients with an
equivocal clinical presentation and a score between 4 to 6 [27]. (See "Acute
appendicitis in adults: Clinical manifestations and differential diagnosis".)
Several other scoring systems have been described as well, but none are
typically in common use [28-30]. A systematic review of several published
scoring systems showed a diagnostic sensitivity of 53 to 99 percent and
specificity of 30 to 99 percent [31]. As a general rule, the addition of these
decision aids to clinical judgment has the potential to improve specificity
and lead to lower false-positive rates in diagnosis of acute appendicitis, but
decision aids cannot definitively determine or exclude the possibility of
appendicitis [31].
DIAGNOSTIC EVALUATION
Imaging Imaging modalities such as computed tomography (CT) and
ultrasonography (US) are increasingly used to support the clinical diagnosis
of acute appendicitis. Although some studies suggest that the increased use
of imaging has decreased the nontherapeutic appendectomy rate (NAR) for
acute appendicitis [32,33], many surgeons will and should proceed with
surgical exploration, in the absence of imaging, if there is strong clinical
support for appendicitis. (See "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis", section on 'Clinical
manifestations'.)
Based upon prospective trials and retrospective data, imaging studies do
not improve the overall diagnostic accuracy for acute appendicitis (image 1
and image 2); the diagnostic accuracy of an experienced surgeon is
comparable to CT scan imaging in the assessment of patients with an
equivocal presentation of acute appendicitis [2,4,5,7]. However, in a
retrospective review, the CT scan changed the treatment plan in 58 percent
of patients [34]. Differences in studies may, in part, be due to the
experience of the surgeons and the populations being evaluated. A
prospective study of 2763 patients found that the sensitivity, specificity,
positive predictive value, and negative predictive value of preoperative
evaluations included [5]:

Ultrasonography
99.1, 91.7, 96.5, and 97.7 percent, respectively
Computed tomography
96.4, 95.4, 95.6, and 96.3 percent, respectively
Clinical examination
99.0, 76.1, 88.1, and 97.6 percent, respectively
Diagnostic imaging is unnecessary when the clinical diagnosis of acute
appendicitis is nearly certain for either presence or absence of appendicitis.
Diagnostic imaging should be performed and is most likely to alter
treatment when the diagnosis of appendicitis is clinically suspected but
unclear. Diagnostic imaging may be useful in children, elder adults, or
women of childbearing age with an unclear presentation. Similarly, patients
with comorbidities such as diabetes, obesity, and immunocompromise may
have a higher occurrence of atypical presentation of acute appendicitis.
These populations are more likely to present with unclear symptoms such
as vague abdominal pain. (See "Acute appendicitis in children: Diagnostic
imaging" and "Management of acute appendicitis in adults", section on
'Special considerations' and "Acute appendicitis in pregnancy", section on
'Diagnosis'.)
Computed tomography Based upon retrospective reviews, adult women
are more than twice as likely as men to have a nontherapeutic
appendectomy for acute appendicitis [33,35-38], and, therefore, women
may benefit from a preoperative CT scan if the diagnosis is uncertain
(image 3 and image 4). A retrospective review of 1425 consecutive patients
undergoing an appendectomy found that adult women evaluated with a
preoperative CT scan had a significantly lower nontherapeutic
appendectomy rate (NAR) compared with adult women without a
preoperative diagnostic CT scan (21 versus 8 percent) [33]. There was no
reduction in NAR for men or children.
Preoperative CT protocols for imaging include:
Standard abdominal-pelvic CT with IV and oral contrast

Focused appendiceal CT with rectal contrast

Noncontrast CT
In most clinical settings, if there is sufficient diagnostic concern and
uncertainty to warrant a CT scan to diagnose appendicitis, a full abdominalpelvic CT with IV and oral contrast should be performed or a decision should
be made to proceed to the operating room for abdominal exploration by
laparotomy or laparoscopy.
Standard CT scan with contrast A commonly used protocol involves a
standard abdominal and pelvic CT scan (16-MDCT or higher) with
intravenous and oral contrast. (See "Principles of computed tomography of
the chest".)
A number of findings suggest acute appendicitis on standard abdominal CT
scanning [21,39,40]:
Enlarged appendiceal diameter >6 mm with an occluded lumen
Appendiceal wall thickening (>2 mm)
Periappendiceal fat stranding
Appendiceal wall enhancement
Appendicolith (seen in approximately 25 percent of patients)
The sensitivity and specificity of CT with IV and oral contrast for acute
appendicitis is in the range of 91 to 98 and 75 to 93 percent, respectively
[2,4,19,34,41-43]. Air in the appendix or a contrast-filled lumen in a normal
appearing appendix virtually excludes the diagnosis. However, a
nonvisualized appendix does not rule out appendicitis. This is particularly
important to remember in patients who have had symptoms for a short
duration, since only minimal inflammatory changes may be present in the
right lower quadrant.
An advantage of a complete abdominal CT scan is that it permits
visualization of the entire abdomen. An alternative diagnosis is found in up
to 15 percent of patients [34]. Furthermore, a CT scan can assist in the

