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Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute
Naresh Ramarajan1, Rajesh Krishnamoorthi, Laleh Gharahbaghian
1Division of Emergency Medicicine, University of California Los Angeles, 924 Westwood Boulevard, Suite 300, Los Angeles, CA, 90095.
Insights
Many children with equivocal ultrasound for appendicitis can be safely observed at home without follow-up CT. This study assessed appendicitis prevalence and outcomes, finding observation safe for low-risk pediatric patients.
Area of Science:
- Pediatric radiology
- Emergency medicine
- Diagnostic imaging
Background:
- Follow-up computed tomography (CT) is often recommended for pediatric appendicitis after equivocal ultrasound (US) findings.
- Current practice regarding home observation versus follow-up CT for these cases is not well-documented.
- Limited data exist on the safety and prevalence of appendicitis in children with equivocal US managed with or without immediate follow-up CT.
Purpose of the Study:
- To determine the prevalence of acute appendicitis in pediatric patients with equivocal US.
- To evaluate outcomes for patients managed with and without follow-up CT.
- To identify factors associated with the decision to order a follow-up CT.
Main Methods:
- Retrospective analysis of pediatric patients (1-18 years) with equivocal US findings from 2003-2008.
- Utilized recursive partitioning and multivariate logistic regression to identify predictors of follow-up CT ordering.
- Compared appendicitis prevalence and patient outcomes based on CT follow-up status.
Main Results:
- 55% of children with equivocal US did not receive a follow-up CT; none returned with missed appendicitis.
- Overall appendicitis prevalence in equivocal US cases was 12.5%.
- Prevalence was 22.1% with follow-up CT versus 4.7% without. Predictors for CT included age >11, leukocytosis >15,000, and US signs of appendicitis.
Conclusions:
- Children with equivocal US and low risk for appendicitis can be safely observed.
- Observation and reassessment may be appropriate before resorting to further imaging (US or CT).
- This approach aids in judicious use of imaging, minimizing radiation exposure in pediatric appendicitis diagnosis.
Background:
Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.
Methods:
Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.
Results:
Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.
Conclusions:
We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.
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