Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

Official 2023 guideline from the American College of Emergency Physicians.

Strength

Recommendations

Clinical Prediction Rules

Level B

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.

Level C

In adult patients, due to insufficient data, do not use clinical prediction rules to identify patients for whom no advanced imaging is required.

Diagnosis

Level B

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.

Level C

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.

Level B

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.

Level C

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.

Literature

Original/Primary Reference

Diercks DB, Adkins EJ, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients with Suspected Appendicitis. Ann Emerg Med. 2023;81(6):e115-e152.

Summary By

Eric Steinberg, DO, MEHP

What do the ratings mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus.