Appendicitis ConcernAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

486 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx53

HPI

›Abdominal pain pattern

›Migration

›Periumbilical to right lower quadrant

›No migration

›Timeline and progression

›Hours

›Days

›Context

›Recent gastroenteritis symptoms

›Recent travel

OPQRST

›OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with movement

›Worse with cough

›Quality

›Dull ache

›Sharp focal pain

›Region and radiation

›Right lower quadrant

›Flank or groin radiation

›Severity

›Mild

›Severe

›Timing

›Constant

›Intermittent

Associated symptoms

›GI symptoms

›Anorexia

›Nausea

›Vomiting

›Bowel and urinary symptoms

›Diarrhea

›Constipation

›Dysuria

›Hematuria

Gynecologic and pregnancy

›Pregnancy risk

›LMP timing

›Pregnancy test result if known

›Gynecologic symptoms

›Vaginal bleeding

›Vaginal discharge

›Pelvic pain

Pediatrics and older adults

›Pediatric features

›Poor feeding

›Irritability

›Atypical pain localization

›Older adult features

›Minimal pain

›Minimal fever

›Delayed presentation

02Alarm Features/alarm21

Immediate escalation triggers

›Shock or impending shock

›SBP less than 90 mmHg

›Altered mental status

›Cool mottled skin

›Peritonitis

›Rebound tenderness

›Involuntary guarding

›Rigid abdomen

Sepsis physiology

›High risk vitals

›Fever 38.0 C or higher

›Hypothermia less than 36.0 C

›HR 120 or higher

›Perfusion concern

›Lactate 2 mmol/L or higher

›Oliguria

Cannot miss alternate emergencies

›Pregnancy related emergencies

›Ectopic pregnancy concern

›Hemodynamic instability with positive pregnancy test

›Vascular emergencies

›AAA concern

›Mesenteric ischemia concern

03Medications/meds20

Current and recent medications

›Prescription and OTC

›NSAIDs

›Acetaminophen

›Opioids

›Recent antibiotics

›Within last 30 days

›Current course

High risk medication classes

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Aspirin or P2Y12 inhibitor

›Steroids and immunosuppressants

›Chronic systemic steroids

›Biologics

Contraindications and interaction traps

›Contrast risk factors

›Prior contrast reaction

›Severe kidney disease history

›Analgesic cautions

›NSAID avoidance if CKD

›Opioid risk with sleep apnea

04Diet/diet12

Recent intake and hydration

›Oral intake pattern

›Poor intake

›Unable to tolerate PO

›Hydration indicators

›Dry mucous membranes

›Reduced urine output

Exposure related triggers

›Foodborne illness exposures

›Undercooked meats

›Unpasteurized foods

›Alcohol exposure

›Recent heavy intake

›Binge pattern

05Review of Systems/ros27

Constitutional and infectious

›Systemic symptoms

›Fever

›Chills

›Malaise

›Inflammatory symptoms

›Night sweats

›Weight loss

GI and hepatobiliary

›GI symptoms

›Abdominal distension

›Hematochezia

›Melena

›Hepatobiliary symptoms

›Jaundice

›RUQ pain

GU and cardiopulmonary

›GU symptoms

›Dysuria

›Frequency

›Flank pain

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

Neuro and skin

›Neuro symptoms

›Syncope

›Confusion

›Skin findings

›Rash

›Purpura

06Collateral History and Family History/chafh20

Collateral and reliability

›Information sources

›Family

›EMS

›Care facility

›Reliability flags

›Cognitive impairment

›Language barrier

Family history

›Abdominal surgical history patterns

›Familial inflammatory bowel disease

›Familial colorectal cancer

›Early cardiovascular disease

›First degree relative

›Age less than 55 male

›Age less than 65 female

Exposure context

›Sick contacts

›Household gastroenteritis

›Daycare exposure

›Social supports

›Reliable transport

›Reliable follow up

07Risk Factors/rf20

Appendicitis and complications

›Higher risk of perforation

›Age under 5 years

›Older adult

›Symptoms longer than 48 hours

›Immunocompromised state

›Transplant

›Neutropenia

›Chronic steroids

GU and gynecologic risks

›Nephrolithiasis risk

›Prior stones

›Low urine output

›STI and PID risk

›New sexual partner

›Prior PID

Surgical and device related risks

›Prior abdominal surgery

›Adhesions risk

›Altered anatomy

›Implanted devices

›VP shunt

›Peritoneal dialysis catheter

08Differential Diagnosis/ddx50

Life threatening

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Pelvic pain

›Vaginal bleeding

›Ovarian torsion (N83.5)

