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Pediatric appendicitis in "real-time": the value of sonography in diagnosis and treatment
1Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada. angelang@kkh.com.sg
Insights
Ultrasound is useful for diagnosing appendicitis in children, but accuracy can be reduced by factors like obesity and patient cooperation. Clinical judgment remains essential for accurate diagnosis and treatment.
Area of Science:
- Pediatric Emergency Medicine
- Diagnostic Imaging
- Abdominal Surgery
Background:
- Appendicitis is a common cause of acute abdominal pain in children.
- Clinical diagnosis of appendicitis can be challenging, especially in pediatric populations.
- Ultrasound is frequently used to evaluate suspected appendicitis when clinical diagnosis is uncertain.
Purpose of the Study:
- To assess the diagnostic accuracy of ultrasound for appendicitis in children with clinically equivocal presentations.
- To identify factors contributing to inaccurate ultrasound diagnoses of appendicitis.
- To evaluate the impact of ultrasound findings on the clinical management and outcomes of pediatric appendicitis cases.
Main Methods:
- Retrospective review of 317 children presenting with acute abdominal pain and suspected appendicitis.
- Children included had undergone ultrasound due to uncertain clinical diagnosis.
- Analysis of ultrasound results, clinical management decisions, and patient outcomes.
Main Results:
- Ultrasound demonstrated a positive predictive value of 0.92 and a negative predictive value of 0.88 for appendicitis.
- Sensitivity and specificity were indeterminate due to 43 cases with equivocal ultrasound results.
- Diagnostic accuracy was hindered by perforated appendicitis, retrocecal appendix, abdominal guarding, obesity, and patient cooperation.
- Combined clinical judgment and ultrasound led to minimal non-therapeutic laparotomies (5) and delayed surgeries (8).
Conclusions:
- Ultrasound is a valuable tool for evaluating acute abdominal pain in children.
- Accuracy and triage utility of ultrasound may be limited in pediatric emergency departments.
- Continued clinical assessment is crucial, and appendiceal CT scans may be necessary in select cases for definitive management guidance.
Objectives:
To determine the accuracy of sonography in the diagnosis of clinically equivocal appendicitis, and to identify the factors leading to an inaccurate ultrasound diagnosis. The impact of sonographic findings on clinical management and outcome of children with appendicitis is examined.
Methods:
We performed a retrospective review of 317 children who attended the emergency department (ED) of a children's hospital for acute abdominal pain for which acute appendicitis was the main differential diagnosis. They had ultrasound because the diagnosis was uncertain clinically.
Results:
The positive predictive value of ultrasound for appendicitis was 0.92, and the negative predictive value was 0.88. The sensitivity and specificity could not be determined because there were 43 patients with equivocal ultrasound results. The pitfalls hindering the accuracy of ultrasound diagnosis included a high incidence of perforated appendicitis at presentation, the retrocecal appendix, and other technical factors such as abdominal guarding, excessive bowel gas, obesity, inadequate bladder filling, and the uncooperative patient. When ultrasound findings were combined with clinical judgment in clinical management, there were only five cases of non-therapeutic laparotomy and eight cases of delayed surgery due to missed diagnosis in our cohort.
Conclusions:
Ultrasound is a useful for the evaluation of acute abdominal pain in children. However, in the setting of a pediatric hospital ED, the accuracy of ultrasound and its ability to improve early hospital triage may be reduced. Repeated clinical review is still essential and in selected cases, appendiceal CT scan may be required to guide therapeutic decision making.
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