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The optimal initial management of children with suspected appendicitis: A decision analysis
Abstract
As abdominal imaging has improved, the use of computed tomography (CT) and ultrasonography (US) for evaluating children with suspected appendicitis has increased. The purpose of this study was to determine the optimal management strategy for evaluating children with suspected appendicitis given the current accuracy of abdominal imaging.
Decision analysis was used to evaluate 5 management strategies: discharge, observation, CT, US, and appendectomy. Probabilities and time variables were obtained from publications and a chart review. Each approach was evaluated for its impact on length of stay, hospital charges, cost effectiveness and its capacity to minimize perforation and avoid negative appendectomy (risk-benefit).
Discharge was preferred when the probability of appendicitis was low (<0.09 to <0.47), imaging when in an intermediate range and surgery when high (>0.61 to >0.91). A role for observation was found only when the anticipated time of inpatient observation was brief (<9 hours). Although CT was more expensive than US, CT was more cost effective for preventing negative appendectomy and perforation and achieved a better risk-benefit.
CT has an important role in the management of suspected appendicitis. Among children with a low or high likelihood of appendicitis, the cost of imaging tests required to prevent the complications of appendicitis is high.
... The use of decision analysis to examine diagnostic approaches for children with suspected appendicitis has appeared in the literature over the past 35 years [17][18][19][20][21]. Both Neutra [19,22] and Alvarado [20] developed early decision rules on the basis of symptoms and limited diagnostic tests (e.g., leukocytosis). ...
... Hagendorf et al. [21] compared the effectiveness of observation, US, and CT and concluded that referral to CT was the optimum diagnostic strategy for all patients presenting with symptoms of appendicitis. Their analysis, however, 1) lacked the incorporation of the potential harms of ionizing radiation exposure from CT, 2) did not consider newly proposed S-US/CT imaging protocols, and 3) did not include the use of validated CDRs to augment and assist clinicians in their referral for imaging and ultimately their diagnosis of appendicitis. ...
... The prior probability of appendicitis used in this analysis was 0.388 [18]. This differs from estimates used in other studies [21,23], which use estimates in the 0.50 to 0.60 range and correspond to probabilities of disease upon referral to a surgeon for consultation. The goal of this study was to recommend a strategy for use by an emergency medicine physician upon presentation of a patient with appendicitis-like symptoms at a typical ED, thus the lower prior probability of disease. ...
Objective:
To evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children, the use of a validated clinical decision rule (CDR) and a staged imaging protocol, compared with usual care.
Methods:
We estimated the cost-effectiveness of the three competing strategies using parameters from existing literature as well as a Markov model developed to simulate the effects of exposure to ionizing radiation from a single computed tomography (CT) study in the course of diagnosis. The simulation model was applied to a hypothetical cohort of 100,000 boys and girls, age 10 years, presenting with acute abdominal pain to emergency departments in the United States.
Results:
The integrated strategy, the CDR followed by staged imaging, was found to be the most cost-effective approach. Cost savings accrued from the reduction in CT utilization for low-risk patients compared with the other two strategies. The addition of ultrasound (US) to the CDR strategy reduced CT utilization by an additional 10.9%, its main cost advantage, with negligible change in net health benefits from false-negative US results, and associated morbidity or mortality.
Conclusions:
Results suggest that the integration of staged imaging with the CDR for the diagnosis of appendicitis in children is a cost-effective and cost-saving approach. The model estimates a further 10.9% reduction in the number of CTs from the incorporation of US for patients scoring high or medium risk, in excess of the 19.5% reduction estimated in the CDR validation study.
... Previous decision-analytic models assessed the cost-effectiveness of various imaging protocols for diagnosing pediatric appendicitis but did not address ultrasounds that do not visualize the appendix, did not evaluate MRI, or did not stratify patients by risk. 7, [20][21][22] We aimed to identify the most cost-effective imaging strategy for suspected appendicitis using more robust modeling assumptions than have been previously employed. Our secondary aims were to identify health and facility characteristics that impact cost-effectiveness. ...
... Strategies represented existing described protocols and the existing literature. 7, 20,22 We estimated the costs of imaging and surgical procedures, and the costs and health effects attributable to false-negative and positive diagnoses, including increased risk of perforation and negative appendectomy, respectively. We assumed patients who had imaging tests that were falsely interpreted as negative returned to the ED, at which point they would be diagnosed with appendicitis and have an increased perforation risk. ...
Background:
Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix.
Methods:
We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained).
Results:
The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients' risk of appendicitis but not the proportion of visualized appendices.
Conclusions:
Tailored approaches to imaging based on patients' risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability <16% or >95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization.
... The rate of perforation in adolescents is 10% to 20%. So the likelihood Research Article of perforation decreases with age [20].Another study reports a Perforation rates to be as high as 82% in children younger than 5 years and nearly 100% of 1-year-old [13,21]. In this study, out of 3 patients who were <2years, 2 patients (66.6%) had perforation, out of 10 patients who were between 2 and 5 years, 3 patients (30%) had perforation, out of 87 patients who were between 6 and 14 years, 15 patients (17%) had perforation. ...
... An American study in 2011 reported that Plain AbdominalX-ray result in normal or misleading in up to 77% of acute appendicitis, unless a typical calcified appendicolith is found [11,21]. Despite this, it was often wrongly over-requested by ER pediatricians But the imaging study that shows significant differences is abdominal ultrasound which is needed in 94% of children to reach the diagnosis especially in females older than10years, as this group represents high percent of the total unnecessary appen-dectomies. ...
1. Abstract 1.1. Background: Acute appendicitis still a dilemma in diagnosis, regarding children and adults, although both age groups are sharing the same symptoms and signs but is still difficult in diagnosing acute appendicitis in children. 1.2. Aim: We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the adult &pediatric age groups.
... Rates of perforation remain high, ranging from 20 to 90 %, varying inversely with age [4][5][6]. Diagnostic laparoscopy and negative appendectomy have shown significant increases in hospital costs and patient morbidity [7][8][9][10], as has inpatient observation [10][11][12]. ...
... Rates of perforation remain high, ranging from 20 to 90 %, varying inversely with age [4][5][6]. Diagnostic laparoscopy and negative appendectomy have shown significant increases in hospital costs and patient morbidity [7][8][9][10], as has inpatient observation [10][11][12]. ...
To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not intrinsically non-diagnostic. There was little benefit to additional CT when AS < 6 and US did not show the appendix or evidence of inflammation; this would have avoided CT in 140/211 (66 %) patients. CT demonstrated benefit when AS ≥ 6, suggesting that cases with AS ≥ 6 and features that limit depiction of the appendix on US may be triaged to CT.
... Many workers questioned the rationale of mandatory use of Imaging tools in making diagnosis of AA in those with high clinical scores or index of suspicion [71,72]. They advised that Imaging study should be reserved for those with equivocal clinical findings, especially, women of reproductive age group [73], here; a diagnostic abdominal USS and Laparoscopy are known to mitigate the high negative appendicectomy rates [74]. About 8.9% of the patients had an erect or lateral decubitus abdominal radiograph on suspicion of a perforated appendix, and air under the right diaphragm was seen in cases of perforated appendix. ...
... CT is an important imaging modality and can be used to accurately diagnose appendicitis [6]. Awareness of the negative effects of ionizing radiation, particularly malignancy, has raised concerns about its widespread use in children. ...
Introduction
The US–Mexico border is medically underserved. Recent political changes may render this population even more vulnerable. We hypothesized that children on the border present with high rates of perforated appendicitis due to socioeconomic barriers.
Methods
A prospective survey was administered to children presenting with appendicitis in El Paso, Texas. Primary outcomes were rate of perforation and reason for diagnostic delay. We evaluated the association between demographics, potential barriers to care, risk of perforation and risk of misdiagnosis using logistic regression. p < 0.05 was considered significant.
Results
98 patients participated from October 2016 to February 2017. 96 patients (98%) were Hispanic and 81 (82%) had Medicaid or were uninsured. 11 patients (11%) resided in Mexico or Guatemala. Patients were less likely to receive a CT and more likely to receive an ultrasound if they presented to a freestanding children’s hospital (p = 0.01). 37 patients (38%) presented with perforation, of which 19 (52%) were the result of practitioner misdiagnosis. Patients who presented to a freestanding children’s hospital were less likely to be misdiagnosed than patients presenting to other facilities (p = 0.05). Children who underwent surgery in a freestanding children’s hospital had the shortest length of stay after adjusting for perforation status and potential confounders (p < 0.01).
Conclusion
Children with low socioeconomic status did not have difficulty accessing care on the USA–Mexico border, but they were commonly misdiagnosed. Children were less likely to receive a CT, more likely to be correctly diagnosed and length of stay was shorter when patients presented to a freestanding children’s hospital.
