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Romano VC, Lima NTDMB, Jabour VA, Del Guerra GC, Silvério PRB, Garcia RG, Sameshima YT, Francisco Neto MJ, de Queiroz MRG. Lessons from the pandemic and the value of a structured system of ultrasonographic findings in the diagnosis of COVID-19 pulmonary manifestations. EINSTEIN-SAO PAULO 2024; 22:eAE0780. [PMID: 38865568 PMCID: PMC11155724 DOI: 10.31744/einstein_journal/2024ae0780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/05/2023] [Indexed: 06/14/2024] Open
Abstract
Implementing a structured COVID-19 lung ultrasound system, using COVID-RADS standardization. This case series exams revealed correlations between ultrasonographic and tomographic findings. Ventilatory assessments showed that higher categories required second-line oxygen. This replicable tool will aid in screening and predicting disease severity beyond the pandemic. OBJECTIVE We aimed to share our experience in implementing a structured system for COVID-19 lung findings, elucidating key aspects of the lung ultrasound score to facilitate its standardized clinical use beyond the pandemic scenario. METHODS Using a scoring system to classify the extent of lung involvement, we retrospectively analyzed the ultrasound reports performed in our institution according to COVID-RADS standardization. RESULTS The study included 69 thoracic ultrasound exams, with 27 following the protocol. The majority of patients were female (52%), with ages ranging from 1 to 96 years and an average of 56 years. Classification according to COVID-RADS was as follows: 11.1% in category 0, 37% in category 1, 44.4% in category 2, and 7.4% in category 3. Ground-glass opacities on tomography correlated with higher COVID-RADS scores (categories 2 and 3) in 82% of cases. Ventilatory assessment revealed that 50% of cases in higher COVID-RADS categories (2 and 3) required second-line oxygen supplementation, while none of the cases in lower categories (0 and 1) utilized this support. CONCLUSION Lung ultrasound has been widely utilized as a diagnostic tool owing to its availability and simplicity of application. In the context of the pandemic emergency, a pressing need for a focused and easily applicable assessment arose. The structured reporting system, incorporating ultrasound findings for stratification, demonstrated ease of replicability. This system stands as a crucial tool for screening, predicting severity, and aiding in medical decisions, even in a non-pandemic context. Lung ultrasound enables precise diagnosis and ongoing monitoring of the disease. Ultrasound is an effective tool for assessing pulmonary findings in COVID-19. Structured reports enhance communication and are easily reproducible.
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Affiliation(s)
- Vítor Carminatti Romano
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Victor Arantes Jabour
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | - Rodrigo Gobbo Garcia
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Yoshino Tamaki Sameshima
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Miguel José Francisco Neto
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Opramolla A, Gazzin A, Cisarò F, Pinon M, Calvo P, Rigazio C. Intestinal ultrasonography in pediatric population. Minerva Pediatr (Torino) 2024; 76:100-107. [PMID: 33871250 DOI: 10.23736/s2724-5276.21.06371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bowel ultrasound (US) is a low-cost, non-invasive, bed side practice and a reproducible procedure that represents a high yield tool in clinical practice and in the diagnostic workup of a consistent group of acute and chronic gastrointestinal (GI) tract disease. Moreover, in case of GI diseases of neonatal and pediatric age, it allows an easier evaluation due to the small body size and scarce presence of fat tissue in the abdominal wall and peritoneal cavity and gas content. No particular preparation of the patient is needed, nevertheless a 3- to 5-hour fasting state improves the quality of the examination. The exam focuses on wall thickness and stratification, lumen content, distensibility and compressibility, presence of peristalsis of explorable segment of the GI tract and includes the investigation of mesentery, perivisceral tissues and nodes features. Color doppler flowmetry admits a qualitative evaluation of GI wall and mesentery vascularization. Healthy GI wall appears at a US evaluation as a multilayered structure in which hyperechoic and hypoechoic layers alternate sequentially. In this article we provide a quickly available overview on findings, signs and applications of US in major GI pediatric diseases.
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Affiliation(s)
- Anna Opramolla
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy -
| | - Andrea Gazzin
- Department of Public Health and Pediatric Sciences, School of Medicine, University of Turin, Turin, Italy
| | - Fabio Cisarò
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Michele Pinon
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Pierluigi Calvo
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Caterina Rigazio
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
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Gil LA, Deans KJ, Minneci PC. Appendicitis in Children. Adv Pediatr 2023; 70:105-122. [PMID: 37422289 DOI: 10.1016/j.yapd.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.
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Affiliation(s)
- Lindsay A Gil
- Pediatric Surgery Research Fellow, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 700 Children's Drive, Columbus, OH 43206, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Peter C Minneci
- Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 611 East Livingston Avenue, Columbus, OH 43206, USA.
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Steinl G, Grabski D, Fleming M, Levin D, McGahren E, McCullough W, Gander J. Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis. Pediatr Surg Int 2023; 39:238. [PMID: 37486585 DOI: 10.1007/s00383-023-05521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children. METHODS All children (< 18 years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation. RESULTS 554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001). CONCLUSION Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.
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Affiliation(s)
- Gabrielle Steinl
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - David Grabski
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Mark Fleming
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Daniel Levin
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - Eugene McGahren
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - William McCullough
- Department of Radiology, Santa Clara Homestead Medical Center, Santa Clara, CA, USA
| | - Jeffrey Gander
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA.
