What is the most appropriate next step in management for a patient with right lower quadrant pain, anorexia, RLQ tenderness, rebound tenderness, and a high white blood cell count?

CT Abdomen and Pelvis with IV Contrast is the Most Appropriate Next Step

In a patient presenting with classic signs of appendicitis (RLQ pain, anorexia, RLQ tenderness, rebound tenderness, and leukocytosis), CT abdomen and pelvis with IV contrast is the most appropriate next step in management before proceeding to surgery. 1

Why Imaging Before Surgery is Critical

The clinical diagnosis of appendicitis alone—even with "classic" findings—has an unacceptably high negative appendectomy rate of up to 25% without preoperative imaging. 1 This patient's presentation, while suggestive, warrants confirmation because:

• CT reduces the negative appendectomy rate from 25% to 1.7-7.7%, preventing unnecessary surgery and its associated morbidity. 1
• CT achieves 95% sensitivity and 94% specificity for appendicitis, providing confident diagnosis or exclusion. 1
• CT identifies alternative diagnoses in 23-45% of cases presenting with suspected appendicitis, including right colonic diverticulitis, bowel obstruction, gynecologic pathology, and urinary tract conditions. 2

Why Not Proceed Directly to Surgery

Even with classic clinical findings present in this patient, proceeding directly to open appendectomy (Option C) without imaging is outdated practice because:

• The "classic" presentation (periumbilical pain migrating to RLQ, anorexia, fever, leukocytosis) is only present in approximately 50% of appendicitis cases. 1
• Clinical scoring systems like the Alvarado score have not improved diagnostic accuracy and show mixed results in guiding management. 1
• Imaging does not increase perforation rates from diagnostic delays, dispelling concerns about waiting for CT. 1

Why Not IVF and Observation

Option B (IVF and observation) is inappropriate because:

• This patient has peritoneal signs (rebound tenderness) indicating advanced inflammation requiring definitive diagnosis and treatment. 3
• Prolonged symptom duration before intervention increases perforation risk, which occurs in 17-32% of appendicitis cases. 3
• Observation without imaging leaves the diagnosis uncertain and delays appropriate surgical or medical management. 4

CT Protocol Specifications

Contrast-enhanced CT without enteral contrast is the optimal protocol, achieving:

• Sensitivity of 90-100% and specificity of 94.8-100%. 1
• No need for oral contrast delays, which can postpone diagnosis without improving accuracy. 1
• Ability to identify high-risk features (appendicolith, appendiceal diameter >13mm, mass effect) that predict treatment failure with antibiotics. 4

Critical Pitfalls to Avoid

• Do not assume clinical diagnosis is sufficient even with "classic" findings—the historical negative appendectomy rate of 14.7% based on clinical judgment alone demonstrates this. 1
• Do not delay imaging for oral contrast administration—IV contrast alone provides excellent diagnostic accuracy. 1
• Do not discharge without imaging (Option D)—rebound tenderness indicates peritoneal irritation requiring definitive diagnosis. 3

Management Algorithm After CT

Once CT is obtained:

• If appendicitis confirmed without high-risk features: Either laparoscopic appendectomy or antibiotics can be considered, with antibiotics achieving 70% success in uncomplicated cases. 4
• If high-risk CT features present (appendicolith, diameter >13mm, mass effect): Surgical management is recommended due to 40% antibiotic failure rate. 4
• If alternative diagnosis identified: Appropriate targeted therapy based on CT findings. 1, 2