Acute appendicitis is a common inflammatory disease state that may result in an acute abdomen and require emergent surgical intervention. The diagnosis of appendicitis is multifaceted: it is important to take into account the clinical picture, imaging studies, and laboratory findings. The clinical presentation of appendicitis is most commonly right lower quadrant (RLQ) pain with associated nausea and vomiting. These symptoms can mimic many other intra-abdominal pathologies, making diagnosis difficult. A clinical diagnosis can be made with the assistance of physical examination tests such as Rosving’s, McBurney’s, Psoas, and Obturator signs [1, Kostakis, et al.]. Although, these predictive tests are sensitive, the use of imaging modalities, such as RLQ ultrasound (US) and computed-tomography (CT) scans help further affirm a possible diagnosis. The introduction of such imaging techniques has decreased the incidence of negative appendectomies in the presence of atypical symptoms [2, Sondawle, et al.] [4].
The current preferred imaging modality in diagnosing acute appendicitis is CT scan, however it has become a less favorable option due to the increased awareness of radiation exposure, costliness, and time consumption [3, Anderson, et al.]. Conversely, US is a valuable tool in diagnosing appendicitis because it is a rapid, cost-effective, non-invasive test that can be done at the bedside and involves no radiation [4, Karimi, et al.] [5, Nordin, et al.]. While ultrasound is a more desirable imaging modality, it is only diagnostic about 40% of the time [6, Cohen, et al.] due to variations in operator-dependent skill and patient body habitus [4, Karimi, et al.]. Appendicitis can be misdiagnosed vs. missed when relying on clinical suspicion and imaging alone, therefore, lab studies can also be useful in corroborating suspected appendicitis. A number of studies have found that lab values like white blood cell (WBC) count and C-reactive protein (CRP) have increasing value in the diagnosis of appendicitis [7, Xharra, et al.]. Specifically, a study by Beltran et al. found that the diagnostic accuracy of WBC count was higher than that of the diagnostic accuracy of CRP [5].
However, similar to US, lab values like WBC counts are not adequate diagnostic tools when used alone, therefore leading to a more comprehensive diagnostic algorithm like the Alvarado Score [1]. The Alvarado Score encompasses a set of diagnostic criteria including: RLQ tenderness, leukocytosis, rebound pain, migration of pain, fever, anorexia, nausea, and left shift; a total score of 3 or less being associated with a low risk for appendicitis [1].
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The aim of this study is to conduct a retrospective analysis on adult patients with RLQ pain and a non diagnostic ultrasound. This data can be correlated with WBC counts to determine if a patient can be safely discharged home without a definitive CT scan and then experience an uncomplicated postoperative clinical course without return to the ED.