... [6][7][8][9][10][11][12][13][14] Computed tomography scans, the imaging modality of choice, have improved diagnosis of appendicitis 15,16 and have been reported to be costeffective. 17 As a result, use of CT for diagnosing pediatric appendicitis has increased. [18][19][20][21][22][23] The National Ambulatory Medical Care Survey data for patients younger than 19 years old presenting to a pediatric ED noted a rise in CT use from 0.9% in 1998 to 15.4% in 2008. ...
Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care.
We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters.
In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio.
Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
... Establecer entonces qué pacientes corresponden a una AA en evolución, a diferencia de aquellos con cambios inflamatorios secundarios o transitorios es un desafío permanente para el clínico, donde la US ofrece un apoyo que, en nuestra opinión, no ha sido completamente valorado. La literatura reporta los cambios obtenidos en el manejo de pacientes con intervención de la tomografía computada (3,4) , cuyo uso implica una dosis de radiación que pudiera evitarse haciendo buen uso de la US, trabajando en equipo con los clínicos (5) . Los resultados obtenidos en el grupo de pacientes cuyos estudios demostraron progresión de los cambios inflamatorios, da cuenta de que es posible contribuir con la US a distinguir aquellos pacientes que padecen un proceso inflamatorio del apéndice que requerirá de intervención quirúrgica. ...
Patients with unspecific acute abdominal pain and patients with nonspecific acute abdominal pain and no conclusive physical examination for appendicitis are usually kept under medical control. In our Emergency Department, some pediatricians and surgeons have added a second ultrasound (US) examination to clinical follow-up in patients with low suspicion of appendicitis and discordant or no conclusive initial findings. The objective of this study was to evaluate the role of a second US scan in medical or surgical treatment. We retrospectively evaluated medical records (from November2006 to June 2008) of 1.959 patients with a history of acute abdominal pain referred for abdominal US examination. Fifty-four patients, 22 males and 32 females aged between 3 and 14 years, received clinical indication for a second US study during that period. US monitoring was performed between 5 to 36 hours after the first examination. Patient history details, ultrasonographic characterization of cecal appendix, and clinical evolution were registered. Ten patients had progressive inflammatory appendicular changes. All of them underwent surgery and appendicitis was confirmed in eight cases (80%). Ten patients showed no changes on the second US scan; 40% of patients underwent surgery with biopsies confirming lymphoid hyperplasia (2), and congestive changes (2). Fifteen patients had a second US study that showed regression of inflammatory changes; all of them received medical treatment. In 19 patients, comparison was not feasible since appendixes appeared normal on US examination, or due to insufficient visualization of appendix. Our results suggest that ultrasound follow-up promotes adequate decision-making when facing surgical or medical treatment options for pediatric patients presenting with abdominal pain with initial clinical and imaging findings inconclusive for acute appendicitis.
... This was our classification variable. The domain expert used two criteria to decide whether taking the CT scan was necessary or not: i) whether the clinical condition of the patient justified ordering a CT scan, according to standard clinical benchmarks (Hagendorf 2004 Using the classification variable we trained models for prediction and reserved 33% of the data for testing the models. The 7 models had overall accuracy of more than 72% and the accuracy extended as high as 96% for one of the models. ...
In this study we analyze 1024 free text digital records from pediatric patients who underwent CT scanning. The free text reports are from the digital records of patients who underwent CT scanning in a one-year period in 2004 at the Nagasaki University Medical Hospital in Japan. We use text mining algorithms to model the records. Each scan was evaluated by an expert in the field and classified as to whether the CT scan was necessary or not. A model was built that predicts this classification. The results show that models developed on raw text could contribute significantly to the physician's decision to order a CT scan. Practically this is important because radiation at levels ordinarily used for CT scanning may pose significant health risks especially to children and thus the modeling of unnecessary scanning may lead to less exposure to radiation.
... This complication rate had been considered acceptable because of the preference of a negative laparotomy or laparoscopy over the morbidity of a perforated appendix [2][3][4]. However, the improved quality of computed tomography (CT) has led to the liberal use of this imaging modality to improve the accuracy of diagnosis in both adult and pediatric populations [4,5]. ...
... Ultrasound, with its decreased cost, lack of ionizing radiation and ability to assess ovarian pathology, has been the preferred initial imaging modality in children454647. However, CT should be used in children when the initial ultrasound is negative or non-diagnostic and there is a high clinical suspicion for appendicitis [45,48]. Ultrasound is also the initial imaging procedure of choice in pregnant women, however, the appendix is visualized only 13-50% of the time. ...
ABSTRACT: Intra-abdominal infection (IAI) is an important cause of morbidity and mortality. It is the second most commonly identified cause of severe sepsis in the intensive care unit and it has been associated with a high mortality rate. Most IAI are the result of inflammation and perforations of the gastrointestinal tract, such as appendicitis, peptic ulcer disease, and diverticulitis. Successful treatment of IAI is based on early and appropriate source recognition, containment and antimicrobial coverage. We will review the pathophysiology of IAI and provide clinical guidelines for its management.
... This study did not assess the costs of CT scanning, which given the growing reliance on costly imaging studies and the rising costs of health care, is an important area of further investigation. 17 In summary, our findings of increasing use of imaging studies in patients with appendicitis has not resulted in the unintended consequence of greater harm mediated by prolonged times between presentation to care and surgery since the accuracy and efficiency of CT imaging improved over the years studied. However, these improvements were not associated with reduced rates of appendiceal perforation. ...
The increased use of computed tomography (CT) in patients with appendicitis may cause a delay in surgery and, therefore, higher perforation rates. We examined the use of CT, delay in time to surgery, and perforation rates in appendicitis patients operated on in two periods: Phase 1, 1996 through 1998 and Phase 2, 2001 through 2002. CT was performed in 18 per cent of the Phase 1 group compared with 62 per cent in the Phase 2 group. In the Phase 1 group, patients undergoing CT had a delay to surgery compared with those without CT (18.6 hours vs 7 hours; P < 0.0001). In the Phase 2 group, time to surgery was reduced (median time = 12 hours with CT vs 6 hours without CT; P < 0.001). CT was more accurate in the later group; there were less false-negative and equivocal studies. There was no difference in perforation rates between the Phase 1 and 2 groups. Over time, the increased use, efficiency, and accuracy of CT in patients with acute appendicitis were associated with reduced delays to surgery. The use of CT did not harm patients, but did not translate to better overall outcomes in this group of patients.
... Some of this increased utilization is both beneficial and cost-effective [12] Moreover, a study by McGlynn et al [13] showed that underutilization may occur in certain circumstances. However, it is frequently asserted that a sizable percentage of diagnostic imaging is inappropriate. ...
To determine whether an appropriately designed computerized order entry system for radiology can be clinically accepted and influence ordering practices.
An intranet-based outpatient ordering and scheduling system was designed and implemented beginning in 2001. Indications used to request imaging have been standardized and keystrokes minimized by using menus. The system offers online scheduling and provides patient reminders, preparation instructions, and driving directions. Since November 2004, examination requests have been given utility scores on the basis of the indications provided. Comparative scores for other types of imaging examinations are displayed alongside the scores for the examinations requested. Physicians' performance is tracked, and senior clinicians counsel physicians with many low-scoring examinations. Data collected from the order entry system were used to evaluate rates of use, examinations with low "utility scores," and changes in the scores over the first year of use.
The use of the order entry system has increased steadily, currently constituting 75% of all potential outpatient studies. Since the addition of decision support in November 2004, almost 72,000 examinations have been scored. The highest number of low utility examinations were imaging of the spine, either computed tomography or magnetic resonance imaging. The percentage of low utility examinations declined from 6% to 2% overall. The amount of the decline was greatest for primary care physicians and for those who interacted with the computer themselves rather than through office staff members.
Computerized order entry with decision support can be widely accepted by clinicians and can have an impact on ordering practices.
Aims
The Choosing Wisely Campaign identifies procedures and treatments that lack clinical justification for routine use according to expert opinion and evidence‐based medicine. This study describes the rates and features of two such examples over a 10‐year period.
Methods
This is a cross‐sectional rolling cohort study between 2008 and 2017 in Clalit Health Services, the largest healthcare delivery system in Israel, with seven main hospitals and over 4.5 million members nationwide. All adult members who visited a Clalit Emergency Department (ED), and all children members who visited a Clalit ED for abdominal pain or appendicitis were eligible to be included in this study. Routine chest radiograph (CXR) in the context of pre‐admission assessment for adults and abdominal CT to rule out appendicitis for children.
Results
Of the 3,689,869 adult visits without a clinical indication for a CXR, 9.1% or 337,058 of them received a chest radiograph. Of the 35,973 children visits for presumed appendicitis, 7.2% of them had no imaging performed, 82.3% had an US, 6.9% had an US followed by a CT, and 3.6% or 1,293 of them received a CT. There were several independent risk factors such as BMI, hospital, sex, year, and diagnosis that are associated with having imaging that is not clinically indicated.
