Annals of Emergency Medicine
Volume 55, Issue 1 , Pages 71-116 , January 2010

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

References 

  1. American College of Emergency Physicians. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med. 2000;36:406–415
  2. Centers for Disease Control and Prevention. CDC releases latest data on emergency department visits (Advance Data number 340. 2004-1250). Accessed January 26, 2009 http://www.cdc.gov/nchs/pressroom/04facts/emergencydept.htm
  3. Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205
  4. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005;21:165–169
  5. Bundy DG, Byerley JS, Liles EA, et al. Does this child have appendicitis?. JAMA. 2007;298:438–451
  6. Schriger DL, Cantrill SV, Greene CS. The origins, benefits, harms, and implications of emergency medicine clinical policies. Ann Emerg Med. 1993;22:597–602
  7. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis?. JAMA. 1996;276:1589–1594
  8. Andersson REB. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91:28–37
  9. Gwynn LK. The diagnosis of acute appendicitis: clinical assessment versus computed tomography evaluation. J Emerg Med. 2001;21:119–123
  10. Tzanakis NE, Efstathiou SP, Danulidis K, et al. A new approach to accurate diagnosis of acute appendicitis. World J Surg. 2005;29:1151–1156
  11. Cardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med. 2004;11:1021–1027
  12. 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;230:472–478
  13. Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and C-reactive protein assays. Ann R Coll Surg Engl. 2006;88:27–32
  14. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15:557–564
  15. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med. 2007;25:489–493
  16. Chan MYP, Tan C, Chiu MT, et al. Alvarado score: an admission criterion in patients with right iliac fossa pain. Surg J R Coll Surg Edinb Irel. 2003;1:39–41
  17. Yildirim E, Karagulle E, Kirbas I, et al. Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis. Diagn Interv Radiol. 2008;14:14–18
  18. Kharbanda AB, Taylor GA, Fishman SJ, et al. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005;116:709–716
  19. Wang LT, Prentiss KA, Simon JZ, et al. The use of white blood cell count and left shift in the diagnosis of appendicitis in children. Pediatr Emerg Care. 2007;23:69–76
  20. van den Broek WT, van der Ende ED, Bijnen AB, et al. Which children could benefit from additional diagnostic tools in case of suspected appendicitis?. J Pediatr Surg. 2004;39:570–574
  21. Klein MD, Rabbani AB, Rood KD, et al. Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory. J Pediatr Surg. 2001;36:1375–1380
  22. Jacobs JE, Birnbaum BA, Macari M, et al. Acute appendicitis: comparisons of helical CT diagnosis—focused technique with oral contrast material versus nonfocused technique with oral and intravenous contrast material. Radiology. 2001;220:683–690
  23. Tamburrini S, Brunetti A, Brown M, et al. Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol. 2007;17:2055–2061
  24. Funaki B, Grosskreutz SR, Funake CN. Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital. AJR Am J Roentgenol. 1998;171:997–1001
  25. Giuliano V, Giuliano C, Pinto F, et al. CT method for visualization of the appendix using a fixed oral dosage of diatrizoate—clinical experience in 525 cases. Emerg Radiol. 2005;11:281–285
  26. 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;75:721–725
  27. Lane MJ, Katz DS, Ross BA, et al. Unenhanced helical CT for suspected acute appendicitis. AJR Am J Roentgenol. 1997;168:405–409
  28. Wijetunga R, Tan BS, Rouse JC, et al. Diagnostic accuracy of focused appendiceal CT in clinically equivocal cases of acute appendicitis. Radiology. 2001;221:747–753
  29. Raman SS, Lu DSK, Kadell BM, et al. Accuracy of nonfocused helical CT for the diagnosis of acute appendicitis: a 5-year review. AJR Am J Roentgenol. 2002;178:1319–1325
  30. Ujiki MB, Murayama KM, Cribbins AJ, et al. CT scan in the management of acute appendicitis. J Surg Res. 2002;105:119–122
  31. Malone AJ, Wolf CR, Malmed AS, et al. Diagnosis of acute appendicitis: value of unenhanced CT. AJR Am J Roentgenol. 1993;160:763–766
  32. 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;50:1223–1229
  33. in't Hof KH, van Lankeren W, Krestin GP, et al. Surgical validation of unenhanced helical computed tomography in acute appendicitis. Br J Surg. 2004;91:1641–1645
  34. Lane MJ, Liu DM, Huynh MD, et al. Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive patients. Radiology. 1999;213:341–346
  35. Cakirer S, Basak M, Colakoglu B, et al. Diagnosis of acute appendicitis with unenhanced helical CT: a study of 130 patients. Emerg Radiol. 2002;9:155–161
  36. Horton MD, Counter SF, Florence MG, et al. A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J Surg. 2000;179:379–381
  37. Balthazar EJ, Megibow AJ, Siegel SE, et al. Appendicitis: prospective evaluation with high-resolution CT. Radiology. 1991;180:21–24
  38. Hershko DD, Sroka G, Bahouth H, et al. The role of selective computed tomography in the diagnosis and management of suspected acute appendicitis. Am Surg. 2002;68:1003–1007