›Sudden severe pelvic pain

›Adnexal tenderness

›AAA (I71.4)

›Older age

›Hypotension

›Back pain

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›AF history

›Elevated lactate

Common

›Acute appendicitis (K35.80)

›Migration to right lower quadrant

›Anorexia

›RLQ tenderness

›Gastroenteritis (A09)

›Diarrhea predominant

›Sick contacts

›Ureteral stone (N20.0)

›Colicky flank pain

›Hematuria

›UTI or pyelonephritis (N39.0)

›Dysuria

›Fever

›CVA tenderness

Less common and mimics

›Diverticulitis right sided (K57.32)

›Older age

›Localized tenderness

›Inflammatory bowel disease flare (K50.90)

›Chronic diarrhea

›Weight loss

›Mesenteric adenitis (R59.0)

›Viral prodrome

›Pediatric

›Testicular torsion (N44)

›Scrotal pain

›Abdominal pain in adolescents

Key discriminators

›Appendicitis versus gastroenteritis

›Migration supports appendicitis

›Prominent diarrhea supports gastroenteritis

›Appendicitis versus stone

›Focal RLQ tenderness supports appendicitis

›Colicky flank pain supports stone

›Appendicitis versus gynecologic

›Positive pregnancy test shifts priorities

›Cervical motion tenderness supports PID

09Past Medical History/pmh18

Relevant conditions

›Prior abdominal pathology

›Prior appendicitis workup

›Inflammatory bowel disease

›Metabolic and vascular

›Diabetes mellitus (E11.9)

›Atrial fibrillation (I48.91)

