Use of computed tomography in diagnosing appendicitis: redundant, expensive, toxic, and potentially unnecessary.

CONTEXT Computed tomography is routinely used for the diagnosis of appendicitis despite its high cost and its radiation exposure to patients. OBJECTIVE To examine the usefulness and clinical relevance of computed tomography to diagnose appendicitis at a community-based academic medical center. METHODS A retrospective review of medical records of patients who received a final diagnosis of appendicitis (according to International Classification of Diseases, Ninth Revision) from April 26, 2009, to July 27, 2009, was conducted. Emergency department and admission history, physical examination reports, ultrasonography and computed tomography reports, and operative and pathology reports were included in the review. A modified version of the pediatric appendicitis score (mPAS) was used to determine the utility of imaging vs physical and laboratory examinations. RESULTS Charts from 36 patients, aged 8 to 22 years, were included. All patients had pathologic evidence of appendicitis. Imaging was mentioned in 20 of 36 operative reports, but no operative report mentioned imaging as a crucial factor in surgical decisions. Two of 5 patients with the elevated mPAS of 6 had undergone no imaging; operative decisions were based on history, physical examination, and laboratory results. Among the 35 patients who had mPAS values, 23 (65.7%) had an mPAS of 5 or greater. The average mPAS for all patients was 4.5. Thirty-one of 36 patients (86.1%) had typical physical examination indications for appendicitis. CONCLUSION Computed tomography was used as an initial part of the diagnostic workup in most patients, rather than as a tool for only atypical cases. A tiered approach-consisting of routine clinical evaluation with mPAS, followed by imaging in only atypical cases-would likely result in diagnostic accuracy similar to that obtained with early, routine imaging. Such an approach would also decrease expense and radiation exposure to young, developing bodies.