A patient with 12-hour right lower abdominal pain, tenderness, rebound tenderness, elevated WBC, and Alvarado score of 6, what is the next step in management?

Next Step: CT Abdomen with IV Contrast

For a patient with an Alvarado score of 6 (intermediate risk), CT abdomen and pelvis with IV contrast is the next step in management. This provides the greatest diagnostic benefit, with 90.4% sensitivity and 95% specificity for appendicitis in this equivocal clinical presentation 1.

Why CT is Essential at Alvarado Score 6

An Alvarado score of 6 represents intermediate risk, where only 30-36% of patients actually have appendicitis 2. This lack of diagnostic certainty makes imaging mandatory rather than proceeding directly to surgery or observation alone.

Key Evidence Supporting CT:

• The World Society of Emergency Surgery strongly recommends CT scan for all patients with intermediate Alvarado scores (5-6) to confirm or exclude appendicitis and distinguish complicated from uncomplicated disease 2
• CT identifies alternative diagnoses in 23-45% of patients presenting with right lower quadrant pain, fundamentally changing management 2, 3
• Without preoperative imaging, the negative appendectomy rate is 14.7-25%, which drops to 1.7-7.7% with CT 3

Why Other Options Are Incorrect

Open Appendectomy (Option A) - Wrong

• The Alvarado score should not be used alone for surgical decision-making due to lack of specificity 2
• Proceeding directly to surgery at score 6 would result in unnecessary operations in 64-70% of patients 2
• Even patients with scores ≥7 benefit from preoperative imaging to reduce negative appendectomy rates 3

Antibiotics Alone (Option C) - Wrong

• Antibiotics without confirmed diagnosis is inappropriate 4
• The APPAC trial showed 27% recurrence rate even in CT-proven uncomplicated appendicitis treated with antibiotics 4
• Appendectomy remains the gold-standard treatment per international guidelines 4

IV Fluid and 24-Hour Observation (Option D) - Wrong

• While observation may be appropriate for low-risk patients (Alvarado <5), intermediate-risk patients require timely and systematic diagnostic imaging 2
• Delaying imaging in symptomatic patients with elevated WBC and peritoneal signs risks progression to perforation 4
• The World Society of Emergency Surgery specifically recommends against discharging or observing intermediate-risk patients without imaging 2

Optimal CT Protocol

Order CT abdomen and pelvis with IV contrast without enteral contrast for 3:

• Rapid acquisition without delays from oral contrast administration
• Sensitivity of 85.7-100% and specificity of 94.8-100% 3
• Detection of alternative diagnoses and assessment for perforation/abscess

Clinical Pitfalls to Avoid

• Do not rely on the presence or absence of fever - it is absent in approximately 50% of appendicitis cases 3
• Do not assume normal inflammatory markers exclude appendicitis - appendicitis can occur with normal WBC 5
• Do not discharge intermediate-risk patients without imaging, especially with 12 hours of symptoms and peritoneal signs 2

What Happens After CT

• If CT confirms appendicitis: Proceed to surgical consultation for appendectomy (laparoscopic preferred) 4
• If CT is negative: Consider alternative diagnoses and provide 24-hour follow-up with return precautions 3
• If borderline findings (7-8mm appendix): Hospital observation with serial exams may be appropriate 3