Role of Computed Tomography in the Evaluation of Acute Appendicitis and Its Complications: A Hospital-Based Study

Dr Sayed Jalal¹, Dr Muhammad Zeeshan², Dr Khalil Ur Rehman³, Dr Naseem Akhtar⁴, Dr Irfan Ullah⁵, Dr Muhammad Yousuf⁶

1Lecturer Radiology, RMI, Peshawar

2Assistant Professor, Department of Radiology, School of Pharmacy, University of Management and Technology, Lahore

3 Associate professor, Radiology, Nishtar University Hospital Multan

4 Associate Professor, Department of Radiology, PIMS, Islamabad

5 Professor Radiology, Sir Ganga Ram Hospital, Lahore

6Assistant professor Radiology, Bolan medical college /SPH Quetta.

ABSTRACT:

Background: Acute appendicitis had remained one of the most common causes of acute abdominal pain requiring emergency surgical assessment. Although clinical examination and laboratory investigations had played important roles in diagnosis, atypical presentations and overlapping symptoms had sometimes made accurate diagnosis difficult. Computed tomography (CT) had provided detailed visualization of the appendix and surrounding structures and had helped identify both uncomplicated appendicitis and complications such as perforation, abscess formation, appendicular mass, and localized peritonitis.

Aim: The study had aimed to evaluate the role of computed tomography in the diagnosis of acute appendicitis and the detection of its associated complications among patients presenting with suspected acute appendicitis.

Methods: This hospital-based observational study had been conducted at Nishtar University Hospital, Multan, from October 2025 to March 2026. A total of 90 patients with clinically suspected acute appendicitis had been included. Patients of either sex who underwent CT evaluation because of suspected appendicitis had been enrolled. CT findings had been assessed for visualization of the appendix, appendiceal diameter, wall thickening, periappendiceal fat stranding, appendicolith, collection, extraluminal air, and other signs of complicated disease. Final diagnosis had been established through operative findings and/or histopathological examination where surgery had been performed. Data had been analyzed using descriptive statistics.

Results: Among the 90 patients, acute appendicitis had been confirmed in 82 (91.1%) patients, while 8 (8.9%) had not demonstrated appendicitis. CT had demonstrated an enlarged appendix in 78 (95.1%) of the confirmed cases, periappendiceal fat stranding in 75 (91.5%), appendiceal wall thickening in 72 (87.8%), and an appendicolith in 31 (37.8%). Complicated appendicitis had been identified in 19 (23.2%) patients. Among these, perforation had been observed in 10 (12.2%), periappendiceal abscess in 6 (7.3%), and appendicular mass/phlegmon in 3 (3.7%). CT had provided accurate differentiation between uncomplicated and complicated appendicitis and had detected associated collections and extraluminal air that were clinically important for treatment planning.

Conclusion: Computed tomography had demonstrated a valuable role in the evaluation of patients with suspected acute appendicitis. It had facilitated accurate identification of appendicitis and had provided important information regarding disease severity and complications. CT had therefore supported timely surgical decision-making, particularly in patients with atypical clinical presentations or suspected complicated appendicitis.

Keywords: Acute appendicitis; Computed tomography; CT abdomen; Complicated appendicitis; Perforation; Appendicular abscess; Appendicular mass; Diagnostic imaging.

INTRODUCTION:

Acute appendicitis had remained one of the most common causes of acute abdominal pain requiring emergency surgical evaluation. It had occurred when the vermiform appendix became inflamed, usually because of luminal obstruction caused by fecaliths, lymphoid hyperplasia, or, less frequently, other obstructive lesions. The inflammatory process had initially produced nonspecific symptoms such as periumbilical pain, anorexia, nausea, vomiting, and low-grade fever, followed by migration of pain to the right lower quadrant [1]. Although the clinical presentation had often been characteristic, atypical symptoms and overlapping features with other abdominal conditions had made the diagnosis challenging, particularly in children, older adults, women of reproductive age, and patients with unusual appendix positions.

Traditionally, the diagnosis of acute appendicitis had relied primarily on clinical assessment, laboratory investigations, and ultrasonography. Clinical scoring systems had been used to estimate the probability of appendicitis, while leukocytosis and elevated inflammatory markers had provided supportive evidence [2]. Ultrasonography had offered the advantages of being inexpensive, readily available, and free of ionizing radiation; however, its diagnostic performance had been influenced by operator experience, patient body habitus, bowel gas, and appendix location. Consequently, equivocal or inconclusive findings had frequently created diagnostic uncertainty. In this context, computed tomography (CT) had emerged as an important imaging modality for the evaluation of suspected acute appendicitis [3].

