Paulson et al developed a clinical algorithm for management of a patient with suspected appendicitis. Proper management can prevent unnecessary procedures, reduce costs and minimize complications. The authors are from Duke University.


Classic presentation for acute appendicitis:

(1) anorexia

(2) abdominal rigidity

(3) pain of short duration

(4) migration of pain to the right lower quadrant

(5) pain centered in the right lower quadrant

(6) right lower quadrant tenderness



• Many physicians use leukocytosis as supporting evidence for the diagnosis. However, leukocytosis should not be used alone to make a therapeutic decision, since it has poor specificity.

• All women of childbearing age should have a pregnancy test performed.


If the patient has a classic presentation, then appendectomy is performed.


If the presentation is equivocal, then an imaging study is performed.

(1) for males and nonpregnant women, CT scan of the lower abdomen (early CT scanning can reduce overall costs vs simple observation)

(2) for pregnant women, ultrasonography of the abdomen.


In women, if a gynecologic disorder is suspected, pelvic and endovaginal ultrasonography should be considered.

Finding on Imaging Studies


compatible with appendicitis


appendix not seen

observe with repeat examination or laparoscopy

indeterminate results

observe with repeat examination or laparoscopy

normal findings

supportive care

alternative diagnosis

appropriate management


Common conditions in the differential diagnosis for women:

(1) pelvic inflammatory disease

(2) gastroenteritis

(3) urinary tract infection

(4) ruptured ovarian follicle

(5) ectopic pregnancy


To read more or access our algorithms and calculators, please log in or register.