A patient with right lower abdominal pain, tenderness, and rebound tenderness presents to the ER, what is the next step?

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CT Abdomen and Pelvis with IV Contrast is the Next Step

For a patient presenting with right lower quadrant pain, tenderness, and rebound tenderness, CT abdomen and pelvis with IV contrast should be obtained before proceeding to surgery. 1, 2

Why Imaging Before Surgery is Critical

The negative appendectomy rate without preoperative imaging is unacceptably high at 14.7-25% when relying on clinical examination alone. 1, 2 Preoperative CT dramatically reduces this rate to 1.7-7.7%, preventing unnecessary surgeries and their associated complications. 2, 3

Even with classic clinical presentation (right lower quadrant pain, tenderness, and rebound), imaging remains essential because:

  • Classic presentation occurs in only approximately 50% of actual appendicitis cases 2
  • CT identifies alternative diagnoses in 23-45% of patients with right lower quadrant pain and classic symptoms, fundamentally changing management 2, 4
  • Alternative diagnoses frequently detected include right colonic diverticulitis (8%), ureteral stones, intestinal obstruction (3%), gynecologic pathology (21.6%), and other gastrointestinal conditions (46%) 2

Diagnostic Performance of CT

CT abdomen and pelvis with IV contrast demonstrates:

  • Sensitivity: 85.7-100% 1, 2, 4
  • Specificity: 94.8-100% 1, 2, 4
  • High accuracy for detecting perforation and abscess formation 2

CT without enteral contrast is equally effective (sensitivity 90-100%, specificity 94.8-100%) and allows for rapid diagnosis without delays from oral contrast administration. 2

Why Other Options Are Inappropriate

Open appendectomy (Option A) without imaging:

  • Leads to 14.7-25% negative appendectomy rate 1, 2
  • Misses alternative diagnoses requiring different management 2
  • Exposes patients to unnecessary surgical risks 1

Antibiotics alone (Option C):

  • Cannot be initiated without confirmed diagnosis 2
  • Risks delaying appropriate treatment for alternative pathology 2

IV fluid and 24-hour observation (Option D):

  • Inappropriate for patients with peritoneal signs (rebound tenderness) 2
  • Delays definitive diagnosis and treatment 1
  • Only appropriate for low-risk patients without rebound tenderness 2

Clinical Pitfall to Avoid

Do not rely on absence of fever to exclude appendicitis—fever is absent in approximately 50% of appendicitis cases. 2 The presence of rebound tenderness indicates peritoneal irritation and warrants immediate imaging, not observation. 2

Management Algorithm After CT

  • If CT confirms appendicitis: Proceed to surgical consultation and initiate IV antibiotics 2, 4
  • If CT shows alternative diagnosis: Manage accordingly (e.g., gynecologic surgery for ovarian torsion, antibiotics for diverticulitis) 4
  • If CT is negative/indeterminate: Clinical reassessment with serial examinations and mandatory 24-hour follow-up 2

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Management of Suspected Appendicitis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Guideline

Diagnostic Approach for Right Iliac Fossa Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Diagnostic Approach to Right Lower Quadrant Pain in Young Women

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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