Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis
Official 2023 guideline from the American College of Emergency Physicians.
summary by Eric Steinberg, DO, MEHP
Recommendations
In pediatric patients, clinical prediction rules can be used to risk stratify for possible acute appendicitis. However, do not use clinical prediction rules alone to identify patients who do not warrant advanced imaging for the diagnosis of appendicitis.
In pediatric patients with suspected acute appendicitis, if readily available and reliable, use right lower quadrant (RLQ) ultrasound (US) to diagnose appendicitis. An unequivocally* positive RLQ US with complete visualization of a dilated appendix has comparable accuracy to a positive CT or MRI in pediatric patients.
*A non-visualized or partially-visualized appendix should be considered equivocal. Reasonable options for pediatric patients with an equivocal ultrasound and residual suspicion for acute appendicitis include MRI, CT, surgical consult, and/or observation, depending on local resources and patient preferences with shared decision making.
In adult patients with suspected acute appendicitis, an unequivocally* positive RLQ US has comparable accuracy to a positive CT or MRI for ruling in appendicitis.
*A non-visualized or partially-visualized appendix should be considered equivocal. Reasonable options for pediatric patients with an equivocal ultrasound and residual suspicion for acute appendicitis include MRI, CT, surgical consult, and/or observation, depending on local resources and patient preferences with shared decision making.
In adult and pediatric ED patients undergoing CT for suspected acute appendicitis, use IV contrast when feasible. The addition of oral or rectal contrast does not improve diagnostic accuracy.