ISSN: 2320-5407 Int. J. Adv. Res.

12(05), 311-324

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/18718
DOI URL: http://dx.doi.org/10.21474/IJAR01/18718

RESEARCH ARTICLE
CLINICO-RADIOLOGICAL DIAGNOSIS OFAPPENDICITIS

Dr. Shifa A. Kalokhe, Dr. Saumya Mathews, Dr. Mohit Vardey, Dr. Akhil Guntupalli, Dr. Amolpreet Kaur
and Dr. Ali Reza
Senior Resident, MGM Medical College and Hospital, Navi Mumbai.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background : The symptom of right lower quadrant pain had puzzled
Received: 15 March 2024 clinicians for many centuries. Appendicitis needs to be considered in
Final Accepted: 18 April 2024 the differential diagnosis of nearly every patient presenting with acute
Published: May 2024 abdomen, misdiagnosis of appendicitis is significantly higher in
females. Early diagnosis remains the most important goal in patients,
despite use of ultrasonography, CT scanning and diagnostic
laparoscopy the rate of misdiagnosis of appendicitis and rate of
negative appendicectomy is significantly high. Surgical treatment is a
highly successful medical intervention In this study we have attempted
to find a co-relation between the efficiency of clinical diagnosis with
radiological diagnosis of appendicitis.
Aim and Objectives: To determine the sensitivity, specificity and
diagnostic accuracy of clinical scores, ultrasonography and CT of
abdomen in a case of acute appendicitis.
Materials and Method: 50 patients with acute onset lower abdominal
pain and diagnosed as appendicitis were evaluated by the emergency
surgical team.A detailed clinical evaluation was carried out as per
criteria of the three clinical scores (Alvarado, Fenyo, Ohman).The
inference from each of the scores was noted.The patients underwent
ultrasonography(USG) and contrast CT of the abdomen and pelvis.The
findings of both these investigations and intra operative findings were
noted. The specimen was sent for histopathological examination which
was considered as gold standard for the diagnosis of acute appendicitis.
Result: In this study we found that Alvarado score had the highest
sensitivity among females 92.31% and also the highest NPV
66.67%.Ohmann score had the overall highest sensitivity 100% and
NPV Hence, it can be used as a simple, quick and effective screening
score for detection of appendicitis in a large number of patients. The
score is simple to use and can also be calculated by paramedical staff.
USG of the abdomen is a useful screening tool however CT had a high
specificity 88.89% and PPV 97.30% and diagnostic accuracy of 88%.
Conclusion: Despite the advent of various investigation modalities, a
surgeon's clinical acumen should never be compromised. The clinical
scores and investigations should always be used as an adjunct history
taking and clinical examination. Appendicitis should always be
considered as a differential diagnosis in every case of acute pain
abdomen.

Corresponding Author:- Dr. Ali Reza 311

Address:- Professor, MGM Medical College and Hospital, Navi Mumbai.
ISSN: 2320-5407 Int. J. Adv. Res. 12(05), 311-324

Copy Right, IJAR, 2024,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
The symptom of right lower quadrant pain had puzzled clinicians for many centuries. The appendix was not
identified as an organ capable of causing disease until the 19 century. In textbook titled Elements of Practical
Medicine published in 1839, the symptoms of appendicitis was described differentiating it from typhilitis or
perityphlitis (inflammation of the caecum) as a primary cause for inflammation in the right lower quadrant. Reginald
Fitz in his landmark paper in 1886 first coined the term "appenciditis". 1 The greatest contributor to the advancement
in treatment of appendicitis is Charles Chester McBurney, he described the indication of early laprotomy as
2
treatment for acute appendicitis.'

Appendicitis needs to be considered in the differential diagnosis of nearly every patient presenting with acute
abdomen.3 Appendicitis is most frequently seen in patients in their second through fourth decade of life, which
comprises the working age group. Appendicectomy is the most commonly performed abdominal surgery in
emergency setting. The rate of appendectomy for appendicitis has remained constant 10 per 10,000 patients per
year.4 However, the rate of misdiagnosis of appendicitis has also remained constant along with the rate to
appendiceal rupture. The rate of negative appendectomy is also considerably high with a peak of 23.2% in females.
The percentage of misdiagnosis of appendicitis is significantly higher in females.