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Yang DM. Structured Reporting for Pediatric Appendiceal US: Can It Reduce CT Utilization Rate and Decrease the Negative Appendectomy Rate? JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:663-665. [PMID: 37324983 PMCID: PMC10265244 DOI: 10.3348/jksr.2023.0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023]
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Choi K, Choi JY, Kim HJ, Kim HJ, Jang SK. Added Value of Structured Reporting for US of the Pediatric Appendix: Additional CT Examinations and Negative Appendectomy. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:653-662. [PMID: 37324982 PMCID: PMC10265224 DOI: 10.3348/jksr.2022.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/06/2022] [Accepted: 09/02/2022] [Indexed: 06/17/2023]
Abstract
Purpose This study aimed to determine the incremental value of using a structured report (SR) for US examinations of the pediatric appendix. Materials and Methods Between January 2009 and June 2016, 1150 pediatric patients with suspected appendicitis who underwent US examinations of the appendix were included retrospectively. In November 2012, we developed a five-point scale SR for appendix US examinations. The patients were divided into two groups according to the form of the US report: free-text or SR. The primary clinical outcomes were compared between the two groups, including the rate of CT imaging following US examinations, the negative appendectomy rate (NAR), and the appendiceal perforation rate (PR). Results In total, 550 patients were included in the free-text group and 600 patients in the SR group. The rate of additional CT examinations decreased by 5.3% in the SR group (8.2%, p = 0.003), and the NAR decreased by 8.4% in the SR group (7.8%, p = 0.028). There was no statistical difference in the appendiceal PR (37.6% vs. 48.0%, p = 0.078). Conclusion The use of an SR to evaluate US examinations for suspected pediatric appendicitis results in lower CT use and fewer negative appendectomies without an increase in appendiceal PR.
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Raeisi R, Azizi M, Amiri J, Ghorbanpour M, Esna-Ashari F. Accuracy Evaluation of Pediatric Appendicitis Scoring (PAS) Method in Differentiating Nonspecific Abdominal Pain from Appendicitis. Int J Prev Med 2023; 14:40. [PMID: 37351062 PMCID: PMC10284213 DOI: 10.4103/ijpvm.ijpvm_539_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 10/27/2022] [Indexed: 06/24/2023] Open
Abstract
Background This study aimed at evaluating the accuracy of the pediatric appendicitis scoring method in differentiating nonspecific abdominal pain (NSAP) from appendicitis. Methods This cross-sectional study was conducted on 391 children who were hospitalized in the emergency ward due to acute abdominal pain suspected of appendicitis . Pediatric Appendicitis Score (PAS), C-reactive protein (CRP), and appendicitis pathology results of patients undergoing surgery were recorded. Results The results showed that the no significant difference was found among patients in the three experimental groups (appendicitis, specific abdominal pain except appendicitis, and NSAP) with respect to temperature (p = 0.212), but the other variables were significantly different. Findings showed that high CRP frequency, pain migration to right lower quadrant (RLQ), tenderness in right iliac fossa (RIF), anorexia, leukocytosis, high neutrophil, and mean tenderness in RLQ in the appendicitis group were higher than those in the other two groups (p = 0.001). The PAS questionnaire can also be used as a reliable questionnaire with appropriate sensitivity (0.929) and specificity (0.993), and this questionnaire along with detailed clinical examinations could reduce the rate of negative appendectomy to less than 1%. Conclusions This study showed high accuracy of PAS in diagnosing children with appendicitis and differentiating appendicitis from cases of NSAP and specific abdominal pain other than appendicitis. The PAS system could also significantly reduce cases of negative appendicitis. Although high CRP had an excellent ability to diagnose appendicitis, its accuracy was lower than PAS.
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Affiliation(s)
- Roya Raeisi
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mona Azizi
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Jalaleddin Amiri
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Farzaneh Esna-Ashari
- Community Medicine, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
- School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
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Augustin G, Mikuš M, Bogdanic B, Barcot O, Herman M, Goldštajn MŠ, Tropea A, Vitale SG. A novel Appendicitis TriMOdal prediction Score (ATMOS) for acute appendicitis in pregnancy: a retrospective observational study. Updates Surg 2022; 74:1933-1941. [PMID: 36048362 DOI: 10.1007/s13304-022-01368-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/22/2022] [Indexed: 01/20/2023]
Abstract
Several scoring systems exist for the management of acute appendicitis (AA) during pregnancy. However, the systems are based on the nonpregnant adult population. The aim of this study was to create a highly accurate scoring system that can be applied to pregnant women and to compare it to the most commonly used scores in general population and pregnant women. The creation and subsequent implementation of a highly accurate score system could shorten the diagnostic period and minimize the use of (ionizing) diagnostic imaging allowing the selection of the best treatment approach in pregnant patients with acute appendicitis. A single-center, retrospective cohort observational study was conducted at the University Hospital Centre Zagreb, Zagreb, Croatia. Data were extracted from medical records of pregnant patients with suspected AA from January 2010 to December 2020. A total of 59 pregnant patients diagnosed with AA during pregnancy were identified, 41 were treated surgically, and 18 had non-surgical management. The main objective of our study was the detection of predictive factors of AA during pregnancy. Anorexia, pain migration to the right lower quadrant, rebound pain, axillary temperature over 37.3 °C, CRP/platelet ratio > 0.0422, neutrophil/lymphocyte ratio > 7.182, and ultrasonic signs of AA were scored. Scoring in Appendicitis TriMOdal Score (ATMOS) consists of positive clinical parameter, each bringing 1 point and other parameters mentioned above that bring 2 points each. The score ranges from 0 to 10. Our model of ATMOS yields a high area under the receiver-operating characteristic curve of 0.963. The positive likelihood ratio is 9.97 (95% CI 2.64-38.00), and the negative likelihood ratio is 0.1 (95% CI 0.03-0.31), meaning that 94% of cases with ATMOS > 4 have AA, while less than 13% with an ATMOS ≤ 4 have the diagnosis of AA. The potential of ATMOS differentiating AA during pregnancy was demonstrated. Future prospective, randomized trials are needed to evaluate its accuracy and whether it should be used instead of Alvarado or Tzanakis scores in clinical decision-making.Trial registration number ClinicalTrials.gov-NCT05202483. Date of registration: January 21, 2022.
