Clinical approach to a child with abdominal pain who might have appendicitis

Predictors of critical illness among young males with chest pain, abdominal pain, or headaches in the Republic of Korea Army

Purpose

Chest pain, abdominal pain, and headache are common symptoms associated with critical illness. Here, we aimed to evaluate predictors associated with critical illness in young males of the Republic of Korea Army.

Methods

We retrospectively reviewed previously healthy young males with chest pain, abdominal pain, or headaches who visited Armed Forces Seoul District Hospital between January 2019 and December 2020. Critical illness was defined as a condition that required hospitalization, a procedure or surgery, or referral to a tertiary hospital. The symptoms and signs of critical illness were evaluated.

Results

Of the 762 enrolled patients, a critical illness was diagnosed in 45 patients (5.9%). Among chest pain signs, palpitation (odds ratio [OR], 22.8; 95% confidence interval [CI], 5.08-102.4; p < 0.001), exertional dyspnea (OR, 16.3; 95% CI, 3.38-78.8; p = 0.001), duration (> 5 minutes) (OR, 7.54; 95% CI, 1.93-29.49; p = 0.004), and squeezing type (OR, 5.28; 95% CI, 1.11-25.11; p = 0.037) were significantly associated with critical illness. Among abdominal pain signs, right-lower-quadrant tenderness (OR, 11.87; 95% CI, 4.671-31.87; p < 0.001) was an alarming sign. For headaches, criticality was low (1.5%), and half of patients with critical illness were diagnosed incidentally regardless of headache.

Conclusion

We identified symptoms and signs significantly associated with critical illness in young male patients. This study might serve as a reference for deciding when to transfer soldiers in the field to a rear hospital, thereby contributing to the welfare and combat power of soldiers.

Utility of Computed Tomography Overreading and Abdominal Ultrasound in Children With Suspected Appendicitis and Nondiagnostic Computed Tomography at Community Hospitals

OBJECTIVE

The aim of the study was to examine the ability of overreading of computed tomography (CT) and right lower quadrant ultrasound (RLQ US) to diagnose appendicitis for children with suspected appendicitis with equivocal CTs at community hospitals.

METHODS

This was a retrospective chart review of all children transferred to a children's hospital from community emergency departments with suspected appendicitis over 2 years for whom both CT and RLQ US were performed.

RESULTS

One hundred eighty-four children were included with a median age of 10.8 years, and 57.6% were female. Community hospitals documented that CTs were equivocal for appendicitis in 110 (59.8%), positive in 63 (34.2%), and negative in 11 (6.0%). Ninety-seven CTs (88.1%) designated equivocal at community hospitals were later deemed interpretable by pediatric radiologists: 21 (19.1%) as appendicitis and 76 (69.1%) as normal. In 13 children (11.8%), both the community and children's hospital CT interpretations were equivocal. In equivocal cases, RLQ US was consistent with appendicitis in 6 (46.2%), normal in 5 (41.7%), and nondiagnostic in 2. κ value between CT interpretations at community versus children's hospital was 0.13 (95% confidence interval, 0.05-0.22), and κ value between CT interpretation at the children's hospital and RLQ US was 0.59 (95% confidence interval, 0.48-0.70).

CONCLUSIONS

Most CTs deemed equivocal for appendicitis at community hospitals were interpretable by pediatric radiologists. In a few children for whom CTs were designated nondiagnostic, RLQ US provided a definitive diagnosis in almost 90% of cases. The first step in evaluation of children with suspected appendicitis for whom outside CTs are deemed equivocal should be to have the study reinterpreted by a pediatric radiologist.

Extra-appendiceal findings in pediatric abdominal CT for suspected appendicitis

BACKGROUND

Much has been written regarding the incidence, types, importance and management of abdominal CT incidental findings in adults, but there is a paucity of literature on incidental findings in children.

OBJECTIVE

We sought to determine the prevalence and characteristics of extra-appendiceal and incidental findings in pediatric abdominal CT performed for suspected appendicitis.

MATERIALS AND METHODS

A retrospective review was performed of abdominal CT for suspected appendicitis in a pediatric emergency department from July 2010 to June 2012. Extra-appendiceal findings were recorded. Any subsequent imaging was noted. Extra-appendiceal findings were divided into incidental findings of doubtful clinical significance, alternative diagnostic findings potentially providing a diagnosis other than appendicitis explaining the symptoms, and incidental findings that were abnormalities requiring clinical correlation and sometimes requiring further evaluation but not likely related to the patient symptoms.