Early diagnosis remains the most important goal in patients with suspected appendicitis and can be made on the
basis of history and physical examination in most cases.However, there is a need for other diagnostic modalities to
supplement clinical diagnosis in equivocal cases of acute abdomen presenting with right lower quadrant pain.

Despite the use of ultrasonograpy, computed tomography (CT) scanning and diagnostic laproscopy the rate of
misdiagnosis of appendicitis and rate of negative appendicectomy is significantly high. Surgical treatment of acute
appendicitis is a highly successful medical intervention.

However, the inherent risk of surgical complications cannot be discounted. 5 Furthermore, surgical procedures and
aftercare services occur at a considerable cost. The treating clinician therefore is faced with the need to balance the
considerable morbidity and even mortality associated with missed diagnosis with exposing the patient to
unnecessary surgery and associated morbidity and mortality as a result of positive diagnosis.

Hence, there is a need for a revision in the protocol of diagnosis of appendicitis. In my study I have attempted to
find a co-relation between the efficiency of clinical diagnosis with radiological diagnosis of appendicitis. Thereby,
to substantiate or negate the need for a change in the protocol of diagnosis of appendicectomy in an Indian setup

Aims and Objectives:-

1. To determine the sensitivity, specificity and diagnostic accuracy of clinical scores in a case of acute appendicitis.
2. To determine the sensitivity, specificity diagnostic accuracy of ultrasonography of the abdomen in a case of acute
appendicitis.
3. To determine the sensitivity, specificity diagnostic accuracy of computed tomography of the abdomen in a case of
acuteappendicitis.

Material &Methods:-
Prospective study of 50 patients presenting in the emergency department of a tertiary hospital in Navi Mumbai from
May 2009 -December 2011.

Inclusion Criteria
• Patients presenting with pain in right lower quadrant of abdomen

Exclusion Criteria
Patients below the age of 14yrs.
• Pregnant women.

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Study protocol
1. All patients with acute onset lower abdominal pain were evaluated by the emergency surgical team.
2. Routine hematological and biochemical blood investigations and necessary radiological. Investigations done, if a
decision to perform an emergency appendicectomy was taken, the investigator was informed.
3. A detailed independent clinical evaluation was carried out by the investigator as per criteria of each of the three
clinical scores (Alvarado, Fenyo).
4. The inference from each of the scores was noted.
5. The patients underwent ultrasonography(USG) of the abdomen and pelvis, in case it was not done previously.
6. The patients underwent focused appendiceal CT without administration of oral, intravenous or rectal contrast
material.
7. The findings of both these investigations were noted.
8. The intra operative findings were noted.
9. The specimen was sent for histopathological examination which was considered as gold standard for the diagnosis
of acute appendicitis.
10. Appropriate statistical tools were used for data analysis using SPSS software.

The following definitions were used for recording the symptoms:

• Migration of pain to the right lower quadrant:
Pain starting either in the epigastric region, centrally or in the whole abdomen, eventually migrating down to the
right iliac fossa.

• Pain aggravated by coughing:

The patient was instructed to cough, and any worsening of the pain was registered.

• Rebound tenderness:
Elicited in the right lower quadrant when a hand pressing the abdomen for 10-15 sec was suddenly withdrawn.

•Rigidity:
Involuntary contraction of the abdominal muscles.
Ultrasonographic criteria for diagnosing acute appendicitis

All sonographic examinations were performed with a handheld 5-MHz linear array with transverse and longitudinal
graded compression sonography. The establishment of the diagnosis of acute appendicitis was based on the finding
of a positive sonographic McBurney sign, a blind-ending tubular structure greater than 6 mm in outer diameter, the
noncompressibility of the appendix, the increased flow signals in the appendiceal wall or periappendiceal space
using color Doppler sonography, and the echogenic periappendiceal inflammatory fat change.