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Affiliation(s)
- Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Mislav Mikuš
- School of Medicine, University of Zagreb, Zagreb, Croatia.
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia.
| | - Branko Bogdanic
- Department of Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ognjen Barcot
- Department of Surgery, University Hospital Split, Spinčićeva 1, Split, Croatia
| | - Mislav Herman
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia
| | - Marina Šprem Goldštajn
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia
| | - Alessandro Tropea
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via E. Tricomi 1, 90127, Palermo, Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124, Catania, Italy
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Queiroz MRGD, Francisco MJ, Rahal A, Jabour VA, Andrade GNL, Silva PSDD, Garcia RG, Pereira MDS, Santos MR, Luna PAA, Sameshima YT, Gual F, Dutra MG, Germino BP, Alves IF. Ultrasonographic evaluation of cecal appendix diameter in pediatric population. EINSTEIN-SAO PAULO 2022; 20:eAO6935. [PMID: 35792758 PMCID: PMC9239537 DOI: 10.31744/einstein_journal/2022ao6935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To stratify ultrasound samples in a pediatric population undergoing evaluation for acute appendicitis to examine the variability in cecal appendix diameter, in different age groups, and to determine whether there is a prevalent value for each age group. Methods A retrospective cross-sectional study with 196 children aged 0 to 15 years. Data were extracted from reports of ultrasound examinations carried out between 2008 and 2015. Children with sonographic diagnosis of appendicitis or other signs of periappendiceal inflammation were excluded. Results The evaluation of the anteroposterior measurement of the cecal appendix revealed a mean diameter of 4.14mm (standard deviation: 0.93mm; 95%CI: 3.86-4.14). Cecal appendix diameter did not differ significant between age groups. Conclusion Evaluation of the anteroposterior diameter of the cecal appendix in centimeters in a sample of 196 children aged 0 to15 years revealed a mean diameter of 4.14mm (standard deviation, 0.93mm. There were no significant differences in cecal appendix diameter following stratification by age. Results indicate a single value can be adopted for mean cecal appendix diameter in pediatric populations.
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Acute appendicitis and SARS-CoV-2 in children: imaging findings at a tertiary children's hospital during the COVID-19 pandemic. Pediatr Radiol 2022; 52:460-467. [PMID: 34741178 PMCID: PMC8570768 DOI: 10.1007/s00247-021-05219-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/09/2021] [Accepted: 10/05/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients. MATERIALS AND METHODS Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student's t-test were used for statistical analysis. RESULTS One thousand, six hundred and ninety-three patients < 18 years old met inclusion criteria, with 46% (772/1,693) female, 11 imaged with only CT and 1,682 with US. Comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients, no statistically significant differences in sensitivity or specificity of US (P = 1 and P = 1, respectively), or in the US (P-values ranging from 0.1 to 1.0) or CT imaging findings (P-values ranging from 0.2 to 1.0) in appendicitis were found. Perforation rates were similar between SARS-CoV-2 positive (20/57, 35.1% perforated) and SARS-CoV-2 negative (359/785, 45.7% perforated) patients with appendicitis (P = 0.13). Use of CT following first-line US was similar, with 7/125 (5.6%) of SARS-CoV-2 positive imaged with CT after US and 127/1,557 (8.2%) of SARS-CoV-2 negative imaged with CT after US (P = 0.39). CONCLUSION In pediatric patients with suspected appendicitis, no significant difference was found in the diagnostic performance of US, CT usage or perforation rates between SARS-CoV-2 positive and SARS-CoV-2 negative patients.
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Hoffmann JC, Trimborn CP, Hoffmann M, Schröder R, Förster S, Dirks K, Tannapfel A, Anthuber M, Hollerweger A. Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology. Int J Colorectal Dis 2021; 36:2347-2360. [PMID: 34143276 DOI: 10.1007/s00384-021-03940-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm. METHODS Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database. RESULTS Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA. CONCLUSION Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany.
| | - Claus-Peter Trimborn
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany
| | - Michael Hoffmann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ralf Schröder
- Radiologische Klinik, St. Marien- und St. Annastiftskrankenhaus Ludwigshafen, Ludwigshafen, Germany
| | - Sarah Förster
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Klaus Dirks
- Gastroenterologie, Allgemeine Innere Medizin und Geriatrie, Rems-Murr-Kliniken Winnenden, Winnenden, Germany
| | - Andrea Tannapfel
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Matthias Anthuber
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Alois Hollerweger
- Abteilung für Radiologie und Nuklearmedizin Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Austria
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Goldman MP, Lynders W, Crain M, Nocera Kelley M, Solomon DM, Bokhari SA, Tiyyagura G, Auerbach MA, Emerson BL. A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting. Pediatr Qual Saf 2021; 6:e479. [PMID: 34589653 PMCID: PMC8476057 DOI: 10.1097/pq9.0000000000000479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/09/2021] [Indexed: 10/29/2022] Open
Abstract
The primary aim of this quality improvement initiative was to decrease the use of computerized tomography (CT) in the evaluation of pediatric appendicitis in a community general emergency department (GED) system by 50% (from 32% to 16%) in 1 year. METHODS Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and "over-transfer" rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. RESULTS The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children's hospital rate of 23.5%, and an "over-transfer" rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. CONCLUSIONS Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.