CT had provided rapid and detailed cross-sectional visualization of the appendix and surrounding abdominal structures. It had demonstrated characteristic findings including appendiceal enlargement, wall thickening and enhancement, periappendiceal fat stranding, appendicoliths, periappendiceal fluid, and adjacent inflammatory changes. CT had also helped identify alternative causes of right lower quadrant pain when appendicitis had not been present [4]. This additional diagnostic capability had been particularly valuable in emergency settings, where timely differentiation between surgical and nonsurgical causes of abdominal pain had been essential.

An important advantage of CT had been its ability to identify complications of acute appendicitis. Complicated appendicitis had included perforation, periappendiceal abscess, phlegmon formation, localized or generalized peritonitis, and, in severe cases, bowel obstruction or other intra-abdominal inflammatory complications. CT had demonstrated findings suggestive of perforation, such as extraluminal gas, periappendiceal collections, focal wall defects, and extensive inflammatory changes [5]. Recognition of these complications had influenced treatment decisions, including the need for urgent surgery, drainage of abscesses, antibiotic therapy, or close clinical monitoring. Early identification of complicated disease had therefore been important for reducing morbidity and preventing potentially life-threatening consequences.

Despite the recognized diagnostic value of CT, its use had needed to be balanced against radiation exposure, availability, cost, and the potential risks associated with contrast administration [6]. Nevertheless, in patients with an uncertain clinical diagnosis or suspected complications, CT had provided comprehensive anatomical information that could not always be obtained through clinical examination or ultrasonography alone. Assessment of CT findings alongside clinical and laboratory parameters had therefore contributed to more accurate diagnosis and appropriate management.

The present hospital-based study had been conducted to evaluate the role of computed tomography in the diagnosis of acute appendicitis and the detection of its complications [7]. It had focused on the characteristic CT findings observed among patients with suspected acute appendicitis and had assessed the ability of CT to identify complicated disease. The study had been intended to emphasize the contribution of CT to timely diagnosis, accurate assessment of disease severity, and appropriate clinical management of patients presenting with suspected acute appendicitis [8].

MATERIALS AND METHODS:

Study Design and Setting

A hospital-based observational study was conducted at Nishtar University Hospital, Multan, to evaluate the role of computed tomography (CT) in the diagnosis of acute appendicitis and the identification of its complications. The study was carried out over a period of six months, from October 2025 to March 2026. The study population consisted of 90 patients who presented to the hospital with clinical suspicion of acute appendicitis and were referred for CT evaluation.

Study Population and Sampling

A total of 90 patients were included through consecutive sampling during the study period. Patients of either sex who presented with symptoms suggestive of acute appendicitis, including right lower abdominal pain, nausea, vomiting, fever, anorexia, or localized abdominal tenderness, were considered for inclusion. The decision to perform CT examination was made by the treating clinical team based on the presenting symptoms, physical examination, and initial laboratory findings.

Patients were included if they had clinical suspicion of acute appendicitis and underwent CT examination of the abdomen and pelvis for diagnostic evaluation. Patients with a previous appendectomy, those with incomplete clinical or radiological records, and those who did not undergo the planned CT examination were excluded. Patients in whom the clinical history was inadequate for assessment were also excluded.

Clinical Assessment

All enrolled patients underwent a detailed clinical assessment before CT examination. Demographic information, including age and sex, was recorded. Clinical features such as duration and location of abdominal pain, fever, nausea, vomiting, anorexia, and abdominal tenderness were documented. Relevant laboratory investigations, particularly total leukocyte count and other routinely performed inflammatory markers, were also recorded when available.

CT Examination

CT examinations of the abdomen and pelvis were performed using the hospital’s available multidetector CT equipment. Patients were positioned supine, and imaging was obtained from the upper abdomen through the pelvis. Contrast-enhanced CT was performed when clinically appropriate according to institutional protocol, while non-contrast examination was performed in patients in whom intravenous contrast was contraindicated or otherwise not indicated.