RESULTS

One hundred sixty-five children had abdominal CT for suspected appendicitis. Seventy-seven extra-appendiceal findings were found in 57 (34.5%) patients. Most findings (64 of 77) were discovered in children who did not have appendicitis. Forty-one of these findings (53%) could potentially help explain the patient's symptoms, while 30 of the findings (39%) were abnormalities that were unlikely to be related to the symptoms but required clinical correlation and sometimes further work-up. Six of the findings (8%) had doubtful or no clinical significance.

CONCLUSION

Extra-appendiceal findings are common in children who undergo abdominal CT in the setting of suspected appendicitis. A significant percentage of these patients have findings that help explain their symptoms. Knowledge of the types and prevalence of these findings may help radiologists in the planning and interpretation of CT examinations in this patient population.

Acute abdominal pain in childhood and adolescence: assessing the impact of sonography on diagnosis and treatment

PURPOSE

To assess the impact of ultrasonography on defining the diagnostic and therapeutic pathways for pediatric patients admitted to the emergency department for acute abdominal pain.

METHODS

We performed a retrospective study of all patients aged <16 years with acute abdominal pain who underwent ultrasound examination at our Diagnostic Imaging Department from October 2010 to March 2012. We investigated for each patient the pathway following ultrasound examination and definitive diagnosis. The impact of ultrasonography was defined based on the frequency with which the information resulting from this examination confirmed or denied the diagnostic suspicion made by the emergency physician on the basis of clinical and laboratory findings.

RESULTS

In 497/729 patients (69 %), ultrasound examination did not determine variations in the diagnostic and therapeutic pathways, either because it confirmed the outcome of clinical examination and laboratory tests, or because, even addressing in the opposite direction to these, the emergency physician did not consider its result because of being particularly alarmed or sufficiently reassured by clinical examination and laboratory tests. In the remaining 232/729 cases (31 %), ultrasound examination determined an increase or a reduction of the provided care and attention (subsequently proved justified in the vast majority of cases) in spite of what was initially assessed based on clinical examination and laboratory tests.

CONCLUSIONS

The results of our retrospective study demonstrated that ultrasonography was a valuable tool in the management of pediatric patients with acute abdominal pain together with clinical examination and laboratory tests.

Advanced radiologic imaging for pediatric appendicitis, 2005-2009: trends and outcomes

OBJECTIVES

To examine the variability in the use of computed tomography (CT) and ultrasound (US) for children with appendicitis and identify associations with clinical outcomes, and to demonstrate any trends in diagnostic imaging between 2005 and 2009.

STUDY DESIGN

This was a retrospective review of children evaluated for appendicitis in an emergency department between 2005 and 2009 using an administrative database of 40 pediatric institutions in the United States. Imaging utilization by institutions was studied for association with 3 clinical outcomes.

RESULTS

A total of 55 238 children with appendicitis were studied. Utilization of CT and US varied widely across institutions, with medians of 34% (IQR, 21%-49%) for CT and 6% (IQR, 2%-26%) for US. Increased use of US or a combination of CT and US (but not of CT use alone) was associated with a lower negative appendectomy rate. Imaging was not associated with other clinical outcomes. In children with appendicitis, the use of US has increased since 2007, whereas that of CT has decreased.

CONCLUSION

There is considerable variation in the use of CT and US for children with appendicitis at major pediatric institutions. At the institutional level, increased use of US or combined US and CT is associated with a lower negative appendectomy rate. Despite the better diagnostic accuracy of CT compared with US, the use of CT is decreasing.

Diagnostic imaging and negative appendectomy rates in children: effects of age and gender

BACKGROUND AND OBJECTIVES

Diagnostic imaging is often used in the evaluation of children with possible appendicitis. The utility of imaging may vary according to a patient's age and gender. The objectives of this study were (1) to examine the use of computed tomography (CT) and ultrasound for age and gender subgroups of children undergoing an appendectomy; and (2) to study the association between imaging and negative appendectomy rates (NARs) among these subgroups.

METHODS

Retrospective review of children presenting to 40 US pediatric emergency departments from 2005 to 2009 (Pediatric Health Information Systems database). Children undergoing an appendectomy were stratified by age and gender for measuring the association between ultrasound and CT use and the outcome of negative appendectomy.

RESULTS

A total of 8 959 155 visits at 40 pediatric emergency departments were investigated; 55 227 children had appendicitis. The NAR was 3.6%. NARs were highest for children younger than 5 years (boys 16.8%, girls 14.6%) and girls older than 10 years (4.8%). At the institutional level, increased rates of diagnostic imaging (ultrasound and/or CT) were associated with lower NARs for all age and gender subgroups other than children younger than 5 years, The NAR was 1.2% for boys older than 5 years without any diagnostic imaging.