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Affiliation(s)
- Michael P. Goldman
- From the Department of Pediatrics, and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Conn., Middlesex, Conn
| | - William Lynders
- Middlesex Health, Department of Emergency Medicine, Middlesex, Conn
| | - Michael Crain
- Middlesex Health, Department of Emergency Medicine, Middlesex, Conn
| | - Mariann Nocera Kelley
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine/Traumatology, University of Connecticut School of Medicine, Connecticut Children’s, Hartford, Conn
| | - Daniel M. Solomon
- Department of Surgery, Section of Pediatric Surgery, Yale University School of Medicine, New Haven, Conn
| | - Syed A.J. Bokhari
- Department of Radiology, Section of Pediatric Radiology, Yale University School of Medicine, New Haven, Conn
| | - Gunjan Tiyyagura
- From the Department of Pediatrics, and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Conn., Middlesex, Conn
| | - Marc A. Auerbach
- From the Department of Pediatrics, and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Conn., Middlesex, Conn
| | - Beth L. Emerson
- From the Department of Pediatrics, and the Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Conn., Middlesex, Conn
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Implementation strategies in emergency management of children: A scoping review. PLoS One 2021; 16:e0248826. [PMID: 33761525 PMCID: PMC7990517 DOI: 10.1371/journal.pone.0248826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children. METHODS We conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies. RESULTS We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%). CONCLUSIONS Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.
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Choi J, Kim HJ, Jang SK, Kim HJ, Yeon JW. Useful Ultrasound Findings of Pediatric Patients with Equivocal Results of Appendicitis: Analysis Based on a Structured Report Form. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:182-193. [PMID: 36237470 PMCID: PMC9432416 DOI: 10.3348/jksr.2019.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 05/07/2020] [Indexed: 11/15/2022]
Abstract
Purpose Materials and Methods Results Conclusion
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Affiliation(s)
- Jiyoung Choi
- Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyuk Jung Kim
- Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Suk Ki Jang
- Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun Jin Kim
- Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Jae Woo Yeon
- Department of Radiology, Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
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Utility of Computed Tomography Overreading and Abdominal Ultrasound in Children With Suspected Appendicitis and Nondiagnostic Computed Tomography at Community Hospitals. Pediatr Emerg Care 2020; 36:564-570. [PMID: 33136834 DOI: 10.1097/pec.0000000000002283] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Koberlein GC, Trout AT, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Falcone RA, Garber MD, Joseph MM, Nguyen JC, Safdar NM, Karmazyn B. ACR Appropriateness Criteria ® Suspected Appendicitis-Child. J Am Coll Radiol 2020; 16:S252-S263. [PMID: 31054752 DOI: 10.1016/j.jacr.2019.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 12/29/2022]
Abstract
Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). 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)
| | - George C Koberlein
- Research Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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Conwell NK, Kennedy NJ, Quinton AE. Diagnostic performance of ultrasound to differentiate perforated from non‐perforated paediatric appendicitis: A narrative review. SONOGRAPHY 2020. [DOI: 10.1002/sono.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nancy K. Conwell
- Department of Medical Imaging Toowoomba Hospital South Toowoomba Queensland Australia
| | - Narelle J. Kennedy
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Christopher Kohlenberg Department of Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Ann E. Quinton
- Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School Nepean University of Sydney, Nepean Hospital Penrith New South Wales Australia
- Medical Sonography, School of Health, Medical and Applied Science, Central Queensland University Sydney New South Wales Australia
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Hao TK, Chung NT, Huy HQ, Linh NTM, Xuan NT. Combining Ultrasound with a Pediatric Appendicitis Score to Distinguish Complicated from Uncomplicated Appendicitis in a Pediatric Population. Acta Inform Med 2020; 28:114-118. [PMID: 32742063 PMCID: PMC7382774 DOI: 10.5455/aim.2020.28.114-118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: The accurate diagnosis of complicated appendicitis has been improved by using various diagnostic modalities. However, no preoperative diagnostic method could completely confirm the results. Therefore, preoperative diagnosis of complicated appendicitis to have the right management is still a huge challenge. Objectives: The aim of this study was to evaluate the diagnostic value of ultrasound combined with pediatric appendicitis score for differentiation between acute uncomplicated appendicitis and acute complicated appendicitis in a pediatric population. Methods: We prospectively evaluated 120 pediatric patients who underwent surgery for acute appendicitis from November 2017 to June 2019. Pediatric appendicitis score (PAS) was calculated and ultrasound (US) was performed before surgery. The histopathology of phlegmonous appendicitis corresponds to uncomplicated appendicitis (AUA), while gangrenous appendicitis and perforation are classified as complicated appendicitis (ACA). Results: Histopathologically, the results provided a diagnosis of acute appendicitis including 86 (71.7%) patients with AUA and 34 (28.3%) children with ACA. US findings showed a sensitivity of 23.5%, the specificity of 95.4%, PPV of 66.7%, NPV of 75.9%, and an accuracy of 75%. PAS of 8 was found to be the most appropriate cutoff point compatible with ACA; it resulted in a sensitivity of 76.5% and a specificity of 84.1%. Combining ultrasound with a pediatric appendicitis score resulted in a higher specificity to distinguish complicated from uncomplicated appendicitis when compared with ultrasound or PAS solely. Conclusions: the US is highly specific but nonsensitive for detecting complicated pediatric appendicitis. Combining ultrasound with pediatric appendicitis is a very good concept to distinguish complicated from uncomplicated appendicitis in a pediatric population.