Computed Tomography (CT) of the abdomen was done in all patients using focussed appendiceal visualization
technique without the administration of any contrast material. This includes taking limited 3mm cuts of the lower
abdomen. The CT abdomen findings were noted

Acute appendicitis was diagnosed only on histopathological grounds according to the following criteria:
• Macroscopic signs: intravascular injection of the serosa; fibrinous, purulent film; edematous, hemorrhagic, necrotic
changes of the wall; and blood (not sufficient) or pus on opening of the appendix;
• Microscopic signs: focal or expanded erosion, ulceration, abscess, fistula, necrosis, or perforation
The outcome criteria were the diagnostic accuracy of the final examiner with respect to appendicitis sensitivity,
specificity, positive and negative predictive value, and accuracy, the perforated appendix rate, the rate of
appendectomy with normal findings, the complication rate.
For the outcome criteria, the following definitions were used:
• Perforated appendix rate: Proportion of patients with acute appendicitis who had a histologically proved
perforation
• Negative appendectomy rate: Proportion of patients with appendectomy in whom no appendicitis was found.

Results:-
The data collected from 50 patients was analyzed. Most of the patients were 20-40 yrs of age. There were 33 male
and 17 female patients. There is no significant difference in the incidence in males and females. Of the 50 patients

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operated for appendicitis, 41 patients had a positive histopathology report of acute appendicitis and 9 patients had a
normal appendix report. Hence our negative appendicectomy rate was 18%.
Of the 33 male patients explored, 28 had a histopathology report of acute appendicitis and 5 had a report of normal
appendix.

Thus, the negative appendicectomy rate in males in our institute was 15.15%.

Of the 17 female patients explored, 13 had a histopathology report of acute appendicitis and 4 had a report of normal
appendix.

Hence the negative appendicectomy rate in females was 23.53%. All the females belonged to child bearing age
group.

Association between Alvarado score, histopathology and sex in the diagnosis of acute appendicitis in the study
group

Table 1:- Association between Alvarado score, sex and histopathology.

Sex Alvarado Score Histopathology Total
Yes No
Male Yes Count 20 3 23
Percent 87% 13% 100%
No Count 8 2 10
Percent 80% 20% 100%
Total Count 28 5 33
Percent 84.8% 15.2% 100%
Female Yes Count 12 2 14
Percent 85.7% 14.3% 100%
No Count 1 2 3
Percent 33.33% 66.67% 100%
Total Count 13 4 17
Percent 76.5% 23.5% 100%

Sex Chi Square Test Value Df P Value Association

Male Pearson Chi- Square 0.262 1 0.609 Not Significant
Fischer’s Exact Test 0.627 Not Significant
Female Pearson Chi- Square 3.767 1 0.052 Not Significant
Fischer’s Exact Test 0.121 Not Significant
b. 2 cells (50.0%) have expected count less than 5.
c. 3 cells (75.0%) have expected count less than 5.

Measure Estimate 95% Confidence Interval

Lower Upper
Sensitivity 87.80 74.46 94.68
Specificity 88.89 56.5 98.01
PPV 97.30 86.18 99.52
NPV 61.54 35.52 82.29
Diagnostic Accuracy 88 76.19 94.38
Association between Fenvo score, histopathology and sex in the diagnosis of acute appendicitis in the study group

Table 2:- Association between Fenyo score, sex and histopathology.

Sex Alvarado Score Histopathology Total
Yes No
Male Yes Count 20 3 23
Percent % 87% 13% 100%

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No Count 8 2 10
Percent % 80% 20% 100%
Total Count 28 5 33
Percent % 84.8% 15.2% 100%
Female Yes Count 3 1 4
Percent % 75% 25% 100%
No Count 10 3 13
Percent % 76.9% 23.1% 100%
Total Count 13 4 17
Percent % 76.5% 23.5% 100%

Sex Chi Square Test Value Df P Value Association

Male Pearson Chi- Square 0.262 1 0.609 Not Significant
Fischer’s Exact Test 0.627 Not Significant
Female Pearson Chi- Square 0.006 1 0.937 Not Significant
Fischer’s Exact Test 1.000 Not Significant
b. 2 cells (50.0%) have expected count less than 5.
c. 3 cells (75.0%) have expected count less than 5.

Measure Male Female

Sensitivity 71.43 92.31
Specificity 40 50
PPV 86.96 85.71
NPV 20 66.67
Diagnostic Accuracy 66.67 82.35
Association between Ohmann score, histopathology and sex in the diagnosis of acute appendicitis in the study group

Table 3:- Association between Ohmann score, sex and histopathology.

