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Guideline Summary
Guideline Title
Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis.
Bibliographic Source(s)
Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. 2010 Jan;55(1):71-116. [71 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000 Oct;36(4):406-15. [137 references] PubMed External Web Site Policy

Scope

Disease/Condition(s)

Acute, nontraumatic abdominal pain and possible or suspected appendicitis

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Clinical Specialty
Emergency Medicine
Pediatrics
Radiology
Surgery
Intended Users
Physicians
Guideline Objective(s)
  • To provide evidence-based recommendations on critical issues in the evaluation and management of emergency department patients with suspected appendicitis
  • To address the following critical questions:
    • Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis?
    • In adult patients with suspected acute appendicitis who are undergoing a computed tomography (CT) scan, what is the role of contrast?
    • In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of CT and ultrasound in diagnosing acute appendicitis?
Target Population

Patients presenting to the emergency department (ED) with acute, nontraumatic abdominal pain and possible or suspected appendicitis

Note: This guideline is not intended to address the care of patients with trauma-related abdominal pain, or pregnant patients.

Interventions and Practices Considered
  1. Patient history and physical examination
  2. Risk stratification to guide further testing and management
  3. Computed tomography with or without contrast
  4. Ultrasound
Major Outcomes Considered
  • Diagnostic performance outcomes (e.g., sensitivity, specificity, likelihood ratios, predictive values) 
  • Missed or delayed diagnosis of appendicitis

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

This clinical policy was created after careful review and critical analysis of the medical literature. Multiple searches of MEDLINE and the Cochrane database were performed. Specific key words/phrases used in the searches are identified under each critical question in the original guideline document. To update the 2000 American College of Emergency Physicians (ACEP) policy, all searches were limited to English-language sources, human studies, and to articles published from January 2000 to March 2007. Additional articles were reviewed from the bibliography of articles cited and from published textbooks and review articles. Subcommittee members supplied articles from their own files, and more recent articles identified during the process were also included.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Strength of Evidence

Literature Classification Schema*

Design/Class Therapy† Diagnosis‡ Prognosis§
1 Randomized, controlled trial or meta-analyses of randomized trials Prospective cohort using a criterion standard Population prospective cohort
2 Nonrandomized trial Retrospective observational Retrospective cohort
Case control
3 Case series
Case report
Other (e.g., consensus, review)
Case series
Case report
Other (e.g., consensus, review)
Case series
Case report
Other (e.g., consensus, review)

*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
Objective is to measure therapeutic efficacy comparing ≥2 interventions.
Objective is to determine the sensitivity and specificity of diagnostic tests.
§Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

  Design/Class
Downgrading 1 2 3
None I II III
1 level II III X
2 levels III X X
Fatally flawed X X X

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

All articles used in the formulation of this clinical policy were graded by at least 2 subcommittee members for strength of evidence and classified by the subcommittee members into 3 classes of evidence on the basis of the design of the study, with design 1 representing the strongest evidence and design 3 representing the weakest evidence for therapeutic, diagnostic, and prognostic clinical reports, respectively (see the "Rating Scheme for the Strength of Evidence" field). Articles were then graded on 6 dimensions thought to be most relevant to the development of a clinical guideline: blinded versus nonblinded outcome assessment, blinded or randomized allocation, direct or indirect outcome measures (reliability and validity), biases (e.g., selection, detection, transfer), external validity (i.e., generalizability), and sufficient sample size. Articles received a final grade (Class I, II, III) on the basis of a predetermined formula, taking into account design and quality of study (see the "Rating Scheme for the Strength of Evidence" field). Articles with fatal flaws were given an "X" grade and not used in formulating recommendations in this policy. Evidence grading was done with respect to the specific data being extracted and the specific critical question being reviewed. Thus, the level of evidence for any one study may vary according to the question, and it is possible for a single article to receive different levels of grading as different critical questions are answered. Question-specific level of evidence grading may be found in the Evidentiary Table included at the end of the original guideline document.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

This policy is a product of the American College of Emergency Physicians (ACEP) clinical policy development process, including expert review, and is based on the existing literature; where literature was not available, consensus of emergency physicians was used.

