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AppendicitisWorkup
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Dec27,2015

ApproachConsiderations
Patientswithappendicitismaynothavethereportedclassicclinicalpicture3745%
ofthetime,especiallywhentheappendixislocatedinanunusualplace(see
Anatomy).Insuchcases,imagingstudiesmaybeimportantbutnotalways
available.However,patientswithappendicitisusuallyhaveaccessorysignsthatmay
behelpfulfordiagnosis(seePhysicalExamination).Forexample,theobturatorsign
ispresentwhentheinternalrotationofthethighelicitspain(ie,pelvicappendicitis),
andthepsoassignispresentwhentheextensionoftherightthighelicitspain(ie,
retroperitonealorretrocecalappendicitis).
Laboratorytestsarenotspecificforappendicitis,buttheymaybehelpfultoconfirm
diagnosisinpatientswithanatypicalpresentation.Forexample,liverandpancreatic
functiontests(eg,transaminases,bilirubin,alkalinephosphatase,serumlipase,
amylase)maybehelpfultodeterminethediagnosisinpatientswithanunclear
presentation.Forwomenofchildbearingage,thelevelofurinarybetahuman
chorionicgonadotropin(betahCG)isusefulindifferentiatingappendicitisfromearly
ectopicpregnancy.

CBCCount
Studiesconsistentlyshowthat8085%ofadultswithappendicitishaveawhite
bloodcell(WBC)countgreaterthan10,500cells/L.Neutrophiliagreaterthan75%
occursin78%ofpatients.Lessthan4%ofpatientswithappendicitishaveaWBC
countlessthan10,500cells/Landneutrophilialessthan75%.
DueholmetalfurtherdelineatedtherelationshipbetweentheWBCcountandthe
likelihoodofappendicitisbycalculatinglikelihoodratiosfordefinedintervalsofthe
WBCcount. [24]
Table2.WBCCountandLikelihoodofAppendicitis(OpenTableinanewwindow)
WBC(10,000)

LikelihoodRatio(95%CI)

47

0.10(00.39)

79

0.52(01.57)

911

0.29(00.62)

1113

2.8(1.24.4)

1315

1.7(03.6)

1517

2.8(06.0)

1719

3.5(010)

1922

Source:Dueholmetal. [24]
CI=confidenceintervalWBC=whitebloodcell.
CBCtestsareinexpensive,rapid,andwidelyavailablehowever,thefindingsare
nonspecific.Ininfantsandelderlypatients,aWBCcountisespeciallyunreliable
becausethesepatientsmaynotmountanormalresponsetoinfection.Inpregnant
women,thephysiologicleukocytosisrenderstheCBCcountuselessforthe
diagnosisofappendicitis.

CReactiveProtein
Creactiveprotein(CRP)isanacutephasereactantsynthesizedbytheliverin
responsetoinfectionorinflammationandrapidlyincreaseswithinthefirst12hours.
CRPhasbeenreportedtobeusefulinthediagnosisofappendicitishowever,it
lacksspecificityandcannotbeusedtodistinguishbetweensitesofinfection.
CRPlevelsofgreaterthan1mg/dLarecommonlyreportedinpatientswith
appendicitis,butveryhighlevelsofCRPinpatientswithappendicitisindicate
gangrenousevolutionofthedisease,especiallyifitisassociatedwithleukocytosis
andneutrophilia.However,CRPnormalizationoccurs12hoursafteronsetof
symptoms.Severalprospectivestudieshaveshownthat,inadultswhohavehad
symptomsforlongerthan24hours,anormalCRPlevelhasanegativepredictive
valueof97100%forappendicitis. [5,6,7]ThimsenetalnotedthatanormalCRP
levelafter12hoursofsymptomswas100%predictiveofbenign,selflimitedillness.
[5]

CRPsensitivity
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MultiplestudieshaveexaminedthesensitivityofCRPlevelaloneforthediagnosis
ofappendicitisinpatientsselectedtoundergoappendectomy.Gurleyiketalnoteda
CRPsensitivityof96.6%in87of90patientswithhistologicallyprovendisease. [25]
Similarly,ShakhetrahfoundaCRPsensitivityof95.5%in85of89patientswith
histologicallyprovenappendicitis. [26]AsfaretalreportedaCRPsensitivityof93.6%
in78patientsundergoingappendectomy, [27]andErkasapetalfoundaCRP
sensitivityof96%inagroupof102adultpatientswithRLQpain,55ofwhom
proceededtoappendectomy. [28]

