The American College of Emergency Physicians has produced a policy entitled: ‘Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis‘
It contains the following questions and recommendations:
1. Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis?
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).
2. In adult patients with suspected acute appendicitis who are undergoing a CT scan, what is the role of contrast?
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.
3. In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of CT and ultrasound in diagnosing acute appendicitis?
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.
The full document contains a helpful summary of existing literature on clinical scoring systems and laboratory investigations, including positive and negative likelihood ratios for various tests.