AC Search
Document Navigator

Suspected Appendicitis-Child

Variant: 1   Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US abdomen Usually Not Appropriate O
US abdomen RLQ Usually Not Appropriate O
US pelvis Usually Not Appropriate O
Radiography abdomen Usually Not Appropriate ☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 2   Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US abdomen Usually Appropriate O
US abdomen RLQ Usually Appropriate O
Radiography abdomen May Be Appropriate (Disagreement) ☢☢
MRI abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) O
MRI abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) O
CT abdomen and pelvis with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
CT abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
US pelvis Usually Not Appropriate O
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 3   Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US abdomen May Be Appropriate (Disagreement) O
US abdomen RLQ May Be Appropriate O
MRI abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢☢
CT abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
US pelvis Usually Not Appropriate O
Radiography abdomen Usually Not Appropriate ☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 4   Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast Usually Appropriate O
MRI abdomen and pelvis without IV contrast Usually Appropriate O
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢☢
US abdomen May Be Appropriate (Disagreement) O
US abdomen RLQ May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
US pelvis Usually Not Appropriate O
Radiography abdomen Usually Not Appropriate ☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Variant: 5   Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
Procedure Appropriateness Category Peds Relative Radiation Level
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢☢
MRI abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) O
MRI abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) O
CT abdomen and pelvis without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
US abdomen Usually Not Appropriate O
US abdomen RLQ Usually Not Appropriate O
US pelvis Usually Not Appropriate O
Radiography abdomen Usually Not Appropriate ☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢☢

Panel Members
Andrew T. Trout, MDa; George C. Koberlein, MDb; Cynthia K. Rigsby, MDc; Ramesh S. Iyer, MDd; Adina L. Alazraki, MDe; Sudha A. Anupindi, MDf; Dianna M. E. Bardo, MDg; Brandon P. Brown, MDh; Sherwin S. Chan, MD, PhDi; Tushar Chandra, MDj; Jonathan R. Dillman, MD, MSck; Scott R. Dorfman, MDl; Richard A. Falcone Jr., MD, MPHm; Matthew D. Garber, MDn; Madeline M. Joseph, MDo; Jie C. Nguyen, MD, MSp; Nabile M. Safdar, MD, MPHq; Boaz Karmazyn, MDr.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Discussion of Procedures by Variant
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
A. Radiography Abdomen
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
B. US Abdomen RLQ
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
C. US Abdomen
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
D. US Pelvis
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
E. CT Abdomen and Pelvis
Variant 1: Child. Suspected acute appendicitis, low clinical risk. Initial imaging.
F. MRI Abdomen and Pelvis
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
A. Radiography Abdomen
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
B. US Abdomen RLQ
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
C. US Abdomen
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
D. US Pelvis
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
E. CT Abdomen and Pelvis
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. Initial imaging.
F. MRI Abdomen and Pelvis
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
A. Radiography Abdomen
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
B. US Abdomen RLQ
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
C. US Abdomen
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
D. US Pelvis
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
E. CT Abdomen and Pelvis
Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging.
F. MRI Abdomen and Pelvis
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
A. Radiography Abdomen
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
B. US Abdomen RLQ
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
C. US Abdomen
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
D. US Pelvis
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
E. CT Abdomen and Pelvis
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
F. MRI Abdomen and Pelvis
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
A. Radiography Abdomen
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
B. US Abdomen RLQ
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
C. US Abdomen
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
D. US Pelvis
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
E. CT Abdomen and Pelvis
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
F. MRI Abdomen and Pelvis
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Glass CC, Rangel SJ. Overview and diagnosis of acute appendicitis in children. [Review]. Semin Pediatr Surg. 25(4):198-203, 2016 Aug.
2. Tseng P, Berdahl C, Kearl YL, et al. Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis?. J Emerg Med. 50(4):638-42, 2016 Apr.
3. Larson DB, Trout AT, Fierke SR, Towbin AJ. Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roentgenol. 204(4):849-56, 2015 Apr.
4. Kharbanda AB, Stevenson MD, Macias CG, et al. Interrater reliability of clinical findings in children with possible appendicitis. Pediatrics. 129(4):695-700, 2012 Apr.
5. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: a continuing diagnostic challenge. Pediatr Emerg Care. 16(3):160-2, 2000 Jun.