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Affiliation(s)
| | - Nguyen Tien Chung
- Department of Internal Medicine, University Of Traditional Medicine, Ha Noi, Vietnam
| | - Huynh Quang Huy
- Department of Radiology, Pham Ngoc Thach University of Medicine, Vietnam
| | | | - Nguyen Thanh Xuan
- Department of Abdominal Emergency and Pediatric Surgery, Hue Central Hospital, Vietnam
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Pop GN, Costea FO, Lungeanu D, Iacob ER, Popoiu CM. Ultrasonographic findings of child acute appendicitis incorporated into a scoring system. Singapore Med J 2020; 63:35-41. [PMID: 32668829 DOI: 10.11622/smedj.2020102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study aimed to investigate the ultrasonographic features of child acute appendicitis and incorporate them into a scoring algorithm that will quantify the risk of complications and the strength of recommendation for surgical intervention. METHODS 179 patients with suspected appendicitis and who had undergone ultrasonographic examination were included in this study. Based on their medical evaluation and post-surgical histopathological results, patients were categorised into the confirmed appendicitis (n = 101); and non-appendicitis (n = 78) groups. RESULTS In the appendicitis group, the appendix was visualised in 66 (65.3%) patients. In cases where the appendix was not visualised, we looked out for secondary inflammatory signs, which were present in 32 (31.7%) patients. Using stepwise logistic regression, Blumberg's sign, free fluid or collection, hyperaemia, non-compressible appendix and an appendix diameter > 7 mm were found to be significant predictive factors for appendicitis. A new scoring system called POPs was developed, combining inflammatory predictors and ultrasonography findings, with an area under the receiving operating characteristic curve of 0.958 (95% confidence interval 0.929-0.986). CONCLUSION The newly developed POPs-based diagnosis scheme proved a promising alternative to existing scoring systems, such as the Alvarado score. Although further calibration would be beneficial, the proposed scoring scheme is simple and easy to understand, memorise and apply in the emergency room.
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Affiliation(s)
- Gheorghe Nicusor Pop
- Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania.,Centre for Modelling Biological Systems and Data Analysis, Department of Functional Sciences, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
| | | | - Diana Lungeanu
- Centre for Modelling Biological Systems and Data Analysis, Department of Functional Sciences, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
| | - Emil Radu Iacob
- Department of Pediatric Surgery, Victor Babes University of Medicine and Pharmacy, Timişoara, Romania.,The Louis Turcanu Emergency Clinical Hospital for Children, Timişoara, Romania
| | - Calin Marius Popoiu
- Department of Pediatric Surgery, Victor Babes University of Medicine and Pharmacy, Timişoara, Romania.,The Louis Turcanu Emergency Clinical Hospital for Children, Timişoara, Romania
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Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
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Mahankali SK, Abdel Razek AAK, Ahamed SA. Reliability of standardized reporting system of acute appendicitis in adults at low-dose 320-rows CT. Eur J Radiol Open 2019; 6:330-335. [PMID: 31768408 PMCID: PMC6872863 DOI: 10.1016/j.ejro.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/01/2019] [Accepted: 11/02/2019] [Indexed: 12/26/2022] Open
Abstract
Aim To assess the reliability of a standardized reporting system of acute appendicitis at low-dose 320-rows CT. Subjects and Methods Retrospective analysis CT of 78 patients with pathologically proven acute appendicitis. The study was performed at a low-dose 320-rows CT. The image analysis was performed by 2 radiologists according to a standardized reporting system of acute appendicitis. Results There was an excellent overall of the inter-observer agreement of both observers for the standardized reporting system of acute appendicitis (K = 0.89, 95 % CI = 0.87-0.92, P = 0.001). There was good inter-observer agreement for visualization of the appendix (K = 0.78, P = 0.001), the tip diameter (K = 0.75, P = 0.001), and a single wall thickness of appendix (K = 0.77, P = 0.001). There was excellent inter-observer agreement for outer to outer wall diameter (K = 0.82, P = 0.001), mucosal hyper-enhancement (K = 0.80, P = 0.001), appendicolith (K = 0.86, P = 0.001), gas in the appendix (K = 0.82, P = 0.001), surrounding fat stranding (K = 0.81, P = 0.001), focal cecal thickening (K = 0.85, P = 0.001), peri-appendiceal air (K = 0.87, P = 0.001), peri-appendicular fluid collection, phlegmon, or abscess (K = 0.82, P = 0.001), and right ovary cyst (K = 0.83, P = 0.001). Conclusion we concluded that excellent reliability of a standardized reporting system of acute appendicitis in the adults using low-dose 320-rows CT.