Conclusions
Overall, this study found that diagnostic imaging practices are applied inconsistently by hospital and by population. Intervention efforts should be focused on subpopulations at greatest risk to further reduce exposure to such imaging.
Background:
Data from the American College of Surgeons National Surgical Quality Improvement Program identified our hospital as an outlier for preoperative computed tomography (CT) use in the diagnosis of acute appendicitis in children. We performed a quality improvement project to reduce this utilization in favor of ultrasound-based diagnoses (ultrasonography [US]) through creation and implementation of an evidence-based appendicitis algorithm.
Methods:
Over a 2-y period (1 y preceding and 1 y following institution of the algorithm), the clinical information of all pediatric patients operated on for suspicion of acute appendicitis following imaging studies in our institution was collated. Basic characteristics were compared before and after protocol implementation using the chi-square test for categorical variables and the nonparametric, independent sample test of medians for numerical variables. Imaging modalities used and clinical outcomes were compared using chi-square analysis.
Results:
A total of 227 patients (117 preprotocol and 110 postprotocol implementation) were evaluated in our emergency department and operated on for suspicion of acute appendicitis. There were no differences in age, sex, race, or body mass index between the two periods. There were also no differences in length of stay (P = 0.27), acute and perforated appendicitis rates (P = 0.59), negative appendectomy rates (P = 0.40), or postoperative complications (P = 0.19). There was a significant reduction in the utilization of CT, from 65.8% to 22.0%, with a concurrent increase in the utilization of US (P < 0.001).
Conclusions:
With the implementation of a standardized, multidisciplinary algorithm, CT utilization was decreased and concurrently US utilization was increased without sacrificing diagnostic accuracy or patient outcomes.
Background:
Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation.
Objective:
To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis.
Methods:
We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy.
Results:
In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003).
Conclusion:
Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.
Appendicitis is the most common cause of acute abdominal pain that requires surgical intervention in the Western world.
Patients with appendicitis may present with a wide variety of symptoms that can lead to confusion and delay in diagnosis and treatment.
The delayed diagnosis of appendicitis has severe consequences.
The normal appendix is a blind-ended tubular structure (Fig. 10.1) with a diameter of less than 7 mm and a wall thickness of less than 2 mm.
There are a variety of other conditions in childhood that occur with abdominal pain that must be differentiated from acute appendicitis; furthermore one-third of children with acute appendicitis have atypical clinical findings so the clinical diagnosis is often not simple.
In these patients imaging plays a key role in the diagnosis of suspected appendicitis.
The principal imaging technique for evaluating children with suspected appendicitis is graded-compression US. The normal appendix measures 6 mm or less in maximal outer diameter, is compressible, and lacks adjacent inflammatory changes.
Although common, acute appendicitis can be a difficult diagnosis because a number of other common pathologic abdominal processes share a similar clinical presentation.
Computed tomography (CT) has become the predominant imaging method used to diagnose appendicitis in children in the United States.
The diagnosis of appendicitis with CT is made by identifying an abnormal appendix and periappendiceal signs of appendicitis.
CT is also more useful than US for evaluating complications of acute appendicitis, such as phlegmon and abscess.
Magnetic resonance (MR) imaging can be used to evaluate for abdominal disease without the use of ionizing radiation.
The criterion to define the abnormal appendix was the same one used for the detection of the abnormal appendix at CT and US.
In conclusion ultrasonography (US) remains the standard imaging technique to investigate acute appendicitis. MR imaging may be used as a complementary examination when US is inconclusive or when it is important to avoid exposure to CT radiation or contrast material in children with signs and symptoms of appendicitis.
Abdominal pain in children is a common presentation. When severe, differentiating surgical from medical causes is required. This chapter systematically reviews the causes of gastrointestinal emergencies past the neonatal period outlining the imaging algorithms and multi-modality imaging findings of the most common causes.
Patients with unspecific acute abdominal pain and patients with nonspecific acute abdominal pain and nonconclusive physical examination for appendicitis are usually kept under medical control. In our Emergency Department some pediatricians and surgeons have added a second ultrasound (US) examination to clinical follow-up in patients with low suspicion of appendicitis and discordant or nonconclusive initial findings. The objective of this study was to evaluate the role of a second US scan in medical or surgical treatment. We retrospectively evaluated medical records (from November 2006 to June 2008) of 1.959 patients with a history of acute abdominal pain referred for abdominal US examination. Fifty-four patients, 22 males and 32 females aged between 3 and 14 years, received clinical indication for a second US study during that period. US monitoring was performed between 5 to 36 hours after the first examination. Patient history details, ultrasonographic characterization of cecal appendix, and clinical evolution were registered. Ten patients had progressive inflammatory appendicular changes. All of them underwent surgery and appendicitis was confirmed in eight cases (80%). Ten patients showed no changes on the second US scan; 40% of patients underwent surgery with biopsies confirming lymphoid hyperplasia (2), and congestive changes (2). Fifteen patients had a second US study that showed regression of inflammatory changes; all of them received medical treatment. In 19 patients comparison was not feasible since appendixes appeared normal on US examination, or due to insufficient visualization of appendix. Our results suggest that ultrasound follow-up promotes adequate decision-making when facing surgical or medical treatment options for pediatric patients presenting with abdominal pain with initial clinical and imaging findings inconclusive for acute appendicitis.
Investigating the anamnesis and palpating the abdomen are two most important parameters in order to diagnose an acute appendicitis. Further laboratory studies and sonography give guiding information, but they are not as evident as the physical examination. Even more specialized examinations, such as MRI, should be reserved for detailed questions. In general the child should be operated on as soon as the diagnosis has been made. Nevertheless, as long as there is no perforation or peritonitis, the operation might be delayed for a short term. There is no need to operate on in it after midnight. Especially in childhood, it can be waited until the next morning. Conservative treatment of the acute appendicitis has not succeeded, as the rate of complications is too high. First choice of the operative treatment especially in infants seems to be the open appendectomy. However, the laparoscopic appendectomy is advancing and often indicated. Surgical results of open or laparoscopic appendectomy are almost equal and are dependent on the experience by the surgeon.
INDICATION Abdominal ultrasound has become an extremely useful imaging modality in emergency medicine. In combination with CT, abdominal ultrasound can diagnose many of the disease processes thatmust be identified by the emergency physician. Ultrasound has several advantages that make it ideal for use in the ED-most notably, that it is portable and hence can be done at the bedside in an unstable patient. In addition, other advantages that it has over CT are that it does not require an oral preparation, so it can be done immediately, does not expose the patient to ionizing radiation, and does not involve the risks inherent to intravenous contrast, such as in patients with iodine allergies and renal failure. Many of the commonindications for abdominal ultrasound, such as right upper quadrant pain, flank pain, trauma, and evaluation of the aorta, are covered elsewhere. However, there are several other unique disease entities that can be diagnosed with abdominal ultrasound and with which the emergency physician should be familiar. DIAGNOSTIC CAPABILITIES Gastrointestinal Tract Acute Appendicitis Acute appendicitis can be diagnosed with ultrasound and is the preferred initial imaging modality by some clinicians for certain populations, such as in pregnant patients, to avoid ionizing radiation (1,2).
A study previously performed at our institution demonstrated that surgeon-performed ultrasound (SPUS) was accurate compared to radiology department ultrasound (RDUS) when evaluating children with suspected appendicitis. The purpose of this study was to determine if these results were reproducible and if SPUS decreased time to definitive diagnosis.
A surgery resident performed examinations and ultrasounds on children with suspected appendicitis. Final diagnosis was confirmed by pathology. Results were compared to RDUS and combined with the previous study for a final comparison with RDUS. Mean time to diagnosis was recorded. Data were analyzed using Fisher exact and Student's t test.
Fifty-eight patients underwent SPUS, of these 35 had RDUS. The accuracy of SPUS alone was 93 % (54/58) and RDUS accuracy was 94 % (33/35) (p = 1). When SPUS was combined with clinical examination accuracy increased to 95 % (55/58). When results were combined with the previous study, overall accuracy of SPUS was 90 % (101/112) compared to overall RDUS accuracy of 89 % (50/56). Mean time to diagnosis for RDUS was 135 min (n = 35), whereas mean time to diagnosis for SPUS was 30 min (n = 58; p = 0.0001).
SPUS is accurate and reproducible in evaluating children with suspected appendicitis. SPUS potentially decreases time to definitive therapy and emergency department wait times.
OBJECTIVE. The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population.
SUBJECTS AND METHODS. Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up.
RESULTS. Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]).
CONCLUSION. Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.
