The Effect of Abdominal Pain Duration on the Accuracy of Diagnostic Imaging for Pediatric Appendicitis

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

doi:10.1016/j.annemergmed.2012.05.034

Cited by 56 publications

(36 citation statements)

References 50 publications

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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: 66%

“…49,50 Despite previously reported inverse association between the use of diagnostic US and negative appendectomy rate in children, 26,51,52 this pathway was associated with a higher negative appendectomy rate than that reported in the two key U.S.-wide studies by Bachur and colleagues and other authors. 26,44,53 This difference may be in part explained by the high rate of hemorrhagic ovarian cysts (six of 14 negative appendectomies), which may mimic appendicitis on US 54 and one case of successfully managed ovarian torsion that required urgent operative management.…”

Section: Discussionmentioning

confidence: 99%

“…This difference may be in part explained by the difference in the criteria for equivocal US. For example, during our prospective application of previously published criteria 30 we have classified US with incomplete or no visualization of the appendix with no secondary signs of appendicitis as equivocal, 30 whereas Bachur and colleagues 44 classified these as negative.…”

Section: Discussionmentioning

confidence: 99%

“…A CT was required in only 3% of the equivocal USs. Bachur and colleagues 44 recently commented that serial examinations potentially followed by repeat US in well-appearing children with inconclusive US examinations represent an option to avoid overreliance on CT, especially in children with brief duration of abdominal pain.…”

Section: Discussionmentioning

confidence: 99%

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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: 66%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

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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“…As the accuracy of US increases with increased duration of symptoms; 14 after a period of observation a repeat US may provide additional information. In our study, 21% of children with repeat US had fully visualized appendices.…”

Section: Discussionmentioning

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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Clinical correlation needed: What do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis?

Ramarajan

Krishnamoorthi

Gharahbaghian

et al. 2014

J. Clin. Ultrasound

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The Effect of Abdominal Pain Duration on the Accuracy of Diagnostic Imaging for Pediatric Appendicitis

Cited by 56 publications

References 50 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

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

Clinical correlation needed: What do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis?

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