Effectiveness of a Staged US and CT Protocol for the Diagnosis of Pediatric Appendicitis: Reducing Radiation Exposure in the Age of ALARA

Krishnamoorthi, Rajesh; Ramarajan, Naresh; Wang, Nancy E.; Newman, Beverley; Rubesova, Erika; Mueller, Claudia; Barth, Richard A.

doi:10.1148/radiol.10100984

Cited by 182 publications

(140 citation statements)

References 21 publications

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“…The authors recommended further prospective study be done to investigate alternative diagnostic approaches in this population. These results were subsequently retrospectively confirmed by Krishnamoorthi and colleagues 36 and prospectively by Santillanes and colleagues. 37 In a key study, Kharbanda and colleagues 38 have recently validated and refined a clinical pathway to identify children at low risk of acute appendicitis.…”

Section: Discussionsupporting

confidence: 53%

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Schuh

Langer

Kulik

et al. 2015

Academic Emergency Medicine

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Objectives: The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US.Methods: This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies.Results: Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. Conclusions:The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans.

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Section: Discussionsupporting

confidence: 53%

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Schuh

Langer

Kulik

et al. 2015

Academic Emergency Medicine

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“…Whether a patient of suspected AA should undergo CT scan or not is decided by the attending radiologist based on the USG findings and overall merit of the case. Many institutions follow this principle of USG first followed by CT scan if indicated especially in pediatric cases [15,16]. Third, another school of thought is that WBC count and serum biomarkers such as CRP help in the diagnosis of AA [17,18].…”

Section: Discussionmentioning

confidence: 99%

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis

Debnath

Kumar²,

Mathur

et al. 2012

Indian J Surg

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The purposes of this study were to revisit the utility of ultrasonography (USG) as a primary imaging modality in acute appendicitis (AA) and to establish the role of CT scan as a second-line/problem-solving modality. All cases of suspected AA were referred for urgent USG. USG was done with standard protocol for appendicitis. Limited computed tomographic (CT) scan [NCCT ± CECT (IV contrast only)] was done for the lower abdomen and pelvis where sonographic findings were equivocal. One hundred and twenty-one patients were referred for USG for suspected appendicitis. Eight-four patients underwent surgery for AA based on clinical as well as imaging findings, of whom 76 had appendicitis confirmed at histopathology. Three patients were misdiagnosed (3.6 %) on USG as appendicitis. Of 76 patients of appendicitis confirmed histopathologically, 63 (82.8 %) had features of appendicitis on USG and did not require any additional imaging modality. Of 121 patients, 12 (10 %) needed CT scan because of atypical features on USG. Of these 12 patients, seven had retrocecal appendicitis, and three high-up paracolic appendicitis. USG alone had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81, 88, 92.6, 71.6, and 83 %, respectively. When combined with CT scan in select cases, the sensitivity, specificity, PPV, NPV, and accuracy of combined USG + CT scan were 96 % (P 00.0014), 89 %, 93 %, 93.5 % (P00.0001), and 93 % (P00.0484), respectively. Twentyeight (23 %) patients were given alternative diagnosis on USG. Dedicated appendiceal USG should be used as a primary imaging modality in diagnosing or excluding AA. Appendiceal CT can serve as a problem-solving modality.

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“…The transverse outer diameter of a normal appendix was 6 mm or less. 6,8 Acute appendicitis was diagnosed when there was an incompressible appendix with a transverse outer diameter of 6 mm or greater and secondary signs, 12 which included a mural thickness of greater than 2 mm and inflamed periappendiceal hyperechoic fat. 6,8 The radiologists who performed sonography subjectively defined equivocal appendicitis when the transverse outer diameter of the appendix measured greater than 6 mm without secondary signs or when they could not identify the connection between tubular structures suggesting the presence of a distended appendix and cecum due to an unusual location of the appendix or a poor sonic window.…”