SensitivityofWBCcountandCRPlevelincombination
InvestigatorshavealsostudiedtheabilityofcombinationsofWBCcountandCRP
toreliablyruleoutthediagnosisofappendicitis.GronroosandGronroosfoundthat
theWBCcountorCRPlevelwasabnormalinall200patientswithappendicitisin
theircohortof300patientsoperatedforsuspectedappendicitis. [29]OrtegaDeballon
etalfoundthatanormalWBCcountandCRPlevelhadanegativepredictivevalue
of92.3%forthepresenceofappendicitisinprospectivelystudiedpatientsreferred
toasurgeonforRLQpain. [30]
SomestudieshaveexaminedthesensitivityofacombinedWBCcountandCRP
levelinthesubpopulationofpatientsolderthan60years.Gronroosstudied83
patientsolderthan60yearswhounderwentappendectomy(73foundtohave
appendicitis)andfoundthatnopatientwithappendicitishadbothanormalWBC
countandCRPlevel. [31]Yangetalretrospectivelystudied77patientsolderthan60
yearswithhistologicallyprovenappendicitisandfoundthatonly2hadanormal
"triplescreen"(seebelow). [32]
SeveralstudiesalsoexaminedtheaccuracyoftheWBCcountandCRPlevelinthe
subpopulationofpediatricpatientswithsuspectedappendicitis.Gronroosevaluated
100childrenwithpathologyprovenappendicitisandfoundthatboththeWBCcount
andCRPlevelwerenormalin7of100patients. [33]Stefanuttietalprospectively
studiedmorethan100childrenundergoingsurgeryforsuspectedappendicitisand
foundthateithertheWBCcountorCRPlevelwaselevatedin98%ofthosewith
pathologyprovenappendicitis. [34]

TriplescreenofWBCcount,CRPlevel,andneutrophilia
Mohammedetalprospectivelystudied216childrenadmittedforsuspected
appendicitisandfoundatriplescreensensitivityof86%andanegativepredictive
valueof81. [35]However,Yangetalfoundthatonly6of740patientswith
appendicitishadaWBCcountlessthan10,500cells/LANDneutrophiliathatwas
lessthan75%,ANDanormalCRPlevel,yieldingasensitivityof99.2%forthe
"triplescreen." [36]

Urinalysis
Urinalysismaybeusefulindifferentiatingappendicitisfromurinarytractconditions.
Mildpyuriamayoccurinpatientswithappendicitisbecauseoftherelationshipof
theappendixwiththerightureter.Severepyuriaisamorecommonfindingin
urinarytractinfections(UTIs).Proteinuriaandhematuriasuggestgenitourinary
diseasesorhemocoagulativedisorders.
Onestudyof500patientswithacuteappendicitisrevealedthatapproximatelyone
thirdreportedurinarysymptoms,mostcommonlydysuriaorrightflankpain. [37]One
in7patientshadpyuriagreaterthan10WBCsperhighpowerfield(hpf),and1in6
patientshadgreaterthan3redbloodcells(RBCs)perhpf.Thus,thediagnosisof
appendicitisshouldnotbedismissedduetothepresenceofurologicsymptomsor
abnormalurinalysis. [37]

Urinary5HIAA
AccordingtoareportbyBolandparvazetal,measurementoftheurinary5
hydroxyindoleaceticacid(U5HIAA)levelscouldbeanearlymarkerofappendicitis.
[8]Therationaleofsuchmeasurementisrelatedtothelargeamountofserotonin
secretingcellsintheappendix.TheinvestigatorsnotedthatU5HIAAlevels
increasedsignificantlyinacuteappendicitis,decreasingwhentheinflammation
shiftedtonecrosisoftheappendix. [8]Therefore,suchdecreasecouldbeanearly
warningsignofperforationoftheappendix.

