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Absolute neutrophil count as a diagnostic guide for the use of MRI in the workup of suspected appendicitis in children. J Pediatr Surg 2019; 54:1359-1364. [PMID: 30001891 DOI: 10.1016/j.jpedsurg.2018.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE To assess the additive value of magnetic resonance imaging (MRI) in the setting of an equivocal US (Eq-US) with or without an elevated absolute neutrophil count (ANC). METHODS Single-institution, retrospective review of children ages 5-18 years who presented to the ER with suspected appendicitis from 9/2015 to 8/2016. US, ANC, and MRI results were reviewed. Imaging was identified as positive/suspicious, normal, or equivocal and ANC <8000/mm3 was defined as normal. RESULTS 738 patients with a median age of 11 years (IQR 8-14) met inclusion criteria. US was equivocal in 61.4%. Among 304 (67.1%) patients with an Eq-US and normal ANC, only 5 (1.6%) had acute appendicitis. In contrast, 28 of 149 patients (18.8%) with Eq-US and elevated ANC had appendicitis. MRI was performed in 125 patients with Eq-US and was positive/suspicious in 2.9% (2/69) with normal ANC and 25.0% (14/56) with elevated ANC. MRI had 94.7% sensitivity and 100% specificity for acute appendicitis in patients with an Eq-US. CONCLUSIONS MRI has high sensitivity and specificity for diagnosing acute appendicitis in children. Patients with Eq-US plus a normal ANC have a very low likelihood of appendicitis and do not typically require further imaging. MRI may have utility for children with Eq-US and elevated ANC. LEVEL OF EVIDENCE Level III.
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Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, Feig BW, Fowler KJ, Kambadakone AR, Lambert DL, Levy AD, Marin D, Moreno C, Peterson CM, Scheirey CD, Siegel A, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol 2019; 15:S373-S387. [PMID: 30392606 DOI: 10.1016/j.jacr.2018.09.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
Appendicitis remains the most common surgical pathology responsible for right lower quadrant (RLQ) abdominal pain presenting to emergency departments in the United States, where the incidence continues to increase. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of experts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Brooks D Cash
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Harringa JB, Bracken RL, Davis JC, Mao L, Kitchin DR, Robbins JB, Ziemlewicz TJ, Pickhardt PJ, Reeder SB, Repplinger MD. Prospective evaluation of MRI compared with CT for the etiology of abdominal pain in emergency department patients with concern for appendicitis. J Magn Reson Imaging 2019; 50:1651-1658. [PMID: 30892788 DOI: 10.1002/jmri.26728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Computed tomography (CT) is commonly used in the Emergency Department (ED) to evaluate patients with abdominal pain, but exposes them to ionizing radiation, a possible carcinogen. MRI does not utilize ionizing radiation and may be an alternative. PURPOSE To compare the sensitivity of MRI and CT for acute abdominopelvic ED diagnoses. STUDY TYPE Prospective, observational cohort. POPULATION ED patients ≥12 years old and undergoing CT for possible appendicitis. FIELD STRENGTH/SEQUENCE 1.5 T MRI, including T1 -weighted, T2 -weighted, and diffusion-weighted imaging sequences. ASSESSMENT Three radiologists independently interpreted each MRI and CT image set separately and blindly, using a standard case report form. Assessments included likelihood of appendicitis, presence of an alternative diagnosis, and likelihood that the alternative diagnosis was causing the patient's symptoms. An expert panel utilized chart review and follow-up phone interviews to determine all final diagnoses. Times to complete image acquisition and image interpretation were also calculated. STATISTICAL TESTS Sensitivity was calculated for each radiologist and by consensus (≥2 radiologists in agreement) and are reported as point estimates with 95% confidence intervals. Two-sided hypothesis tests comparing the sensitivities of the three image types were conducted using Pearson's chi-squared test with the traditional significance level of P = 0.05. RESULTS There were 15 different acute diagnoses identified on the CT/MR images of 113 patients. Using individual radiologist interpretations, the sensitivities of noncontrast-enhanced MRI (NCE-MR), contrast-enhanced MR (CE-MR), and CT for any acute diagnosis were 77.0% (72.6-81.4%), 84.2% (80.4-88.0%), and 88.7% (85.5-92.1%). Sensitivity of consensus reads was 82.0% (74.9-88.9%), 87.1% (81.0-93.2%), 92.2% (87.3-97.1%), respectively. There was no difference in sensitivities between CE-MR and CT by individual (P = 0.096) or consensus interpretations (P = 0.281), although NCE-MR was inferior to CT in both modes of analysis (P < 0.001, P = 0.031, respectively). DATA CONCLUSION The sensitivity of CE-MR was similar to CT when diagnosing acute, nontraumatic abdominopelvic pathology in our cohort. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1651-1658.
