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Scope of Application
This guideline is intended for physicians working in hospital-based emergency departments (EDs).
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 patients who are pregnant.
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.
In emergency department patients with possible acute appendicitis, can a clinical prediction rule be used to identify patients for whom no advanced imaging is required?
None specified.
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 adult patients, due to insufficient data, do not use clinical prediction rules to identify patients for whom no advanced imaging is required.
None specified.
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 adult patients, due to insufficient data, do not use clinical prediction rules to identify patients for whom no advanced imaging is required.
In emergency department patients with suspected acute appendicitis, is the diagnostic accuracy of ultrasound comparable to CT or MRI for the diagnosis of acute 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.
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 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.
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 emergency department patients who are undergoing CT of the abdomen and pelvis for suspected acute appendicitis, does the addition of contrast improve diagnostic accuracy?
None specified.
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.
In adult ED patients undergoing CT for suspected acute appendicitis, non-contrast CT scans may be used for the evaluation of acute appendicitis with minimal reduction in sensitivity.
None specified.
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.
In adult ED patients undergoing CT for suspected acute appendicitis, non-contrast CT scans may be used for the evaluation of acute appendicitis with minimal reduction in sensitivity.