CTScanning
Computedtomography(CT)scanningwithoralcontrastmediumorrectal
Gastrografinenemahasbecomethemostimportantimagingstudyinthe
evaluationofpatientswithatypicalpresentationsofappendicitis.Intravenous
contrastisusuallynotnecessary.
Studieshavefoundadecreaseinnegativelaparotomyrateandappendiceal
perforationratewhenpelvicCTimagingwasusedinselectedpatientswith
suspectedappendicitis. [38,39,40,41]AnenlargedappendixisshownintheCT
below.

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CTscanrevealsanenlargedappendixwiththickenedwalls,whichdonotfillwithcolonic
contrastagent,lyingadjacenttotherightpsoasmuscle.

TheuseofCThasdramaticallyincreasedsincetheintroductionofmultidetectorCT
(MDCT)scanners.Alarge,singlecenterstudyfoundthatMDCThasahighrateof
sensitivityandspecificity(98.5%and98%,respectively)fordiagnosingacute
appendicitis. [42]
Inadultswithappendicitis,thediagnosticperformanceofCTscanswithintravenous
contrastaloneiscomparabletothatofscanswithbothintravenousandoral
contrast,andpatientswhoreceiveCTscanswithintravenouscontrastaloneare
dischargedmorequicklyfromtheemergencydepartment. [43]
Concernshavegrownoverthepossibleadverseeffectsonpatientsfromexposure
toradiationfromCTscanning.LowdoseabdominalCTallowsfora78%reduction
inradiationexposurecomparedtotraditionalabdominopelvicCTandmaybe
preferablefordiagnosingchildrenandyoungadultsinwhomexposuretoCT
radiationisofparticularconcern. [9]Ultrasonographymayofferasaferalternativeas
aprimarydiagnostictoolforappendicitis,withCTscanningusedinthosecasesin
whichultrasonogramsarenegativeorinconclusive.
GotoImagingofAppendicitisformoreinformationonthistopic.

Ultrasonography
BecauseofconcernsaboutpatientexposuretoradiationduringCTscans,
ultrasonographyhasbeensuggestedasasaferprimarydiagnosticmodalityfor
appendicitis,withCTscanningusedsecondarilywhenultrasonogramsarenegative
orinconclusive. [44,45,46]
Ahealthyappendixusuallycannotbeviewedwithultrasonography.When
appendicitisoccurs,theultrasonogramtypicallydemonstratesanoncompressible
tubularstructureof79mmindiameter(seetheimagesbelow).

Sagittalgradedcompressiontransabdominalsonogramshowsanacutelyinflamedappendix.
Thetubularstructureisnoncompressible,lacksperistalsis,andmeasuresgreaterthan6mmin
diameter.Athinrimofperiappendicealfluidispresent.

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Transversegradedcompressiontransabdominalsonogramofanacutelyinflamedappendix.
Notethetargetlikeappearanceduetothickenedwallandsurroundingloculatedfluidcollection.

Inpediatricpatients,theACEP2010clinicalpolicyupdaterecommendsusing
ultrasonographyforconfirmation,butnotexclusion,ofacuteappendicitis.To
definitivelyexcludeacuteappendicitis,CTisrecommended. [10,11]
Ultrasonographyfollowedbymagneticresonanceimaging(MRI)appearstobean
effectivecombinationforaccuratelydiagnosingappendicitisinchildren. [47,48]Ina
retrospectivestudyof662patientsyoungerthanage18yearspresentingtothe
emergencydepartmentwithabdominalpain,ultrasonography/MRIwasperformedin
397patientsandCTscanningwasusedin265.Intheultrasonography/MRIgroup,
ultrasoundwaspositiveforappendicitisin19.7%ofpatients,andMRIidentifiedan
additional62cases,ofwhich7(11.3%)werecomplicated.IntheCTgroup,55.4%
ofpatientspositiveforappendicitis,ofwhich19.4%werecomplicated. [47,48]
Thefalsepositiveratewassimilarinthetwogroups(1.4%inthe
ultrasonography/MRIgroupand2.5%intheCTgroup),andtherewerenofalse
negativesineithergroup. [47,48]Nosignificantdifferencesbetweengroupswere
observedinmeanoveralllengthofhospitalstay,timetoantibioticadministration,
timetoappendectomy,orperforationrate. [47,48]
Vaginalultrasonographyaloneorincombinationwithtransabdominalscanmaybe
usefultodeterminethediagnosisinwomenofchildbearingage.Onestudyof22
pregnantwomeninthefirstandsecondtrimestersshowedthatgradedcompression
ultrasonographyhadasensitivityof66%andspecificityof95%. [12]
GotoImagingofAppendicitisformoreinformationonthistopic.

