Impact of Imaging on Negative Appendectomy Rate

  • Courtney A. Coursey
  • Ricardo D. Moreno
Part of the Medical Radiology book series (MEDRAD)


A negative appendectomy is defined as the removal of a normal appendix during an urgent appendectomy performed because of suspected acute appendicitis. In this chapter, we will trace the historical acceptability of a negative appendectomy rate, negative appendectomy rates in the pre-CT era, and negative appendectomy rates in the CT era. Gender differences in the impact of CT on negative appendectomy rates will be reviewed. Controversies related to the role of CT in lowering negative appendectomy rates will be discussed. Acceptable rates of negative appendectomy in the CT era will be addressed. The impact of ultrasound on negative appendectomy rates and the impact of imaging on negative appendectomy rates in children also will be discussed.


Acute Appendicitis Pelvic Inflammatory Disease Preoperative Compute Tomography Normal Appendix Negative Appendectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Andersson RE, Hugander A, Ravn H et al (2000) Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 24:479–485PubMedCrossRefGoogle Scholar
  2. Applegate KE, Sivit SJ, Salvator AE (2001) Effect of cross-sectional imaging on negative appendectomy and perforation rates in children. Radiology 220:103–107PubMedGoogle Scholar
  3. Augustin T, Bhende S, Chavda K et al (2009) CT scans and acute appendicitis: a 5 year analysis from a rural teaching hospital. J Gastroin Surg 13:1306–1312CrossRefGoogle Scholar
  4. Balthazar EJ, Megibow AJ, Hulnick D et al (1986) CT of appendicitis. AJR 147:705–710PubMedGoogle Scholar
  5. Barnes BA, Behringer GE, Wheelock FC et al (1962) Treatment of appendicitis at the Massachusetts General Hospital (1937–1959). JAMA 180:122–126PubMedGoogle Scholar
  6. Bendeck SE, Nino-Murcia M, Berry GJ et al (2002) Imaging for suspected appendicitis: negative appendectomy and perforation rates. Radiology 225:131–136PubMedCrossRefGoogle Scholar
  7. Borgstein PJ, Gordijn RV, Eijsbouts QAJ et al (1997) Acute appendicitis—a clear-cut case in men, a guessing game in young women. Surg Endo 11:923–927CrossRefGoogle Scholar
  8. Brandt M-M, Wahl WL (2003) Liberal use of CT scanning helps to diagnose appendicitis in adults. Am Surg 69:727–734PubMedGoogle Scholar
  9. Brownlee S (2008) Overtreated: why too much medicine is making us sicker and poorer. Bloomsbury Publishing, New YorkGoogle Scholar
  10. Cantrell JR, Stafford ED (1955) The diminishing mortality from appendicitis. Ann of Surg 141:749–756Google Scholar
  11. Chang FC, Hogle HH, Welling DR (1973) The fate of the negative appendix. Am J Surg 126:752–754PubMedCrossRefGoogle Scholar
  12. Chooi WK, Brown JA, Zetler P et al (2007) Imaging of acute appendicitis and its impact on negative appendectomy and perforation rates: The St. Paul’s experience. Can Assoc of Rad Jnl 58:220–224Google Scholar
  13. Colson M, Skinner KA, Dunnington G (1997) High negative appendectomy rates are no longer acceptable. Am J Surg 174:723–726PubMedCrossRefGoogle Scholar
  14. Coursey CA, Nelson RC, Patel MB et al (2010) Making the diagnosis of acute appendicitis: Do more preoperative CT scans mean fewer negative appendectomies? A 10 year study. Radiology 254:460–468PubMedCrossRefGoogle Scholar
  15. Detmer DE, Nevers LE, Sikes ED (1981) Regional results of acute appendicitis care. JAMA 246:1318–1320PubMedCrossRefGoogle Scholar
  16. Egdahl RH (1964) Current mortality in appendicitis. Am J Surg 107:757–759PubMedCrossRefGoogle Scholar
  17. Eldar S, Nash E, Sabo E et al (1997) Delay of surgery in acute appendicitis. Am J Surg 173:194–198PubMedCrossRefGoogle Scholar
  18. Fish B, Smulewicz JJ, Barek L (1981) Role of computed tomography in diagnosis of appendiceal disorders. N Y State J Med 81:900–904PubMedGoogle Scholar