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Affiliation(s)
- John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - John C Davis
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Lu Mao
- Department of Biostatistics and Medical Informatics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Douglas R Kitchin
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Timothy J Ziemlewicz
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
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54
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Mervak BM, Wilson SB, Handly BD, Altun E, Burke LM. MRI of acute appendicitis. J Magn Reson Imaging 2019; 50:1367-1376. [PMID: 30883988 DOI: 10.1002/jmri.26709] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/21/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Benjamin M. Mervak
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
| | - Sarah B. Wilson
- University of North Carolina Radiology Residency Program Chapel Hill North Carolina USA
| | - Brian D. Handly
- University of North Carolina Department of RadiologyDivision of Pediatric Imaging Chapel Hill North Carolina USA
| | - Ersan Altun
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
| | - Lauren M. Burke
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
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Mushtaq R, Desoky SM, Morello F, Gilbertson-Dahdal D, Gopalakrishnan G, Leetch A, Vedantham S, Kalb B, Martin DR, Udayasankar UK. First-Line Diagnostic Evaluation with MRI of Children Suspected of Having Acute Appendicitis. Radiology 2019; 291:170-177. [PMID: 30747595 DOI: 10.1148/radiol.2019181959] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Advances in abdominal MRI have enabled rapid, free-breathing imaging without the need for intravenous or oral contrast material. The use of MRI as the primary imaging modality for suspected appendicitis has not been previously studied. Purpose To determine the diagnostic performance of MRI as the initial imaging modality in children suspected of having acute appendicitis. Materials and Methods The study included consecutive patients 18 years of age and younger presenting with acute abdominal pain at a tertiary care institution from January 2013 through June 2016 who subsequently underwent an unenhanced MRI examination as the primary diagnostic imaging modality. Electronic medical records and radiology reports were retrospectively evaluated for the feasibility and diagnostic performance of MRI, with surgical pathology and follow-up electronic records as reference standards. Statistical analyses were performed by using simple binomial proportions to quantify sensitivity, specificity, and accuracy, and exact 95% confidence intervals (CIs) were obtained. Results After exclusions, 402 patients (median age: 13 years; interquartile range [IQR], 9-15 years; 235 female patients; 167 male patients) were included. Sedation for MRI was required in 13 of 402 patients (3.2%; 95% CI: 1.7%, 5.5%). The appendix was visualized in 349 of 402 patients (86.8%; 95% CI: 83.1%, 90%); for the remaining patients, a diagnosis was provided on the basis of secondary signs of appendicitis. The sensitivity, specificity, and accuracy of MRI as the primary diagnostic imaging modality for the evaluation of acute appendicitis were 97.9% (95 of 97; 95% CI: 92.8%, 99.8%), 99% (302 of 305; 95% CI: 97.2%, 99.8%), and 98.8% (397 of 402; 97.1%, 99.6%), respectively. Among patients with negative findings for appendicitis at MRI, an alternate diagnosis was provided in 113 of 304 patients (37.2%; 95% CI: 31.7%, 42.9%). Conclusion When performed as the initial imaging modality in children suspected of having acute appendicitis, MRI examinations had high diagnostic performance for the diagnosis of acute appendicitis and in providing alternative diagnoses. © RSNA, 2019 See also the editorial by Dillman and Trout in this issue.
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Affiliation(s)
- Raza Mushtaq
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Sarah M Desoky
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Frank Morello
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Dorothy Gilbertson-Dahdal
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Geetha Gopalakrishnan
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Aaron Leetch
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Srinivasan Vedantham
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Bobby Kalb
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Diego R Martin
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Unni K Udayasankar
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
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56
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Roh AT, Xiao Z, Cheng JY, Vasanawala SS, Loening AM. Conical ultrashort echo time (UTE) MRI in the evaluation of pediatric acute appendicitis. Abdom Radiol (NY) 2019; 44:22-30. [PMID: 30066168 DOI: 10.1007/s00261-018-1705-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) sequences with conical k-space trajectories are able to decrease motion artifacts while achieving ultrashort echo times (UTE). We assessed the performance of free-breathing conical UTE MRI in the evaluation of the pediatric pelvis for suspected appendicitis. METHODS Our retrospective review of 84 pediatric patients who underwent MRI for suspected appendicitis compared three contrast-enhanced sequences: free-breathing conical UTE, breath-hold three-dimensional (3D) spoiled gradient echo (BH-SPGR), and free-breathing high-resolution 3D SPGR (FB-SPGR). Two radiologists performed blinded and independent evaluations of each sequence for image quality (four point scale), anatomic delineation (four point scale), and diagnostic confidence (five point scale). Subsequently, the three sequences were directly compared for overall image quality (- 3 to + 3 scale). Scores were compared using Kruskal-Wallis and Wilcoxon signed-rank tests. RESULTS UTE demonstrated significantly better perceived signal-to-noise ratio (SNR) and fewer artifacts than BH-SPGR and FB-SPGR (means of 3.6 and 3.4, 3.4 and 3.2, 3.1 and 2.7, respectively; p < 0.0006). BH-SPGR and FB-SPGR demonstrated significantly better contrast than UTE (means of 3.6, 3.4, and 3.2, respectively; p < 0.03). In the remaining categories, UTE performed significantly better than FB-SPGR (p < 0.00001), while there was no statistical difference between UTE and BH-SPGR. Direct paired comparisons of overall image quality demonstrated the readers significantly preferred UTE over both BH-SPGR (mean + 0.5, p < 0.00001) and FB-SPGR (mean + 1.2, p < 0.00001). CONCLUSIONS In the evaluation of suspected appendicitis, free-breathing conical UTE MRI performed better in the assessed metrics than FB-SPGR. When compared to BH-SPGR, UTE demonstrated superior perceived SNR and fewer artifacts.
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Affiliation(s)
- Albert T Roh
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Zhibo Xiao
- Radiology, First Affiliated Hospital, Chongqing, China
| | - Joseph Y Cheng
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | | | - Andreas M Loening
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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57
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Abstract
The diagnosis of pediatric appendicitis can be difficult, with a substantial proportion misdiagnosed based on clinical features and laboratory tests alone. Accordingly, advanced imaging with ultrasound (US), computed tomography (CT), and/or magnetic resonance imaging has become routine for most children undergoing diagnostic evaluation for appendicitis. There is increasing interest in the use of US as the primary imaging modality and reserving CT as a secondary diagnostic modality in equivocal cases. Magnetic resonance imaging, using a rapid protocol, without contrast or sedation, has been found to be highly sensitive and specific in the evaluation of children with acute right lower quadrant pain in a number of studies. Because magnetic resonance imaging has the advantage over CT of not using contrast or ionizing radiation, it may replace CT in many instances, whether after US as part of a stepwise imaging algorithm or as a primary imaging modality. Accessibility and cost, however, limit its more widespread use currently.