BACKGROUND: In our clinical practice, we have observed that despite the great technological advances in diagnostic methods acute appendicitis still represents a problem in children, resulting in late diagnosis and treatment, and case of greater severity. Our objective is to assess the current state of diagnosis and treatment of acute appendicitis in children treated in two important referral hospitals of São Paulo (Brazil), over a 30 month's period. METHODS: The variables studied were: age, sex, clinical manifestations, time for the diagnosis to be established, the findings from physical examination and laboratory tests, surgical findings and antibiotic protocols, postoperative complications and hospital lenght of stay. RESULTS: In the present sample, of 300 children, 65% were boys and 35% girls, with an initial diagnosis of appendicitis being made in 63% of the cases. The signs and symptoms most frequently encountered were: abdominal pain in the right iliac fossa (85.3%) and peritoneal irritation in this region (82%). We identified leukocytosis in 83% of the patients and the urine analysis showed leukocyturia in 39.7% of the patients. Around 92.4% of the simple radiological studies of the abdomen produced images that were not specific to acute appendicitis. Ultrasonography studies diagnosed the disease in 80.1% of the cases. Various antibiotic schemes were used, although there was special attention towards Gram-negative and anaerobic bacteria. The main complication was infection of the surgical wound, and there was no mortality. The average hospital length of stay was 5 days. CONCLUSION: In spite of greater knowledge of acute appendicitis and greater refinement of laboratory and radiological techniques, the diagnosis is still delayed and disease constitutes a cause of great morbidity among pediatric age groups.
OBJETIVOS: Avaliar o estado atual do diagnóstico e tratamento da apendicite aguda em crianças operadas em dois grandes hospitais quaternários da cidade de São Paulo, no período de 30 meses. MÉTODO: Nossa casuística constou de 300 crianças operadas por apendicite aguda no período de 1998 a 2000 (65% do sexo masculino e 35% feminino). Foram analisadas as variáveis idade, sexo, manifestações clínicas, tempo gasto para o diagnóstico, achados de exame físico, laboratoriais e cirúrgicos, antimicrobianos administrados, complicações pós-operatórias e tempo de internação. Utilizou-se o teste t de Student para avaliar duas variantes e Análise de Variâncias quando mais de duas. RESULTADOS: Diagnosticou-se inicialmente apendicite aguda em apenas 63% dos casos, tendo os 35% restantes, diagnóstico de abdome agudo cirúrgico. O tempo decorrido na realização do diagnóstico foi superior a 24 horas em 57,4% dos casos, denotando retardo importante na sua elaboração. Dor abdominal (85,3%) e irritação peritoneal (82%) em fossa ilíaca direita foram os sinais e sintomas mais freqüentes. Identificou-se leucocitose em 83% dos pacientes e leucocitúria em 39,7 %. Em 92,4% das radiografias simples de abdome encontramos imagens sugestivas de apendicite aguda. A ultra-sonografia abdominal foi diagnóstica em 80,1% dos casos. Utilizaram-se esquemas antimicrobianos especialmente para agentes gram-negativos e anaeróbicos. A principal complicação foi infecção da ferida cirúrgica, não tendo sido observada mortalidade no grupo. A média de internação foi de 5.2 e 6,0 dias para meninos e meninas respectivamente. CONCLUSÃO: Mesmo com melhor conhecimento sobre apendicite aguda, refinamento técnico, laboratorial, radiológico e uso de antibioticoterapia adequada, o tempo de para diagnóstico e a morbidade ainda se mantém alta na idade pediátrica.
Acute appendicitis is the most common surgical emergency during childhood. Accurate early diagnosis is important to avoid complications and unnecessary interventions. In 2002, Samuel developed the Pediatric Appendicitis Score (PAS) based on a series of data obtained from anamnesis, physical examination, and laboratory tests. The main purpose of this study was to check the validity of PAS and its applicability to our population.
Prospective observational study, carried out at Hospital Río Hortega (Valladolid, Spain), between June 2009 and May 2010. Data from 101 patients who presented to the emergency department experiencing abdominal pains were recovered.
A total of 101 patients were included in the study: 55 were boys and 46 girls. The mean age was 9.51 (2.76) years. Diagnosis was acute appendicitis in 28 patients, adenitis in 8 patients, nonspecific abdominal pain in 51 patients, and other diagnoses in 14 patients. The mean (SD) PAS for children with and without appendicitis was 7.43 (1.79) and 4.97 (1.67), respectively (P < 0.001).
With a cutoff PAS of 3 or lower, there were no patients diagnosed with acute appendicitis; hence, these patients could be discharged without any image studies. If all the patients with a PAS of 8 or higher undergo surgery, we would find in our sample a 4.95% rate of negative appendicectomy, less than other studies have shown. The application of this score in the emergency department could help in the decision making process, aiding in the identification of patients with a low risk of having appendicitis and enabling a better use of resources by avoiding unnecessary diagnostic tests.
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.
To evaluate use of imaging in children with acute abdominal pain who present to U.S. emergency departments (EDs).
This study received expedited review by the institutional review board. The National Hospital Ambulatory Medical Care Survey is a government-administered yearly survey of EDs that is used to estimate ED care throughout the United States. This retrospective cohort study interrogated the database for the period from 1999 to 2007. Univariate regression analysis was performed, and a multivariate regression model was developed.
From 1999 to 2007, 16 900 000 pediatric ED visits were made for acute abdominal pain. Odds of undergoing computed tomography (CT) in this population increased during each year of the study period. No significant changes occurred in use of ultrasonography, number of patients admitted to the hospital, or number of patients with acute appendicitis. A multivariate model for CT use revealed increased odds of CT use in teens, white patients, the Midwest region, urban settings, patients with private insurance, and patients who were admitted or transferred. Odds of undergoing CT were significantly lower among patients who presented to a pediatric-focused emergency department (adjusted odds ratio, 0.72; 95% confidence interval: 0.58, 0.90).
The main findings of this study are that the rate of CT use in the evaluation of abdominal pain in children increased every year between 1999 and 2007 and that the use of CT was greater among children seen in adult-focused EDs. Factors affecting CT use include sex, race, age, insurance status, and geographic region.
Use of CT in the evaluation of suspected appendicitis in children is common. Expanding the use of US would eliminate the radiation exposure associated with CT.
We describe new criteria that improve US's diagnostic accuracy for appendicitis, making it more comparable to CT in terms of sensitivity and specificity.
We conducted a retrospective review of 304 consecutive patients undergoing US for the diagnosis of appendicitis in our institution during 2006. The sensitivity, specificity and accuracy of the maximal outer diameter (MOD) at various measurements was calculated and compared to pathology results. Additional variables (appendiceal wall thickness, fecalith, hyperemia, fat stranding, free fluid, age and weight) were also evaluated.
The highest sensitivity (98.7%) and specificity (95.4%) were identified when MOD was ≥7 mm or wall thickness was >1.7 mm. These values resulted in correctly classifying 96.6% of cases, with 1 (0.5%) false-negative and 6 (2.9%) false-positive studies. Incorporating secondary signs of appendicitis, age or weight did not alter accuracy.
These findings identify new US criteria that compare favorably to CT. In children with suspected appendicitis, using US as the initial imaging study will ultimately lead to improved accuracy, lower cost and the elimination of ionizing radiation exposure.
The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.
Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.
One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).
Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.
Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.
Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.
Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.
Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.
To compare the cost-effectiveness of different imaging strategies in the diagnosis of pediatric appendicitis by using a decision analytic model.
Approval for this retrospective study based on literature review was not required by the institutional Research Ethics Board. A Markov decision model was constructed by using costs, utilities, and probabilities from the literature. The risk of radiation-induced cancer was modeled by using the Biological Effects of Ionizing Radiation VII report, which is based primarily on data from atomic bomb survivors. The three imaging strategies were ultrasonography (US), computed tomography (CT), and US followed by CT if the initial US study was negative. The model simulated the short-term and long-term outcomes of the patients, calculating the average quality-adjusted life span and health care costs.
For a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients. In the base-case analysis, US followed by CT was the most costly and most effective strategy, CT was the second-most costly and second-most effective strategy, and US was the least costly and least effective strategy. The incremental cost-effectiveness ratios (ICERs) of CT to US and of US followed by CT to US were both well below the societal willingness-to-pay threshold of $50,000 (in U.S. dollars). The ICER of US followed by CT to CT was less than $10,000 in both male and female patients.
In a Markov-based decision model of pediatric appendicitis, the most cost-effective method of imaging pediatric appendicitis was to start with a US study and follow each negative US study with a CT examination.
Protocol development between radiology and pediatric emergency medicine requires a multidisciplinary approach to manage straightforward as well as complex and time-sensitive needs for emergency department patients. Imaging evaluation requires coordination of radiologic technologists, radiologists, transporters, nurses and coordinators, among others, and might require accelerated routines or occur at sub-optimal times. Standardized protocol development enables providers to design a best practice in all of these situations and should be predicated on evidence, mission, and service expectations. As in any new process, constructive feedback channels are imperative for evaluation and modification.
The differential diagnosis of abdominal pain in children can be challenging. We applied quantitative decision-making methods to this process and sought to determine if their use provided measurable benefit.