Surgical history

›Prior abdominal surgery

›Cesarean section

›Bowel surgery

›Prior pelvic surgery

›Ovarian cyst surgery

›Tubal ligation

Baseline status

›Functional baseline

›Independent ADLs

›Frailty indicators

›Prior hospitalizations

›Recent ED visits

›ICU history

10Physical Exam/exam32

General and vitals pattern

›Appearance

›Toxic appearing

›Non toxic

›Vitals interpretation

›Fever pattern

›Tachycardia out of proportion

Abdominal exam

›Inspection and auscultation

›Distension

›Bowel sounds reduced

›Palpation and peritoneal signs

›RLQ tenderness

›Rebound tenderness

›Guarding

Focused maneuvers

›Appendicitis maneuvers

›Rovsing sign

›Psoas sign

›Obturator sign

›Hernia evaluation

›Inguinal hernia

›Femoral hernia

GU and pelvic

›External genital exam

›Testicular tenderness

›High riding testis

›Pelvic exam when indicated

›Cervical motion tenderness

›Adnexal tenderness

Cardiopulmonary and skin

›Cardiopulmonary

›Murmur

›Rales

›Skin and perfusion

›Capillary refill delayed

›Rash or purpura

11Lab Studies/labs27

Core labs

›CBC

›Leukocytosis support

›Normal WBC does not exclude appendicitis

›CMP

›Electrolytes for dehydration

›Creatinine for imaging contrast planning

›CRP

›Supportive when elevated

›Lower values early possible

Pregnancy and urinalysis

›Pregnancy test

›Urine hCG

›Serum hCG if high concern or equivocal

›Urinalysis

›Hematuria supports stone

›Pyuria supports UTI

Sepsis and perfusion

›Lactate

›2 mmol/L or higher supports hypoperfusion

›Normal lactate does not exclude perforation

›Blood cultures

›If sepsis physiology

›If immunocompromised with fever

Coagulation and blood type

›Coagulation studies

›If anticoagulated

›If planned procedure

›Type and screen

›If operative pathway likely

›If pregnancy related bleeding concern

12Imaging/img46

Scoring Systems

›Clinical decision tools

›Alvarado score

›Migration of pain

›Anorexia

›Nausea or vomiting

›RLQ tenderness

›Rebound or peritoneal irritation

›Fever

›Leukocytosis

›Neutrophilia

›AIR score

›RLQ pain

›Rebound or guarding

›CRP categories

›WBC categories

›Interpretation and use

›Low risk supports observation or alternate workup

›Intermediate risk supports imaging selection by population

›High risk supports surgical consult pathway

MRI

›Indications

›Pregnancy with persistent concern

›Pediatric or young adult when ultrasound nondiagnostic

›Protocol and pearls

›Non contrast MRI abdomen pelvis

›Alternative diagnoses detection

›Indications

›Adult with intermediate to high suspicion

›Nondiagnostic ultrasound with ongoing concern

›Protocol and pearls

›CT abdomen pelvis with IV contrast if renal function acceptable

›Non contrast CT for stone pathway when appropriate

›Pitfalls and cautions

›Radiation exposure

›Contrast reaction risk

Ultrasound

›First line populations

›Pediatrics

›Pregnancy

›Reproductive age with gynecologic differential

›Technique and interpretation

›Graded compression appendix assessment

›Secondary signs

›Free fluid

›Echogenic fat

›Limitations

›Nondiagnostic common with obesity

›Retrocecal appendix limitations

13Special Tests/spec12

Bedside pathways

›POCUS adjuncts

›Hydronephrosis for stone

›Free fluid assessment when unstable

›Focused pelvic ultrasound

›Intrauterine pregnancy assessment

›Adnexal mass or free fluid

Procedural diagnostics

›Pelvic swabs when indicated

›NAAT for gonorrhea

›NAAT for chlamydia

›Surgical consultation diagnostics

›Serial abdominal exams

›Observation with repeat labs

14ECG/ecg12

Indications in abdominal pain

›Atypical presentations

›Older adult with epigastric pain

›Diabetic with atypical symptoms

›Hemodynamic compromise

›Hypotension

›Tachyarrhythmia

High risk patterns

›Ischemia

›ST elevation

›New ST depression

›Arrhythmia

›Atrial fibrillation with RVR

›Ventricular ectopy

15Assessment/ax23

Working diagnosis and severity

›Suspected acute appendicitis (K35.80)

›Clinical probability tier

›Low

›Intermediate

›High

›Complication concern

›Perforation concern

›Abscess concern

Complications and alternate diagnoses to rule out

›Perforated appendicitis (K35.32)