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Yu YR, Rosenfeld EH, Dadjoo S, Orth RC, Lopez ME, Shah SR, Naik-Mathuria BJ. Accuracy of surgeon prediction of appendicitis severity in pediatric patients. J Pediatr Surg 2019; 54:2274-2278. [PMID: 31097307 DOI: 10.1016/j.jpedsurg.2019.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/08/2019] [Accepted: 04/16/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity. METHODS From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ2. A p-value<0.05 was considered statistically significant. RESULTS Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 103/μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F). CONCLUSION While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited. TYPE OF STUDY Prospective survey. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yangyang R Yu
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030.
| | - Eric H Rosenfeld
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Shaahin Dadjoo
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Robert C Orth
- Division of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street Suite 470, Houston, TX 77030
| | - Monica E Lopez
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Sohail R Shah
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
| | - Bindi J Naik-Mathuria
- The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030
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Sams C, Ayyala RS, Swenson DW. Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population. BJR Open 2019; 1:20190016. [PMID: 33178945 PMCID: PMC7592479 DOI: 10.1259/bjro.20190016] [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: 03/06/2019] [Revised: 08/17/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.
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Affiliation(s)
- Cassandra Sams
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - Rama S Ayyala
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - David W. Swenson
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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25
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Shea LAG, Towbin AJ. The state of structured reporting: the nuance of standardized language. Pediatr Radiol 2019; 49:500-508. [PMID: 30923882 DOI: 10.1007/s00247-019-04345-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/04/2018] [Accepted: 01/11/2019] [Indexed: 12/26/2022]
Abstract
Radiology reports are the principal form of communication with the referring provider. Unfortunately, they can be a form of communication riddled with errors and inscrutable statements burying the intended meaning, failing to achieve the main task for which it was made: communicating key imaging findings as they pertain to the clinical question being posed. Structured reporting is a multifaceted and modular solution to problematic reports, with variable iterations and benefits. Structured reports have been adapted across departments and even national societies, with standardized format, content and language. Newer developments include contextual reporting and common data elements. Herein, we discuss the various forms and levels of structured reporting and the latest advancements, as well as the general acceptance within radiology. We also discuss some areas for improvement as the practice of structured reporting matures.
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Affiliation(s)
- Lindsey A G Shea
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH, 45229, USA. .,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Park SB, Kim MJ, Ko Y, Sim JY, Kim HJ, Lee KH. Structured Reporting versus Free-Text Reporting for Appendiceal Computed Tomography in Adolescents and Young Adults: Preference Survey of 594 Referring Physicians, Surgeons, and Radiologists from 20 Hospitals. Korean J Radiol 2019; 20:246-255. [PMID: 30672164 PMCID: PMC6342761 DOI: 10.3348/kjr.2018.0109] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To survey care providers' preference between structured reporting (SR) and free-text reporting (FTR) for appendiceal computed tomography (CT) in adolescents and young adults. MATERIALS AND METHODS An ethical committee approved this prospective study. The requirement for participant consent was waived. We distributed the Likert scale-based SR form delivering the likelihood of appendicitis across 20 hospitals through a large clinical trial. In the final phase of the trial, we invited 706 potential care providers to participate in an online survey. The survey questions included usefulness in patient management, communicating the likelihood of appendicitis, convenience, style and format, and overall preference. Logistic regression analysis was performed for the overall preference. Three months after the completion of the trial, we checked if the use of the SR was sustained. RESULTS Responses were analyzed from 594 participants (175 attendings and 419 trainees; 225 radiologists, 207 emergency physicians, and 162 surgeons). For each question, 47.3-64.8% of the participants preferred SR, 13.1-32.7% preferred FTR, and the remaining had no preference. The overall preference varied considerably across the hospitals, but slightly across the departments or job positions. The overall preference for SR over FTR was significantly associated with attendings, SR experience for appendiceal CT, hospitals with small appendectomy volume, and hospitals enrolling more patients in the trial. Five hospitals continued using the SR in usual care after the trial. CONCLUSION Overall, the care providers preferred SR to FTR. Further investigation into the sustained use of the SR is needed.
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Affiliation(s)
- Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Min Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea.
| | - Yousun Ko
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Ji Ye Sim
- Department of Radiology, Hanil General Hospital, Seoul, Korea
| | - Hyuk Jung Kim
- Department of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Kyoung Ho Lee
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting. Pediatr Surg Int 2018; 34:1287-1292. [PMID: 30293146 DOI: 10.1007/s00383-018-4350-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting. MATERIALS AND METHODS All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported. RESULTS Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively. CONCLUSION These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.
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28
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Bonasso PC, Dassinger MS, Wyrick DL, Gurien LA, Burford JM, Smith SD. Review of bedside surgeon-performed ultrasound in pediatric patients. J Pediatr Surg 2018; 53:2279-2289. [PMID: 29807830 DOI: 10.1016/j.jpedsurg.2018.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/21/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS There are no standards for the practice of PSPBUS. CONCLUSIONS As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY Review Article. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick C Bonasso
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202.
