What is the preferred initial imaging modality for suspected appendicitis in adults when feasible?

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The main idea is that for adults with suspected appendicitis, the most accurate and informative imaging is a CT scan of the abdomen and pelvis with intravenous contrast. IV contrast makes the appendix and surrounding tissues much easier to see, so you can clearly identify signs of appendicitis such as wall thickening, luminal dilation, periappendiceal fat stranding, and any appendicolith. It also helps distinguish appendicitis from other causes of abdominal pain that can mimic it, like diverticulitis, colitis, or kidney issues, and it can quickly reveal complications such as perforation or an abscess.

Ultrasound can be useful in certain populations (for example, children, pregnant patients, or when avoiding radiation is a priority), but in adults it’s more operator-dependent and often less sensitive due to body habitus or overlying gas, which can limit visualization. Plain X-ray abdomen generally does not provide diagnostic information for appendicitis. If contrast cannot be used due to allergy or kidney concerns, a non-contrast CT or ultrasound can be considered, but when feasible, a contrast-enhanced CT offers the highest diagnostic accuracy and most reliable overall assessment.