›Peritonitis signs

›Sepsis physiology

›Pregnancy related emergency

›Positive pregnancy test

›Hemodynamic instability

Supporting features synthesis

›History support

›Migration pattern present

›Anorexia present

›Exam support

›RLQ tenderness

›Guarding or rebound

›Test support

›Leukocytosis

›Imaging consistent

16Plan/plan41

Approach to critical patient

›First 5 minutes

›Continuous monitoring

›SpO2

›Cardiac monitor

›BP cycling

›IV access

›Two large bore IV if unstable

›IO if no access and unstable

›Fluids

›Crystalloid bolus 20 mL/kg if shock physiology

›Reassess after each bolus

›Antibiotics

›If sepsis physiology or perforation concern, start within 60 minutes

›Local protocol dependent selection

Analgesia and antiemetics

›Analgesia

›Acetaminophen PO or IV 1000 mg once

›Ketorolac IV 15 mg once

›Hydromorphone IV 0.2 mg to 0.5 mg once

›Antiemetic

›Ondansetron IV 4 mg once

›Metoclopramide IV 10 mg once

Antibiotics when indicated

›Uncomplicated appendicitis pathway

›Ceftriaxone IV 2 g once

›Metronidazole IV 500 mg once

›Perforation or abscess concern pathway

›Piperacillin tazobactam IV 3.375 g once

›Local protocol dependent alternatives

Imaging and consultation sequencing

›Imaging selection by population

›Pediatrics first line ultrasound

›Pregnancy first line ultrasound then MRI if needed

›Adult CT with IV contrast if appropriate

›Consultation

›General surgery early for high probability

›OB GYN early if pregnancy related emergency concern

Reassessment loop

›Timing

›Recheck pain and vitals every 30 to 60 minutes

›Repeat abdominal exam after analgesia

›Escalation triggers

›New peritonitis signs

›Rising lactate

›Worsening hypotension

17Disposition/dispo19

ICU and high acuity criteria

›ICU level care

›Vasopressor requirement

›Persistent lactate 4 mmol/L or higher

›Altered mental status from shock

›Stepdown or monitored bed

›Persistent tachycardia 120 or higher

›Significant comorbidity burden

Admission and observation criteria

›Inpatient admission

›Perforation or abscess concern

›Intractable vomiting

›Uncontrolled pain requiring IV opioids

›Observation pathway

›Equivocal imaging with improving exam

›Intermediate risk score with planned serial exams

Discharge criteria

›Low risk and alternate diagnosis likely

›Stable vitals

›Pain controlled on oral meds

›Tolerating PO

›Reliable follow up within 24 to 48 hours

18Discharge Instructions/di23

Copy discharge instructions

›Diagnosis summary:

›You were evaluated for possible appendicitis.

›Your tests today did not show appendicitis that needs urgent surgery right now.

›Medications:

›Acetaminophen as directed on the bottle.

›Avoid NSAIDs if you have kidney disease or were told not to take them.

›Eating and drinking:

›Small sips of fluids often.

›Return if you cannot keep fluids down.

›Activity:

›Avoid strenuous activity until pain improves.

›Do not drive if taking sedating pain medicine.

›Follow up:

›Follow up with a clinician within 24 to 48 hours.

›Return sooner if symptoms worsen.

›Return to ED now if:

›Worsening right lower belly pain

›New fever

›Repeated vomiting

›Fainting or severe weakness

›New belly rigidity

›Blood in vomit or stool

›Pregnancy concern or positive pregnancy test with pain or bleeding

19References/r10

Guidelines and evidence

›Key sources

›World Society of Emergency Surgery Jerusalem guidelines for acute appendicitis, 2020

›American College of Radiology Appropriateness Criteria Right Lower Quadrant Pain Suspected Appendicitis, update cycle dependent

›Society of American Gastrointestinal and Endoscopic Surgeons guidelines for appendicitis management, update cycle dependent

›Decision tools and pathways

›Alvarado score validation literature, multiple cohorts

›Appendicitis Inflammatory Response score validation literature, multiple cohorts

›Project instructions source

›Local protocol dependent items require institutional alignment

›Imaging and antibiotic selection vary by site

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Appendicitis ConcernAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