After obtaining institutional review board approval, we recorded key elements of the history, physical examination, laboratory, and imaging evaluations along with the cost and the time spent in the emergency department (ED) for children presenting with abdominal pain. Initially, data were collected (group 1, n = 1366 patients) and then presented to the ED pediatricians. For subsequent patients, ED physicians received a sheet specific to that patient's age and sex reporting the most common diagnoses and the elements of the evaluation that had proven most useful (group 2, n = 624 patients). We compared the difference in length of stay and costs before and after intervention, between study groups, by age groups, and separately by sex using a 2-factor analysis of variance.
The diagnostic workup cost less in boys aged 2 to 12 years after the intervention. In boys and girls older than 12 years, the cost trended lower.
This study demonstrates that ED physicians equipped with specific information were able to complete their diagnostic evaluation of children presenting with abdominal pain at a lower cost.
Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis.
Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons.
Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups.
More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.
Harmonic imaging (HI), a relatively new ultrasound modality, was initially reported to be of use only in obese adult patients. HI increases the contrast and spatial resolution resulting in artefact-free images, and has been shown in adults to significantly improve abdominal sonography. Regarding its application in paediatric patients, just a handful reports exist and these do not encompass its use in intestinal sonography.
To compare the sonomorphological image quality of HI and fundamental imaging (FI, conventional grey-scale imaging) in the diagnosis of histologically confirmed appendicitis in children.
For this prospective comparative study, 50 children (male/female 25/25; mean age 9.9 years) suspected of having appendicitis were recruited. In all patients US examination of the appendix and periappendiceal region was performed preoperatively and appendectomy carried out. The final diagnosis was based on histological examination of the appendix. Both FI and HI were used in the US examination (tissue harmonic imaging, THI; Sonoline Elegra, Siemens; 7.5 MHz linear transducer). A detailed comparison of the images from FI and HI was performed using a scoring system. The parameters compared included delineation of the appendiceal contour, wall, mucosa, contents of the appendix and surrounding tissues. Furthermore, periappendiceal findings such as mesenteric echogenicity, free fluid, lymph nodes and adjacent bowel wall thickening were compared.
In 43 children (86%) acute appendicitis was histologically confirmed. The inflamed appendix could be depicted in the HI and FI modes in 93% and 86%, respectively. HI was found to be significantly better for the depiction of the outer contour, wall, mucosa and contents of the appendix (P<0.01). This was also true for the demonstration of free fluid, mesenteric lymph nodes, adjacent bowel walls and mesenteric echogenicity.
HI should be the preferred modality for scanning the right lower abdomen in suspected acute appendicitis. The diagnosis of acute appendicitis can then be more definitely ascertained.
Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.
To evaluate the accuracy of ultrasonography (US) and of abdominal computed tomography (CT) performed in addition to US in the diagnosis of childhood appendicitis.
Six hundred children with suspected appendicitis were included in a prospective randomized study. After clinical examination, the patients were randomly assigned to undergo US only (283 patients) or US with abdominal CT (317 patients). Radiologic findings were correlated with surgical, histopathologic, and clinical follow-up findings.
Two hundred forty-four (40.7%) of all patients had appendicitis. In the US only group, US had a sensitivity of 86%, specificity of 95%, positive predictive value of 91%, negative predictive value of 92%, and diagnostic accuracy of 92%. The combination of US and CT performed in the other group yielded a sensitivity of 99%, specificity of 89%, positive predictive value of 87%, negative predictive value of 99%, and diagnostic accuracy of 93%. Analysis of data on US performed in all 600 patients and on CT performed in 317 patients revealed, respectively, sensitivities of 80% and 97%, specificities of 94% and 93%, positive predictive values of 91% and 92%, negative predictive values of 88% and 98%, and diagnostic accuracies of 89% and 95%. The overall negative appendectomy rate was 3.7%; and the perforation rate, 21%.
US is valuable in the diagnosis of appendicitis in children. In inconclusive cases, performing additional abdominal CT can improve diagnostic accuracy and thereby decrease the negative appendectomy rate without an increase in the perforation rate.
To determine which patients suspected of having acute appendicitis benefit from preoperative imaging.
The medical records of 462 consecutive patients who underwent appendectomy for clinically suspected acute appendicitis and underwent preoperative evaluation at our institution were retrospectively reviewed. Patients were divided into four groups: women (n = 166), girls (n = 46), men (n = 178), and boys (n = 72). Preoperative computed tomography (CT) or ultrasonography (US), requested by the referring clinician, was performed in 313 of the 462 patients. Unnecessary, or negative, appendectomy and perforation rates were calculated for each group for preoperative evaluation with CT, with US, and with neither CT nor US. In addition, the sensitivity and positive predictive value of CT and US were calculated for diagnosing appendicitis.
In women, the negative appendectomy rate was significantly lower for those who underwent preoperative CT (7% [six of 85 patients], P =.005) or US (8% [four of 49 patients], P =.019), as compared with 28% [nine of 32 patients] for those who underwent no preoperative imaging (P >.35 for all groups). The negative appendectomy rates for girls, men, and boys were not significantly affected by preoperative imaging. The sensitivity of CT and US for diagnosing acute appendicitis exceeded 93% and 77%, respectively, in all groups. The positive predictive values for both CT and US were greater than 92% in all groups.
Women suspected of having appendicitis benefit the most from preoperative CT or US, with a statistically significantly lower negative appendectomy rate than women who undergo no preoperative imaging. Therefore, we propose that preoperative imaging be considered part of the routine evaluation of women suspected of having acute appendicitis.
Context Limited computed tomography with rectal contrast (CTRC) has been shown
to be 98% accurate in the diagnosis of appendicitis in the adult population,
but data are lacking regarding the accuracy and effectiveness of this technique
in diagnosing pediatric appendicitis.Objective To determine the diagnostic value of a protocol involving ultrasonography
and CTRC in the diagnosis and management of appendicitis in children and adolescents.Design, Setting, and Participants Prospective cohort study of 139 children and adolescents aged 3 to 21
years (2 patients were older than 18 years) who had equivocal clinical findings
for acute appendicitis and who presented to the emergency department of a
large, urban, pediatric teaching hospital between July and December 1998.Interventions Children were first evaluated with pelvic ultrasonography. If the result
was definitive for appendicitis, laparotomy was performed; if ultrasonography
was negative or inconclusive, CTRC was obtained. Patients who did not undergo
laparotomy had telephone follow-up at 2 weeks and medical records of all patients
were reviewed 4 to 6 months after study completion.Main Outcome Measures Specificity, sensitivity, positive predictive value, negative predictive
value, and accuracy of tests based on final diagnoses; surgeons' estimated
likelihood of appendicitis on a scale of 1 to 10 for each case and their case
management plans before imaging, after ultrasonography, and after CTRC.Results A total of 108 patients underwent both ultrasonography and CTRC examinations.
The protocol had a sensitivity of 94%, specificity of 94%, positive predictive
value of 90%, negative predictive value of 97%, and accuracy of 94%. A normal
appendix was identified by ultrasonography in 2 (2.4%) of 83 patients without
appendicitis and by CTRC in 62 (84%) of 74 patients. A negative ultrasonography
result did not change the surgeons' clinical confidence level in excluding
appendicitis (P=.06), while a negative CTRC result
did have a significant effect (P<.001). Positive
results obtained for either ultrasonography or CTRC significantly affected
surgeons' estimated likelihood of appendicitis (P=.001
and P<.001, respectively). Ultrasonography resulted
in a beneficial change in patient management in 26 (18.7%) of 139 children
while CTRC correctly changed management in 79 (73.1%) of 108.Conclusions These data show that CTRC following a negative or indeterminate ultrasonography
result is highly accurate in the diagnosis of appendicitis in children.
OBJECTIVE. The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population.
SUBJECTS AND METHODS. Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up.
RESULTS. Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]).
CONCLUSION. Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.
Objectives:
To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations.
Methods:
This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions).
Results:
The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance.
Conclusions:
Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.
Background/purpose:
The aim of this study was to evaluate the usefulness of ultrasonography in the routine management of children with suspected appendicitis in a children's hospital.
Methods:
Data from surgical, radiologic, and pathologic databases were cross referenced retrospectively to allow for review of all children undergoing appendectomy and all children undergoing an ultrasound scan to rule out appendicitis in the 3-year period August 1, 1996 to July 31, 1999.
Results:
Pathology reports were available for 1,007 of 1,032 patients undergoing appendectomy. Eighty-four percent had acute appendicitis (26% of these were perforated). Fifty-eight percent of all children undergoing appendectomy had at least 1 preoperative ultrasound scan. Eighty-six percent of those having ultrasound scans had acute appendicitis compared with 82% of those who did not have an ultrasound scan (P <.05 chi(2) Test). During the same period, 2,056 ultrasound examinations were performed by staff radiologists who were available 24 hours a day to rule out appendicitis. Ultrasonography in this setting had a sensitivity of 89%, specificity of 95%, positive predictive value of 86%, and a negative predictive value of 96% (true-positives, n = 496; false-positive, n = 81; true-negative, n = 1,417; false-negative, n = 62). An alternate ultrasound diagnosis was offered in 157 children.
