Abstract
Background:Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis.Methods:A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed.Results:For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes.Conclusion:Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
Highlights
Diagnostic work-up of acute appendicitis remains challenging
In the second diagnostic stage of patients diagnosed with acute appendicitis, a differentiation between complicated and uncomplicated appendicitis is needed
As no clinical or laboratory test has both high sensitivity and high specificity, relying only on such parameters means balancing the tradeoffs between the risk of delaying treatment of complicated appendicitis and the risk of negative surgical explorations
Summary
The subject of appendicitis diagnostics is not new, a watertight work-up to accurately diagnose acute appendicitis remains challenging. In the second diagnostic stage of patients diagnosed with acute appendicitis, a differentiation between complicated and uncomplicated appendicitis is needed. Even if a clinical scoring model would be able to rule out acute appendicitis, imaging is still needed in most cases to correctly diagnose the cause of the abdominal pain for that particular patient. It reduces the risk that another diagnosis is missed as cause of abdominal pain in need of (urgent) treatment It minimizes NARs and it may help to differentiate between uncomplicated and complicated appendicitis, which is important because this may lead to different management strategies. With the current and ever increasing improvements in CT techniques, especially so for the low-dose CT modalities, it is hard to imagine a diagnostic paradigm in acute appendicitis not taking advantage of modern imaging In this respect, leaving out imaging features in scoring systems may have no promising future. Cross-sectional imaging is not needed in patients with abdominal pain at low-risk of appendicitis or any other disease requiring treatment
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