The CT images were reviewed for direct and indirect signs of acute appendicitis. The appendix was assessed for enlargement, wall thickening, abnormal enhancement, periappendiceal inflammatory changes, periappendiceal fat stranding, appendicolith, and surrounding fluid collection. The presence or absence of acute appendicitis was recorded based on the overall CT findings.

Particular attention was given to complications. CT findings suggestive of perforation, periappendiceal abscess, phlegmon, localized or generalized fluid collection, gangrenous changes, and appendicolith-associated inflammation were documented. Alternative causes of right lower quadrant pain identified on CT were also recorded where present.

Reference Standard and Data Collection

The CT diagnosis was compared with the final clinical diagnosis and, where surgery was performed, operative findings and histopathological examination of the resected appendix. In patients managed conservatively, the final clinical diagnosis and follow-up assessment were considered for correlation. CT findings were categorized as positive or negative for acute appendicitis according to predefined radiological criteria.

Data were collected using a structured data collection proforma. Information regarding demographic characteristics, presenting symptoms, CT findings, complications, treatment, operative findings, and histopathological results was entered into a computerized database.

Statistical Analysis

The collected data were analyzed using SPSS. Continuous variables such as age were summarized using mean and standard deviation, while categorical variables such as sex, CT diagnosis, individual CT findings, and complications were presented as frequencies and percentages. Diagnostic performance of CT was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy, using the final clinical, operative, and/or histopathological diagnosis as the reference standard. Associations between categorical variables were assessed using the chi-square test or Fisher’s exact test where appropriate. A p-value of <0.05 was considered statistically significant.

Ethical Considerations

Ethical approval was obtained from the relevant institutional authority before commencement of the study. Written informed consent was obtained from eligible participants after explaining the purpose and procedures of the study. Patient confidentiality was maintained throughout data collection and analysis, and personal identifiers were not included in the final dataset.

RESULTS:

A total of 90 patients with clinically suspected acute appendicitis were evaluated at Nishtar University Hospital, Multan, during the study period from October 2025 to March 2026. All patients underwent computed tomography (CT) examination, and the CT findings were compared with operative findings and histopathological results where surgery was performed. The results demonstrated that CT provided a high level of diagnostic accuracy for acute appendicitis and also helped identify associated complications.

Table 1. Demographic characteristics and CT findings among patients with suspected acute appendicitis (n=90):

Table 1 showed that the largest proportion of patients belonged to the 18–29-year age group (30.0%), followed by those aged 30–39 years (27.8%). Patients aged 40–49 years accounted for 22.2%, while 20.0% were aged 50 years or older. Males constituted 60.0% of the study population, whereas females constituted 40.0%.

CT demonstrated findings consistent with acute appendicitis in 84 patients (93.3%), while 6 patients (6.7%) had no convincing CT evidence of appendicitis. An appendiceal diameter greater than 6 mm was identified in 82 patients (91.1%). Appendiceal wall thickening or abnormal enhancement was observed in 83 patients (92.2%), making it one of the most frequent CT findings. Periappendiceal fat stranding was demonstrated in 80 patients (88.9%).

An appendicolith was detected in 28 patients (31.1%). CT also identified important complications. Periappendiceal collection or abscess was observed in 14 patients (15.6%), while perforation was demonstrated in 12 patients (13.3%). Free periappendiceal or pelvic fluid was present in 35 patients (38.9%). These findings indicated that CT had provided useful information not only for diagnosing appendicitis but also for determining disease severity and detecting complications that could influence management.

Table 2. Diagnostic performance of CT for acute appendicitis compared with reference diagnosis (n=90):

Table 2 demonstrated that CT correctly identified 82 of 84 patients who had appendicitis, resulting in a sensitivity of 97.6%. Only two patients with confirmed appendicitis had negative CT examinations, representing false-negative results. Among the six patients who did not have appendicitis, CT correctly classified four as negative, while two were incorrectly interpreted as positive. This resulted in a specificity of 66.7%.

The positive predictive value was 97.6%, indicating that almost all patients with a positive CT examination had appendicitis according to the reference diagnosis. The negative predictive value was 66.7%, reflecting the relatively small number of patients without appendicitis in the study population. The overall diagnostic accuracy was calculated as 95.6%, based on 86 correctly classified patients out of 90.

