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Appendicitis (Suspected)

Evaluation and Management of Emergency Department Patients with Suspected Appendicitis (January 2010)

Complete Clinical Policy on Suspected Appendicitis (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments.

Inclusion Criteria. This guideline is intended for patients presenting to the ED with acute, nontraumatic abdominal pain and possible or suspected appendicitis.

Exclusion Criteria. This guideline is not intended to address the care of patients with trauma-related abdominal pain, or pregnant patients.

Critical Questions

1. Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis?

  • Level A recommendations. None specified.
  • Level B recommendationsIn patients with suspected acute appendicitis, use clinical findings (ie, signs and symptoms) to risk-stratify patients and guide decisions about further testing (eg, no further testing, laboratory tests, and/or imaging studies), and management (eg, discharge, observation, and/or surgical consultation).
  • Level C recommendations. None specified.

2. In adult patients with suspected acute appendicitis who are undergoing a CT scan, what is the role of contrast?

  • Level A recommendations. None specified.

  • Level B recommendations In adult patients undergoing a CT scan for suspected appendicitis, perform abdominal and pelvic CT scan with or without contrast (intravenous [IV], oral, or rectal). The addition of IV and oral contrast may increase the sensitivity of the CT scan for the diagnosis of appendicitis.

  • Level C recommendations. None specified.

3. In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of CT and ultrasound in diagnosing acute appendicitis?

  • Level A recommendations. None specified.
     

  • Level B recommendations.
    1. In children, use ultrasound to confirm acute appendicitis but not to definitively exclude acute appendicitis. 
    2. In children, use an abdominal and pelvic CT to confirm or exclude acute appendicitis.
       

  • Level C recommendations.  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 after ultrasound, CT may be performed.

Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations