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Appendicitis (Jan 2010)

Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis (January 2010)

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

  • Can clinical findings be used to guide decision-making in the risk stratification of patients with possible appendicitis?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In 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.

    Level A Recommendations

    None specified.

    Level B Recommendations

    In 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.

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

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

    Recommendations
    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.

    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.

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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