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Published on: April 7, 2023
Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis
Suzanne Schuh1, Carina Man2, Eman Marie2
1Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
Insights
This study shows a new ultrasound-MRI pathway accurately diagnoses appendicitis in children, even after unclear initial ultrasounds. The rapid MRI approach significantly improves diagnostic accuracy in emergency settings.
Area of Science:
- Pediatric Emergency Medicine
- Diagnostic Imaging
- Radiology
Background:
- Appendicitis diagnosis in children often presents challenges in the emergency department.
- Ultrasound (US) is a common first-line imaging modality, but can yield non-diagnostic results.
- Accurate and timely diagnosis is crucial to prevent complications and unnecessary surgeries.
Purpose of the Study:
- To evaluate the diagnostic accuracy of a combined ultrasound-magnetic resonance imaging (US-MRI) clinical pathway.
- To assess the pathway's effectiveness in diagnosing appendicitis in pediatric patients presenting to the emergency department.
- To determine if the US-MRI pathway improves diagnostic accuracy following non-diagnostic ultrasounds.
Main Methods:
- A prospective cohort study involving 624 children aged 4-17 years with suspected appendicitis.
- Initial assessment included ultrasound (US) and clinical re-evaluation.
- Children with non-diagnostic US results underwent ultra-rapid MRI as part of the US-MRI pathway.
- Diagnostic accuracy was assessed based on clinical outcomes, including surgery and CT utilization.
Main Results:
- The US-MRI pathway demonstrated high clinical accuracy, with 98.6% of cases having accurate outcomes.
- Sensitivity was 100%, specificity 98.3%, positive predictive value 90.5%, and negative predictive value 100% for the pathway.
- Overall diagnostic accuracy for the entire algorithm across all patients was 98.7%.
Conclusions:
- The US-MRI pathway offers high clinical diagnostic accuracy for suspected pediatric appendicitis, particularly after non-diagnostic ultrasounds.
- This imaging strategy can reliably aid in the diagnosis of appendicitis in pediatric emergency settings.
- The study supports the integration of rapid MRI into diagnostic algorithms for pediatric appendicitis.
Objective:
to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED).
Study Design:
prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway.
Results:
150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT.
Conclusion:
this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.
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