  19. Flum DR, Morris A, Koepsell T et al (2001) Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 286:1748–1753PubMedCrossRefGoogle Scholar
  20. Frei SP, Bond WF, Bazuro RK (2008) Appendicitis outcomes with increasing computed tomographic scanning. Am J Emerg Med 26:39–44PubMedCrossRefGoogle Scholar
  21. Fuchs JR, Schlamberg JS, Shortsleeve MJ et al (2002) Impact of abdominal CT imaging on the management of appendicitis: an update. J Surg Res 106:131–136PubMedCrossRefGoogle Scholar
  22. Gale ME, Birnbaum S, Gerzof SG et al (1985) CT appearance of appendicitis and its local complications. J Comput Assist Tomogr 9:34–37PubMedCrossRefGoogle Scholar
  23. Ganguli S, Raptopoulos V, Komlos F et al (2006) Right lower quadrant pain: value of the nonvisualized appendix in patients at multidetector CT. Radiology 241:175–180PubMedCrossRefGoogle Scholar
  24. Garcia Pena BM, Mandl KD, Kraus SJ et al (1999) Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 282:1041–1046PubMedCrossRefGoogle Scholar
  25. Graff L, Radford MJ, Werne C (1991) Probability of appendicitis before and after observation. Ann Emerg Med 20:503–507PubMedCrossRefGoogle Scholar
  26. Grumbach K (2002) The ramifications of specialty-dominated medicine. Health Aff 21:155–157CrossRefGoogle Scholar
  27. Hebert JJ, Taylor AJ, Winter TC (2006) Comparison of colonic transit between polyethylene glycol and water as oral contrast vehicles in the CT evaluation of acute appendicitis. AJR 187:1188–1191PubMedCrossRefGoogle Scholar
  28. Hobson T, Rosenman LD (1964) Acute appendicitis—when is it right to be wrong? Am J Surg 108:306–312PubMedCrossRefGoogle Scholar
  29. Huynh LN, Coughlin BF, Wolfe J et al (2004) Patient encounter times intervals in the evaluation of emergency department patients requiring abdominopelvic CT: oral contrast versus no contrast. Am Soc Emergency Radiol 10:310313Google Scholar
  30. Johnson PT, Eng J, Moore CJ et al (2005) Multidetector-row CT of the appendix in healthy adults. Emer Radiol 12:248–253CrossRefGoogle Scholar
  31. Jones PF (2001) Management of suspected acute appendicitis. Br J Surg 88:1570–1577PubMedCrossRefGoogle Scholar
  32. Jones B, Fishman EK, Siegelman SS (1983) Computed tomography and appendiceal abscess: special applicability in the elderly. J Comput Assist Tomogr 7:434–438PubMedCrossRefGoogle Scholar
  33. Jones K, Pena AA, Dunn EL et al (2004) Are negative appendectomies still acceptable? Am J Surg 188:748–754PubMedCrossRefGoogle Scholar
  34. Kazarian KK, Roeder WJ, Mersheimer WL (1970) Decreasing mortality and increasing morbidity from acute appendicitis. Am J Surg 119:681–685PubMedCrossRefGoogle Scholar
  35. Keyzer C, Pargov S, Tack D et al (2008) Normal appendix in adults: reproducibility of detection with unenhanced and contrast-enhanced MDCT. AJR 191:507–514PubMedCrossRefGoogle Scholar
  36. Kim K, Lee CC, Song K-J et al (2008) The impact of helical computed tomography on the negative appendectomy rate: a multi-center comparison. J Emer Med 34:3–6CrossRefGoogle Scholar
  37. Korner H, Sondenaa K, Soreide JA et al (1997) Index of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 21:313–317PubMedCrossRefGoogle Scholar
  38. Lane MJ, Liu DM, Huynh MD et al (1999) Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive patients. Radiology 213:341–346PubMedGoogle Scholar
  39. Lewis FR, Holcroft JW, Boey J et al (1975) Appendicitis: a critical review of diagnosis and treatment in 1,000 cases. Arch Surg 110:677–684PubMedGoogle Scholar
  40. Malone AJ, Wolf CR, Malmed AS et al (1993) Diagnosis of acute appendicitis: value of unenhanced CT. AJR 160:763–766PubMedGoogle Scholar
  41. Martin AE, Vollman D, Adler B et al (2004) CT Scans may not reduce the negative appendectomy rate in children. J Pediatr Surg 39:886–890PubMedCrossRefGoogle Scholar