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58
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Kennedy TM, Thompson AD, Choudhary AK, Caplan RJ, Schenker KE, DePiero AD. Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis. Am J Emerg Med 2018; 37:1723-1728. [PMID: 30587395 DOI: 10.1016/j.ajem.2018.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/17/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs). METHODS A retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 109/L. RESULTS Of the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively. CONCLUSIONS In pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.
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Affiliation(s)
- Thomas M Kennedy
- Division of Emergency Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Amy D Thompson
- Division of Emergency Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Arabinda K Choudhary
- Department of Radiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Richard J Caplan
- Value Institute, Christiana Care Health System, Newark, DE, USA.
| | - Kathleen E Schenker
- Department of Radiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Andrew D DePiero
- Division of Emergency Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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Wi SA, Kim DJ, Cho ES, Kim KA. Diagnostic performance of MRI for pregnant patients with clinically suspected appendicitis. Abdom Radiol (NY) 2018; 43:3456-3461. [PMID: 29869102 DOI: 10.1007/s00261-018-1654-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant patients and the value of additional diffusion-weighted MRI (DWI). METHODS A total of 125 pregnant patients with clinically suspected appendicitis who underwent 1.5 T MRI were enrolled between May 2011 and January 2016. During this period, two radiologists prospectively predicted acute appendicitis on MRI during daily interpretation. We retrospectively reviewed clinical records, and radiological results were correlated with surgical pathology and clinical outcomes. We calculated the sensitivity, specificity, and accuracy of MRI for diagnosing acute appendicitis. We performed additional DWI between August 2014 and January 2016, and we calculated sensitivity, specificity, and accuracy of MRI with or without DWI. RESULTS The sensitivity, specificity, and accuracy of MRI for acute appendicitis were 100%, 95%, and 96%, respectively. The sensitivity, specificity, and accuracy of MRI without DWI (n = 72) vs. with DWI (n = 53) were 100%, 94.7%, and 95.8% versus 100%, 95%, and 96%, respectively. CONCLUSIONS MRI has high accuracy for the diagnosis of acute appendicitis in pregnant patients. Therefore, MRI is recommended for use as a first-line diagnostic test for pregnant patients with clinically suspected appendicitis.
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Affiliation(s)
- Sung Ah Wi
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea
| | - Dae Jung Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea.
| | - Eun-Suk Cho
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Kyoung Ah Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea
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Thrombophlebitis of the Right Renal Capsular Vein during the Early Postpartum Period. Case Rep Obstet Gynecol 2018; 2018:3096468. [PMID: 30402311 PMCID: PMC6198557 DOI: 10.1155/2018/3096468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/25/2018] [Indexed: 11/18/2022] Open
Abstract
Venous thrombophlebitis is an uncommon cause of fever and lower abdominal pain during the early postpartum period. It mostly occurs in the right ovarian vein, and computed tomography (CT) is useful for diagnosis. We present a case of thrombophlebitis of the renal capsular vein. A 27-year-old postpartum woman presented with right lower abdominal pain and fever unresponsive to antibiotics. Contrast CT showed a ring-enhancing mass in the right retroperitoneum, which was distinct from the right ovarian vein. Exploratory laparoscopy revealed a retroperitoneal hematoma and normal appendix. Reconstruction of CT images revealed that the mass was connected to the right renal capsular vein. Anticoagulation therapy improved the patient's symptoms. Postpartum thrombophlebitis can occur at locations other than the ovarian vein, such as the renal capsular vein. If a retroperitoneal mass is discovered during puerperium, a thorough investigation of the mass's continuity with surrounding vessels is essential to avoid unnecessary surgery.
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MRI of the Nontraumatic Acute Abdomen: Description of Findings and Multimodality Correlation. Gastroenterol Clin North Am 2018; 47:667-690. [PMID: 30115443 DOI: 10.1016/j.gtc.2018.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Obtaining a specific diagnosis in the nontraumatic acute abdomen can be clinically challenging, because a wide range of disease processes affecting a number of different organ systems may have very similar presentations. Although computed tomography and ultrasound examination are the imaging tests most commonly used to evaluate the acute abdomen, MRI can often offer comparable diagnostic performance, and may be considered when other modalities are equivocal, suboptimal, or contraindicated. In some circumstances, MRI is emerging as an appropriate first-line imaging test.
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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
OBJECTIVE Diagnosing pediatric appendicitis is difficult because clinical findings are nonspecific. Improved accuracy can be obtained with ultrasound (US), CT, or MRI, despite considerable variation in their use at different institutions. This article reviews the evidence for best practices in imaging pediatric appendicitis. CONCLUSION When each modality is optimally used, a stepwise imaging approach that begins with graded compression US and proceeds to CT or MRI in select cases is currently best practice.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix. Am J Emerg Med 2018; 37:879-883. [PMID: 30097276 DOI: 10.1016/j.ajem.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.
