Clinical Skills Muse #19: Appendicitis and CT

Acute appendicitis represents the most common specific identifiable cause of an acute abdomen worldwide. Accurate diagnosis of acute appendicitis is often difficult clinically. Although there is some continuing controversy in the surgical and clinical literature, a consensus is emerging regarding the utility of routine CT for most, if not all, adult patients with suspected acute appendicitis. Increasing evidence suggests that even young adult men should routinely undergo CT rather than initial surgical exploration, and there is no convincing evidence-based data that the routine use of CT increases the perforation rate. CT, regardless of the protocol used, permits diagnosis or exclusion of appendicitis and alternative diagnoses accurately compared with the historical 20% negative appendectomy rate.

Furthermore, CT establishes the severity of appendicitis. The paradox is that the increased use of CT may have made accurate diagnosis more difficult in some patients, especially those in the earlier stages of appendicitis. Because patients are being scanned earlier, and because findings may therefore be more subtle or false-negative on unenhanced CT or on CT with oral/rectal contrast only, IV contrast should be considered routinely for imaging all patients with suspected appendicitis. Thin cuts, cine review of images on a monitor, and careful review of the right lower quadrant anatomy, as well as routine scanning of the entire abdomen and pelvis, should be performed in all cases. Radiologists need to appreciate the overlap of normal and abnormal appendiceal sizes, and should use all the CT findings present to make or exclude the diagnosis of appendicitis.

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Maynard Luterman