Diagnosing acute appendicitis: surgery or imaging?

Investigation of suspected appendicitis varies widely across different countries, which creates variation in outcome for patients. Use of imaging drives much of this variation, with concerns over delay of imaging and radiation exposure of computed tomography being balanced against the risks of unnecessary surgery. Two national, prospective snapshot audits (UK n = 3326 and Netherlands n = 1934) reported investigation, management and outcome of appendicectomy and can be compared to generate treatment recommendations. Preoperative imaging was conducted in 32.8% of UK patients in contrast to 99.5% of patients in the Netherlands. A large difference in the normal appendicectomy rate was observed (20.6% in the UK vs 3.2% in the Netherlands) and the connection between these two outcome differences cannot be neglected. This article discusses the role of imaging in the diagnostic work-up of patients who are suspected of acute appendicitis, comparing national snapshot studies as a model to do so