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Affiliation(s)
- Laurie Malia
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Jesse J Sturm
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Sharon R Smith
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | - Henry Chicaiza
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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Laparoscopic Appendectomy in Pregnancy With Acute Appendicitis: Single Center Experience With World Review. Surg Laparosc Endosc Percutan Tech 2018; 27:460-464. [PMID: 28984719 DOI: 10.1097/sle.0000000000000478] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This clinical study is aiming to discuss the therapeutic benefit of laparoscopic appendectomy (LA) by comparing with conventional open appendectomy (OA) in pregnancy. MATERIALS AND METHODS The clinical data of 26 pregnant women who underwent appendectomy from 2012 to 2016 was retrospectively analyzed. The variables analyzed included baseline information, operation characteristics, maternal complications, and infant health outcomes. The patients were divided in 2 LA and OA groups according to the surgical approach and their clinical characteristics were compared. RESULTS Of reported 26 patients, 7 underwent LA whereas the remaining 19 patients underwent OA. The median age of the patients was 28 years (range, 19 to 39 y). The median gestational period was 21.5 weeks (range, 5 to 33 wk). The postoperative pathology showed complicated appendicitis 7 cases. The result showed significantly shorter operation time (42.14±8.63 vs. 65.21±26.58 min, P=0.003), hospital stay (4.14±1.77 vs. 6.47±2.72 d, P=0.021), and earlier recovery of gastrointestinal function in the LA group compared with OA group. There were no maternal and fetal deaths occurred in perioperative period in both groups. CONCLUSIONS LA has not increased morbidity and mortality but displayed shorter hospital stay, operation time and recovery of gastrointestinal function to OA as well as good cosmetic results. Therefore, LA in patients with pregnancy can be considered as preferred approach in sophisticated hands without increased risks.
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Visibility of Normal Appendix on CT, MRI, and Sonography: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2018; 211:W140-W150. [PMID: 30040469 DOI: 10.2214/ajr.17.19321] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of the present study is to assess the visibility of the normal appendix on CT, MRI, or ultrasound (US) images of a healthy population. MATERIALS AND METHODS The MEDLINE and EMBASE databases were searched to identify articles on the rates of detection of a normal appendix on CT, MRI, or US that appeared in the literature published up to January 20, 2017. Pooled detection rates were assessed using random-effects modeling, and rates associated with different imaging modalities were compared. Meta-regression analyses were performed to assess factors influencing detection rates and heterogeneity. RESULTS Thirty-two studies (21 CT studies with 5296 patients, 7 MRI studies with 600 patients, and 4 US studies with 1221 patients) were included in our meta-analysis. The overall normal appendix detection rate tended to be highest for CT (84%), followed by US (71%) and MR (69%), but no statistically significant differences were noted (for CT vs MRI, p = 0.16; for CT vs US, p = 0.23; and for MRI vs US, p = 0.91). Meta-regression analyses of the appendix detection rate with CT revealed that the year of publication of the study, the number of CT channels, and slice thickness affected study heterogeneity. CONCLUSION Normal appendixes seemed to be more visible on CT than on MRI or US, although this finding did not have statistical significance. With respect to CT, detection of normal appendixes was significantly better when more channels and thinner slices were used.
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Suspicion of appendicitis in pregnant women: emergency evaluation by sonography and low-dose CT with oral contrast. Eur Radiol 2018; 29:345-352. [PMID: 29948087 DOI: 10.1007/s00330-018-5573-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS • In pregnant women, US is limited by an important number of indeterminate results • Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women • An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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Repplinger MD, Pickhardt PJ, Robbins JB, Kitchin DR, Ziemlewicz TJ, Hetzel SJ, Golden SK, Harringa JB, Reeder SB. Prospective Comparison of the Diagnostic Accuracy of MR Imaging versus CT for Acute Appendicitis. Radiology 2018; 288:467-475. [PMID: 29688158 DOI: 10.1148/radiol.2018171838] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose To compare the accuracy of magnetic resonance (MR) imaging with that of computed tomography (CT) for the diagnosis of acute appendicitis in emergency department (ED) patients. Materials and Methods This was an institutional review board-approved, prospective, observational study of ED patients at an academic medical center (February 2012 to August 2014). Eligible patients were nonpregnant and 12- year-old or older patients in whom a CT study had been ordered for evaluation for appendicitis. After informed consent was obtained, CT and MR imaging (with non-contrast material-enhanced, diffusion-weighted, and intravenous contrast-enhanced sequences) were performed in tandem, and the images were subsequently retrospectively interpreted in random order by three abdominal radiologists who were blinded to the patients' clinical outcomes. Likelihood of appendicitis was rated on a five-point scale for both CT and MR imaging. A composite reference standard of surgical and histopathologic results and clinical follow-up was used, arbitrated by an expert panel of three investigators. Test characteristics were calculated and reported as point estimates with 95% confidence intervals (CIs). Results Analysis included images of 198 patients (114 women [58%]; mean age, 31.6 years ± 14.2 [range, 12-81 years]; prevalence of appendicitis, 32.3%). The sensitivity and specificity were 96.9% (95% CI: 88.2%, 99.5%) and 81.3% (95% CI: 73.5%, 87.3%) for MR imaging and 98.4% (95% CI: 90.5%, 99.9%) and 89.6% (95% CI: 82.8%, 94.0%) for CT, respectively, when a cutoff point of 3 or higher was used. The positive and negative likelihood ratios were 5.2 (95% CI: 3.7, 7.7) and 0.04 (95% CI: 0, 0.11) for MR imaging and 9.4 (95% CI: 5.9, 16.4) and 0.02 (95% CI: 0.00, 0.06) for CT, respectively. Receiver operating characteristic curve analysis demonstrated that the optimal cutoff point to maximize accuracy was 4 or higher, at which point there was no difference between MR imaging and CT. Conclusion The diagnostic accuracy of MR imaging was similar to that of CT for the diagnosis of acute appendicitis.
