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Media Gallery

CT scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.
Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.
Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent with acute appendicitis.
Perforated appendicitis.
Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.

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Table 1. MANTRELS Score

Characteristic	Score
M = Migration of pain to the RLQ	1
A = Anorexia	1
N = Nausea and vomiting	1
T = Tenderness in RLQ	2
R = Rebound pain	1
E = Elevated temperature	1
L = Leukocytosis	2
S = Shift of WBCs to the left	1
Total	10
Source: Alvarado.^[18]
RLQ = right lower quadrant; WBCs = white blood cells

Table 2. WBC Count and Likelihood of Appendicitis

WBC (× 10,000)	Likelihood Ratio (95% CI)
4-7	0.10 (0-0.39)
7-9	0.52 (0-1.57)
9-11	0.29 (0-0.62)
11-13	2.8 (1.2-4.4)
13-15	1.7 (0-3.6)
15-17	2.8 (0-6.0)
17-19	3.5 (0-10)
19-22	∞
Source: Dueholm et al.^[23]
CI = confidence interval; WBC = white blood cell.

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