AbdominalRadiography
Thekidneysuretersbladder(KUB)radiographicviewistypicallyusedtovisualizean
appendicolithinapatientwithsymptomsconsistentwithappendicitis.Thisfindingis
highlysuggestiveofappendicitis,butappendicolithsalsooccurinfewerthan10%of
cases.Theconsensusintheliteratureisthatplainradiographsareinsensitive,
nonspecific,andnotcosteffective.
GotoImagingofAppendicitisformoreinformationonthistopic.

BariumEnemaStudy
Inthepast,bariumenemaexaminationwasusedtodiagnoseappendicitisinthe
eraofultrasonographyandCTscanning,bariumenemastudyhasessentiallyno
roleinthediagnosisofacuteappendicitis.
Asinglecontraststudycanbeperformedonanunpreparedbowel.Absentor
incompletefillingoftheappendixcoupledwithpressureeffectorspasminthe
cecumsuggestsappendicitis.Thetypicalradiologicsignofappendicitisisthe
"reverse3,"whichtypicallymanifestsasanindentationofthececum.However,the
appendixcannotbevisualizedin50%ofhealthyindividualstherefore,barium
enemalacksreliability.
GotoImagingofAppendicitisformoreinformationonthistopic.

RadionuclideScanning
Wholebloodiswithdrawnforradionuclidescanning.Neutrophilsandmacrophages
arelabeledwithtechnetiumTc99m(99m Tc)albuminandadministered
intravenously.Then,imagesoftheabdomenandpelvisareobtainedseriallyover4

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hours.LocalizeduptakeoftracerintheRLQsuggestsappendicealinflammation
thisisshownintheimagebelow.

Technetium99mradionuclidescanoftheabdomenshowsfocaluptakeoflabeledWBCsinthe
rightlowerquadrantconsistentwithacuteappendicitis.

GotoImagingofAppendicitisformoreinformationonthistopic.

MRI
Traditionally,magneticresonanceimaging(MRI)hasplayedarelativelylimitedrole
intheevaluationofappendicitisbecauseofitshighcost,longscantimes,and
limitedavailability.However,thelackofionizingradiationmakesitanattractive
modalityinpregnantpatients.Infact,CobbenetalshowedthatMRIisfarsuperior
totransabdominalultrasonographyinevaluatingpregnantpatientswithsuspected
appendicitis. [49]Moreover,thesensitivityandspecificityofMRIforappendicitis
appearstobesimilartothoseofcomputedtomography(CT)scanning. [50]
Nonetheless,whenevaluatingpregnantpatientswithsuspectedappendicitis,
gradedcompressionultrasonographyshouldbetheimagingtestofchoice.If
ultrasonographydemonstratesaninflamedappendix,thepatientshouldundergo
appendectomy.Ifgradedcompressionultrasonographyisnondiagnostic,thepatient
shouldundergoMRIoftheabdomenandpelvis.
Whenusedforevaluatingpediatricpatients,MRIhasahighersensitivitythan
ultrasound.InaprospectivecomparisonofultrasoundandMRIin104childrenwith
suspectedappendicitis,researchersfoundthatMRIhadasensitivityof100%
comparedtoultrasoundwhichhadasensitivityof76%.ToleranceofMRIwas
comparabletothatoftoleranceforultrasound. [51]
Aretrospectivestudyof662patientsyoungerthatage18yearswhopresentedto
theemergencydepartmentwithabdominalpainfoundthatultrasoundfollowed
selectivelybyMRIaccuratelydiagnosedpediatricappendicitis. [47,48]
GotoImagingofAppendicitisformoreinformationonthistopic.

