Performance of Ultrasound in the Diagnosis of Appendicitis in Children in a Multicenter Cohort

Mittal, Manoj K.; Dayan, Peter; Macias, Charles G.; Bachur, Richard G.; Bennett, Jonathan E.; Dudley, Nanette C.; Bajaj, Lalit; Sinclair, Kelly; Stevenson, Michelle D.; Kharbanda, Anupam B.

doi:10.1111/acem.12161

Cited by 149 publications

(112 citation statements)

References 30 publications

(51 reference statements)

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“…[40][41][42][43] Our study had a high rate of equivocal US that was comparable to that found in our recent study of appendicitis 9 and higher than that reported in a multisite study by Bachur et al 44 who found a 14% equivocal US rate. This difference may be in part explained by the difference in the criteria for equivocal US.…”

Section: Discussionsupporting

confidence: 85%

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: 85%

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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“…16 Consequently, a substantial proportion of paediatric appendicitis cases may be misdiagnosed if clinical decision making is based on physical examination, symptoms and laboratory investigations alone. 17 To prevent misdiagnosis and reduce negative appendectomy rates, imaging has been recommended as part of the diagnostic pathway. 16 Ultrasound (US) is generally the diagnostic imaging modality of choice where paediatric appendicitis is suspected as it is: readily available; has no radiation risk; is relatively fast; and, in comparison to other cross-sectional imaging modalities, is relatively inexpensive.…”

Section: Introductionmentioning

confidence: 99%

Is magnetic resonance imaging a viable alternative to ultrasound as the primary imaging modality in the diagnosis of paediatric appendicitis? A systematic review

2016

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yesBackground: Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention\ud in paediatric patients. Ultrasound is generally the diagnostic imaging modality of choice, followed\ud by CT, where paediatric appendicitis is suspected. However, high operator dependency and\ud diagnostic restrictions related to anatomical and clinical presentation may limit consistency of application.\ud This paper explores whether MRI is a viable alternative to ultrasound as the primary imaging\ud modality.\ud Method: A systematic review of the literature was undertaken. A search of Medline, Cinahl, PubMed\ud Central and Google Scholar was undertaken supplemented by a review of reference lists, author\ud searching and review of NICE evidence base for existing guidelines. Included studies were assessed for\ud bias using the QUADAS-2 quality assessment tool and data were extracted systematically using a purposefully\ud designed electronic data extraction proforma.\ud Results: Seven studies were included in final review. The age range of participants extended from 0 to 19\ud years. Only one study with a patient age range of 0e14 used sedation. Sensitivity estimates from the\ud included studies ranged from 92% to 100% while specificity ranged from 89% to 100%. A significant\ud variation in the number and type of sequences was noted between the studies.\ud Conclusion: MRI offers high sensitivity and specificity comparable to contrast enhanced CT and greater\ud than ultrasound as reported in the literature. Where accessibility is not a restriction, MRI is a viable\ud alternative to ultrasound in the assessment and diagnosis of paediatric appendicitis. Clinical practice\ud recommendations have been provided to facilitate the translation of evidence into practice.Funding info requested 17/03/201

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“…However, complete visualization of the appendix using US has recently been reported to range from 25% to 73%, leaving the clinician with a significant diagnostic conundrum. 13 The objective of this study was to determine outcomes in children with suspected appendicitis who have incompletely visualized appendices on US. We also examined the frequency of incomplete visualization, the diagnostic accuracy of US when the appendix is visualized, and the predictive value of secondary signs of inflammation when the appendix is not visualized.…”

mentioning

confidence: 99%

Outcomes of Children With Suspected Appendicitis and Incompletely Visualized Appendix on Ultrasound

et al. 2014

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Objectives: The objective was to review the clinical outcomes of children with suspected appendicitis after an ultrasound (US) examination fails to fully visualize the appendix, the diagnostic characteristics of US in children with suspected appendicitis, and the predictive value of secondary signs of appendicitis when the appendix is not fully visualized.Methods: This was a retrospective health record review of children aged 3 to 17 years presenting to a tertiary pediatric emergency department (ED) with suspected appendicitis. Descriptive statistics and diagnostic test characteristics are reported.Results: Overall, 968 children had US. The appendix was fully visualized in 442 cases (45.7%), and 526 (54.3%) children had incompletely visualized appendices. The disposition of those with incompletely visualized appendices were as follows: 59.1% were discharged home, 10.5% went directly to the operating room, and 30.4% were admitted to the hospital for further observation. Of those discharged home based on clinical findings after incompletely visualized appendices, fewer than 0.3% ended up having appendicitis. Ultimately 15.6% of children with incompletely visualized appendices had pathologyconfirmed appendicitis. The sensitivity and specificity of US for children with fully visualized appendices were 99.5% (95% confidence interval [CI] = 96.7% to 100%) and 81.3% (95% CI = 75.2% to 86.2%), respectively. The sensitivity and specificity for the presence of any secondary sign in diagnosing appendicitis were 40.2% (95% CI = 29.6% to 51.7%) and 90.6% (95% CI = 87.5% to 93.2%), respectively. Conclusions:Children with incompletely visualized appendices on US can be safely discharged home based on clinical findings with an acceptable rate of missed appendicitis. Children with nonreassuring clinical examinations following incompletely visualized appendices on US may benefit from further imaging studies prior to appendectomy, to reduce the rate of negative appendectomy. While the presence of secondary signs of inflammation can be used to rule in appendicitis, statistical strength to rule out appendicitis in the absence of secondary signs is insufficient.ACADEMIC EMERGENCY MEDICINE 2014;21:538-542

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Performance of Ultrasound in the Diagnosis of Appendicitis in Children in a Multicenter Cohort

Cited by 149 publications

References 30 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

Is magnetic resonance imaging a viable alternative to ultrasound as the primary imaging modality in the diagnosis of paediatric appendicitis? A systematic review

Outcomes of Children With Suspected Appendicitis and Incompletely Visualized Appendix on Ultrasound

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