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Affiliation(s)
- Michael D Repplinger
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Perry J Pickhardt
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Jessica B Robbins
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Douglas R Kitchin
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Tim J Ziemlewicz
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott J Hetzel
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Sean K Golden
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - John B Harringa
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott B Reeder
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
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Foley WD. CT Features for Complicated versus Uncomplicated Appendicitis: What Is the Evidence? Radiology 2018; 287:116-118. [PMID: 29558303 DOI: 10.1148/radiol.2018180022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- W Dennis Foley
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, Wis 53226
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70
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Abstract
Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.
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Affiliation(s)
- Amy L Puchalski
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Christyn Magill
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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71
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Riley R, Murphy J, Higgins T. MRI imaging in pediatric appendicitis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Jung JY, Na JU, Han SK, Choi PC, Lee JH, Shin DH. Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients. World J Emerg Med 2018; 9:26-32. [PMID: 29290892 DOI: 10.5847/wjem.j.1920-8642.2018.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Accurate and timely diagnosis of acute surgical disease in pregnant patient is challenging. Although magnetic resonance imaging (MRI) is the most accurate modality to diagnose acute appendicitis in pregnant patients, it is often used as a last resort because of high cost and long scan time. We performed this study to analyze differential diagnoses of appendix MRI and to investigate if there are any blood tests that can predict surgical condition in pregnant patients. METHODS A retrospective, cross-sectional study was conducted on 46 pregnant patients who underwent non-enhanced appendix MRI in suspicion of acute appendicitis from 2010 to 2016. Differential diagnoses of appendix MRI were analyzed and blood tests were compared between those who had surgical and non-surgical disease. RESULTS Appendix MRI differentiated two surgical disease; acute appendicitis and ovarian torsion; and various non-surgical conditions such as uterine myoma, hydronephrosis, ureterolithiasis and diverticulitis among clinically suspected acute appendicitis in pregnancy. The diagnostic accuracy of MRI for acute appendicitis in this study was 93.5%. Patients who had surgical disease showed significantly higher WBC count (≥11,000/mm3), proportion of neutrophils in the WBC (≥79.9%), neutrophil-to-lymphocyte ratio (NLR≥6.4), levels of C-reactive protein (CRP≥1.82 mg/dL) and bilirubin (≥0.66 mg/dL) than those who had non-surgical disease. CONCLUSION MRI can reliably differentiate surgical conditions and several blood tests (WBC, proportion of neutrophils in the WBC, NLR, CRP, bilirubin) can help anticipate acute surgical condition among pregnant patients suspected to have acute appendicitis.
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Affiliation(s)
- Ji Yong Jung
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Ung Na
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Kuk Han
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pil Cho Choi
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jang Hee Lee
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyuk Shin
- Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Schuh AM, Klein EJ, Allred RJ, Christensen A, Brown J. Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem. J Emerg Med 2018; 54:131-132. [DOI: 10.1016/j.jemermed.2017.08.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/11/2017] [Indexed: 11/15/2022]
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Martin JF, Mathison DJ, Mullan PC, Otero HJ. Secondary imaging for suspected appendicitis after equivocal ultrasound: time to disposition of MRI compared to CT. Emerg Radiol 2017; 25:161-168. [PMID: 29249008 DOI: 10.1007/s10140-017-1570-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 12/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to compare MRI to CT as a secondary imaging modality for children age 5 years and older with suspected appendicitis after an equivocal abdominal ultrasound in terms of (1) the time to ED disposition decision, (2) surgery consultation rate, and (3) imaging test accuracy. METHODS We retrospectively studied children with suspected appendicitis and equivocal ultrasound results who underwent MR or CT as secondary imaging in a pediatric emergency department over two-consecutive 9-month periods. No oral or intravenous contrast was utilized for MRI. No sedation was utilized for any modality. Time of disposition is the time to admission or discharge order. RESULTS Twenty-five patients underwent CT and 30 underwent MRI, with no significant difference in the median time from ultrasound to disposition between the CT (5.9 h, IQR 4.5, 8.4) and the MRI (5.9 h, IQR 4.6, 6.9) groups (p = 0.65). Fifteen patients had appendicitis. Of the 40 negative or equivocal studies, surgery was consulted for 79% in the CT and 48% in the MRI group (odds ratio 4.12, 95% CI 1.02-16.67). Diagnostic accuracy was as follows: MRI: sensitivity of 90%, specificity of 97.1%, positive predictive value of 90%, and negative predictive value of 97.1%. Abdominal CT: sensitivity of 88%, specificity of 98.6%, positive predictive value of 95.7%, and negative predictive value of 95.8%. CONCLUSION MRI is a feasible alternative to CT for secondary imaging in acute appendicitis for showing comparable ED throughput metrics and diagnostic accuracy, with added benefits of reduced radiation and avoidance of intravenous contrast.
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Affiliation(s)
- James F Martin
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - David J Mathison
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - Paul C Mullan
- Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Boulevard, Philadelphia, PA, 20910, USA.