GrossandMicroscopicEvaluation
Intheearlystagesofappendicitis,theappendixgrosslyappearsedematouswith
dilationoftheserosalvessels.Microscopydemonstratesneutrophilinfiltrateofthe
mucosalandmuscularislayersextendingintothelumen.Astimepasses,the
appendicealwallgrosslyappearsthickened,thelumenappearsdilated,anda
serosalexudate(fibrinousorfibrinopurulent)maybeobservedasgranular
roughening.Atthisstage,mucosalnecrosismaybeobservedmicroscopically.
Atthelaterstagesofappendicitis,theappendixgrosslyshowsmarkedsignsof
mucosalnecrosisextendingintotheexternallayersoftheappendicealwallthatcan
becomegangrenous.Sometimes,theappendixmaybefoundinacollectionofpus.
Atthisstageofappendicitis,microscopymaydemonstratemultiplemicroabscesses
oftheappendicealwallandseverenecrosisofalllayers.
Treatment&Management

ContributorInformationandDisclosures
Author
SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofNorthCarolinaatChapel
HillSchoolofMedicine
SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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AppendicitisWorkup:ApproachConsiderations,CBCCount,CReactiveProtein

ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,
UniversityHospitals,CaseWesternReserveUniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanHeartAssociation,AmericanThoracicSociety,
ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyofEmergency
Medicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergencyMedicine,CharlesDrewUniversityofMedicineandScience
FormerChair,DepartmentofEmergencyMedicine,MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
WilliamLober,MD,MSAssociateProfessor,HealthInformaticsandGlobalHealth,SchoolsofMedicine,Nursing,andPublicHealth,UniversityofWashington
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1.PolitesSF,MohamedMI,HabermannEB,etal.Asimplealgorithmreducescomputedtomographyuseinthediagnosisofappendicitisinchildren.Surgery.2014
Jun19.[Medline].
2.DouglasD.AlgorithmcutspediatricCTuseinsuspectedappendicitis.ReutersHealthInformation.July10,2014.[FullText].
3.YehB.Evidencebasedemergencymedicine/rationalclinicalexaminationabstract.Doesthisadultpatienthaveappendicitis?.AnnEmergMed.2008Sep.52(3):301
3.[Medline].
4.MarkleGB4th.Heeldropjarringtestforappendicitis.ArchSurg.1985Feb.120(2):243.[Medline].
5.ThimsenDA,TongGK,GruenbergJC.ProspectiveevaluationofCreactiveproteininpatientssuspectedtohaveacuteappendicitis.AmSurg.1989Jul.55(7):4668.
[Medline].
6.deCarvalhoBR,DiogoFilhoA,FernandesC,BarraCB.[Leukocytecount,Creactiveprotein,alpha1acidglycoproteinanderythrocytesedimentationrateinacute
appendicitis].ArqGastroenterol.2003JanMar.40(1):2530.[Medline].
7.AlbuE,MillerBM,ChoiY,etal.DiagnosticvalueofCreactiveproteininacuteappendicitis.DisColonRectum.1994Jan.37(1):4951.[Medline].
8.BolandparvazS,VaseiM,OwjiAA,AtaEeN,AminA,DaneshbodY,etal.Urinary5hydroxyindoleaceticacidasatestforearlydiagnosisofacuteappendicitis.
ClinBiochem.2004Nov.37(11):9859.[Medline].
9.KimK,KimYH,KimSY,KimS,LeeYJ,KimKP,etal.LowdoseabdominalCTforevaluatingsuspectedappendicitis.NEnglJMed.2012Apr26.366(17):1596
605.[Medline].
10.HowellJM,EddyOL,LukensTW,ThiessenME,WeingartSD,DeckerWW.Clinicalpolicy:Criticalissuesintheevaluationandmanagementofemergency
departmentpatientswithsuspectedappendicitis.AnnEmergMed.2010Jan.55(1):71116.[Medline].
11.[Guideline]NationalGuidelineClearinghouse(NGC).Guidelinesummary:Clinicalpolicy:criticalissuesintheevaluationandmanagementofemergencydepartment
patientswithsuspectedappendicitis.NationalGuidelineClearinghouse(NGC),Rockville(MD).Availableathttp://guideline.gov/content.aspx?id=15598.Accessed:
November18,2013.
12.BarloonTJ,BrownBP,AbuYousefMM,WarnockN,BerbaumKS.Sonographyofacuteappendicitisinpregnancy.AbdomImaging.1995MarApr.20(2):14951.
[Medline].
13.ManterolaC,VialM,MoragaJ,AstudilloP.Analgesiainpatientswithacuteabdominalpain.CochraneDatabaseSystRev.2011Jan19.1:CD005660.[Medline].
14.KaramanakosSN,SdralisE,PanagiotopoulosS,KehagiasI.Laparoscopyintheemergencysetting:aretrospectivereviewof540patientswithacuteabdominal
pain.SurgLaparoscEndoscPercutanTech.2010Apr.20(2):11924.[Medline].
15.NiwaH,HiramatsuT.Ararepresentationofappendicealdiverticulitisassociatedwithpelvicpseudocyst.WorldJGastroenterol.2008Feb28.14(8):12935.
[Medline].[FullText].
16.PlaceRC.Acuteurinaryretentionina9yearoldchild:anatypicalpresentationofacuteappendicitis.JEmergMed.2006Aug.31(2):1735.[Medline].
17.OtoA,ErnstRD,MileskiWJ,NishinoTK,LeO,WolfeGC,etal.LocalizationofappendixwithMDCTandinfluenceoffindingsonchoiceofappendectomyincision.
AJRAmJRoentgenol.2006Oct.187(4):98790.[Medline].
18.SedlakM,WagnerOJ,WildB,PapagrigoriadesS,ExadaktylosAK.Istherestillaroleforrectalexaminationinsuspectedappendicitisinadults?.AmJEmergMed.
2008Mar.26(3):35960.[Medline].
19.AlvaradoA.Apracticalscorefortheearlydiagnosisofacuteappendicitis.AnnEmergMed.1986May.15(5):55764.[Medline].
20.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospectivepediatriccohort.AnnEmergMed.2007Jun.49(6):77884,
784.e1.[Medline].
21.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospectivepediatriccohort.AnnEmergMed.2007Jun.49(6):77884,
784.e1.[Medline].
22.MigraineS,AtriM,BretPM,LoughJO,HincheyJE.Spontaneouslyresolvingacuteappendicitis:clinicalandsonographicdocumentation.Radiology.1997Oct.
205(1):558.[Medline].
23.CobbenLP,deVanOtterlooAM,PuylaertJB.Spontaneouslyresolvingappendicitis:frequencyandnaturalhistoryin60patients.Radiology.2000May.215(2):349
52.[Medline].
24.DueholmS,BagiP,BudM.Laboratoryaidinthediagnosisofacuteappendicitis.Ablinded,prospectivetrialconcerningdiagnosticvalueofleukocytecount,
neutrophildifferentialcount,andCreactiveprotein.DisColonRectum.1989Oct.32(10):8559.[Medline].