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Lori A Gurien
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Jeffrey M Burford
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Samuel D Smith
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
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Dokumcu Z, Toker Kurtmen B, Divarci E, Tamay PB, Kose T, Sezak M, Ozok G, Ergun O, Celik A. Retrospective Multivariate Analysis of Data from Children with Suspected Appendicitis: A New Tool for Diagnosis. Emerg Med Int 2018; 2018:4810730. [PMID: 30275991 PMCID: PMC6157147 DOI: 10.1155/2018/4810730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/17/2018] [Accepted: 08/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Decision-making for management may sometimes be difficult in acute appendicitis (AA). Various diagnostic scoring systems exist, but their sensitivity and specificity rates are far from ideal. In this study, the determination of the predictors and the effect of radiological data and developing a new scoring system were aimed. METHODS Medical records of patients who were hospitalized for AA between February 2012 and October 2016 were retrospectively reviewed. All data were compared between patients with and without appendicitis. The multivariate analysis was performed to define significant variables and to examine the sensitivity and specificity of each group of predictors including radiological data. A new scoring system (NSS) was formed and was compared with two existing scoring systems: pediatric appendicitis score (PAS) and Alvarado scoring system (ASS) by using reclassification method. RESULTS Negative appendectomy rate was 11.3%. Statistical analysis identified 21 independently significant variables. The heel drop test had the highest odds ratio. Sensitivity and specificity rates of clinical predictors were 84.6% and 94.8%, respectively. Radiological predictors increased the sensitivity rate to 86.9%. Sensitivity and specificity rates for PAS, ASS, and NSS were 86.8% and 83.9%, 84.7% and 81.6%, and 96.8% and 95.6%, respectively. The "re-assessed negative appendectomy rate" was 6.2% and false positive results were remarkably more common in patients with duration of symptoms less than 24 hours. CONCLUSION Radiological data improves the accuracy of diagnosis. Containing detailed clinical and radiological data, NSS performs superiorly to PAS and ASS, regarding sensitivity and specificity without any age limitation. The efficiency of NSS may be enhanced by determining different predictors for different phases of the inflammatory process.
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Affiliation(s)
- Zafer Dokumcu
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Bade Toker Kurtmen
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Emre Divarci
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Petek Bayindir Tamay
- Ege University Faculty of Medicine Department of Radiology, Division of Pediatric Radiology, Izmir, Turkey
| | - Timur Kose
- Ege University Faculty of Medicine Department of Biostatistics and Medical Informatics, Izmir, Turkey
| | - Murat Sezak
- Ege University Faculty of Medicine Department of Pathology, Izmir, Turkey
| | - Geylani Ozok
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Orkan Ergun
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
| | - Ahmet Celik
- Ege University Faculty of Medicine Department of Pediatric Surgery, Izmir, Turkey
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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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31
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Kelly BS, Bollard SM, Weir A, O'Brien C, Mullen D, Kerin M, McCarthy P. Improving diagnostic accuracy in clinically ambiguous paediatric appendicitis: a retrospective review of ultrasound and pathology findings with focus on the non-visualised appendix. Br J Radiol 2018; 92:20180585. [PMID: 30102564 DOI: 10.1259/bjr.20180585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare pre-operative ultrasound to histopathological results and retrospectively assess the diagnostic accuracy of ultrasound in paediatric appendicitis. METHODS 5 year review of all appendectomies performed in patients <16 years old in a tertiary referral university hospital. 983 patients had an appendicectomy over the time period while 189 patients had a preoperative ultrasound. We retrospectively reviewed all of the preoperative imaging in conjunction with the reports for the 189 patients; our aim was to determine the sensitivity of preoperative ultrasound for the diagnosis of acute appendicitis. RESULTS Of the 189 patients who had an ultrasound, 102 had histology positive for appendicitis and 87 had normal histology. Sensitivity overall was 72.55% [95% confidence interval (CI) 62.82 to 80.92] and specificity was 77.01% (95% CI 66.75 to 85.36). A suggested ultrasound diagnosis of appendicitis made positive pathology three times more likely and a normal ultrasound made positive pathology three times less likely [positive-predictive value 3.16 (95% CI 2.11 to 4.72) negative predictive value 0.36 (95% CI 0.25 to 0.50)]. 77% (67/87) of the patients whose pathology was ultimately normal had an ultrasound which was either normal or suggested an alternative diagnosis. However, in the 33 (17%) of patients with a non-visualised appendix, no secondary signs of inflammation or alternative diagnosis 16 (48%) had pathologically confirmed appendicitis. CONCLUSION Ultrasound has the potential to improve diagnostic accuracy in clinically ambiguous appendicitis. ADVANCES IN KNOWLEDGE This paper furthers the evidence on the efficacy of ultrasound as a diagnostic tool in acute appendicitis in children, especially when the diagnosis is clinically equivocal. It also sheds further light on the "non-visualized appendix" with almost half of these patients having pathologically confirmed appendicitis; meaning advanced imaging with CT or MR may be indicated in this cohort.
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Affiliation(s)
- B S Kelly
- Department of Radiology, Galway University Hospital, Galway, Ireland.,Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - S M Bollard
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - A Weir
- Department of Radiology, Galway University Hospital, Galway, Ireland.,Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - C O'Brien
- Departmentof Radiology, St Vincents University Hospital, Elm park, Dublin, Ireland
| | - D Mullen
- Department of Pathology, Galway University Hospital, Galway, Ireland
| | - M Kerin
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - P McCarthy
- Department of Radiology, Galway University Hospital, Galway, Ireland
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Abbas PI, Zamora IJ, Elder SC, Brandt ML, Lopez ME, Orth RC, Bisset GS, Cruz AT. How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department. Pediatr Emerg Care 2018; 34:381-384. [PMID: 29851913 DOI: 10.1097/pec.0000000000000720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score). METHODS In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range. RESULTS A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39). CONCLUSIONS The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.
