The Role of CT in Diagnosis

of Acute Appendicitis
Christopher C. Lee, MD, FAAEM
Department of Emergency Medicine
Stony Brook University Medical Center

Acute Appendicits
Prevalence of acute appendicitis is 12% to
28% in acute abdominal pain
Up to 32% if less than 50 years of age
Medical-Legal Reality
Abdominal pain is the 4th highest closed
claim dollars
Majority are missed appendicitis

Is It Appendicitis by History?
Location is unreliable and non-specific
RLQ abdominal pain: 81% sensitive and
53% specific
Migration: 64% sensitive and 82% specific
Anorexia: 68% sensitive and 36% specific
Nausea: 58% sensitive and 37% specific

Is It Appendicitis by Physical
Exam?

Fever: 67% sensitive and 79% specific

Rebound: 76% sensitive and 69% specific
Guarding: 74% sensitive and 57% specific
Psoas sign: 16% sensitive and 95%
specific

The Role of CT
CT is the imaging modality of choice for
those patients with suspected appendicitis

NEJM 1998 Rao

Appendicitis Mimics

Diverticulitis (right sided)

Epiploic appendagitis
Omental Infarct
Mesenteric adenitis
Bacterial ileocecitis
Crohns disease
Renal Stone/Pyelonephritis
Ovarian torsion/cyst
Acute Cholecystitis
Tubo-ovarian abscess

Appendicitis on CT

Signs of appendicitis
Enlarged appendix (diameter>6mm, wall
thickness>2mm)
Increased wall enhancement (if IV contrast)
Appendix is non-filling of oral contrast (the walls
are too edematous)
Appendicoliths:20-40%, may confer a greater
risk of perforation
RLQ inflammatory changes (fat stranding, fluid
phlegmon, abscess, extraluminal air,
adenopathy, adjacent bowel wall thickening)

Role of CT
Clinical impact: has decreased the falsenegative appendectomy rate
Balthazar et al studies: 146 patients and
found the negative appendectomy rate has
gone from 20% to 4% in male and 8% in
female with those undergoing CT
Rhea et al. showed a negative
appendectomy rate of 3% in 753 patients
using appendiceal CT

Role of CT
Abdominal CT scanning in reproductive-age
woman with right lower quadrant abdominal
pain: does its use reduce negative
appendectomy rates and healthcare costs?
4 year period retrospective study
Preoperative CT group had 17% negative
appendectomy rate c/w 42% with CT
Saved $1412/ patient
Morse BC Am Surg, 2007. Jun;73(6):580-4

Role of CT
Routine versus selective abdominal CT in
the evaluation of RLQ pain: a randomized
trial.
152 patients were randomized to selective
(n=80) and mandatory (n=72)
CT was done 54/80 patients in selective
group
CT was done 70/72 patients in mandatory
group

Role of CT
Decreased negative appendectomy rate in
mandatory group (1/39, 2.6%) c/w (6/43,
13.9%) in selective group.
There was also decrease in perforation
rate 7/38 (18.4%) in selective group c/w
4/39 (10.3%)
Lee CC, Singer AJ et al. Acad Emerg Med, 2007
Feb;14(2):117-22

Role of CT
Impact of helical CT in clinically evident
appendicitis
Of 157 study patients, 71 were considered
to have clinically evident appendicits
before CT.
91 out of 157 patient had findings of acute
appendicitis on CT
19/71 patients with clinically evident
appendicitis did not have appendicitis

 14/52 patients with an Alvarado score >or

=8 did not have appendicitis.
3/91 patients with acute appendicitis
based on CT did not have appendicitis
The specificities of clinical impression and
Alvarado score >or= 8 were 71.6% which
is lower than CT, 95.5% (p<0.05)
Kim K, Lee CC. Emerg Med J, 2008. Aug;25(8):477-81

Role of CT
The impact of helical CT on the negative
appendectomy rate: a multi-center
comparison
Multi-center comparative study to
determine the association between CT use
and negative appendectomy rates at 3
different medical centers

 The three centers had significant different

rates of CT utilization for diagnosis of
acute appendicitis
86.9%, 66.4%, and 13.3% (p<0.05) had
CT
2.5%, 16.8%, and 23.3% (p<0.05) had
negative appendectomy rates
Kim K, Lee CC. J Emerg Med. 2008 Jan;34(1):3-6.

Conclusion
There is lower negative appendectomy
rate when using CT.
Cost effective
Few studies shows that there is lower rate
of perforation