CONCLUSIONS

The impact of diagnostic imaging on negative appendectomy rate varies by age and gender. Diagnostic imaging for boys older than 5 years with suspected appendicitis has no meaningful impact on NAR. Diagnostic strategies for possible appendicitis should incorporate the risk of negative appendectomy by age and gender.

Cancer risks associated with external radiation from diagnostic imaging procedures

The 600% increase in medical radiation exposure to the US population since 1980 has provided immense benefit, but increased potential future cancer risks to patients. Most of the increase is from diagnostic radiologic procedures. The objectives of this review are to summarize epidemiologic data on cancer risks associated with diagnostic procedures, describe how exposures from recent diagnostic procedures relate to radiation levels linked with cancer occurrence, and propose a framework of strategies to reduce radiation from diagnostic imaging in patients. We briefly review radiation dose definitions, mechanisms of radiation carcinogenesis, key epidemiologic studies of medical and other radiation sources and cancer risks, and dose trends from diagnostic procedures. We describe cancer risks from experimental studies, future projected risks from current imaging procedures, and the potential for higher risks in genetically susceptible populations. To reduce future projected cancers from diagnostic procedures, we advocate the widespread use of evidence-based appropriateness criteria for decisions about imaging procedures; oversight of equipment to deliver reliably the minimum radiation required to attain clinical objectives; development of electronic lifetime records of imaging procedures for patients and their physicians; and commitment by medical training programs, professional societies, and radiation protection organizations to educate all stakeholders in reducing radiation from diagnostic procedures.

Imaging acute appendicitis: state of the art

The goal of this review is to present the state of the art in imaging tests for the diagnosis of acute appendicitis. Relevant publications regarding performance and advantages/disadvantages of imaging modalities for the diagnosis of appendicitis in different clinical situations were reviewed. Articles were extracted from a computerized database (MEDLINE) with the following activated limits: Humans, English, core clinical journals, and published in the last five years. Reference lists of relevant studies were checked manually to identify additional, related articles. Ultrasound (US) examination should be the first imaging test performed, particularly among the pediatric and young adult populations, who represent the main targets for appendicitis, as well as in pregnant patients. A positive US examination for appendicitis or an alternative diagnosis of possible gastrointestinal or urological origin, or a negative US, either showing a normal appendix or presenting low clinical suspicion of appendicitis, should lead to a final diagnosis. A negative or indeterminate examination with a strong clinical suspicion of appendicitis should be followed by a computed tomography (CT) scan or alternatively, a magnetic resonanace imaging (MRI) scan in a pregnant patient. A second US examination in a patient with persistent symptoms, especially if the first one was performed by a less experienced imaging professional, is a valid alternative to a CT.

The role of emergency ultrasound in the diagnosis of acute non-traumatic epigastric pain

The epigastrium is the site where pain coming from both abdominal and extra-abdominal organs is frequently referred. Although acute or chronic diseases of the stomach, duodenum, liver, pancreas and biliary tree are the most common causes of acute epigastric pain, several other entities, potentially more severe, should also be suspected and investigated. Clinical bedside ultrasonography (US) is actually the first-line imaging in acute epigastric pain patients presenting to the hospital Emergency Department (ED) because it is rapid, noninvasive, relatively inexpensive and focused, repeatable and reliable. Moreover, the systematic use of emergency US as a complement to routine management might save economic resources by avoiding further costs for complications and substantially reducing the time for making an accurate diagnosis. The purpose of this paper is to review the US spectrum of the most common diseases responsible for acute epigastric pain onset. We also propose a focused, well codified US protocol, that we call the "$ approach", based on our clinical experience and the current literature for acute non-traumatic epigastric pain evaluation in an emergency setting. Its systematic application by the emergency physician may reduce the wait for diagnosis and the over-usage of second-line radiological techniques, including computed tomography, as well as to increase the diagnostic accuracy with potential benefits for patient (safety), physician (efficacy) and the institution (efficiency).

[Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children]

BACKGROUND/AIMS

Acute appendicitis (AA) remains a diagnostic challenge in children, despite ongoing researches. With an aim to facilitate making diagnosis of AA many scoring systems have been created; among them Alvarado score is the most popular. C-reactive protein (CRP) has proven significance for diagnosing AA in adults, but not in children. The aim of this study was to evaluate significance of Alvarado score, as well as CRP values, in making diagnosis of AA in children.

METHODS

This prospective six-month study was performed on 257 patients under the age of 15, admitted for acute abdominal pain in the Clinic of Pediatric Surgery and Orthopedics in the Clinical Centre of Nis. Alvarado score and CRP values were determined on admission and compared with final diagnosis on discharge. The patients were divided into two groups: group I--non operated patients with abdominal pain (n=184) and group II--operated on patients for appendectomy (n=73).