  39. Kamel IR, Goldberg SN, Keogan MT, et al. Right lower quadrant pain and suspected appendicitis: nonfocused appendiceal CT—review of 100 cases. Radiology. 2000;217:159–163
  40. Schuler JG, Shortsleeve MJ, Goldenson RS, et al. Is there a role for abdominal computed tomographic scans in appendicitis?. Arch Surg. 1998;133:373–377
  41. Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol. 1997;169:1275–1280
  42. Pickuth D, Spielmann RP. Unenhanced spiral CT for evaluating acute appendicitis in daily routine (A prospective study). Hepatogastroenterology. 2001;48:140–142
  43. Walker S, Haun W, Clark J, et al. The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg. 2000;180:450–455
  44. Wong SK, Chan LP, Yeo A. Helical CT imaging of clinically suspected appendicitis: correlation of CT and histological findings. Clin Radiol. 2002;57:741–745
  45. D'Ippolito G, Netto de Mello GG, Szejnfeld J. The value of unenhanced CT in the diagnosis of acute appendicitis. Sao Paulo Med J. 1998;116:1838–1845
  46. Morris KT, Kavanagh M, Hansen P, et al. The rational use of computed tomography scans in the diagnosis of appendicitis. Am J Surg. 2002;183:547–550
  47. Naffaa LN, Ishak GE, Haddad MC. The value of contrast-enhanced helical CT scan with rectal contrast enema in the diagnosis of acute appendicitis. J Clin Imaging. 2005;29:255–258
  48. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology. 1997;202:139–144
  49. Mun S, Ernst RD, Chen K, et al. Rapid CT diagnosis of acute appendicitis with IV contrast material. Emerg Radiol. 2006;12:99–102
  50. Anderson BA, Salem L, Flum DR. A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg. 2005;190:474–478
  51. Mittal VK, Goliath J, Sabir M, et al. Advantages of focused helical computed tomographic scanning with rectal contrast only vs triple contrast in the diagnosis of clinically uncertain acute appendicitis (A prospective randomized study). Arch Surg. 2004;139:495–500
  52. Bendeck SE, Nino-Murcia M, Berry GJ, et al. Imaging for suspected appendicitis: negative appendectomy and perforation rates. Radiology. 2002;225:131–136
  53. Yao CC, Lin CS, Yang CC. Laparoscopic appendectomy for ruptured appendicitis. Surg Laparosc Endosc Percutan Tech. 1999;9:271–273
  54. Klempa I. Current therapy of complicated appendicitis. Chirurg. 2002;73:799–804
  55. Baldisserotto M, Marchiori E. Accuracy of noncompressive sonography of children with appendicitis according to the potential positions of the appendix. AJR Am J Roentgenol. 2000;175:1387–1392
  56. Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology. 2002;223:633–638
  57. Chang CC, Tsai CY, Lin CC, et al. Comparison between technetium-99m hexamethylpropyleneamineoxide labeled white blood cell abdomen scan and abdominal sonography to detect appendicitis in children with an atypical clinical presentation. Hepatogastroenterology. 2003;50:426–429
  58. Dilley A, Wesson D, Munden M, et al. The impact of ultrasound examinations on the management of children with suspected appendicitis: a 3-year analysis. J Pediatr Surg. 2001;36:303–308
  59. Lowe LH, Penney MW, Stein SM, et al. Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. AJR Am J Roentgenol. 2001;176:31–35
  60. Sivit CJ, Applegate KE, Stallion A, et al. Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT. AJR Am J Roentgenol. 2000;175:977–980
  61. Teo EL, Tan KP, Lam SL, et al. Ultrasonography and computed tomography in a clinical algorithm for the evaluation of suspected acute appendicitis in children. Singapore Med J. 2000;41:387–392
  62. Kaiser S, Finnbogason T, Jorulf HK, et al. Suspected appendicitis in children: diagnosis with contrast-enhanced versus nonenhanced helical CT. Radiology. 2004;231:427–433
  63. Acosta R, Crain EF, Goldman HS. CT can reduce hospitalization for observation in children with suspected appendicitis. Pediatr Radiol. 2005;35:495–500
  64. Hoecker CC, Billman GF. The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med. 2005;28:415–421
  65. Mullins ME, Kircher MF, Ryan DP, et al. Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. AJR Am J Roentgenol. 2001;176:37–41
  66. Kharbanda AB, Taylor GA, Bachur RG. Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology. 2007;243:520–526
  67. Brody AS, Frush DP, Huda W, et al. Radiation risk to children from computed tomography. Pediatrics. 2007;120:677–682
  68. American Academy of Pediatrics. Committee on Environmental Health (Risk of ionizing radiation exposure to children: a subject review). Pediatrics. 1998;101:717–719
  69. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–2284
  70. Garcia Pena BM, Taylor GA, Fishman SJ, et al. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics. 2002;110:1088–1093
  71. Wan MJ, Krahn M, Ungar WJ, et al. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis—a Markov decision analytic model. Radiology. 2009;250:378–386

 Approved by the ACEP Board of Directors, October 2, 2009

 Supported by the Emergency Nurses Association, November 3, 2009

PII: S0196-0644(09)01644-8

doi: 10.1016/j.annemergmed.2009.10.004

Annals of Emergency Medicine
Volume 55, Issue 1 , Pages 71-116 , January 2010