486 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx53

HPI

›Abdominal pain pattern

›Migration

›Periumbilical to right lower quadrant

›No migration

›Timeline and progression

›Hours

›Days

›Context

›Recent gastroenteritis symptoms

›Recent travel

OPQRST

›OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with movement

›Worse with cough

›Quality

›Dull ache

›Sharp focal pain

›Region and radiation

›Right lower quadrant

›Flank or groin radiation

›Severity

›Mild

›Severe

›Timing

›Constant

›Intermittent

Associated symptoms

›GI symptoms

›Anorexia

›Nausea

›Vomiting

›Bowel and urinary symptoms

›Diarrhea

›Constipation

›Dysuria

›Hematuria

Gynecologic and pregnancy

›Pregnancy risk

›LMP timing

›Pregnancy test result if known

›Gynecologic symptoms

›Vaginal bleeding

›Vaginal discharge

›Pelvic pain

Pediatrics and older adults

›Pediatric features

›Poor feeding

›Irritability

›Atypical pain localization

›Older adult features

›Minimal pain

›Minimal fever

›Delayed presentation

02Alarm Features/alarm21

Immediate escalation triggers

›Shock or impending shock

›SBP less than 90 mmHg

›Altered mental status

›Cool mottled skin

›Peritonitis

›Rebound tenderness

›Involuntary guarding

›Rigid abdomen

Sepsis physiology

›High risk vitals

›Fever 38.0 C or higher

›Hypothermia less than 36.0 C

›HR 120 or higher

›Perfusion concern

›Lactate 2 mmol/L or higher

›Oliguria

Cannot miss alternate emergencies

›Pregnancy related emergencies

›Ectopic pregnancy concern

›Hemodynamic instability with positive pregnancy test

›Vascular emergencies

›AAA concern

›Mesenteric ischemia concern

03Medications/meds20

Current and recent medications

›Prescription and OTC

›NSAIDs

›Acetaminophen

›Opioids

›Recent antibiotics

›Within last 30 days

›Current course

High risk medication classes

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Aspirin or P2Y12 inhibitor

›Steroids and immunosuppressants

›Chronic systemic steroids

›Biologics

Contraindications and interaction traps

›Contrast risk factors

›Prior contrast reaction

›Severe kidney disease history

›Analgesic cautions

›NSAID avoidance if CKD

›Opioid risk with sleep apnea

04Diet/diet12

Recent intake and hydration

›Oral intake pattern

›Poor intake

›Unable to tolerate PO

›Hydration indicators

›Dry mucous membranes

›Reduced urine output

Exposure related triggers

›Foodborne illness exposures

›Undercooked meats

›Unpasteurized foods

›Alcohol exposure

›Recent heavy intake

›Binge pattern

05Review of Systems/ros27

Constitutional and infectious

›Systemic symptoms

›Fever

›Chills

›Malaise

›Inflammatory symptoms

›Night sweats

›Weight loss

GI and hepatobiliary

›GI symptoms

›Abdominal distension

›Hematochezia

›Melena

›Hepatobiliary symptoms

›Jaundice

›RUQ pain

GU and cardiopulmonary

›GU symptoms

›Dysuria

›Frequency

›Flank pain

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

Neuro and skin

›Neuro symptoms

›Syncope

›Confusion

›Skin findings

›Rash

›Purpura

06Collateral History and Family History/chafh20

Collateral and reliability

›Information sources

›Family

›EMS

›Care facility

›Reliability flags

›Cognitive impairment

›Language barrier

Family history

›Abdominal surgical history patterns

›Familial inflammatory bowel disease

›Familial colorectal cancer

›Early cardiovascular disease

›First degree relative

›Age less than 55 male

›Age less than 65 female

Exposure context

›Sick contacts

›Household gastroenteritis

›Daycare exposure

›Social supports

›Reliable transport

›Reliable follow up

07Risk Factors/rf20

Appendicitis and complications

›Higher risk of perforation

›Age under 5 years

›Older adult

›Symptoms longer than 48 hours

›Immunocompromised state

›Transplant

›Neutropenia

›Chronic steroids

GU and gynecologic risks

›Nephrolithiasis risk

›Prior stones

›Low urine output

›STI and PID risk

›New sexual partner

›Prior PID

Surgical and device related risks

›Prior abdominal surgery

›Adhesions risk

›Altered anatomy

›Implanted devices

›VP shunt

›Peritoneal dialysis catheter

08Differential Diagnosis/ddx50

Life threatening

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Pelvic pain

›Vaginal bleeding

›Ovarian torsion (N83.5)

›Sudden severe pelvic pain

›Adnexal tenderness

›AAA (I71.4)

›Older age

›Hypotension

›Back pain

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›AF history

›Elevated lactate

Common

›Acute appendicitis (K35.80)

›Migration to right lower quadrant

›Anorexia

›RLQ tenderness

›Gastroenteritis (A09)

›Diarrhea predominant

›Sick contacts

›Ureteral stone (N20.0)

›Colicky flank pain

›Hematuria

›UTI or pyelonephritis (N39.0)

›Dysuria

›Fever

›CVA tenderness

Less common and mimics

›Diverticulitis right sided (K57.32)

›Older age

›Localized tenderness

›Inflammatory bowel disease flare (K50.90)

›Chronic diarrhea

›Weight loss

›Mesenteric adenitis (R59.0)

›Viral prodrome

›Pediatric

›Testicular torsion (N44)

›Scrotal pain

›Abdominal pain in adolescents

Key discriminators

›Appendicitis versus gastroenteritis

›Migration supports appendicitis

›Prominent diarrhea supports gastroenteritis

›Appendicitis versus stone

›Focal RLQ tenderness supports appendicitis

›Colicky flank pain supports stone

›Appendicitis versus gynecologic

›Positive pregnancy test shifts priorities

›Cervical motion tenderness supports PID

09Past Medical History/pmh18

Relevant conditions

›Prior abdominal pathology

›Prior appendicitis workup

›Inflammatory bowel disease

›Metabolic and vascular

›Diabetes mellitus (E11.9)

›Atrial fibrillation (I48.91)