Sex Alvarado Score Histopathology Total
Yes No
Male Yes Count 28 3 31
Percent % 90.3 9.7 100
No Count 0 2 2
Percent % 0 100 100
Total Count 28 5 33
Percent % 84.8 15.2 100
Female Yes Count 13 4 17
Percent % 76.5 23.5 100
Total Count 13 4 17
Percent % 76.5 23.5 100

Chi Square Test Value Df P Value Association

Pearson Chi- Square 11.932 1 0.001 Significant
Fischer’s Exact Test 0.019 Significant
b. 3 cells (75.0%) have expected count lesstI
c. No statistics are computed because Ohmann score is a constant.

Association between Ultrasonography of abdomen, histopathology and sex in the diagnosis of acute appendicitis in
the study

Table 4:- Association between USG, sex and histopathology.

Sex Alvarado Score Histopathology Total
Yes No
Male Yes Count 5 3 8

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Percent % 62.5 37.5 100

No Count 23 2 25
Percent % 92 8 100
Total Count 28 5 33
Percent % 84.8 15.2 100
Female Yes Count 5 4 9
Percent % 55.6 44.4 100
No Count 8 0 8
Percent % 100 0 100
Total Count 13 4 17
Percent % 100 23.5 100

Sex Chi Square Test Value Df P Value Association

Male Pearson Chi- Square 4.103 1 0.043 Significant
Fischer’s Exact Test 0.078 Not Significant
Female Pearson Chi- Square 04.650 1 0.031 Significant
Fischer’s Exact Test 0.082 Not Significant
b. 2 cells (50.0%) have expected count less than 5.
c. 2 cells (50.0%) have expected count less than 5.

Measure Male Female

Sensitivity 17.86 38.46
Specificity 40 0
PPV 62.5 55.56
NPV 8 0
Diagnostic Accuracy 21.21 29.41
Association between CT scan abdomen, sex and histopathology in the diagnosis of acute appendicitis in the study
group

Table 5:- Association between CT, sex and histopathology.

Sex Alvarado Score Histopathology Total
Yes No
Male Yes Count 25 1 26
Percent % 96.2 3.8 100
No Count 3 4 7
Percent % 42.9 57.1 100
Total Count 28 5 33
Percent % 84.8 15.2 100
Female Yes Count 11 0 11
Percent % 100 0 100
No Count 2 4 6
Percent % 33.3 66.7 100
Total Count 13 4 17
Percent % 100 23.5 100

Sex Chi Square Test Value Df P Value Association

Male Pearson Chi- Square 12.186 1 0.000 Significant
Fischer’s Exact Test 0.004 Significant
Female Pearson Chi- Square 9.590 1 0.002 Significant
Fischer’s Exact Test 0.006 Significant
b. 2 cells (50.0%) have expected count less than 5.
c. 3 cells (75.0%) have expected count less than 5.

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Measure Male Female

Sensitivity 89.29 84.62
Specificity 80 100
PPV 96.15 100
NPV 57.14 66.67
Diagnostic Accuracy 87.88 88.24

Annexure
Chart 1:- Incidence of appendicitis in male and female patients.
100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
Male Female

No Appendicitis

Chart 2:- Association of Alvarado Score, Sex and histopathological findings in study group.

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Chart 3:- Association of Fenyo Score, Sex and histopathological findings in study group.

Chart 4:- Association of Ohmann Score, Sex and histopathological findings in study group.

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Chart 5:- Association of USG, Sex and histopathological findings in study group.

Chart 6:- Association of CT, Sex and histopathological findings in study group.

Discussion:-
Despite improvement in imaging techniques and laboratory investigations, routine diagnosis of acute appendicitis
still poses a challenging problem. The major area of concern worldwide are the rate of negative appendicectomies
(20-30%), perforated appendix (15-20%), delayed operations and longer hospital stay due to delay in diagnosis.
Over the years, several diagnostic scoring systems have been evolved so as to aid the clinician in making a quick
decision.Various imaging modalities have been employed for the visualization of the inflamed appendix.

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We, in our study have aimed at studying the pattern of this extremely common disease. We have evaluated the
usefulness of these scores and imaging modalities in an Indian setup in the diagnosis of acute appendicitis.

We found that maximum number of patients belonged to 20-30 age group. The incidence of appendicitis increases
as the age increases.There is no significant difference in the incidence among males and females.Of our 50 patients
9 were found to have a normal appendix. Thus, we had a negative appendicectomy rate of 18%.