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Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis. Radiology 2017; 286:1022-1029. [PMID: 29156146 DOI: 10.1148/radiol.2017162755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose To establish, in a large cohort, the diagnostic performance of a staged algorithm involving ultrasonography (US) followed by conditional unenhanced magnetic resonance (MR) imaging for the imaging work-up of pediatric appendicitis. Materials and Methods A staged imaging algorithm in which US and unenhanced MR imaging were performed in pediatric patients suspected of having appendicitis was implemented at the authors' institution on January 1, 2011, with US as the initial modality followed by unenhanced MR imaging when US findings were equivocal. A search of the radiology database revealed 2180 pediatric patients who had undergone imaging for suspected appendicitis from January 1, 2011, through December 31, 2012. Of the 2180 patients, 1982 (90.9%) were evaluated according to the algorithm. The authors reviewed the electronic medical records and imaging reports for all patients. Imaging reports were reviewed and classified as positive, negative, or equivocal for appendicitis and correlated with surgical and pathology reports. Results The frequency of appendicitis was 20.5% (407 of 1982 patients). US alone was performed in 1905 of the 1982 patients (96.1%), yielding a sensitivity of 98.7% (386 of 391 patients) and specificity of 97.1% (1470 of 1514 patients) for appendicitis. Seventy-seven patients underwent unenhanced MR imaging after equivocal US findings, yielding an overall algorithm sensitivity of 98.2% (400 of 407 patients) and specificity of 97.1% (1530 of 1575 patients). Seven of the 1982 patients (0.4%) had false-negative results with the staged algorithm. The negative predictive value of the staged algorithm was 99.5% (1530 of 1537 patients). Conclusion A staged algorithm of US and unenhanced MR imaging for pediatric appendicitis appears to be effective. The results of this study demonstrate that this staged algorithm is 98.2% sensitive and 97.1% specific for the diagnosis of appendicitis in pediatric patients. © RSNA, 2017.
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Affiliation(s)
- Elizabeth H Dibble
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - David W Swenson
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Claudia Cartagena
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Grayson L Baird
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Thaddeus W Herliczek
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
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Skubic JJ, Salim A. Emergency general surgery in pregnancy. Trauma Surg Acute Care Open 2017; 2:e000125. [PMID: 29766116 PMCID: PMC5887777 DOI: 10.1136/tsaco-2017-000125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/20/2017] [Accepted: 08/28/2017] [Indexed: 01/07/2023] Open
Abstract
It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.
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Affiliation(s)
- Jeffrey J Skubic
- Division of Trauma, Burn and Surgical Critical Care, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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77
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Pediatric Emergency MRI: What You Need to Know to Make It Through the Night. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0248-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shin I, Chung YE, An C, Lee HS, Kim H, Lim JS, Kim MJ. Optimisation of the MR protocol in pregnant women with suspected acute appendicitis. Eur Radiol 2017; 28:514-521. [PMID: 28894912 DOI: 10.1007/s00330-017-5038-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the optimal magnetic resonance (MR) imaging protocol in pregnant women suspected of having acute appendicitis. MATERIALS AND METHODS One hundred and forty-six pregnant women with suspected appendicitis were included. MR images were reviewed by two radiologists in three separate sessions. In session 1, only axial single-shot turbo spin echo (SSH-TSE) T2-weighted images (WI) were included with other routine sequences. In sessions 2 and 3, coronal and sagittal T2WI were sequentially added. The visibility of the appendix and diagnostic confidence of appendicitis were evaluated in each session using a 5-point grading scale. If diseases other than appendicitis were suspected, specific diagnosis with a 5-point confidence scale was recorded. Diagnostic performance for appendicitis and other diseases were evaluated. RESULTS Twenty-five patients (17.1%) were diagnosed with appendicitis. Among the patients with normal appendix, 28 were diagnosed with other disease. Diagnostic performance including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve values for diagnosing appendicitis and other diseases showed no significant difference among sets for both reviewers (p>0.05). CONCLUSION Diagnostic performance of MR in pregnant patients with suspected appendicitis can be preserved with omission of sagittal or both coronal and sagittal SSH-T2WI. KEY POINTS • Diagnostic performance of appendicitis is preserved with omission of sagittal/coronal T2WIs. • Diagnosis of other disease may be sufficient with axial T2WIs only. • Careful serial omission of sagittal and coronal T2WIs can be considered.
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Affiliation(s)
- Ilah Shin
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Chansik An
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Honsoul Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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Kim JR, Suh CH, Yoon HM, Jung AY, Lee JS, Kim JH, Lee JY, Cho YA. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: A systematic review and meta-analysis. J Magn Reson Imaging 2017; 47:767-778. [PMID: 28815859 DOI: 10.1002/jmri.25825] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/10/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To evaluate in pediatric patients the diagnostic performance of magnetic resonance imaging (MRI) for suspected appendicitis and its negative appendectomy rate. MATERIALS AND METHODS The study involved diagnostic accuracy studies that used MRI for pediatric patients with suspected appendicitis. Various field strengths and sequences were used in each included study. The diagnostic accuracy of MRI in pediatric patients with suspected appendicitis and negative appendectomy rate were assessed. A search of MEDLINE and EMBASE databases was performed until January 10, 2017. Two reviewers assessed the methodological quality of the articles using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Pooled sensitivity and specificity for appendicitis diagnosis were calculated using hierarchical logistic regression modeling. Meta-regression was performed to explore factors affecting study heterogeneity. The pooled negative appendectomy rate was analyzed. RESULTS Thirteen original articles with 1946 patients were included. The summary sensitivity and specificity were 97% (95% confidence interval [CI], 95-98%) and 97% (95% CI, 93-98%), respectively; the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.97-0.99). In meta-regression, use of diffusion-weighted imaging (P < 0.01) and age (P < 0.01) affected heterogeneity, but there was no difference according to intravenous contrast agent use (P = 0.95). The pooled negative appendectomy rate of MRI was 4.5% (95% CI, 1.9-7.1%). CONCLUSION MRI shows excellent diagnostic performance for appendicitis in pediatric patients regardless of the use of intravenous contrast media. Therefore, nonenhanced-only MRI protocols might be appropriate for pediatric patients with suspected appendicitis. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:767-778.
