Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template

Nielsen, Jason W.; Boomer, Laura A.; Kurtovic, Kelli; Lee, Eric; Kupzyk, Kevin; Mallory, Ryan; Adler, Brent H.; Bates, D. Gregory; Kenney, Brian D.

doi:10.1016/j.jpedsurg.2014.10.033

Cited by 81 publications

(67 citation statements)

References 22 publications

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“…When our US reports were indeterminate, our patients had four times the rate of follow-up CTs and twice the rate of negative laparotomies. Similar numbers have been reported by Nielsen et al [5]. From their reported data, Larson et al [3] found that indeterminate US reports were 2.7 times more likely to have followup CT studies (55/123) than determinate US results (208/1,234), P<0.0001.…”

supporting

confidence: 80%

“…This was true regardless of the US result and highlights that the diagnosis of appendicitis is made with the synthesis of data from multiple sources, clinical, laboratory and imaging, which may at times be contradictory. Nielsen et al [5] have found that the introduction of a US reporting scheme that did not include indeterminate categories decreased both the rate of follow-up CT studies and negative laparotomies while increasing US sensitivity and accuracy [5]. The results from our study identified ways to increase determinacy and accuracy [2] and we have begun to implement these changes while monitoring for negative outcomes.…”

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confidence: 60%

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Appendiceal ultrasound: the importance of determinacy

et al. 2015

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"The first job of the radiologist is to minimize doubt."-William E. Shiels, 1954Shiels, -2015 We appreciate the thoughtful comments of Drs. Trout and Larson [1] concerning our article in this issue of Pediatric Radiology and the opportunity to further this discussion with a few additional thoughts. There are striking similarities between our two studies with respect to design and results but there are substantial differences in the conclusions drawn [2,3].Patients referred for US evaluation for acute appendicitis have already been stratified into an indeterminate risk group based on their clinical data. Those thought to have a very high probability of acute appendicitis may be sent directly to surgery and those thought to have a very low probability of appendicitis often are not imaged at all. It is for those patients whose probability of acute appendicitis is indeterminate that clinicians seek our help with US imaging. When clinicians order an imaging test to assist in establishing or excluding the diagnosis of acute appendicitis, they should know the likelihood that the test will provide a determinate result and how accurate that result will be. We presented our appendiceal US data in two ways so as to clearly provide this information to our clinicians. The intention-to-diagnose analysis categorizes indeterminate results as missed cases based on the final outcome. Contrary to Trout and Larson's statement, this analysis is specifically endorsed by Fedko et al. [4] because it allows for "transparent reporting of all results and determination of diagnostic yield" and likelihood ratios and informs physicians what proportion of appendiceal US examinations will not yield determinate results. The intention-to-diagnose method does underestimate measures of the diagnostic performance of US such as accuracy and sensitivity for the determinate results. To account for this, we performed a second analysis using the standard binary approach that excludes indeterminate studies because this analysis relates to clinicians the accuracy of appendiceal US when a determinate result is given.In our opinion, indeterminate results do not yield useful information. Trout and Larson think they do. They assert that indeterminate results reflect a range of probabilities that a given patient has appendicitis and that this information is meaningful to clinicians. While we did find a narrow range of prevalences of appendicitis in our three indeterminate groups, we disagree that this information is clinically useful. Our findings do not support their assertion on two grounds.

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confidence: 60%

Appendiceal ultrasound: the importance of determinacy

et al. 2015

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“…It is estimated that in the US universal imaging with CT would avoid 12 unnecessary appendicectomies but could result in one additional cancer death. 25 In the US, it is reported that 50% of patients who undergo appendicectomies in childhood and 95-99% in adulthood have a CT scan before surgery, 1-20 with scans commonly being performed in an emergency department before assessment by a surgeon. 2 In the EU in 2013, 12.9% of patients undergoing appendicectomy had a CT scan during the diagnostic workup.…”

Section: Imagingmentioning

confidence: 99%

Acute appendicitis

Baird

Simillis

Kontovounisios

et al. 2017

BMJ

148

107

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“…However, both US and CT have been reported to improve accuracy in the diagnosis of acute appendicitis [20] . CT scan rates for the diagnosis of acute appendicitis have been increasing nationally [21,22] .…”

Section: Resultsmentioning

confidence: 99%

Combination of Alvarado score and ultrasound findings in diagnosis of acute appendicitis in children

Fakhry

Shawky

2017

J Pediatr Dis

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Appendicitis is the most common cause of emergency abdominal surgeries in children. Ultrasound (US) has been proven to be a helpful imaging modality in patient evaluation, especially in children suspected of appendicitis. The Alvarado score is a 10-point scoring system for the diagnosis of appendicitis based on clinical data and differential leukocyte count. The aim of the present study was to evaluate a combination of clinical scoring (Alvarado score) and US findings for accurate diagnosis of appendicitis in children. The study was done in Menoufia University Hospitals from March 2011 to January 2013. 322 children with abdominal pain clinically suspected of having appendicitis were included in the study and clinically assessed to calculate the Alvarado score. Patients were referred to the radiology department for abdominal US. Among the 153 of the 322 patients who were operated on, 149 patients were diagnosed pre-operatively with acute appendicitis and 4 girls were diagnosed with complex ovarian cysts. Of the 149 patients diagnosed with appendicitis, the percentage of appendicitis was 93% (139/149) and 10 (7%) patients had normal appendix. The prevalence of appendicitis among the patients of the study was 43% (139/322). In conclusion, a combination of Alvarado scores and abdominal US is a good approach for the diagnosis of appendicitis in children to reduce the number of laparotomies for normal appendix. In the case of normal appendix or nonvisualization of the appendix via abdominal US without a high Alvarado score, appendicitis can be safely ruled out. If it is proven as an inflamed appendix on US or a high Alvarado score, patient should be subjected for appendectomy without delay. Keywords

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Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template

Cited by 81 publications

References 22 publications

Appendiceal ultrasound: the importance of determinacy

Appendiceal ultrasound: the importance of determinacy

Acute appendicitis

Combination of Alvarado score and ultrasound findings in diagnosis of acute appendicitis in children

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