In the January 2010 issue of the Annals of Emergency Medicine, the American College of Emergency Physicians published a clinical policy focusing on critical issues in the emergency department evaluation and management of patients presenting with suspected appendicitis. This is a revision of a clinical policy on abdominal pain that was initially published in 2000.

This clinical policy can also be found on ACEP’s Web site, www.acep.org, and will be abstracted on the National Guideline Clearinghouse Web site, www.guidelines.gov.

This clinical policy takes an evidence-based approach to answering three frequently encountered questions related to emergency department decision-making. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:

Level A recommendations represent patient management principles that reflect a high degree of clinical certainty. Level B recommendations represent patient management principles that reflect moderate clinical certainty. Level C recommendations represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on consensus of the members of the Clinical Policies Committee.

During development, this clinical policy was reviewed by individual emergency physicians and by individual members of the American Academy of Pediatrics, the American College of Radiology, the Society for Academic Emergency Medicine, the Society for Pediatric Radiology, ACEP’s Pediatric Emergency Medicine Section, and ACEP’s Emergency Ultrasound Section. Their responses were used to further refine and enhance this policy; however, their responses do not imply endorsement of this clinical policy.

Despite the advent of computed tomography (CT), appendicitis remains a high-frequency malpractice risk for emergency physicians. Appendicitis is the second most common cause of malpractice litigation in children 6 to 17 years old. Even in the hands of the most experienced clinicians, accurately diagnosing appendicitis can be challenging.

Although CT is frequently used to evaluate patients with possible appendicitis, decisions about the use of contrast remain controversial. Also, diagnosing appendicitis in children frequently involves balancing the utility of CT with the theoretical risks of ionizing radiation. As a result, ultrasound is used in some centers to make this diagnosis. However, deciding when to use ultrasound and interpreting the results can be challenging. These and other issues related to the clinical assessment of patients with possible appendicitis are addressed in this policy.

Question 1: Can clinical findings be used to guide decision-making in the risk stratification of patients with possible appendicitis? This question was chosen to determine if there is a role for clinical findings to risk-stratify and guide management and disposition of patients with suspected appendicitis, versus just relying on laboratory and radiologic studies to diagnose and manage these patients.