http://emedicine.medscape.com/article/773895workup#showall

6/8

7/29/2016

AppendicitisWorkup:ApproachConsiderations,CBCCount,CReactiveProtein

25.GurleyikE,GurleyikG,UnalmiserS.AccuracyofserumCreactiveproteinmeasurementsindiagnosisofacuteappendicitiscomparedwithsurgeon'sclinical
impression.DisColonRectum.1995Dec.38(12):12704.[Medline].
26.ShakhatrehHS.TheaccuracyofCreactiveproteininthediagnosisofacuteappendicitiscomparedwiththatofclinicaldiagnosis.MedArh.2000.54(2):10910.
[Medline].
27.AsfarS,SafarH,KhoursheedM,DashtiH,alBaderA.WouldmeasurementofCreactiveproteinreducetherateofnegativeexplorationforacuteappendicitis?.JR
CollSurgEdinb.2000Feb.45(1):214.[Medline].
28.ErkasapS,AtesE,UstunerZ,SahinA,YilmazS,YasarB,etal.Diagnosticvalueofinterleukin6andCreactiveproteininacuteappendicitis.SwissSurg.2000.
6(4):16972.[Medline].
29.GronroosJM,GronroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.BrJSurg.1999Apr.86(4):5014.[Medline].
30.OrtegaDeballonP,RuizdeAdanaBelbelJC,HernandezMatiasA,GarciaSeptiemJ,MorenoAzcoitaM.Usefulnessoflaboratorydatainthemanagementofright
iliacfossapaininadults.DisColonRectum.2008Jul.51(7):10939.[Medline].
31.GronroosJM.IstherearoleforleukocyteandCRPmeasurementsinthediagnosisofacuteappendicitisintheelderly?.Maturitas.1999Mar15.31(3):2558.
[Medline].
32.YangHR,WangYC,ChungPK,etal.Roleofleukocytecount,neutrophilpercentage,andCreactiveproteininthediagnosisofacuteappendicitisintheelderly.Am
Surg.2005Apr.71(4):3447.[Medline].
33.GronroosJM.DonormalleucocytecountandCreactiveproteinvalueexcludeacuteappendicitisinchildren?.ActaPaediatr.2001Jun.90(6):64951.[Medline].
34.StefanuttiG,GhirardoV,GambaP.Inflammatorymarkersforacuteappendicitisinchildren:aretheyhelpful?.JPediatrSurg.2007May.42(5):7736.[Medline].
35.MohammedAA,DaghmanNA,AboudSM,OshibiHO.ThediagnosticvalueofCreactiveprotein,whitebloodcellcountandneutrophilpercentageinchildhood
appendicitis.SaudiMedJ.2004Sep.25(9):12125.[Medline].
36.YangHR,WangYC,ChungPK,ChenWK,JengLB,ChenRJ.Laboratorytestsinpatientswithacuteappendicitis.ANZJSurg.2006JanFeb.76(12):714.
[Medline].
37.TundidorBermudezAM,AmadoDieguezJA,MontesdeOcaMastrapaJL.[Urologicalmanifestationsofacuteappendicitis].ArchEspUrol.2005Apr.58(3):20712.
[Medline].
38.RaoPM,RheaJT,RattnerDW,etal.IntroductionofappendicealCT:impactonnegativeappendectomyandappendicealperforationrates.AnnSurg.1999Mar.
229(3):3449.[Medline].
39.McGoryML,ZingmondDS,NanayakkaraD,MaggardMA,KoCY.Negativeappendectomyrate:influenceofCTscans.AmSurg.2005Oct.71(10):8038.[Medline].
40.HarswickC,UyenishiAA,KordickMF,ChanSB.Clinicalguidelines,computedtomographyscan,andnegativeappendectomies:acaseseries.AmJEmergMed.
2006Jan.24(1):6872.[Medline].
41.FreiSP,BondWF,BazuroRK,RichardsonDM,SierzegaGM,ReedJF.Appendicitisoutcomeswithincreasingcomputedtomographicscanning.AmJEmergMed.