6. Bonadio W, Peloquin P, Brazg J, et al. Appendicitis in preschool aged children: Regression analysis of factors associated with perforation outcome. J Pediatr Surg. 50(9):1569-73, 2015 Sep.
7. Bachur RG, Hennelly K, Callahan MJ, Chen C, Monuteaux MC. Diagnostic imaging and negative appendectomy rates in children: effects of age and gender. Pediatrics. 129(5):877-84, 2012 May.
8. Hendriks IG, Langen RM, Janssen L, Verrijth-Wilms IM, Wouda S, Janzing HM. Does the Use of Diagnostic Imaging Reduce the Rate of Negative Appendectomy?. Acta Chir Belg. 115(6):393-6, 2015 Nov-Dec.
9. Mariadason JG, Wang WN, Wallack MK, Belmonte A, Matari H. Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl. 94(6):395-401, 2012 Sep.
10. Pastore V, Cocomazzi R, Basile A, Pastore M, Bartoli F. Limits and advantages of abdominal ultrasonography in children with acute appendicitis syndrome. Afr J Paediatr Surg. 11(4):293-6, 2014 Oct-Dec.
11. Golden SK, Harringa JB, Pickhardt PJ, et al. Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT. Emerg Med J. 33(7):458-64, 2016 Jul.
12. Lietzen E, Ilves I, Salminen P, et al. Clinical and laboratory findings in the diagnosis of right lower quadrant abdominal pain: outcome analysis of the APPAC trial. Clinical Chemistry & Laboratory Medicine. 54(10):1691-7, 2016 Oct 01.
13. Saucier A, Huang EY, Emeremni CA, Pershad J. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics. 133(1):e88-95, 2014 Jan.
14. Tan WJ, Acharyya S, Goh YC, et al. Prospective comparison of the Alvarado score and CT scan in the evaluation of suspected appendicitis: a proposed algorithm to guide CT use. J Am Coll Surg. 220(2):218-24, 2015 Feb.
15. Athans BS, Depinet HE, Towbin AJ, Zhang Y, Zhang B, Trout AT. Use of Clinical Data to Predict Appendicitis in Patients with Equivocal US Findings. Radiology. 280(2):557-67, 2016 Aug.
16. Fleischman RJ, Devine MK, Yagapen MA, et al. Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems. Pediatric Emergency Care. 29(10):1060-5, 2013 Oct.
17. Rezak A, Abbas HM, Ajemian MS, Dudrick SJ, Kwasnik EM. Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg. 146(1):64-7, 2011 Jan.
18. Santillanes G, Simms S, Gausche-Hill M, et al. Prospective evaluation of a clinical practice guideline for diagnosis of appendicitis in children. Acad Emerg Med. 19(8):886-93, 2012 Aug.
19. Trout AT, Sanchez R, Ladino-Torres MF, Pai DR, Strouse PJ. A critical evaluation of US for the diagnosis of pediatric acute appendicitis in a real-life setting: how can we improve the diagnostic value of sonography?. Pediatr Radiol. 42(7):813-23, 2012 Jul.
20. Abo A, Shannon M, Taylor G, Bachur R. The influence of body mass index on the accuracy of ultrasound and computed tomography in diagnosing appendicitis in children. Pediatr Emerg Care. 27(8):731-6, 2011 Aug.
21. Yigiter M, Kantarci M, Yalcin O, Yalcin A, Salman AB. Does obesity limit the sonographic diagnosis of appendicitis in children?. J Clin Ultrasound. 39(4):187-90, 2011 May.
22. Binkovitz LA, Unsdorfer KM, Thapa P, et al. Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol. 45(13):1934-44, 2015 Dec.
23. Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Academic Emergency Medicine. 20(7):697-702, 2013 Jul.
24. Peletti AB, Baldisserotto M. Optimizing US examination to detect the normal and abnormal appendix in children. Pediatr Radiol. 36(11):1171-6, 2006 Nov.
25. Unlu C, de Castro SM, Tuynman JB, Wust AF, Steller EP, van Wagensveld BA. Evaluating routine diagnostic imaging in acute appendicitis. Int J Surg. 7(5):451-5, 2009 Oct.
26. Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg. 51(12):1939-1943, 2016 Dec.
27. Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 21(2):163-70, 2014 Feb.