treatment plan for patients with a palpable abdominal mass, such as those
in whom an appendiceal phlegmon or abscess may have developed. These
features are more likely in patients who present after having prolonged
symptoms (four to five days). (See "Management of acute appendicitis in
adults".)
A drawback of the standard CT protocol is that it takes up to two hours to
administer oral contrast. In addition, a CT scan involves radiation exposure
and intravenous contrast, with the potential for contrast-induced renal
nephropathy. Cost and availability are also considerations, particularly in
resource-poor settings.
Appendiceal CT A focused appendiceal CT scan can be performed with
rectal contrast alone and thin cuts through the right iliac fossa. Because full
oral contrast is not given, the scan can be performed within 15 minutes.
Rectal contrast provides good visualization of the pericecal region without
the need to wait for oral contrast to reach the right lower quadrant, which
may be an unpleasant procedure for the patient.
In a report using a limited appendiceal CT scan with rectal contrast, the
sensitivity of the most common findings for acute appendicitis were as
follows [21]:
Right lower abdominal quadrant fat stranding (100 percent sensitivity)
Focal cecal thickening (69 percent specificity)
Adenopathy (63 percent sensitivity)
One study reported that a focal appendiceal CT had 98 percent accuracy
and sensitivity with rectal contrast along a limited area (15 cm) of the pelvis
centered 3 cm superior to the cecal tip [17,44].
The relevance of focal appendiceal imaging is questionable outside of large
medical centers, as this technique requires personnel to administer rectal
contrast and a radiologist on site for the verification of positioning. In
addition, an appendiceal CT scan only evaluates the appendix, and the
images may be unrevealing in the presence of other abdominal pathology.

Unenhanced CT The administration of contrast for imaging adds time,

expense, and risk of an allergic reaction. A number of studies have
suggested that adequate imaging can be obtained without contrast. In
various reports, unenhanced CT had a sensitivity of 88 to 96 percent,
specificity of 91 to 98 percent, and diagnostic accuracy of 94 to 97 percent
for appendicitis, with the added advantage of total exam time of 5 to 15
minutes [7,45,46].
Test characteristics may depend, at least in part, upon the patient's body
habitus [2]. Some radiologists maintain that if the BMI exceeds 25 that the
CT is less accurate and therefore oral contrast is necessary.
An important limitation of unenhanced CT is the diminished ability to
diagnose other abdominal pathology, potentially diminishing the role of the
examination in patients in whom there is diagnostic uncertainty (eg, elder
patients, women, atypical presentation).
Unenhanced CT may be of some value in patients who have renal failure or
clinical instability. However, for most patients where there is sufficient
diagnostic uncertainty to warrant a CT scan for appendicitis, a full
abdominal-pelvic CT with IV and oral contrast should be performed or a
decision should be made to proceed to the operating room for abdominal
exploration.
Ultrasonography Ultrasound (US) is reliable to confirm the clinical
diagnosis of acute appendicitis, but is not reliable to exclude the diagnosis
(image 5 and image 6) [47]. Accuracy is diminished in obese patients.
At least eight sonographic findings suggestive of internal inflammatory
changes of the appendix have been described [48-50]. The most accurate
ultrasound finding for acute appendicitis is an appendiceal diameter of >6
mm with a sensitivity, specificity, negative predictive value, and positive
predictive value of 98 percent [49,50]. In various reports, the sensitivity and
specificity by US in the diagnosis of appendicitis ranged from 35 to 98
percent and 71 to 98 percent, respectively [2,7,33,36].
Advantages of US compared with CT imaging include:
Results may be obtained more efficiently (institution and practitioner
dependent)