Surgical history

›Prior abdominal surgery

›Cesarean section

›Bowel surgery

›Prior pelvic surgery

›Ovarian cyst surgery

›Tubal ligation

Baseline status

›Functional baseline

›Independent ADLs

›Frailty indicators

›Prior hospitalizations

›Recent ED visits

›ICU history

10Physical Exam/exam32

General and vitals pattern

›Appearance

›Toxic appearing

›Non toxic

›Vitals interpretation

›Fever pattern

›Tachycardia out of proportion

Abdominal exam

›Inspection and auscultation

›Distension

›Bowel sounds reduced

›Palpation and peritoneal signs

›RLQ tenderness

›Rebound tenderness

›Guarding

Focused maneuvers

›Appendicitis maneuvers

›Rovsing sign

›Psoas sign

›Obturator sign

›Hernia evaluation

›Inguinal hernia

›Femoral hernia

GU and pelvic

›External genital exam

›Testicular tenderness

›High riding testis

›Pelvic exam when indicated

›Cervical motion tenderness

›Adnexal tenderness

Cardiopulmonary and skin

›Cardiopulmonary

›Murmur

›Rales

›Skin and perfusion

›Capillary refill delayed

›Rash or purpura

11Lab Studies/labs27

Core labs

›CBC

›Leukocytosis support

›Normal WBC does not exclude appendicitis

›CMP

›Electrolytes for dehydration

›Creatinine for imaging contrast planning

›CRP

›Supportive when elevated

›Lower values early possible

Pregnancy and urinalysis

›Pregnancy test

›Urine hCG

›Serum hCG if high concern or equivocal

›Urinalysis

›Hematuria supports stone

›Pyuria supports UTI

Sepsis and perfusion

›Lactate

›2 mmol/L or higher supports hypoperfusion

›Normal lactate does not exclude perforation

›Blood cultures

›If sepsis physiology

›If immunocompromised with fever

Coagulation and blood type

›Coagulation studies

›If anticoagulated

›If planned procedure

›Type and screen

›If operative pathway likely

›If pregnancy related bleeding concern

12Imaging/img46

Scoring Systems

›Clinical decision tools

›Alvarado score

›Migration of pain

›Anorexia

›Nausea or vomiting

›RLQ tenderness

›Rebound or peritoneal irritation

›Fever

›Leukocytosis

›Neutrophilia

›AIR score

›RLQ pain

›Rebound or guarding

›CRP categories

›WBC categories

›Interpretation and use

›Low risk supports observation or alternate workup

›Intermediate risk supports imaging selection by population

›High risk supports surgical consult pathway

MRI

›Indications

›Pregnancy with persistent concern

›Pediatric or young adult when ultrasound nondiagnostic

›Protocol and pearls

›Non contrast MRI abdomen pelvis

›Alternative diagnoses detection

›Indications

›Adult with intermediate to high suspicion

›Nondiagnostic ultrasound with ongoing concern

›Protocol and pearls

›CT abdomen pelvis with IV contrast if renal function acceptable

›Non contrast CT for stone pathway when appropriate

›Pitfalls and cautions

›Radiation exposure

›Contrast reaction risk

Ultrasound

›First line populations

›Pediatrics

›Pregnancy

›Reproductive age with gynecologic differential

›Technique and interpretation

›Graded compression appendix assessment

›Secondary signs

›Free fluid

›Echogenic fat

›Limitations

›Nondiagnostic common with obesity

›Retrocecal appendix limitations

13Special Tests/spec12

Bedside pathways

›POCUS adjuncts

›Hydronephrosis for stone

›Free fluid assessment when unstable

›Focused pelvic ultrasound

›Intrauterine pregnancy assessment

›Adnexal mass or free fluid

Procedural diagnostics

›Pelvic swabs when indicated

›NAAT for gonorrhea

›NAAT for chlamydia

›Surgical consultation diagnostics

›Serial abdominal exams

›Observation with repeat labs

14ECG/ecg12

Indications in abdominal pain

›Atypical presentations

›Older adult with epigastric pain

›Diabetic with atypical symptoms

›Hemodynamic compromise

›Hypotension

›Tachyarrhythmia

High risk patterns

›Ischemia

›ST elevation

›New ST depression

›Arrhythmia

›Atrial fibrillation with RVR

›Ventricular ectopy

15Assessment/ax23

Working diagnosis and severity

›Suspected acute appendicitis (K35.80)