Conclusions:
Ultrasound scan improves diagnostic accuracy in children with suspected appendicitis. The high negative predictive value of ultrasound scan, especially when used repeatedly, may reduce the need for admission to hospital for clinical observation to rule out appendicitis.
Purpose:
Abdominal sonography has gained popularity in establishing the diagnosis of appendicitis in children with equivocal clinical presentations. However, no clear outcome benefits have been demonstrated to date. The authors conducted a retrospective study to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography.
Methods:
The charts of 454 consecutive patients undergoing appendectomy for acute appendicitis between January 1, 1998 and December 4, 1999 were reviewed. Patients operated on after clinical evaluation only were compared with patients operated on after abdominal sonography.
Results:
Forty-two percent of patients (n = 191) constituted the sonography group. When compared with the clinical group, these patients had higher prevalence of female gender (52% v 38%; P =.004), longer symptom duration (2.2 +/- 2.5 v 1.6 +/- 1.6 days; P =.003), higher incidence of preoperative in-patient observation (19% v 4%; P <.001), longer duration between evaluation and operation (8.0 +/- 3.9 v 4.9 +/- 2.9 hours; P <.001), higher incidence of normal appendices on pathologic examination (13% v 6%; P =.006), and higher incidence of postoperative abscesses or phlegmons (4.4% v 1.2%; P =.04). The groups did not differ significantly in age, hospital stay, incidence of complicated appendicitis, or incidence of wound infection.
Conclusions:
Patients undergoing sonography before appendectomy have a longer delay before operation, a higher rate of misdiagnosis, and more postoperative complications. Limiting sonography to truly equivocal cases and using it early in the diagnostic workup may improve outcomes in this group of patients.
Out of 363 children admitted to a surgical unit with acute abdominal pain only 126 (35%) had an operation. Of these, 20 first underwent a period of "active observation." This procedure, used to help reach a diagnosis or decision in doubtful cases, is safe and useful and may be applied at home or in hospital.
The morbidity rate from perforation demands that appendicitis be diagnosed promptly in children with abdominal pain. Although admitting and observing uncertain instances of appendicitis can refine the diagnostic accuracy, it is often claimed, but not proved, that this necessitates increasing the number of perforations. To assess the risk of perforation while observing uncertain instances of childhood appendicitis, we admitted 150 consecutive referrals during a period of one and one-half years. Immediate appendectomy was performed for 74 patients (49 percent) with convincing clinical signs and symptoms for appendicitis. The remaining 76 (51 percent) with unconvincing clinical signs and symptoms were observed as inpatients. One-third of the patients admitted for observation (26 of 76) underwent appendectomy after an average period of 12 hours. Two-thirds (50 of 76) of the patients got better and were discharged from the hospital without an appendectomy after an average admission of two days. Seven of the 100 appendices removed were normal. Three of the observed patients had perforations, one of whom may have perforated during observation, but that child went on to do well. The 50 patients who got well without appendectomy were similar to the patients with appendicitis, but significantly less likely to have peritoneal signs (8 versus 70 percent), tenderness in the right lower quadrant (48 versus 81 percent) and guarding (19 versus 75 percent). We conclude that admission and active observation in the hospital of children with possible, but unconvincing, signs and symptoms of appendicitis is a safe and effective way to determine which patients need an operation.
Early diagnosis and prompt surgical treatment have long been advocated for acute appendicitis to prevent the consequences of perforation. The frequency of perforation in a series of patients with appendicitis has been used as an index of the promptness of surgical care in comparing the care given among hospitals or over time. Data presented illustrate that perforation of the appendix is strongly influenced by patient factors, over which surgeons often have little control. First, variation of a few hours in the timing of surgical care once patients have been admitted appears to be a much less important contributor to perforation than variations in the length of the prehospitalization phase of illness. Second, the risk of perforation depends not only upon the duration of the symptoms of the patient but also upon other patient characteristics, particularly age. Third, the increased perforation rates among patients at the extremes of age appear to be due not just to differences in the timing of surgical treatment but to real differences in the natural history of the disease. These observations suggest that perforation rates should have, at most, a rather limited role as indicators of the quality or timeliness of surgical care. The findings also permit speculation that a single clinical strategy may not necessarily be optimal for all patients with appendicitis.
The physician's estimate of the probability that a patient has a particular disease is a principal factor in the determination of whether to withhold treatment, obtain more data by testing, or treat without subjecting the patient to the risks of further diagnostic tests. Using the concepts of decision analysis, we have derived expressions for two threshold probabilities involved in this choice: a "testing" threshold and a "test-treatment" threshold. Values can be assigned to these thresholds from data on the reliability and potential risks of the diagnostic test and the benefits and risks of a specific treatment. Treatment should be withheld if the probability of disease is smaller than the testing threshold, and treatment should be given without further testing if the probability of disease is greater than the test-treatment threshold. The test should be performed (with treatment depending on the test outcome) only if the probability of disease is between the two thresholds. The method exposes important principles of decision making and helps the clinician develop a rational, quantitative approach to the use of diagnostic tests.
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Appendicitis is the most common cause of abdominal pain requiring surgery in children. Missed appendicitis is also a frequent cause of professional liability in an emergency department (ED). A retrospective review of all patients with appendicitis diagnosed in the ED was undertaken to identify: 1) how many patients required more than one visit to diagnose appendicitis and 2) the clinical characteristics that distinguished the patients who visited twice from patients who were diagnosed on the first visit. A total of 87 patients with appendicitis were seen by pediatricians in the ED from 1987 to 1989. The patients included 43 girls and 44 boys (mean age, 8.9 years). Six patients (7%) were seen twice before the diagnosis of appendicitis was made. They returned to the ED on average 29 hours after the first visit. The ED discharge diagnosis of the six "missed" patients included: probable Campylobacter (n = 1), viral urinary tract infection (n = 1), gastroenteritis (n = 2), and abdominal pain (n = 2). The six missed patients were different from the other patients with appendicitis. They were more likely to have a normal appetite, to have diarrhea, and to be afebrile. All the patients had at least two of the four following signs and symptoms: vomiting, tenderness, guarding, and right lower quadrant (RLQ) pain. At the time of surgery, 23/81 (28%) of the one-visit group had a ruptured appendix, whereas 3/6 (50%) of the missed patients had a ruptured appendix.
Conclusions:
1) Seven percent of the patients were seen twice in our ED before the diagnosis of appendicitis was made.(ABSTRACT TRUNCATED AT 250 WORDS)
To determine whether the use of ultrasonography (US) improves the outcome of children with appendicitis.
All cases of patients (<17 years old) with pathologically confirmed appendicitis treated in the ED between July 1992 and December 1995 were retrospectively reviewed.
231 charts met criteria for analysis. 100 (43%) patients had US prior to surgery. Age, race, and insurance status were similar for children in the US and non-US groups; there were no differences between the groups at presentation in mean temperature, mean WBC count, or percentage of children with vomiting, diarrhea, abdominal tenderness, or guarding. Those in the non-US group were more often male (71%, p=0.002) and more frequently had right lower quadrant pain (65%, p=0.003). Time from ED triage to the OR was 17.1 hours (US group) vs 10.4 hours (non-US group) (p=0.002). The perforation rates and the complication (abscess, wound infection, wound dehiscence) rates were similar for children in the two groups. Hospital charges were higher in the US group than in the non-US group ($14,123 vs $13,021, p=0.007).
The use of US did not result in early diagnosis of appendicitis, nor was it associated with a reduction in perforation or complication rates. Among children with clinical evidence of appendicitis, US was associated with a delay in surgery and an increase in hospital charges.
To evaluate the role of ultrasonography in children with equivocal signs of acute appendicitis, and correlate with initial clinical impression and pathological findings.
This is a prospective evaluation of all children presenting with a possible diagnosis of appendicitis during a 14-month study period. Patients with unequivocal clinical signs of appendicitis underwent appendectomy without ultrasonography. Patients with equivocal signs had documentation of the clinical impression and subsequent abdominal ultrasound. Statistical analysis of results was performed using the chi-square test (P <0.05 significant).
Two hundred fifteen consecutive children were enrolled. Signs were unequivocal in 116 and equivocal in 99. Seven patients in the first group had a normal appendix at operation. Of the 99 patients with equivocal signs, there were 28 true positives, 3 false positives, 64 true negatives, and 4 false negatives. In equivocal cases, sensitivity of the initial clinical impression versus ultrasound was 50% and 88%, respectively (P <0.05). Specificity was 85% and 96%, respectively. The positive and negative predictive values improved from 63% to 90% and 78% to 94%, respectively, with the use of ultrasonography.