2008Jan.26(1):3944.[Medline].
42.PickhardtPJ,LawrenceEM,PoolerBD,BruceRJ.Diagnosticperformanceofmultidetectorcomputedtomographyforsuspectedacuteappendicitis.AnnInternMed.
2011Jun21.154(12):78996.[Medline].
43.KepnerAM,BacasnotJV,StahlmanBA.Intravenouscontrastalonevsintravenousandoralcontrastcomputedtomographyforthediagnosisofappendicitisinadult
EDpatients.AmJEmergMed.2012May23.[Medline].
44.BrennerDJ,HallEJ.Computedtomographyanincreasingsourceofradiationexposure.NEnglJMed.2007Nov29.357(22):227784.[Medline].
45.ZilbertNR,StamellEF,EzonI,SchlagerA,GinsburgHB,NadlerEP.Managementandoutcomesforchildrenwithacuteappendicitisdifferbyhospitaltype:areas
forimprovementatpublichospitals.ClinPediatr(Phila).2009Jun.48(5):499504.[Medline].
46.DoriaAS,MoineddinR,KellenbergerCJ,EpelmanM,BeyeneJ,SchuhS,etal.USorCTforDiagnosisofAppendicitisinChildrenandAdults?AMetaAnalysis.
Radiology.2006Oct.241(1):8394.[Medline].
47.BoggsW.Ultrasound/MRIStrategyDiagnosesAppendicitisinKidsWithoutRadiation.MedscapeMedicalNews.Availableat
http://www.medscape.com/viewarticle/821332.Accessed:March12,2014.
48.AspelundG,FingeretA,GrossE,KesslerD,KeungC,ThirumoorthiA,etal.Ultrasonography/MRIVersusCTforDiagnosingAppendicitis.Pediatrics.2014Mar3.
[Medline].
49.CobbenLP,GrootI,HaansL,BlickmanJG,PuylaertJ.MRIforclinicallysuspectedappendicitisduringpregnancy.AJRAmJRoentgenol.2004Sep.183(3):6715.
[Medline].
50.RepplingerMD,LevyJF,PeethumnongsinE,etal.SystematicreviewandmetaanalysisoftheaccuracyofMRItodiagnoseappendicitisinthegeneralpopulation.J
MagnResonImaging.2015Dec22.[Medline].
51.ThiemeME,LeeuwenburghMM,ValdehuezaZD,BoumanDE,deBruinIG,SchreursWH,etal.DiagnosticaccuracyandpatientacceptanceofMRIinchildrenwith
suspectedappendicitis.EurRadiol.2013Oct19.[Medline].
52.SingerDD,ThodeHCJr,SingerAJ.EffectsofpainseverityandCTimagingonanalgesiaprescriptioninacuteappendicitis.AmJEmergMed.2016Jan.34(1):36
9.[Medline].
53.ErikssonS,GranstrmL.Randomizedcontrolledtrialofappendicectomyversusantibiotictherapyforacuteappendicitis.BrJSurg.1995Feb.82(2):1669.
[Medline].
54.SalminenP,PaajanenH,RautioT,etal.AntibioticTherapyvsAppendectomyforTreatmentofUncomplicatedAcuteAppendicitis:TheAPPACRandomizedClinical
Trial.JAMA.2015Jun16.313(23):23408.[Medline].
55.BonadioW,RebillotK,UkwuomaO,SaracinoC,IskhakovA.Managementofpediatricperforatedappendicitis:comparingoutcomesusingearlyappendectomyvs
solelymedicalmanagement.PediatrInfectDisJ.2015Dec14.[Medline].
56.BickellNA,AufsesAHJr,RojasM,BodianC.Howtimeaffectstheriskofruptureinappendicitis.JAmCollSurg.2006Mar.202(3):4016.[Medline].
57.AbouNuktaF,BakhosC,ArroyoK,KooY,MartinJ,ReinholdR,etal.Effectsofdelayingappendectomyforacuteappendicitisfor12to24hours.ArchSurg.2006
May.141(5):5046discussion5067.[Medline].