Section: Sonography and Ctmentioning

confidence: 99%

“…Normal appendix (3) Acute gastroenteritis (3) a Normal appendix and diverticulitis (10) Diverticulitis (10) a Normal appendix and ileocolitis (4) Ileocolitis (4) a Normal appendix and right ureter stone (1) Right ureter stone (1) a Nonperforated appendicitis (8) Nonperforated appendicitis (8) Perforated appendicitis (14) Perforated appendicitis (12) Diverticular abscess (1) Perforated appendiceal mucocele (1) Equivocal appendicitis (1) Normal appendix (1) Appendiceal mucocele (1) Nonperforated appendicitis (1) the appendix were easily detectable on sonography, which might be due to the improved sonographic equipment and the accumulated expertise compared to the previous study. Although CT was recommended when perforated appendicitis was imaged on sonography in this study population, we suggest that there is no need to recommend additional CT when the contour of the appendix is easily visualized on sonography.…”

Section: Diagnosis On Both Sonography and Ct Final Diagnosismentioning

confidence: 99%

“…7 However, because of radiation exposure during CT, recent studies have suggested performing initial sonography and limiting CT in patients with acute abdominal pain. 8,9 Unfortunately, the precise utility of sonography in the initial assessment of patients with suspected acute appendicitis is still widely debated. 1 Therefore, some clinicians prefer performing CT for diagnosis or exclusion of acute appendicitis.…”

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confidence: 99%

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Does Computed Tomography Have Any Additional Value After Sonography in Patients With Suspected Acute Appendicitis?

Koo

Kim

Yang

et al. 2013

J of Ultrasound Medicine

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cute appendicitis is the most common condition requiring prompt abdominal surgery to minimize morbidity and mortality. Sonography and computed tomography (CT) have been widely used as the preferred imaging tools in patients with suspected acute appendicitis. 1 In previous studies of these diagnostic techniques, the sensitivities and specificities of sonography were 67% to 88% and 78% to 100%, respectively, whereas the sensitivities and specificities of CT were 76% to 96% and 75% to 95%. [2][3][4][5][6] Hye Soo Koo, MD, Hyun Cheol Kim, MD, Dal Mo Yang, MD, Sang Won Kim, MD, Seong Jin Park, MD, Jung Kyu Ryu, MD Received December 17, 2012, Objectives-The purpose of this study was to evaluate the additional value of supplementary computed tomography (CT) after sonography for diagnosing acute appendicitis.Methods-Among 140 consecutive patients with suspected acute appendicitis who underwent both initial sonography and supplementary CT within 12 hours, 88 patients whose appendices could not be visualized on sonography were excluded. The remaining 52 patients (mean age, 37.3 years; range, 15-98 years) were enrolled in this study. Two radiologists retrospectively reviewed the findings of 52 sonographic and CT examinations, and the appendix of each patient was classified as normal, equivocal appendicitis, nonperforated acute appendicitis, or perforated appendicitis. Causes of right lower quadrant pain other than appendicitis were also recorded. The additional value of supplementary CT was evaluated by performing head-to-head comparisons between CT and sonographic results.Results-No patients with a normal appendix on sonography showed appendicitis on CT. In addition, there were no patients with a sonographic diagnosis of appendicitis who had a normal appendix on CT. Ten patients (19.2%) were determined to have additional value gained from CT. Among these 10 patients, however, the additional information from CT affected treatment modality decisions in only 5.Conclusions-Initial sonography can be as effective as CT in patients with suspected acute appendicitis when the results are definite. Supplementary CT should only be performed when sonography is inconclusive.

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Effectiveness of a Staged US and CT Protocol for the Diagnosis of Pediatric Appendicitis: Reducing Radiation Exposure in the Age of ALARA

Abstract: A staged US and CT imaging protocol in which US is performed first in children suspected of having acute appendicitis is highly accurate and offers the opportunity to substantially reduce radiation.

Cited by 182 publications

References 21 publications

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis

Does Computed Tomography Have Any Additional Value After Sonography in Patients With Suspected Acute Appendicitis?

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