The low false positive rate (6%) in clinically obvious cases of appendicitis does not, in our opinion, warrant ultrasonography. In clinically equivocal cases, ultrasonography is a fast, sensitive, and specific diagnostic modality to diagnose or rule out appendicitis, avoiding the need for prolonged observation and/or hospitalization.
Appendicitis remains a difficult diagnosis in children. Ultrasonography is increasingly used for the diagnosis of appendicitis, although the proper clinical role for this test remains unclear.
To evaluate the clinical utility of ultrasonography in appendicitis, the authors analyzed prospectively all children evaluated for possible appendicitis from January 1 through December 31, 1997. Children with a high clinical suspicion of appendicitis were referred for surgery (n = 122). Children with equivocal findings of appendicitis were referred for early ultrasonography (EUS) and formed the study cohort (n = 103). An initial management plan was made to operate or observe each patient, and a risk of appendicitis (doubtful, possible, probable) was assigned by a pediatric surgery fellow. EUS was then performed, and its effect on management was assessed.
Using clinical judgment to operate at initial presentation, the sensitivity was 38% and specificity was 95%. Using EUS alone, the sensitivity was 87% and specificity was 88%. The management of 30 of 103 patients (30%) was changed after EUS, including a decision to operate in 28 patients and a decision not to operate in two patients.
EUS appears to have substantial clinical utility in children with equivocal findings of appendicitis, and its use complements the clinical management. The use of EUS can improve patient care and reduce hospital resource utilization.
Children evaluated in the emergency department for possible appendicitis are often admitted for observation, despite the widespread availability of accurate diagnostic studies, particularly computed tomography (CT). We sought to establish effective and efficient strategies for using CT to diagnose and manage children with possible appendicitis.
Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric teaching hospital.
All patients admitted from January 1996 to August 1997 for suspected appendicitis. METHOD OF ANALYSIS: Three modeled strategies were empirically applied to the retrospective cohort of patients admitted for observation. Outcomes and costs under the modeled strategies were compared with those under current practice. The three strategies were: 1) to obtain CT scans on all patients and discharge those with normal findings; 2) to obtain CT scans and admit all patients; 3) to selectively obtain CT scans on those patients with a peripheral white blood cell count >10 000/mm(3) (10 x 10(9)/L) and admit all. The sensitivity and specificity of CT for diagnosing appendicitis were determined empirically from the data. A sensitivity analysis was performed.
The number of preoperative inpatient observation days, total hospital costs, and the rates of both missed appendicitis and negative laparotomies.
Of 609 patients hospitalized for possible appendicitis, 287 went directly to the operating room and 14 patients had known perforation and abscess. Three hundred eight children were observed and comprised the study cohort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of these had a normal appendix at pathology. Three patients were discharged from the hospital after observation and were subsequently readmitted with appendicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current practice strategy, the cohort collectively accumulated 487 inpatient observation days and incurred a per patient cost of $5831. All three CT strategies would have reduced the total number of inpatient observation days, operations, negative laparotomies, as well as the per patient cost. The strategy of obtaining CT scans on all patients and then admitting them had the lowest rate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtaining CT scans and sending home those with negative findings was $150,304. Even at the lowest reported sensitivity and specificity of CT in the literature, the ordering of the three strategies remained constant and continued to reduce total cost per patient.
Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for children with appendicitis.
There is strong evidence that imaging with ultrasound and CT can be of substantial diagnostic value in the diagnosis of acute appendicitis in children, but there is limited information of the impact of imaging on the management of these patients and its possible effect on surgical findings.
We studied the impact of imaging in the management of acute appendicitis, in particular its effect on the rate of negative appendectomies and perforations.
We reviewed retrospectively the clinical records and imaging findings of 633 consecutive children and adolescents seen on an emergency basis with clinical suspicion of acute appendicitis. Two hundred seventy patients were operated upon on clinical evidence alone, while 360 were referred for US or CT, and occasionally both, because of doubtful clinical findings.
Acute appendicitis was found in 237 of those on clinical grounds alone, 68 of whom had perforation and related complications. Thus the rate of negative exploration and the rate of perforation were13 % and 29 %, respectively. One hundred eighty-two patients had preoperative US (sensitivity 74 %, specificity 94 %), 119 had CT (sensitivity 84 %, specificity 99 %), and 59 had both US and CT (sensitivity 75 %, specificity 100 %, but often with interpretation at variance with each other). The rate of negative appendectomy and perforation was 8 % and 23 %, respectively, for US, 5 % and 54 % for CT, and 9 % and 71 % when both examinations were performed. There is no statistical significance between the rates of diagnostic performance of US, CT, or their combination, nor between the negative appendectomy rates of each group, but the rate of perforation was significantly higher when CT was performed, alone or after US.
The retrospective nature of the study prevents precise definition of the clinical characteristics and selection criteria for diagnostic examinations that may contribute to the management of children with suspected acute appendicitis. It was designed, however, to reflect the diagnostic approach and management of these patients, under the care of many decision makers and interpreters of imaging examinations, prevalent today in most hospital-based clinical practices. It is suggested that imaging increases diagnostic accuracy in difficult cases, but it might be one of the factors increasing the rate of perforations.
We sought to determine radiologists' confidence in interpretation of sonography and CT performed using rectal contrast material for diagnosing pediatric appendicitis.
We prospectively examined 139 children and young adults with equivocal clinical findings for appendicitis who were seen in the emergency department of an urban pediatric teaching hospital between July and December, 1998. Patients were initially examined with pelvic sonography. If the sonographic results were equivocal or if the appendix was not visualized, CT was performed. Radiologists recorded their level of confidence in interpretation of the sonograms and CT examinations.
Sonography was interpreted with very low, low, or medium confidence in 59 (42.4%) of 139 patients and with high or very high confidence in 80 (57.6%) of 139. CT was interpreted with very low, low, or medium confidence in nine (8.3%) of 108 and with high or very high confidence in 99 (91.7%) of 108 children. Radiologists were more confident in their interpretation of CT than sonography (p < 0.001). If the sonography was a true-positive examination, radiologists were more confident in its interpretation than if it was a false-positive study (p = 0.003). Radiologists were more confident in sonographic interpretation of a true-negative examination than of a false-negative study (p = 0.03). Patient age and sex and the radiologists' level of experience did not make a significant difference in the confidence of interpretation of sonography or CT.
In the evaluation of childhood appendicitis, radiologists' confidence in interpretation is influenced by the choice of imaging technique as well as by the results of the study.
Colonic contrast material evaluation of suspected appendicitis in pediatric patients is technically more challenging than in adults because less intraabdominal fat is present. To determine the accuracy and feasibility of focused CT for pediatric patients, we carried out this retrospective investigation.
Between November 1995 and July 1999, 199 pediatric patients (1-18 years old; mean age, 12 years) were examined with focused CT in the emergency division for suspected appendicitis. The findings on CT were compared with the findings at surgery, pathology, and clinical follow-up.
There were 64 true-positive CT scans, two false-negative, 128 true-negative, one false-positive, and four indeterminate. Seventy-four patients underwent appendectomy, with a negative appendectomy rate of 9%. One hundred twenty-five patients without appendicitis were treated nonoperatively. The true-positive rate was 32%, true-negative rate was 64%, sensitivity was 97%, specificity was 99%, positive predictive value was 98%, negative predictive value was 98%, and overall accuracy was 96%. Pediatric patients tolerated the procedure well. Colonic contrast material saved time and provided improved identification of the cecum and appendix. In 62 patients without appendicitis, focused CT provided alternative diagnoses.
Focused CT appears to be nearly as accurate in pediatric patients as in adults. Focused CT provided alternative diagnoses in 48% of the patients for whom CT findings were negative for appendicitis.
The purpose of this investigation is to determine the sensitivity, specificity, and accuracy of unenhanced limited CT of the abdomen in children with suspected appendicitis and compare these results with graded compression sonography.
Seventy-six children underwent unenhanced limited CT over a 11-month period for evaluation of suspected appendicitis. A historical cohort of 86 consecutive children who had undergone graded compression sonography was identified. Results were correlated with surgical, pathologic, chart, and clinical follow-up data. The sensitivity, specificity, accuracy, rate of alternate diagnosis, time to perform examinations, and charge at our institution were determined for unenhanced limited CT and sonography.
Sensitivity, specificity, and accuracy for unenhanced limited CT were 97%, 100%, 99%, respectively, and were 100%, 88%, 91%, respectively, for sonography. Alternate diagnoses were suggested in 35% and 28% children without appendicitis who had unenhanced limited CT and sonography, respectively. Unenhanced limited CT required 5 min and sonography required 20-30 min to perform. The charge at our institution was $408 for unenhanced limited CT and $295 for sonography.
CT can be performed rapidly in children without IV, oral, or rectal contrast medium. Unenhanced limited CT and sonography are highly sensitive, specific, and accurate in the evaluation of children with suspected appendicitis.