›Clinical probability tier

›Low

›Intermediate

›High

›Complication concern

›Perforation concern

›Abscess concern

Complications and alternate diagnoses to rule out

›Perforated appendicitis (K35.32)

›Peritonitis signs

›Sepsis physiology

›Pregnancy related emergency

›Positive pregnancy test

›Hemodynamic instability

Supporting features synthesis

›History support

›Migration pattern present

›Anorexia present

›Exam support

›RLQ tenderness

›Guarding or rebound

›Test support

›Leukocytosis

›Imaging consistent

16Plan/plan41

Approach to critical patient

›First 5 minutes

›Continuous monitoring

›SpO2

›Cardiac monitor

›BP cycling

›IV access

›Two large bore IV if unstable

›IO if no access and unstable

›Fluids

›Crystalloid bolus 20 mL/kg if shock physiology

›Reassess after each bolus

›Antibiotics

›If sepsis physiology or perforation concern, start within 60 minutes

›Local protocol dependent selection

Analgesia and antiemetics

›Analgesia

›Acetaminophen PO or IV 1000 mg once

›Ketorolac IV 15 mg once

›Hydromorphone IV 0.2 mg to 0.5 mg once

›Antiemetic

›Ondansetron IV 4 mg once

›Metoclopramide IV 10 mg once

Antibiotics when indicated

›Uncomplicated appendicitis pathway

›Ceftriaxone IV 2 g once

›Metronidazole IV 500 mg once

›Perforation or abscess concern pathway

›Piperacillin tazobactam IV 3.375 g once

›Local protocol dependent alternatives

Imaging and consultation sequencing

›Imaging selection by population

›Pediatrics first line ultrasound

›Pregnancy first line ultrasound then MRI if needed

›Adult CT with IV contrast if appropriate

›Consultation

›General surgery early for high probability

›OB GYN early if pregnancy related emergency concern

Reassessment loop

›Timing

›Recheck pain and vitals every 30 to 60 minutes

›Repeat abdominal exam after analgesia

›Escalation triggers

›New peritonitis signs

›Rising lactate

›Worsening hypotension

17Disposition/dispo19

ICU and high acuity criteria

›ICU level care

›Vasopressor requirement

›Persistent lactate 4 mmol/L or higher

›Altered mental status from shock

›Stepdown or monitored bed

›Persistent tachycardia 120 or higher

›Significant comorbidity burden

Admission and observation criteria

›Inpatient admission

›Perforation or abscess concern

›Intractable vomiting

›Uncontrolled pain requiring IV opioids

›Observation pathway

›Equivocal imaging with improving exam

›Intermediate risk score with planned serial exams

Discharge criteria

›Low risk and alternate diagnosis likely

›Stable vitals

›Pain controlled on oral meds

›Tolerating PO

›Reliable follow up within 24 to 48 hours

18Discharge Instructions/di23

Copy discharge instructions

›Diagnosis summary:

›You were evaluated for possible appendicitis.

›Your tests today did not show appendicitis that needs urgent surgery right now.

›Medications:

›Acetaminophen as directed on the bottle.

›Avoid NSAIDs if you have kidney disease or were told not to take them.

›Eating and drinking:

›Small sips of fluids often.

›Return if you cannot keep fluids down.

›Activity:

›Avoid strenuous activity until pain improves.

›Do not drive if taking sedating pain medicine.

›Follow up:

›Follow up with a clinician within 24 to 48 hours.

›Return sooner if symptoms worsen.

›Return to ED now if:

›Worsening right lower belly pain

›New fever

›Repeated vomiting

›Fainting or severe weakness

›New belly rigidity

›Blood in vomit or stool

›Pregnancy concern or positive pregnancy test with pain or bleeding

19References/r10

Guidelines and evidence

›Key sources

›World Society of Emergency Surgery Jerusalem guidelines for acute appendicitis, 2020

›American College of Radiology Appropriateness Criteria Right Lower Quadrant Pain Suspected Appendicitis, update cycle dependent

›Society of American Gastrointestinal and Endoscopic Surgeons guidelines for appendicitis management, update cycle dependent

›Decision tools and pathways

›Alvarado score validation literature, multiple cohorts

›Appendicitis Inflammatory Response score validation literature, multiple cohorts

›Project instructions source

›Local protocol dependent items require institutional alignment

›Imaging and antibiotic selection vary by site

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.