Evaluation and Management of Emergency Department Patients with Suspected Appendicitis

Publication Date: February 28, 2023
Last Updated: March 1, 2023

Summary of Recommendations

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. (B)
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In adult patients, due to insufficient data, do not use clinical prediction rules to identify patients for whom no advanced imaging is required. (C)
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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. (B)
*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
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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. (C)
*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
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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. (B)
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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. (C)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Evaluation and Management of Emergency Department Patients with Suspected Appendicitis

Authoring Organization

Publication Month/Year

February 28, 2023

Last Updated Month/Year

February 14, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients presenting to the emergency department with suspected appendicitis. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the below critical questions. For each question, a systematic literature search was performed, evidence was graded and synthesized, and recommendations were made based on the strength of the available data. The background text, systematic review, and critical analysis of the literature will be published later this year in the Annals of Emergency Medicine.

Target Patient Population

Adult and pediatric patients with suspected appendicitis

Target Provider Population

Emergency physicians, internal medicine, pediatrics and other allied providers

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D001064 - Appendicitis

Keywords

appendicitis

Supplemental Methodology Resources

Methodology Supplement