Rating Scheme for the Strength of the Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)

Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Expert review comments were received from individual emergency physicians and from individual members of the American Academy of Pediatrics, the American College of Radiology, the Society for Academic Emergency Medicine, the Society for Pediatric Radiology, the American College of Emergency Physicians (ACEP) 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.

This clinical policy was approved by the ACEP Board of Directors, October 2, 2009.

Supported by the Emergency Nurses Association, November 3, 2009.

Recommendations

Major Recommendations

Definitions for the strength of evidence (Class I–III) and strength of recommendations (Level A–C) are repeated at the end of the Major Recommendations.

  1. Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis?

    Patient Management Recommendations

    Level A recommendations. None specified.

    Level B recommendations. In patients with suspected acute appendicitis, use clinical findings (i.e., signs and symptoms) to risk-stratify patients and guide decisions about further testing (e.g., no further testing, laboratory tests, and/or imaging studies), and management (e.g., discharge, observation, and/or surgical consultation).

    Level C recommendations. None specified.

  1. In adult patients with suspected acute appendicitis who are undergoing a computed tomography (CT) scan, what is the role of contrast?

    Patient Management Recommendations

    Level A recommendations. None specified.

    Level B recommendations. In adult patients undergoing a CT scan for suspected appendicitis, perform abdominal and pelvic CT scan with or without contrast (intravenous [IV], oral, or rectal). The addition of IV and oral contrast may increase the sensitivity of the CT scan for the diagnosis of appendicitis.

    Level C recommendations. None specified.

  1. In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of CT and ultrasound in diagnosing acute appendicitis?

    Patient Management Recommendations

    Level A recommendations. None specified.

    Level B recommendations.

    1. In children, use ultrasound to confirm acute appendicitis but not to definitively exclude acute appendicitis.
    2. In children, use an abdominal and pelvic CT to confirm or exclude acute appendicitis.

    Level C recommendations. Given the concern over exposing children to ionizing radiation, consider using ultrasound as the initial imaging modality. In cases in which the diagnosis remains uncertain after ultrasound, CT may be performed.

Definitions:

Strength of Evidence

Literature Classification Schema*

Design/Class Therapy† Diagnosis‡ Prognosis§
1 Randomized, controlled trial or meta-analyses of randomized trials Prospective cohort using a criterion standard Population prospective cohort
2 Nonrandomized trial Retrospective observational Retrospective cohort
Case control
3 Case series
Case report
Other (e.g., consensus, review)
Case series
Case report
Other (e.g., consensus, review)
Case series
Case report
Other (e.g., consensus, review)

*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
Objective is to measure therapeutic efficacy comparing ≥2 interventions.
Objective is to determine the sensitivity and specificity of diagnostic tests.
§Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

  Design/Class
Downgrading 1 2 3
None I II III
1 level II III X
2 levels III X X
Fatally flawed X X X

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)

Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate evaluation and management of emergency department patients with nontraumatic acute abdominal pain can lessen diagnostic test ordering, when appropriate, and can limit exposure to ionizing radiation in children through the use of ultrasound in select cases.

Potential Harms
  • False-positive evaluation may lead to the removal of a normal appendix. False-negative evaluation may lead to missed diagnosis of appendicitis.
  • Contrast has disadvantages. Oral contrast requires time to administer, requires time to transit the bowel, and may be difficult to tolerate for patients with abdominal pain and vomiting. Rectal contrast requires less time to administer than oral contrast but may be uncomfortable and unpleasant. Intravenous (IV) contrast may lead to serious allergic reactions and renal failure. Contrast also adds to cost.
  • Computed tomography exposes the patient to ionizing radiation.