Our rate of complication was 14.63%. Of the 6 patients that had a complication only 2 were < 40 yrs whereas 4 were
> 40 yrs. Thus, the incidence of complications due to appendicitis in patients > 40 yrs Was 57.14% as compared to
5.88% among patients > 40 yes of age.This indicates the need for early diagnosis and surgical intervention if
appendicitis is suspected in elderly patients. Atypical presentation has been common in this age group. CT scan has
been shown to be sensitive in diagnosis such atypical cases.

The simplicity of a score for acute appendicitis is quite appealing. The idea of improving the diagnostic accuracy
simply by assigning numeric values to defined signs and symptoms has been a goal in some of scores described.
Parameters comprising the score usually include general signs of abdominal illness (e.g. type, location and migration
of pain, body temperature, signs of peritoneal irritation, nausea, vomiting etc) as well as routine laboratory findings
(leukocytosis).

Such simple scoring systems may work as expected in the original setting, but they do not take into consideration
different diagnostic weights of each parameter in different subpopulation (eg. children, women etc). Thus, scores
usually did not repeat their good results when applied to different populations, which led to the creation of new
scoring systems and their re-evaluation in different settings.

Clinical scoring systems have proved useful in the management of number of surgical conditions. In the past few
years various clinical scoring systems have been developed to aid the diagnosis of acute appendicitis including
Ohman6,7, Lindberg8 Eskelinen 9,10,Teicher11 and Alvarado12 A significant reduction of negative appendicectomy
rate to 7.8% was noted in studies when patients were subjected to scoring systems." 13

Alvarado score
In our study the accuracy of the score was as follows:
Measure Male (%) Female (%) Total (%)

Sensitivity 71.43 92.31 78.05

Specificity 40 50 44.44
PPV 86.96 85.71 86.49
NPV 20 66.67 30.77
Diagnostic Accuracy 66.67 82.35 72
In our study the sensitivity of Alvarado score among female patients was 92.31% which is higher than that obtained
in a study conducted by M. Horzic et al (83.3%) in 126 female patients. "The positive predictive value of Alvarado
score is 86.96 % for males, 85.71% for females and 86.49% for both. This is comparable to the study conducted by
Khan I et al wherein the positive predictive value for Alvarado score was 84.3 %(males 88% and females 82.1%)14

Alvarado score had a diagnostic accuracy of 82.35% for females which is comparable to a study done by Faran
Kiani et al.15

Fenyo score
In our study the accuracy of the score was as follows:
Measure Male (%) Female (%) Total (%)

Sensitivity 71.43 23.08 56.10

Specificity 40 75 55.56
PPV 86.96 75 85.19
NPV 20 23.08 21.74

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Diagnostic Accuracy 66.67 35.29 56

The sensitivity of Fenyo score was 56,10% and spelley we 3556% which is much lower compared to the original
sody conduces by Fenyo et al. 16 The positive predictive value among females was 75%, which is comparable to a
study conducted by Enochsson et all which had a PPV OF 79%. The overall PPV value in their study was; which is
comperable to our PPV OF 86.96% 17

Ohmann score
In our study the accuracy of the score was as follows:
Measure Male (%) Female (%) Total (%)

Sensitivity 100 50 100

Specificity 40 50 22.22
PPV 90.32 76.47 85.42
NPV 100 23.53 100
Diagnostic Accuracy 90.91 50 86
In our study Ohmann score had a sensitivity of 100% and a negative predictive value of 100% for male patients
which is comparable to the study conducted by Nagarajan G and Subramanyam P which had a sensitivity of 94.4%
and a NPV of 87.5% among male patients. 18

The specificity of Ohmann score among female patients was 50%, the PPV is 76.47% and diagnostic accuracy is
50% which is comparable to the study conducted by Horzic et al which had a specificity of 33.3%, a PPV of 86.5%
and a diagnostic accuracy of 66.4%.19

In our study the sensitivity is 100%, the NPV IS 100% and the and the diagnostic accuracy is 86% which is
comparable to the original study by Ohmann et al which had a sensitivity of 91.5%, NPV of 97.2% and diagnostic
accuracy of 87.6%.20

Ultrasonography
In our study the accuracy of the score was as follows:
Measure Male (%) Female (%) Total (%)

