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Mostbeck, Gerhard; Adam, E. Jane; Nielsen, Michael Bachmann; Claudon, Michel; Clevert, Dirk-André; Nicolau, Carlos; Nyhsen, Christiane; Owens, Catherine M. (2016): How to diagnose acute appendicitis: ultrasound first. In: Insights into Imaging, Vol. 7, No. 2: pp. 255-263


Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates. Main Messages . Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA). . Primary US for AA diagnosis will decrease ionizing radiation and cost. . Sensitivity of US to diagnose AA is lower than of CT/MRI. . Non-visualization of the appendix should lead to clinical reassessment. . Complementary MRI or CT may be performed if diagnosis remains unclear.