No radiation exposure
No use of intravenous or intestinal contrast agents
Disadvantages of US compared with CT imaging include:
Less diagnostic accuracy
Less likely to reveal an accurate alternative diagnosis
Accuracy is operator dependent
Technical challenges: Patients with a large body habitus and/or a large
amount of overlying bowel gas
Imaging costs The use of preoperative imaging studies in the diagnosis of
acute appendicitis has increased with time, from 32 percent (1995 through
1999) to 95 percent (2001 through 2008), at one representative academic
institution [33]. The increase in the use of CT scanning for the diagnosis of
appendicitis has been largely justified by the assumption that it decreases
the rates of perforated appendicitis as well as nontherapeutic
appendectomies [51,52]. In two studies that performed cost analysis, one
showed that the cost of a nontherapeutic appendectomy was 16 times more
expensive than a focused appendiceal CT scan, while another reported that
an appendectomy was 22 times more expensive than nonenhanced CT
scanning, implying cost savings if a reduction in nontherapeutic
appendectomy rates could be achieved [46,53]. However, in one
retrospective review, most patients undergoing a nontherapeutic
appendectomy had a preoperative CT scan, and more than 50 percent of
those patients had CT interpretations that were positive for, or could not
exclude, acute appendicitis [33].
Several studies have failed to demonstrate a significant reduction in the
overall institutional rates for nontherapeutic appendectomies despite the
increased use of CT scan over time [19,34,35,37,41,54-56]. Results of
studies that included analysis of perforated appendicitis are mixed. One
study showed an observed rate of appendiceal perforation of 9 percent in
patients who underwent routine CT imaging compared with 25 percent in
patients in whom CT scanning was not used [37]. Other studies have

demonstrated a fairly constant rate of perforated appendix over time

despite the increased use of CT scan [33,35,56].
Cost analysis for studies such as these is complicated by the value of CT
scanning in patients in whom therapeutic appendectomy was performed; as
a result, the cost savings depend upon an absolute rate reduction for
nontherapeutic appendectomies [34,57]. Additionally, cost calculations
depend upon local institutional variables and surgeon variables; selected
institutional observations may not be applicable to all practices.
Laboratory tests Laboratory tests serve a supportive role in the diagnosis
of appendicitis. No single laboratory test or combination of tests is an
absolute marker for appendicitis [49,54].
A complete blood count (CBC) with a differential should be obtained, but
cannot be used to confirm or exclude the diagnosis of appendicitis. A mild
leukocytosis and a left shift (increase in total white blood cell count, bands
[immature neutrophils], and neutrophils) can be present in acute
appendicitis as well as other acute etiologies of abdominal pain.
A pregnancy test should be performed for all women of childbearing age.
Although mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have
been noted to be a marker for appendiceal perforation with a sensitivity of
70 percent and a specificity of 86 percent [58], the test is not discriminatory
and generally not helpful in the evaluation of patients suspected of acute
appendicitis.
Exploratory laparotomy/laparoscopy The acceptable nontherapeutic
appendectomy rate (NAR) varies depending upon the age and sex of the
patient. For example, in young healthy males with right lower quadrant
pain, the negative appendectomy rate (NAR) should be less than 10
percent, while a rate that approaches 20 percent is reasonable in young
women in whom other pelvic processes can make accurate diagnosis more
difficult (eg, pelvic inflammatory diseases, tubo-ovarian abscess) [45,59].
No significant difference in NAR was noted in comparing laparoscopic and
open appendectomy [33]. A low NAR has been achieved in some centers
that use close in-hospital observation [60].

SUMMARY
The constellation of findings from history, physical examination, and
laboratory studies will usually lead an experienced examiner to the correct
diagnosis of appendicitis without diagnostic imaging (see 'Diagnosis'
above). A clinical diagnosis can be more challenging in women, who may
benefit from the addition of radiologic imaging when the diagnosis is
unclear.
The patient presenting with acute abdominal pain should undergo a
thorough physical examination, including a digital rectal examination.
Women should undergo a pelvic examination. (See 'Diagnosis' above and
"History and physical examination in adults with abdominal pain".)
Based upon prospective trials and retrospective data, imaging studies do
not improve the overall diagnostic accuracy for acute appendicitis (image 1
and image 2); the diagnostic accuracy of an experienced surgeon is
comparable to CT scan imaging in the assessment of patients with an
equivocal presentation of acute appendicitis. (See 'Imaging' above.)
Diagnostic imaging is advised when the diagnosis of appendicitis is
suspected but unclear (eg, elderly patients, patients with comorbid
illnesses, women of childbearing age). In this clinical setting, we perform a
standard abdominal CT scan with intravenous and oral contrast. (See
'Standard CT scan with contrast' above.)
Ultrasound (US) is reliable to confirm the clinical diagnosis of acute
appendicitis, but is not reliable to exclude the diagnosis (image 5 and image
6). (See 'Ultrasonography' above.)
Laboratory tests serve a supportive role in the diagnosis of appendicitis.
No single laboratory test or combination of tests is an absolute marker for
appendicitis. However, a complete blood count and a pregnancy test in
premenopausal women should be obtained in patients with acute
abdominal pain, but cannot confirm or exclude a diagnosis of acute
appendicitis. (See 'Laboratory tests' above.)
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Disclosures
Disclosures: Ronald F Martin, MD Nothing to disclose. Martin Weiser,
MD Nothing to disclose. Wenliang Chen, MD, PhD Nothing to disclose.
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