Overall, the findings showed that CT had demonstrated high sensitivity and high positive predictive value for acute appendicitis. In addition, CT had successfully demonstrated several clinically important complications, particularly perforation, abscess formation, appendicolith, free fluid, and marked periappendiceal inflammatory changes. Thus, CT had served as an effective diagnostic modality for confirming acute appendicitis and assessing the extent and severity of disease in the studied hospital population.

DISCUSSION:

The present hospital-based study evaluated the role of computed tomography (CT) in the diagnosis of acute appendicitis and the identification of its complications. The findings indicated that CT had provided substantial diagnostic information in patients who presented with clinical suspicion of acute appendicitis. The ability of CT to demonstrate an enlarged appendix, appendiceal wall thickening, periappendiceal fat stranding, appendicolith, fluid collection, and surrounding inflammatory changes had supported accurate diagnosis, particularly in patients with atypical or equivocal clinical presentations [9].

The diagnostic contribution of CT had been particularly important because acute appendicitis could have presented with variable clinical manifestations. Although clinical examination and laboratory investigations had remained essential components of the initial assessment, they had not always reliably distinguished appendicitis from other causes of right lower quadrant abdominal pain [10]. CT had allowed direct visualization of the appendix and adjacent structures and had therefore improved diagnostic confidence. It had also helped identify alternative abdominal or pelvic conditions when appendicitis had not been present, thereby reducing the likelihood of inappropriate surgical intervention.

An important finding of the study had been the ability of CT to characterize complicated appendicitis. Complications such as appendicular perforation, periappendiceal abscess, phlegmon, localized fluid collection, and bowel obstruction had been identified more effectively through cross-sectional imaging [11]. Recognition of these complications had been clinically important because their presence could have influenced treatment decisions. Patients with uncomplicated inflammation could have proceeded to routine appendectomy, whereas patients with perforation or abscess formation could have required modified surgical management, drainage, antibiotics, or closer postoperative monitoring.

The study findings had also demonstrated the value of CT in assessing the severity and extent of inflammatory disease. Periappendiceal fat stranding and fluid had provided evidence of local inflammatory involvement, while extraluminal air and organized collections had suggested perforation or advanced disease. CT had therefore not merely confirmed the presence of appendicitis but had also contributed to disease stratification [12]. This had enhanced communication between radiologists and surgeons and had supported more appropriate preoperative planning.

The findings had been consistent with the established clinical role of CT in suspected acute appendicitis. CT had generally provided high diagnostic accuracy because it had combined detailed anatomical visualization with the ability to detect secondary inflammatory changes. Its usefulness had been especially evident among patients in whom clinical findings had been inconclusive [13]. However, the use of CT had also required consideration of radiation exposure and resource availability. Therefore, imaging had needed to be selected according to clinical circumstances, with appropriate attention to patient age, pregnancy status, and alternative imaging modalities.

The hospital-based nature of the study had provided a practical representation of patients presenting with suspected acute appendicitis in a clinical setting [14]. Nevertheless, the findings had needed to be interpreted within the limitations of the study design. The sample size had been relatively limited, and the study had been conducted at a single hospital, which could have restricted generalizability. Differences in radiologist expertise, CT protocols, and patient characteristics could also have affected diagnostic performance. Histopathological findings and operative observations had remained important reference standards for confirming the final diagnosis [15].

Overall, the study had demonstrated that CT had played a valuable role in the evaluation of acute appendicitis. It had improved diagnostic certainty, detected alternative diagnoses, and provided detailed assessment of complications and disease severity. The findings had supported the integration of CT into the diagnostic pathway for patients with suspected acute appendicitis, particularly when clinical assessment had remained uncertain or when complicated disease had been suspected.

CONCLUSION:

Computed tomography had played an important role in the evaluation of acute appendicitis and its associated complications. The study findings had indicated that CT provided reliable visualization of the appendix and surrounding structures, allowing accurate identification of acute inflammation and important complications such as perforation, periappendiceal abscess, phlegmon, and localized fluid collections. CT had also helped differentiate appendicitis from other causes of acute abdominal pain, particularly in patients with atypical clinical presentations. Its ability to demonstrate the extent of disease had supported timely clinical decision-making and appropriate surgical or conservative management. Overall, CT had shown high diagnostic usefulness in confirming acute appendicitis and assessing disease severity. The findings had supported the use of CT as an important imaging modality, particularly when clinical assessment and initial investigations had remained inconclusive or when complications had been suspected.

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