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Affiliation(s)
- Jeong Rye Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology, Namwon Medical Center, Jeollabuk-do, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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80
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Diagnostic Accuracy of MRI Versus CT for the Evaluation of Acute Appendicitis in Children and Young Adults. AJR Am J Roentgenol 2017; 209:911-919. [PMID: 28796552 DOI: 10.2214/ajr.16.17413] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Appendicitis is frequently diagnosed in the emergency department, most commonly using CT. The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced MRI with that of contrast-enhanced CT for the diagnosis of appendicitis in adolescents when interpreted by abdominal radiologists and pediatric radiologists. SUBJECTS AND METHODS Our study included a prospectively enrolled cohort of 48 patients (12-20 years old) with nontraumatic abdominal pain who underwent CT and MRI. Fellowship-trained abdominal and pediatric radiologists reviewed all CT and MRI studies in randomized order, blinded to patient outcome. Likelihood for appendicitis was rated on a 5-point scale (1, definitely not appendicitis; 5, definitely appendicitis) for CT, the unenhanced portion of the MRI, and the entire contrast-enhanced MRI study. ROC curves were generated and AUC compared for each scan type for all six readers and then stratified by radiologist type. Image test characteristics, interrater reliability, and reading times were compared. RESULTS Sensitivity and specificity were 85.9% (95% CI, 76.2-92.7%) and 93.8% (95% CI, 89.7-96.7%) for unenhanced MRI, 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for contrast-enhanced MRI, and 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for CT. No difference was found in the diagnostic accuracy or interpretation time when comparing abdominal radiologists to pediatric radiologists (CT, 3.0 min vs 2.8 min; contrast-enhanced MRI, 2.4 min vs 1.8 min; unenhanced MRI, 1.5 min vs 2.3 min). Substantial agreement between abdominal and pediatric radiologists was seen for all methods (κ = 0.72-0.83). CONCLUSION The diagnostic accuracy of MRI to diagnose appendicitis was very similar to CT. No statistically significant difference in accuracy was observed between imaging modality or radiologist subspecialty.
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81
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Knoepp US, Mazza MB, Chong ST, Wasnik AP. MR Imaging of Pelvic Emergencies in Women. Magn Reson Imaging Clin N Am 2017; 25:503-519. [PMID: 28668157 DOI: 10.1016/j.mric.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zani A, Teague WJ, Clarke SA, Haddad MJ, Khurana S, Tsang T, Nataraja RM. Can common serum biomarkers predict complicated appendicitis in children? Pediatr Surg Int 2017; 33:799-805. [PMID: 28456849 DOI: 10.1007/s00383-017-4088-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis. METHODS Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)]. RESULTS Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 109/L in 58% CA and 43% SA (p < 0.0001). CONCLUSIONS Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
| | - Warwick J Teague
- Paediatric Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Simon A Clarke
- Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Munther J Haddad
- Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sanjeev Khurana
- Paediatric Surgery, Adelaide Women's and Children's Hospital, Adelaide, Australia
| | - Thomas Tsang
- Paediatric Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Ramesh M Nataraja
- Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia.,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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83
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Sartelli M, Catena F, Abu-Zidan FM, Ansaloni L, Biffl WL, Boermeester MA, Ceresoli M, Chiara O, Coccolini F, De Waele JJ, Di Saverio S, Eckmann C, Fraga GP, Giannella M, Girardis M, Griffiths EA, Kashuk J, Kirkpatrick AW, Khokha V, Kluger Y, Labricciosa FM, Leppaniemi A, Maier RV, May AK, Malangoni M, Martin-Loeches I, Mazuski J, Montravers P, Peitzman A, Pereira BM, Reis T, Sakakushev B, Sganga G, Soreide K, Sugrue M, Ulrych J, Vincent JL, Viale P, Moore EE. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017; 12:22. [PMID: 28484510 PMCID: PMC5418731 DOI: 10.1186/s13017-017-0132-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022] Open
Abstract
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
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Affiliation(s)
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | | | - Marco Ceresoli
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Osvaldo Chiara
- Emergency Department, Trauma Center, Niguarda Hospital, Milan, Italy
| | - Federico Coccolini
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Hannover, Germany
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Ewen A Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, AB Canada
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Francesco M Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, Dublin, Ireland
| | - John Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, St. Louis, MO USA
| | - Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Emergency post-operative Department, Otavio De Freitas Hospital and Osvaldo Cruz Hospital Recife, Recife, Brazil
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michael Sugrue
- Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Jan Ulrych
- 1st Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Praha, Czech Republic
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver, CO USA
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84
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Systematic Review Classification. AJR Am J Roentgenol 2017; 208:W195. [PMID: 28436698 DOI: 10.2214/ajr.16.17644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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85
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Fullerton K, Depinet H, Iyer S, Hall M, Herr S, Morton I, Lee T, Melzer-Lange M. Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments. Acad Emerg Med 2017; 24:400-409. [PMID: 28039951 DOI: 10.1111/acem.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. METHODS This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. RESULTS In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). CONCLUSION Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.