The aim of this study was to evaluate the usefulness of ultrasonography in the routine management of children with suspected appendicitis in a children's hospital.
Data from surgical, radiologic, and pathologic databases were cross referenced retrospectively to allow for review of all children undergoing appendectomy and all children undergoing an ultrasound scan to rule out appendicitis in the 3-year period August 1, 1996 to July 31, 1999.
Pathology reports were available for 1,007 of 1,032 patients undergoing appendectomy. Eighty-four percent had acute appendicitis (26% of these were perforated). Fifty-eight percent of all children undergoing appendectomy had at least 1 preoperative ultrasound scan. Eighty-six percent of those having ultrasound scans had acute appendicitis compared with 82% of those who did not have an ultrasound scan (P <.05 chi(2) Test). During the same period, 2,056 ultrasound examinations were performed by staff radiologists who were available 24 hours a day to rule out appendicitis. Ultrasonography in this setting had a sensitivity of 89%, specificity of 95%, positive predictive value of 86%, and a negative predictive value of 96% (true-positives, n = 496; false-positive, n = 81; true-negative, n = 1,417; false-negative, n = 62). An alternate ultrasound diagnosis was offered in 157 children.
Ultrasound scan improves diagnostic accuracy in children with suspected appendicitis. The high negative predictive value of ultrasound scan, especially when used repeatedly, may reduce the need for admission to hospital for clinical observation to rule out appendicitis.
We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1-32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between postoperative morbidity and timing of surgery evident (Spearmans correlation coefficient = -0.079, p = 0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.
To determine the accuracy of a focused computed tomographic (CT) technique with oral and intravenous contrast materials for the diagnosis of appendicitis.
Ninety-three abdominal-pelvic contrast material-enhanced CT scans obtained during 6 years in 54 girls and 39 boys (age range, 1-18 years) with right lower quadrant pain were retrospectively reviewed. The detected abnormal findings were recorded as being in the region above the upper pole of the right kidney, between the upper pole of the right kidney and the lower pole of the right kidney (RLP), or below the iliac crest. Sensitivity, specificity, and positive and negative predictive values were calculated. chi(2) analysis was performed to determine whether there were significant differences among patient groups according to region of detected disease.
Fifty-five scans were abnormal: 38 showed appendicitis; and 17, other diseases. No scans, except two that showed pneumonia, had key findings above the RLP. Nineteen scans showed key findings between the RLP and the iliac crest. Thirty-three scans had diagnostic findings only below the iliac crest. The sensitivity (97%), specificity (93%), positive predictive value (90%), and negative predictive value (98%) of interpretation with all images for the diagnosis of appendicitis were the same as those of interpretation with only the focused images.
CT performed to diagnose appendicitis can be limited to the region below the RLP.
Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery.
To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy.
Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998.
Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix.
Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P =.005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P =.17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001).
Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.
To prospectively compare resident and attending radiologic interpretations of nonenhanced limited computed tomographic (CT) scans obtained in children suspected of having appendicitis.
Seventy-five consecutive children underwent nonenhanced limited CT for suspected appendicitis. The scans were prospectively interpreted by a resident and an attending radiologist, each unaware of the other's interpretation. The probability that the findings indicated a diagnosis of appendicitis, level of certainty in the interpretation, and presence of an alternate diagnosis were statistically analyzed.
Nineteen children (25%) had appendicitis. The area under the receiver operating characteristic curve was not significantly different between residents (0.97 +/- 0.02) and attendings (0.95 +/- 0.04). The percentage agreement between residents and attendings was 91% (kappa = 0.73 +/- 0.095). The average level of certainty tended to be higher for attendings (93% +/- 15) than residents (89% +/- 12). The sensitivity, specificity, and accuracy of resident interpretations were 63%, 96%, and 88%, respectively, compared with those of attending interpretations--95%, 98%, and 97%, respectively. Residents and attendings noted alternate diagnoses in 30% of children without appendicitis.
A high level of agreement exists between resident and attending radiologists in the interpretation of nonenhanced limited CT scans in children suspected of having appendicitis. Residents, however, tend to be less confident in their interpretations.
Negative appendectomy (NA)--the nonincidental removal of a normal appendix--occurs commonly but the associated clinical- and system-level costs are not well studied.
The frequency of adverse clinical outcomes and associated financial burden of hospitalizations during which NA is performed is greater than previously recognized and varies widely among demographic groups.
Population-based, retrospective cohort study.
The 1997 Nationwide Inpatient Sample of the Health Care Utilization Project.
All surveyed patients assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy but without an associated diagnosis of acute appendicitis.
The age- and sex-stratified rates of NA, the incidence of associated infectious complications and case fatality, and the average length of stay and hospitalization charges during those admissions.
Nationwide, an estimated 261 134 patients underwent nonincidental appendectomies in 1997, and 39 901 (15.3%) were negative for appendicitis. Women had a higher rate of NA as did patients younger than 5 years and older than 60 years. When compared with patients with appendicitis, NA was associated with a significantly longer length of stay (5.8 vs 3.6 days, P<.001), total charge-admission ($18 780 vs $10 584, P<.001), case fatality rate (1.5% vs 0.2%, P<.001), and rate of infectious complications (2.6% vs 1.8%, P<.001). An estimated $741.5 million in total hospital charges resulted from admissions in which a NA was performed.
There are significant clinical and financial costs incurred by patients undergoing NA during the treatment of presumed appendicitis. These should be considered when evaluating system-level interventions to improve the management of appendicitis.
Appendicitis is generally a more serious disease in the elderly than in the young. In the former, perforation is seen commonly leading to the belief that the appendix perforates more readily and rapidly in the elderly. A competing view is that the appendix perforates relatively more frequently in the elderly than in the young. To distinguish between these two views we analyzed 126 cases of acute appendicitis stratified by age group. The time between onset of symptoms and perforation was calculated with a novel method that utilized the biological concept of T(1/2) for perforation. Our findings suggest that the rate of perforation in the elderly is not significantly different from that in the young but the frequency of perforation is higher in the elderly. We concluded that appendicitis carries a graver prognosis in the elderly because the frequency of appendiceal perforation is higher in the elderly.
To improve clinical results and resource utilization in the care of appendicitis in children, the authors examined the current practice and outcomes of 30 pediatric hospitals.
The Pediatric Health Information System (PHIS) database consists of comparative data from 30 free-standing Children's hospitals. The study population of 3,393 children was derived from the database by selecting the "Diagnosis Related Group Code" for appendicitis (APRDRGv12 164), ages 0 to 17 years, using discharges between October 1, 1999 and September 30, 2000. Data are expressed as the range and median for individual hospital outcomes.
The nonpositive appendectomy rate ranged from 0 to 17% at the 30 hospitals (median, 2.6%). Ruptured appendicitis varied from 20% to 76% (median, 36.5%). The median length of stay (LOS) for nonruptured appendicitis was 2 days (range, 1.4 to 3.1 days), ruptured appendicitis varied from 4.4 to 11 days (median, 6 days). The median readmission rate within 14 days was 4.3% (0 to 10%). Laparoscopic appendectomy varied from 0 to 95% in the 30 hospitals (mean, 31%) The LOS did not vary significantly in laparoscopic versus open for nonruptured (2.3 v 2.0 days) or ruptured appendicitis (5.5 v 6.2 days). Days on antibiotics for ruptured appendicitis ranged from 4.6 to 7.9 days (median, 5.9 days) Children receiving any study varied from 18% to 89% (median, 69%). Ultrasound scan and computed tomography (CT) were comparable in both nonruptured (13% ultrasound scan v 14%) and ruptured appendicitis (14% ultrasound scan v 21% CT).
Significant variability in practice patterns and resource utilization exists in the management of acute appendicitis in pediatric hospitals. Clinical outcomes could be improved by collaborative initiatives to adopt evidence-based best practices.
Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved.
Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results.
Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%.
With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children.
Imaging for suspected appendicitis: Negative appendectomy and perforation rates Jones P: Active observation in management of acute abdominal pain in childhood Acute appendicitis: The continuing role for active observation
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Cost-effectiveness in Health and Medicine Radiation Risks and Pediatric Computed Tomography (CT): A Guide for Health Care Providers
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Gold MR, Siegel JE, Russell LB, et al: Cost-effectiveness in Health and Medicine. New York, NY, Oxford University Press, 1996 30. " Radiation Risks and Pediatric Computed Tomography (CT): A Guide for Health Care Providers, " National Cancer Institute, Summer, 2002 (http://www.cancer.gov/cancerinfo/causes/radiation-risks-pediatric-ct)
Acute appendicitis in children
- Karakas
Nonenhanced limited CT in children suspected of having appendicitis
- Lowe
Suspected appendicitis in children
- Kaiser
Imaging for suspected appendicitis
- Bendeck
False-negative and false-positive errors in abdominal pain evaluation
- Graff
Suspected appendicitis in children
- Fefferman