RESULTS

Values of Alvardo score were statistically significantly different between groups (group I: 4.9 +/- 1.21, group II: 8.55 +/- 1.32). Also, our results showed significantly high values of CRP measured in operated children (group I: 8.17 +/- 4.7 mg/L, group II: 38 +/- 26 mg/L). Values of validity parameters for Alvarado score were: sensitivity 90%, specifity 80%, positive predictive values 87%; for CRP 95%, 70% and 80%, respectively.

CONCLUSION

Alvarado score and CRP are very useful adjuvant diagnostic tool for AA to a less experienced surgeon. High values of Alvarado score and CRP cannot be ignored neither at the same time, used as the sole diagnostic method for discriminating children with AA.

Clinically monitored delay-A valid option in cases with doubtful diagnosis of acute appendicitis

AIM

To evaluate the effect of delayed surgery after a period of observation in patients with doubtful diagnosis of acute appendicitis in the form of improvement in negative appendectomy rates and the incidence of complications.

MATERIALS AND METHODS

One hundred twelve patients operated with the diagnosis of acute appendicitis between May 2008 to June 2009 were included in this retrospective study. They were divided into two groups based on timing of surgery after admission. These two groups were studied in respect to age, sex, Alvarado score at presentation, ultrasound findings, operative findings, histopathology and postoperative complications. Proportions of negative appendectomies, and complicated appendicitis were analysed statistically.

RESULTS

Group wise age and sex distribution was comparable. The mean Alvarado score in the group 1 was 7.9 (range, 6-10) where as in those operated later than 12 hours (group 2), it was 4.5 (range, 3-8). Normal appendectomies were significantly (p < 0.05) less in group 2 (1 out of 40) as compared to group 1 (4 out of 72). The number of complicated appendicitis were higher in group 1 (14/72) as compared to group 2 (4/40) but not significantly (p > 0.06). The number of postoperative complications was also high in group 1 (11 vs 2 in group 2).

CONCLUSION

It is better to wait in cases with doubtful initial diagnosis of appendicitis on admission in order to decrease negative appendectomy rates. These patients need to be continuously monitored clinically to prevent complications.

An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway

OBJECTIVES

In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low-dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure.

METHODS

This was a retrospective outcomes analysis of patients presenting after hours for suspected appendicitis at an academic children's hospital ED over a 6-year period. The pathway established US as the initial imaging modality. CT was recommended only if US was equivocal. Clinical and pathologic outcomes from ED diagnosis and disposition, histopathology and return visits, were correlated with the US and CT. ED diagnosis and disposition, pathology, and return visits were used to determine outcome.

RESULTS

A total of 680 patients met the study criteria. A total of 407 patients (60%) followed the pathway. Two-hundred of these (49%) were managed definitively without CT. A total of 106 patients (26%) had a positive US for appendicitis; 94 (23%) had a negative US. A total of 207 patients had equivocal US with follow-up CT. A total of 144 patients went to the operating room (OR); 10 patients (7%) had negative appendectomies. One case of appendicitis was missed (<0.5%). The sensitivity, specificity, negative predictive value, and positive predictive values of our staged US-CT pathway were 99%, 91%, 99%, and 85%, respectively. A total of 228 of 680 patients (34%) had an equivocal US with no follow-up CT. Of these patients, 10 (4%) went to the OR with one negative appendectomy. A total of 218 patients (32%) were observed clinically without complications.

CONCLUSIONS

Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors' experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one-third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy.

Imaging of acute appendicitis in children: EU versus U.S. ... or US versus CT? A North American perspective

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources.

US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs

This study evaluated the additional value of secondary signs in the diagnosing of appendicitis in children with ultrasound. From May 2005 to June 2006, 212 consecutive paediatric patients with suspected appendicitis were examined. Ultrasonographic depiction of the appendix was classified into four groups: 1, normal appendix; 2, appendix not depicted, no secondary signs of appendicitis; 3, appendix not depicted with one of the following secondary signs: hyperechoic mesenteric fat, fluid collection, local dilated small bowel loop; 4, depiction of inflamed appendix. We classified 96 patients in group 1, 41 in group 2, 13 in group 3, and 62 in group 4. Prevalence of appendicitis was 71/212 (34%). Negative predictive values of groups 1 and 2 were 99% and 100%, respectively. Positive predictive values of groups 3 and 4 were 85% and 95%, respectively. In groups 3 and 4, hyperechoic mesenteric fat was seen in 73/75 (97.3%), fluid collections and dilated bowel loops were seen in 12/75 (16.0%) and 5/75 (6.6%), respectively. This study shows that in case of non-visualization of the appendix without secondary signs, appendicitis can be safely ruled out. Furthermore, secondary signs of appendicitis alone are a strong indicator of acute appendicitis.