The following are excerpts from Ultrasound for Pediatric Appendicitis [this is link to go to. Go there instead of reading this post. What follows below are just a few summary notes for me – again this blog is really just my online perpheral brain. [Also visit HQMedEd. It is awesome so be sure to check it out.]
Ultrasound for Pediatric Appendicitis
November 9, 2014/1 Comment/in Evidence-Based Medicine, Pediatrics, Ultrasound /by Ben Dolan
Clinical Question: What is the role of ultrasound in the evaluation of appendicitis in the pediatric population?
Appendicitis is the most frequent surgical emergency in children, peaking in incidence at 9-12 years of age. Left untreated, obstruction of this recess can lead to perforation in 36 hours with increased morbidity. Because delayed diagnosis may impart long term consequences, it is also one of the most frequently successful malpractice claims against emergency physicians (Ma 2008).
The diagnosis of appendicitis remains a challenge. Laboratory testing is non-specific. Plain films of the abdomen may show an appendicolith, but this happens less than 10% of the time. CT scans impart high loads of ionizing radiation to young patients and MRI is not readily available to most physicians.
Ultrasound was first used to assess for appendicitis in 1981 and criteria for its use were developed in 1986. Through many studies its effectiveness has been proven but limited by differences in operators and poor negative predictive value. Several recent studies have attempted to further characterize ultrasound’s role and limitations.
The Quick Answer:
When appendicitis is suspected but the physical exam is non-diagnostic, ultrasound should be your first imaging test.
Alternatives to sonography for diagnosing appendicitis via imaging include CT and MRI. Both are extremely accurate in determining the presence of acute appendicitis. We know CT is often the first choice due to availability and has the downside of delivering ionizing radiation. Several sources cite its increased utilization in recent years (Pines 2009). Use is reportedly 4.4 times higher in community hospitals that also show less use of ultrasound (Saito 2013). Ladd’s data from 2012 confirm the same, particularly in females with delayed presentations. Regardless, Miglioretti et al reported that a radiation-induced solid cancer is projected to result from every 300-390 abdomen/pelvis CTs in girls and every 670-760 CTs in boys. Due to these risks some centers still accept high rates of negative appendectomies. Studies are emerging that show fast-protocol MRI is accurate, efficacious and limited only by widespread availability (Moore 2012, Johnson 2012). European data show that using MRI as the sole imaging modality may reduce overall cost of care.
If you read one paper on this topic, read this:
Ross MJ, Liu et al: Outcomes of children with suspected appendicitis and incompletely visualized appendix of ultrasound. Acad Emerg Med. 2014 May;21(5):538-42.
For More FOAMed on this topic, check out:
HQMedEd Case Presentation
Special Thanks to Drs. Rob Reardon, Al Tsai, Scott Joing, and Brian Driver for their assistance with this post.
Review the entire post at Ultrasound for Pediatric Appendicitis and be sure to check out all the great references. The post describes the operating characteristics of POCUS (point of care ultrasound) for appendicitis. The post provides convincing evidence that emergency physicians (and hence FPs and Pediatricians) can master POCUS for this indication with a short period of instruction.