Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis

Abstract

IntroductionAcute appendicitis in children is a clinical diagnosis, which often requires preoperative confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many children without incurring the risk of radiation. The objective of the study was to compare the rate of appendiceal rupture and negative appendectomies between children with and without abdominal CTs; and to evaluate the same outcomes for children with and without USs to determine if there were any associations between imaging modalities and outcomes.MethodsWe conducted a retrospective chart review including emergency department (ED) and inpatient records from 1/1/2009–2/31/2010 and included patients with suspected acute appendicitis.Results1,493 children, aged less than one year to 20 years, were identified in the ED with suspected appendicitis. These patients presented with abdominal pain who had either a surgical consult or an abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were sent home following evaluation in the ED and did not return within the subsequent two weeks and were therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population, of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI [49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]). The proportion of children with a negative appendectomy was similar in both groups: CT (7%, 95% CI [2.1,11.9]), US (8%, 95% CI [4.7,11.3]) and neither (12%, 95% CI [5.9,18.1]).ConclusionIn this uncontrolled study, the accuracy of preoperative diagnosis of appendicitis and the incidence of pathology-proven perforation appendix were similar for children with suspected acute appendicitis whether they had CT, US or neither imaging, in conjunction with surgical consult. The imaging modality of CT was not associated with better outcomes for children presenting to the ED with suspected appendicitis.

Overuse of CT and MRI in paediatric emergency departments

“…84 Using ultrasound as the primary imaging modality in children with suspected acute appendicitis has been shown to be cost-effective and to reduce the number of CT scans ordered 82,85,86 without resulting in inferior outcomes. 87,88 However, in some situations a definitive diagnosis cannot be made by ultrasound, requiring further evaluation with CT or MRI. 15 Blumfield et al 89 evaluated the effect of an initiative to reduce radiation exposure by adjustment of paediatric CT protocols, utilizing ultrasound instead of CT as the first modality to evaluate acute appendicitis, increasing the availability of paediatric radiologist and establishing frequent teaching sessions that emphasize the ALARA ("As Low As Reasonably Achievable") principle.…”

Diagnostic accuracy of pediatric atypical appendicitis

“…Some studies report that 20% to 40% of CT scan performed in children for the investigation of abdominal pain revealed no intra-abdominal pathology owing to the risks of radiation exposure. [8,9] Cases where the appendix cannot be visualized but clinical suspicion remains, present a diagnostic dilemma for the physician. In our study, the appendix was not seen on US in 3 cases, which may be related to body habitus.…”

Two-incision laparoscopic appendectomy for a severe hemophilia A child patient with coagulation factor VII deficiency

“…[ 15 – 19 ] CT scan is quite important for this kind of patients in differentiation diagnosis, even though it cannot improve the prognosis of appendicitis in children. [ 20 – 22 ] Additionally, the differential diagnosis included necrotizing fasciitis, gastrointestinal perforation, acute perforated appendicitis, or acute gastroenteritis. The experience of his case emphasizes the importance of correct diagnosis and careful management for an acute abdomen pain in hemophiliac patients.…”