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Affiliation(s)
| | - Holly Depinet
- Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Sujit Iyer
- Dell Children's Medical Center; Austin TX
| | - Matt Hall
- Children's Hospital Association; Overland Park KS
| | | | - Inge Morton
- Children's Hospital Los Angeles; Los Angeles CA
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86
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Diagnostic utility of intravenous contrast for MR imaging in pediatric appendicitis. Pediatr Radiol 2017; 47:398-403. [PMID: 28108797 DOI: 10.1007/s00247-016-3775-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/23/2016] [Accepted: 12/23/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is increasingly employed as a diagnostic modality for suspected appendicitis in children. However, there is uncertainty as to which MRI sequences are sufficient for safe, timely and accurate diagnosis. Several recent studies have described different MRI protocols, including exams both with and without the use of intravenous contrast. OBJECTIVE We hypothesized that intravenous contrast may be useful in some patients but could be safely omitted in others. MATERIALS AND METHODS All MRI examinations (n=112) performed at our institution for evaluating appendicitis in children were retrospectively reevaluated. Exams were reread by pediatric radiologists under three conditions: With postcontrast images, Without postcontrast images, and Without/With - selective use of postcontrast sequences only when needed for diagnostic certainty. Samples were scored as positive, negative or equivocal for appendicitis. Findings were compared to pathological or clinical follow-up in the medical record. RESULTS Without the use of intravenous contrast yielded more equivocal results (12.4%) compared to With contrast (3.4%). By selectively using postcontrast sequences, the Without/With group yielded fewer equivocal results (1.1%) compared to Without while also reducing contrast use 79.8% compared to the With contrast group. No significant differences in conditional sensitivity or conditional specificity were detected among the three groups. CONCLUSION MRI diagnosis of acute appendicitis can be performed without contrast for most patients; injection of contrast can be reserved for only those patients with equivocal non-contrast imaging.
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87
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Guterman S, Mandelbrot L, Keita H, Bretagnol F, Calabrese D, Msika S. Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies. J Gynecol Obstet Hum Reprod 2017; 46:417-422. [PMID: 28934085 DOI: 10.1016/j.jogoh.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. MATERIAL AND METHODS Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. RESULTS The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. CONCLUSION Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.
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Affiliation(s)
- S Guterman
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France
| | - L Mandelbrot
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France.
| | - H Keita
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service d'anesthésie-réanimation, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - F Bretagnol
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - D Calabrese
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - S Msika
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
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Abstract
Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.
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89
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Tez M. CT or MRI. Clin Chem Lab Med 2017; 55:e25. [PMID: 27816959 DOI: 10.1515/cclm-2016-0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 10/04/2016] [Indexed: 11/15/2022]
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90
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Forgotten art. Surgery 2016; 161:1469-1470. [PMID: 27913035 DOI: 10.1016/j.surg.2016.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/23/2016] [Accepted: 09/24/2016] [Indexed: 11/22/2022]
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91
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Al-Katib S, Sokhandon F, Farah M. MRI for appendicitis in pregnancy: is seeing believing? clinical outcomes in cases of appendix nonvisualization. Abdom Radiol (NY) 2016; 41:2455-2459. [PMID: 27511366 DOI: 10.1007/s00261-016-0864-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE The primary objective of this study was to determine the clinical outcomes in cases of appendix nonvisualization with MRI in pregnant patients with suspected appendicitis and the implications of appendix nonvisualization for excluding appendicitis. METHODS Fifty-eight pregnant patients with suspected appendicitis evaluated with MRI at three centers from a single institution were retrospectively reviewed by three radiologists with varying levels of abdominal imaging experience. All scans were performed on a 1.5-Tesla Siemens unit. Cases were evaluated for diagnostic quality, visualization of the appendix, presence of appendicitis, and alternate diagnoses. Clinical outcomes were gathered from the electronic medical record. RESULTS Of the 58 patients who underwent MRI for suspected appendicitis, 50 cases were considered adequate diagnostic quality by all three radiologists. The rate of appendix visualization among the three radiologists ranged from 60 to 76% (p = 0.44). The appendix was nonvisualized by at least one of the three radiologists in 25 cases (50%). Of these, none had a final diagnosis of appendicitis including one patient who underwent appendectomy. MRI suggested an alternate diagnosis in 6 (24%) patients with appendix nonvisualization. For the three reviewers, the agreement level on whether or not the appendix was visualized on the MRI had a Light's kappa value of 0.526, indicating a "moderate" level of agreement (p value < 0.01). CONCLUSION Despite only moderate level of interobserver agreement for appendix visualization, appendix nonvisualization on MRI in pregnant patients with suspected appendicitis confers a significant reduction in the risk of appendicitis compared to all comers as long as the study is adequate diagnostic quality and there are no secondary signs of appendicitis present.
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Affiliation(s)
- Sayf Al-Katib
- Beaumont Health, Department of Diagnostic Radiology and Molecular Imaging, Oakland University William Beaumont School of Medicine, Royal Oak, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.
| | - Farnoosh Sokhandon
- Beaumont Health, Department of Diagnostic Radiology and Molecular Imaging, Oakland University William Beaumont School of Medicine, Royal Oak, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Michael Farah
- Beaumont Health, Department of Diagnostic Radiology and Molecular Imaging, Oakland University William Beaumont School of Medicine, Royal Oak, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
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Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5697692. [PMID: 28044133 PMCID: PMC5156797 DOI: 10.1155/2016/5697692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/17/2022]
Abstract
Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03–0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation.
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93
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Could MRI Become the First-Line Investigation in Suspected Appendicitis? AJR Am J Roentgenol 2016; 207:W103. [DOI: 10.2214/ajr.16.16610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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94
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Baldisserotto M. In Search of a Rational Protocol for the Diagnosis of Acute Appendicitis. Radiology 2016; 280:978-9. [DOI: 10.1148/radiol.2016160484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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