28. Le J, Kurian J, Cohen HW, Weinberg G, Scheinfeld MH. Do clinical outcomes suffer during transition to an ultrasound-first paradigm for the evaluation of acute appendicitis in children?. AJR Am J Roentgenol. 201(6):1348-52, 2013 Dec.
29. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 241(1):83-94, 2006 Oct.
30. Kepner AM, Bacasnot JV, Stahlman BA. Intravenous contrast alone vs intravenous and oral contrast computed tomography for the diagnosis of appendicitis in adult ED patients. Am J Emerg Med. 30(9):1765-73, 2012 Nov.
31. Laituri CA, Fraser JD, Aguayo P, et al. The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography. J Surg Res. 170(1):100-3, 2011 Sep.
32. Latifi A, Labruto F, Kaiser S, Ullberg U, Sundin A, Torkzad MR. Does enteral contrast increase the accuracy of appendicitis diagnosis?. Radiol Technol. 82(4):294-9, 2011 Mar-Apr.
33. Kharbanda AB, Taylor GA, Bachur RG. Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology. 243(2):520-6, 2007 May.
34. Callahan MJ, Anandalwar SP, MacDougall RD, et al. Pediatric CT dose reduction for suspected appendicitis: a practice quality improvement project using artificial gaussian noise--part 2, clinical outcomes. AJR Am J Roentgenol. 204(3):636-44, 2015 Mar.
35. Swanick CW, Gaca AM, Hollingsworth CL, et al. Comparison of conventional and simulated reduced-tube current MDCT for evaluation of suspected appendicitis in the pediatric population. AJR Am J Roentgenol. 201(3):651-8, 2013 Sep.
36. Akhtar W, Ali S, Arshad M, Ali FN, Nadeem N. Focused abdominal CT scan for acute appendicitis in children: can it help in need?. JPMA J Pak Med Assoc. 61(5):474-6, 2011 May.
37. O&#39;Malley ME, Alharbi F, Chawla TP, Moshonov H. CT following US for possible appendicitis: anatomic coverage. Eur Radiol. 26(2):532-8, 2016 Feb.
38. Hoecker CC, Billman GF. The utility of unenhanced computed tomography in appendicitis in children. Journal of Emergency Medicine. 28(4):415-21, 2005 May.J Emerg Med. 28(4):415-21, 2005 May.
39. Ozturkmen Akay H, Akpinar E, Akgul Ozmen C, Ergun O, Haliloglu M. Visualization of the normal appendix in children by non-contrast MDCT. Acta Chir Belg. 107(5):531-4, 2007 Sep-Oct.
40. Dillman JR, Gadepalli S, Sroufe NS, et al. Equivocal Pediatric Appendicitis: Unenhanced MR Imaging Protocol for Nonsedated Children-A Clinical Effectiveness Study. Radiology. 279(1):216-25, 2016 Apr.
41. Duke E, Kalb B, Arif-Tiwari H, et al. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. [Review]. AJR Am J Roentgenol. 206(3):508-17, 2016 Mar.
42. Johnson AK, Filippi CG, Andrews T, et al. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol. 198(6):1424-30, 2012 Jun.
43. Kulaylat AN, Moore MM, Engbrecht BW, et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg. 50(8):1359-63, 2015 Aug.
44. Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatr Radiol. 42(9):1056-63, 2012 Sep.
45. Orth RC, Guillerman RP, Zhang W, Masand P, Bisset GS 3rd. Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis.[Erratum appears in Radiology. 2015 Dec;277(3):927; PMID: 26599937]. Radiology. 272(1):233-40, 2014 Jul.
46. Kinner S, Pickhardt PJ, Riedesel EL, et al. Diagnostic Accuracy of MRI Versus CT for the Evaluation of Acute Appendicitis in Children and Young Adults. AJR Am J Roentgenol. 209(4):911-919, 2017 Oct.
47. Bayraktutan U, Oral A, Kantarci M, et al. Diagnostic performance of diffusion-weighted MR imaging in detecting acute appendicitis in children: comparison with conventional MRI and surgical findings. J Magn Reson Imaging. 39(6):1518-24, 2014 Jun.
48. Epifanio M, Antonio de Medeiros Lima M, Correa P, Baldisserotto M. An Imaging Diagnostic Protocol in Children with Clinically Suspected Acute Appendicitis. Am Surg. 82(5):390-6, 2016 May.