Sensitivity 17.86 38.46 24.39

Specificity 40 0 22.22
PPV 62.50 55.56 58.82
NPV 8 0 6.06
Diagnostic Accuracy 21.21 29.41 24

Since Puylaert emphasized that sonographic visualization of the appendix was the sole indicator for diagnosis of
acute appendicitis in his original description of graded compression sonography, many studies have used graded
compression sonography for a diagnosis of appendicitis with sensitivities and specificities of more than 90% if an
experienced examiner performed the examination. 21-25

Our study had results which are not comparable to standard results, This shows that although USG is a highly
recommended tool in the diagnosis of acute appendicitis, it is highly operator dependant and results will vary from
one centre to the other.

Computed Tomography
In our study the accuracy of the score was as follows:
Measure Male (%) Female (%) Total (%)

Sensitivity 89.29 84.62 87.80

Specificity 80 100 88.89

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PPV 96.15 100 97.30

NPV 57.14 66.67 61.54
Diagnostic Accuracy 87.88 88.24 88
The overall sensitivity of CT scan appendix was 87.80%, specificity was 88.89% and PPV was 97.30% which is
comparable to studies done by Lane et al26, Wise et al27, Cakirer et al 28using focused appendiceal CT without the
use of oral, intravenous or rectal contrast.

Helical CT has proven to be an effective and accurate means of diagnosing acute appendicitis, with reported
sensitivities of 90-100%, specificities of 91-99%, accuracies of 94-98%, positive predictive values of 92-98%, and
negative predictive values of 95-100% 29-32

CT scan of the abdomen in our study showed a specificity of 100% in female patients, hence CT scan is a very
useful modality that can be used in the reduction of negative appendectomy cases among females. Our study also
shows a PPV of 100% among females which helps in reducing the delay in diagnosis and subsequent treatment in
these patients.

Studies comparing the use of sonography with CT in patients suspected of having acute appendicitis have generally
favored CT for providing greater diagnostic accuracy, superior detection and staging of complications, and higher
accuracy for establishing altemative diagnoses. 28,33-34

Studies have also shown that CT may help to decrease hospital costs and negative laparotomy rates. 35,36
The use of CT scan and USG also helps in establishing alternative diagnosis. 37,38

Conclusion:-
In our study we found that Alvarado score had the highest sensitivity among females 92.31% and also the highest
NPV 66.67%.

It is therefore a useful score to reduce the number of misdiagnosis among female patients.

Ohmann score had the highest sensitivity of 100% among males and a NPV of 100%. It can therefore be used as a
simple score to rule out appendicitis in male patients presenting with abdominal pain.

Ohmann score had the overall highest sensivity 100% and NPV100%. Hence, it can be used as a simple, quick and
effective screening score for detection of appendicitis in a large number of patients. The score is simple to use and
can also be calculated by paramedical staff.

It is useful in reducing the delay in diagnosis and also increased hospital stay.

Fenyo score is comparatively cumbersome to use and had low sensitivity and specificity compared to other scores.

USG of the abdomen is a useful screening tool, however is highly operator dependant and should be used to
establish diagnosis and detect alternative diagnosis in equivocal cases.

CT scan had a high specificity 80% and a high positive predictive value 96.15% among males. It also had a
specificity of 100%, a PPV of 100% a NPV of 66.67% among female patients.

Overall it had a high specificity 88.89% and PPV 97.30% and diagnostic accuracy of 88%. CT scan helps in
reducing the number of negative appendicectomies thereby reducing the overall morbidity.

The high cost and limited availability of CT scan in all centres poses a problem especially in a developing country
like India.

The use of CT scan should hence be limited to equivocal cases, elderly patients and non - pregnant women. Thereby,
attempting to considerably reduce the rate of negative appendicectomies.

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The discrepancy in some of the results of this study compared to other studies may be because of the limited
patients, who are not a true representative of the population. There is a need to conduct large cross sectional studies
comparing parameters used in this study to obtain more reliable results.

Despite the advent of various investigation modalities, a surgeon's clinical acumen should never be compromised.
The clinical scores and investigations should always be used as an adjunct history taking and clinical examination.
Appendicitis should always be considered as a differential diagnosis in every case of acute pain abdomen.

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