  42. McGory ML, Zingmond DS, Nanayakkara D et al (2005) Negative appendectomy rate: influence of CT scans. Am Surg 71:803–808PubMedGoogle Scholar
  43. Morse BC, Roettger RH, Kalbaugh CA et al (2007) Abdominal CT scanning in reproductive-age women with right lower quadrant abdominal pain: does it reduce negative appendectomy rate and healthcare costs? Am Surg 73:581–584Google Scholar
  44. Musunuru S, Chen H, Rikkers LF et al (2007) Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental? J Gastrointest Surg 11:1417–1422PubMedCrossRefGoogle Scholar
  45. Naoum JJ, Mileski WJ, Daller JA et al (2002) The use of appendiceal computed tomography scan decreases the frequency of misdiagnosis in cases of suspected appendicitis. Am J Surg 184:587–589PubMedCrossRefGoogle Scholar
  46. Nikolaidis P, Hwang CM, Miller FH et al (2004) The nonvisualized appendix: incidence of acute appendicitis when secondary inflammatory changes are absent. AJR 183:889–892PubMedGoogle Scholar
  47. Paulson EK, Harris JP, Jaffe TA et al (2005) Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multidetector row CT. Radiology 235:879–885PubMedCrossRefGoogle Scholar
  48. Perez J, Barone JE, Wilbanks TO et al (2003) Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Am J Surg 185:194–197PubMedCrossRefGoogle Scholar
  49. Raja AS, Wright C, Sodickson AD et al (2010) Negative appendectomy rate in the era of CT: an 18 year perspective. Radiology 256:460–465PubMedCrossRefGoogle Scholar
  50. Raman SS, Osuagwu FC, Kadell B et al (2008) Effect of CT on false positive diagnosis of appendicitis and perforation. NEJM 358:972–973PubMedCrossRefGoogle Scholar
  51. Rao PM, Rhea JT, Rattner DW et al (1999) Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg 229:344–349PubMedCrossRefGoogle Scholar
  52. Rhea JT, Halpern EF, Ptak T et al (2005) The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 184:1802–1808PubMedGoogle Scholar
  53. Riber C, Tonnesen H, Aru A et al (1999) Observer variation in the assessment of the histopathologic diagnosis of acute appendicitis. Scand J Gastroenterol 34:46–49PubMedCrossRefGoogle Scholar
  54. SCOAP (2008) Negative appendectomy and imaging accuracy in the Washington state surgical care and outcomes assessment program. Ann Surg 248:557–563Google Scholar
  55. Smink DS, Finkelstein JA, Garcia Pena BM et al (2004) Diagnosis of acute appendicitis in children using a clinical practice guideline. J Ped Surg 39:458–463CrossRefGoogle Scholar
  56. Styrud J, Josephson T, Eriksson S (2000) Reducing negative appendectomy: evaluation of ultrasonography and computer tomography in acute appendicitis. Int J Qual Health Care 12:65–68PubMedCrossRefGoogle Scholar
  57. van Breda Vriesman AC, Kole BJ, Puylaert JBCM (2003) Effect of ultrasonography and optional computed tomography on the outcome of appendectomy. Eur Radiol 13:2278–2282PubMedCrossRefGoogle Scholar
  58. Wagner JM, McKinney WP, Carpenter JL (1996) Does this patient have appendicitis? JAMA 276:1589–1594PubMedCrossRefGoogle Scholar
  59. Wagner PL, Eachempatia SR, Soe K (2008) Defining the negative appendectomy rate: for whom is preoperative computed tomography making an impact? Surgery 144:276–282PubMedCrossRefGoogle Scholar
  60. Wang Y, Reen DJ, Puri P (1996) Is a histologically normal appendix following emergency appendectomy always normal? Lancet 347:1076–1079PubMedCrossRefGoogle Scholar
  61. Weyant MJ, Eachempati SR, Maluccio MA et al (2000) Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis. Surgery 128:145–152PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of RadiologyEmory HealthcareAtlantaUSA
  2. 2.Department of General SurgeryThe Southeast Permanente Medical GroupAtlantaUSA

Personalised recommendations