49. Gregory S, Kuntz K, Sainfort F, Kharbanda A. Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis. Value in Health. 19(1):28-35, 2016 Jan.
50. Kim DY, Shim DH, Cho KY. Use of the Pediatric Appendicitis Score in a Community Hospital. Indian Pediatr. 53(3):217-20, 2016 Mar.
51. Ulukaya Durakbasa C, Tasbasi I, Tosyali AN, Mutus M, Sehiralti V, Zemheri E. An evaluation of individual plain abdominal radiography findings in pediatric appendicitis: results from a series of 424 children. Ulus Travma Acil Cerrahi Derg. 12(1):51-8, 2006 Jan.
52. Tayal VS, Bullard M, Swanson DR, et al. ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain. Am J Emerg Med. 26(1):81-5, 2008 Jan.
53. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med. 25(5):489-93, 2007 Jun.
54. Halverson M, Delgado J, Mahboubi S. Extra-appendiceal findings in pediatric abdominal CT for suspected appendicitis. Pediatr Radiol. 44(7):816-20, 2014 Jul.
55. Koning JL, Naheedy JH, Kruk PG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. Pediatric Radiology. 44(8):948-55, 2014 Aug.
56. Pogorelic Z, Rak S, Mrklic I, Juric I. Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children. Pediatr Emerg Care. 31(3):164-8, 2015 Mar.
57. Toprak H, Kilincaslan H, Ahmad IC, et al. Integration of ultrasound findings with Alvarado score in children with suspected appendicitis. Pediatr Int. 56(1):95-9, 2014 Feb.
58. Bachur RG, Callahan MJ, Monuteaux MC, Rangel SJ. Integration of ultrasound findings and a clinical score in the diagnostic evaluation of pediatric appendicitis. J Pediatr. 166(5):1134-9, 2015 May.
59. Fallon SC, Orth RC, Guillerman RP, et al. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol. 45(13):1945-52, 2015 Dec.
60. Nielsen JW, Boomer L, Kurtovic K, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template. J Pediatr Surg. 50(1):144-8, 2015 Jan.
61. Ramarajan N, Krishnamoorthi R, Barth R, et al. An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med. 16(11):1258-65, 2009 Nov.
62. Garcia K, Hernanz-Schulman M, Bennett DL, Morrow SE, Yu C, Kan JH. Suspected appendicitis in children: diagnostic importance of normal abdominopelvic CT findings with nonvisualized appendix. Radiology. 250(2):531-7, 2009 Feb.
63. Stewart JK, Olcott EW, Jeffrey RB. Sonography for appendicitis: nonvisualization of the appendix is an indication for active clinical observation rather than direct referral for computed tomography. J Clin Ultrasound. 40(8):455-61, 2012 Oct.
64. Wiersma F, Toorenvliet BR, Bloem JL, Allema JH, Holscher HC. US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol. 19(2):455-61, 2009 Feb.
65. Srinivasan A, Servaes S, Pena A, Darge K. Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol. EMERG. RADIOL.. 22(1):31-42, 2015 Feb.
66. Ramarajan N, Krishnamoorthi R, Gharahbaghian L, Pirrotta E, Barth RA, Wang NE. Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis?. J Clin Ultrasound. 42(7):385-94, 2014 Sep.
67. Schuh S, Chan K, Langer JC, et al. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med. 22(4):406-14, 2015 Apr.
68. Atema JJ, Gans SL, Van Randen A, et al. Comparison of Imaging Strategies with Conditional versus Immediate Contrast-Enhanced Computed Tomography in Patients with Clinical Suspicion of Acute Appendicitis. Eur Radiol. 25(8):2445-52, 2015 Aug.
69. Thirumoorthi AS, Fefferman NR, Ginsburg HB, Kuenzler KA, Tomita SS. Managing radiation exposure in children--reexamining the role of ultrasound in the diagnosis of appendicitis. J Pediatr Surg. 47(12):2268-72, 2012 Dec.
70. Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 259(1):231-9, 2011 Apr.
71. Herliczek TW, Swenson DW, Mayo-Smith WW. Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. AJR Am J Roentgenol. 200(5):969-73, 2013 May.
72. Aspelund G, Fingeret A, Gross E, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 133(4):586-93, 2014 Apr.
73. Serres SK, Cameron DB, Glass CC, et al. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. Jama, Pediatr.. 171(8):740-746, 2017 Aug 01.
74. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.