Qualifying Statements

Qualifying Statements
  • This policy is not intended to be a complete manual on the evaluation and management of patients with nontraumatic acute abdominal pain but rather a focused examination of critical issues that have particular relevance to the current practice of emergency medicine.
  • It is the goal of the Clinical Policies Committee to provide an evidence-based recommendation when the medical literature provides enough quality information to answer a critical question. When the medical literature does not contain enough quality information to answer a critical question, the members of the Clinical Policies Committee believe that it is equally important to alert emergency physicians to this fact.
  • Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. The American College of Emergency Physicians (ACEP) clearly recognizes the importance of the individual physician's judgment. Rather, this guideline defines for the physician those strategies for which medical literature exists to provide support for answers to the crucial questions addressed in this policy.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. 2010 Jan;55(1):71-116. [71 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2000 (revised 2010 Jan)
Guideline Developer(s)
American College of Emergency Physicians - Medical Specialty Society
Source(s) of Funding

American College of Emergency Physicians

Guideline Committee

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

American College of Emergency Physicians Clinical Policies Committee (Oversight Committee)

Composition of Group That Authored the Guideline

Members of the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: John M. Howell, MD (Subcommittee Chair); Orin L. Eddy, MD; Thomas W. Lukens, MD, PhD; Molly E. W. Thiessen, MD; Scott D. Weingart, MD; Wyatt W. Decker, MD (Committee Chair)

Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee): Wyatt W. Decker, MD (Co-Chair 2006–2007, Chair 2007–2009); Andy S. Jagoda, MD (Chair 2003–2006, Co-Chair 2006–2007); Deborah B. Diercks, MD; Barry M. Diner, MD (Methodologist); Jonathan A. Edlow, MD; Francis M. Fesmire, MD; John T. Finnell, II, MD, MSc (Liaison for Emergency Medical Informatics Section 2004–2006); Steven A. Godwin, MD; Sigrid A. Hahn, MD; Benjamin W. Hatten, MD (Emergency Medical Response Agency [EMRA] Representative 2008–2009); John M. Howell, MD; J. Stephen Huff, MD; Eric J. Lavonas, MD; Thomas W. Lukens, MD, PhD; Sharon E. Mace, MD; Donna L. Mason, RN, MS, CEN (Emergency Nurses' Association [ENA] Representative 2004–2006); Edward Melnick, MD (EMRA Representative 2007–2008); Anthony M. Napoli, MD (EMRA Representative 2004–2006); Devorah J. Nazarian, MD; AnnMarie Papa, RN, MSN, CEN, FAEN (ENA Representative 2007–2009); Jim Richmann, RN, BS, MA(c), CEN (ENA Representative 2006–2007); Scott M. Silvers, MD; Edward P. Sloan, MD, MPH; Molly E. W. Thiessen, MD (EMRA Representative 2006–2008); Robert L. Wears, MD, MS (Methodologist); Stephen J. Wolf, MD; Cherri D. Hobgood, MD (Board Liaison 2004–2006); David C. Seaberg, MD, CPE (Board Liaison 2006–2009); Rhonda R. Whitson, RHIA (Staff Liaison, Clinical Policies Committee and Subcommittees)

Financial Disclosures/Conflicts of Interest

Relevant industry relationships of subcommittee members: There were no relevant industry relationships disclosed by the subcommittee members.

Relevant industry relationships are those relationships with companies associated with products or services that significantly impact the specific aspect of disease addressed in the critical question.

Guideline Endorser(s)
Emergency Nurses Association - Professional Association
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000 Oct;36(4):406-15. [137 references] PubMed External Web Site Policy

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American College of Emergency Physicians Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on January 29, 2003. The information was verified by the guideline developer on March 13, 2003. This NGC summary was updated by ECRI Institute on May 28, 2010. The updated information was verified by the guideline developer on June 30, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please refer to the American College of Emergency Physicians (ACEP) Web site External Web Site Policy.

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