NEGATIVE APPENDECTOMY: DIAGNOSTIC SCORES AND RATIONAL USE OF IMAGING

Abstract

Negative appendectomy remains a relevant indicator of diagnostic error because it exposes patients without appendiceal inflammation to an unnecessary operation and its associated morbidity. This narrative review examined how clinical risk scores and selective imaging can reduce diagnostic uncertainty in suspected acute appendicitis without converting computed tomography into a universal screening test. Searches were conducted in 2026 in PubMed/MEDLINE, the Cochrane Library, and official guideline repositories, prioritizing contemporary guidelines, systematic reviews, randomized trials, prospective diagnostic studies, and seminal score-development papers. The evidence supports a probability-based pathway. The Alvarado score is useful mainly for identifying low-risk presentations, whereas the Appendicitis Inflammatory Response score and Adult Appendicitis Score provide better discrimination in adults; pediatric assessment requires age-appropriate tools and clinical context. Imaging yields the greatest value in intermediate or discordant presentations. Ultrasound is particularly useful in children, adolescents, pregnancy, and settings where radiation avoidance is prioritized, while computed tomography remains the most accurate cross-sectional test in adults and can be performed with low-dose protocols. The main implication is that scores and imaging are complementary rather than competing strategies. Rational sequencing according to pretest probability can reduce false-positive diagnoses, unnecessary operations, radiation exposure, and delays while preserving safety in patients with evolving or atypical disease.