http://emedicine.medscape.com/article/773895workup#showall

7/8

7/29/2016

AppendicitisWorkup:ApproachConsiderations,CBCCount,CReactiveProtein

58.FairBA,KubasiakJC,JanssenI,etal.Theimpactofoperativetimingonoutcomesofappendicitis:aNationalSurgicalQualityImprovementProjectanalysis.AmJ
Surg.2015Mar.209(3):498502.[Medline].
59.BoomerLA,CooperJN,AnandalwarS,etal.Delayingappendectomydoesnotleadtohigherratesofsurgicalsiteinfections:amultiinstitutionalanalysisofchildren
withappendicitis.AnnSurg.2015Dec16.[Medline].
60.[Guideline]KorndorfferJRJr,FellingerE,ReedW.SAGESguidelineforlaparoscopicappendectomy.SurgEndosc.2010Apr.24(4):75761.[Medline].[FullText].
61.WilasrusmeeC,SukratB,McEvoyM,AttiaJ,ThakkinstianA.Systematicreviewandmetaanalysisofsafetyoflaparoscopicversusopenappendicectomyfor
suspectedappendicitisinpregnancy.BrJSurg.2012Nov.99(11):14708.[Medline].
62.LiangMK,LoHG,MarksJL.Stumpappendicitis:acomprehensivereviewofliterature.AmSurg.2006Feb.72(2):1626.[Medline].
63.BarclayL.Ultrasound,CTComparabletoDetectAppendicitisinChildren.MedscapeMedicalNews.Availableathttp://www.medscape.com/viewarticle/817370.
Accessed:December9,2013.
64.LeJ,KurianJ,CohenHW,WeinbergG,ScheinfeldMH.Doclinicaloutcomessufferduringtransitiontoanultrasoundfirstparadigmfortheevaluationofacute
appendicitisinchildren?.AJRAmJRoentgenol.2013Dec.201(6):134852.[Medline].
65.HurstAL,OlsonD,SommeS,etal.Oncedailyceftriaxoneplusmetronidazoleversusertapenemand/orcefoxitinforpediatricappendicitis.JPediatricInfectDis
Soc.2015Dec24.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/773895workup#showall

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