This Patient Does Not Have Acute Appendicitis
Based on the CT findings of a borderline-enlarged appendix (8–9 mm) without periappendiceal fat stranding, fluid, or appendicolith, acute appendicitis is effectively ruled out and the patient should be discharged with safety-net instructions for clinical reassessment within 24–48 hours. 1
Why This Is Not Appendicitis
The Appendiceal Diameter Is Borderline, Not Diagnostic
- The optimal CT cutoff for acute appendicitis is an outer appendiceal diameter >8.2 mm, which yields 88.8% sensitivity and 93.4% specificity. 1 An 8–9 mm measurement sits at the threshold and does not alone confirm the diagnosis. 1
- An enlarged appendix (>7 mm) combined with mesenteric fat stranding has an odds ratio of 3.98 for acute appendicitis, but when only one of these signs is present—as in this case—the likelihood drops dramatically. 2
Critical Inflammatory Signs Are Absent
- Periappendiceal fat stranding is present in 87–100% of true appendicitis cases with 74–80% specificity. 1, 3 Its absence makes acute appendicitis highly unlikely. 1
- Fat stranding combined with an enlarged appendix occurs in 93% of appendicitis cases on CT. 3 When both are absent or only one is present, alternative diagnoses should be considered. 2
- The absence of appendiceal wall enhancement defects, appendicolith, and periappendiceal fluid further lowers the probability of acute inflammation. 1
The Small Mesenteric Lymph Nodes Point to an Alternative Diagnosis
- The 4 mm reactive mesenteric lymph nodes in the right lower quadrant suggest mesenteric adenitis or a self-limited viral process rather than appendicitis. 1
- These findings support a non-operative approach. 1
Recommended Management Algorithm
Step 1: Discharge with Safety-Net Instructions
- The American College of Radiology recommends discharge rather than immediate surgical consultation for patients with a mildly enlarged appendix (8–9 mm) and no inflammatory CT features. 1
- Provide explicit return precautions: worsening pain, fever >38°C, vomiting, inability to tolerate oral intake, or development of peritoneal signs (guarding, rebound tenderness, rigidity). 1
Step 2: Clinical Reassessment Within 24–48 Hours
- Schedule in-person or telephone follow-up to monitor symptom evolution. 1
- If symptoms resolve or improve, no further imaging is needed. 1
Step 3: Reserve Repeat Imaging for Worsening or Persistent Symptoms
- Repeat CT with intravenous contrast only (no oral contrast) should be performed if symptoms worsen or persist beyond 48 hours. 1
- This protocol achieves 96% sensitivity and 93% specificity for detecting appendicitis. 1
Step 4: Do Not Prescribe Empiric Antibiotics
- Antibiotics are not indicated in the absence of confirmed uncomplicated appendicitis. 1
- Antibiotic therapy is reserved for proven cases, where it shows approximately 70% success. 1, 4
Critical Pitfalls to Avoid
Do Not Operate Based on Borderline Diameter Alone
- The historically cited 6 mm cutoff has poor specificity (≈59.6%) and leads to unnecessary surgeries. 1
- The 8.2 mm threshold offers superior diagnostic accuracy and should guide decision-making. 1
Do Not Dismiss the Absence of Fat Stranding
- When periappendiceal fat stranding is absent—as in this case—acute appendicitis is unlikely even with borderline appendiceal enlargement. 1, 3
- In one study, only 2% of patients with a nonvisualized appendix and no secondary inflammatory changes had acute appendicitis. 5
Recognize When to Escalate to Surgery
Immediate surgical consultation is warranted if any of the following develop on repeat imaging or clinical exam: 1
- New periappendiceal fat stranding, indicating acute inflammation. 1
- Appearance of an appendicolith, which predicts perforation (odds ratio 2.47–2.67) and higher antibiotic failure rates. 1, 4
- Imaging evidence of perforation: extraluminal air, abscess, phlegmon, or wall defect. 1
- Clinical deterioration with peritoneal signs (guarding, rebound tenderness, rigidity). 1
Addressing the Patient's Concern
- Reassure the patient that the CT scan is highly accurate for ruling out appendicitis when inflammatory signs are absent. 1, 5
- Explain that the small mesenteric lymph nodes suggest a benign, self-limited process such as viral mesenteric adenitis. 1
- Emphasize the importance of returning if symptoms worsen, as early appendicitis can evolve, but current imaging does not support that diagnosis. 1