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Affiliation(s)
| | | | | | | | | | - Robert C Orth
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital
| | - George S Bisset
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
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Sola R, Theut SB, Sinclair KA, Rivard DC, Johnson KM, Zhu H, St Peter SD, Shah SR. Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children. J Pediatr Surg 2018; 53:984-987. [PMID: 29550036 DOI: 10.1016/j.jpedsurg.2018.02.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Our objective was to increase ultrasound reliability for diagnosing appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative. METHODS A retrospective review of ultrasound use in patients diagnosed with appendicitis in our ED from 1/1/2011 to 6/30/2014 established a baseline cohort. From 8/1/2014 to 7/31/2015 a diagnostic algorithm that prioritized ultrasound over CT was used in our ED, and a standardized template was implemented for the reporting of appendicitis-related ultrasound findings by our radiologists. RESULTS Of 627 patients diagnosed with appendicitis in the ED during the retrospective review, 46.1% (n=289) had an ultrasound. After implementation of the diagnostic algorithm and standardized ultrasound report, 88.4% (n=236) of 267 patients diagnosed with appendicitis had an ultrasound (p<0.01). The frequency of indeterminate results decreased from 44.3% to 13.1%, and positive results increased from 46.4% to 66.1% in patients with appendicitis (p<0.01). The sensitivity of ultrasound (indeterminate counted as negative) increased from 50.6% to 69.2% (p<0.01). CONCLUSIONS Ultrasound reliability for the diagnosis of appendicitis in children can be improved through standardized results reporting. However, these changes should be made as part of a multidisciplinary quality improvement initiative to account for the initial learning curve necessary to increase experience. LEVEL OF EVIDENCE Level II, Study of Diagnostic Test.
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Affiliation(s)
- Richard Sola
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Stephanie B Theut
- Department of Radiology, The Children's Mercy Hospital and Clinics, Kansas City, MO, USA
| | - Kelly A Sinclair
- Department of Emergency Medicine, The Children's Mercy Hospital and Clinics, Kansas City, MO, USA
| | - Doug C Rivard
- Department of Radiology, The Children's Mercy Hospital and Clinics, Kansas City, MO, USA
| | - Kathy M Johnson
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Huirong Zhu
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Shawn D St Peter
- Department of Surgery, The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
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Mangona KLM, Guillerman RP, Mangona VS, Carpenter J, Zhang W, Lopez M, Orth RC. Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference? Acad Radiol 2017; 24:1616-1620. [PMID: 28826614 DOI: 10.1016/j.acra.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 03/06/2017] [Accepted: 06/05/2017] [Indexed: 01/07/2023]
Abstract
RATIONALE AND OBJECTIVES For imaging pediatric appendicitis, ultrasonography (US) is preferred because of its lack of ionizing radiation, but is limited by operator dependence. This study investigates the US diagnostic performance during night shifts covered by radiology trainees compared to day shifts covered by attending radiologists. MATERIALS AND METHODS Appy-Scores (1 = completely visualized normal appendix; 2 = partially visualized normal appendix; 3 = nonvisualized appendix with no inflammatory changes in the expected region of the appendix; 4 = equivocal; 5a = nonperforated appendicitis; 5b = perforated appendicitis) from 2935 US examinations (2161:774, day-to-night) from July 2013 to 2014 were correlated with the intraoperative diagnoses and the clinical follow-up. The diagnostic performance of trainees and attendings was compared with Fisher exact test. Interobserver agreement was measured by Cohen kappa coefficient. RESULTS Appendicitis prevalence was 25.3% (day) and 22.5% (night). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive vale were 94.0%, 93.7%, 93.8%, 97.9%, and 83.4% during the day and 92.0%, 91.2%, 91.3%, 97.5%, and 75.2% at night. Specificity (P = .048) and positive predictive value (P = .011) differed, with more false positives at night (7%) than during the day (4.7%). Trainee and attending agreement was high (k = 0.995), with Appy-Scores of 1, 4, and 5a most frequently discordant. CONCLUSIONS US has a high diagnostic performance and interobserver agreement for pediatric appendicitis when interpreted by radiology trainees during night shifts or attending radiologists during day shifts. However, lower specificity and positive predictive value at night warrants a thorough trainee education to avoid false-positive examinations.
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Affiliation(s)
- Kate Louise M Mangona
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030.
| | - R Paul Guillerman
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030.
| | - Victor S Mangona
- Department of Radiation Oncology, The University of Texas MD. Anderson Cancer Center, Houston, Texas
| | - Jennifer Carpenter
- Texas children's hospital, Department of surgery, Division of pediatric surgery, Houston, Texas
| | - Wei Zhang
- Texas Children's Hospital Outcomes & Impact Service, Houston, Texas
| | - Monica Lopez
- Division of Pediatric Surgery, Baylor College of Medicine, Houston, Texas
| | - Robert C Orth
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030
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Anderson KT, Bartz-Kurycki M, Austin MT, Kawaguchi A, John SD, Kao LS, Tsao K. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. J Pediatr Surg 2017; 52:1909-1915. [PMID: 28927978 DOI: 10.1016/j.jpedsurg.2017.08.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Marisa Bartz-Kurycki
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
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Yu YR, Smith CM, Ceyanes KK, Naik-Mathuria BJ, Shah SR, Vogel AM, Carberry KE, Nuchtern JG, Lopez ME. A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition. J Pediatr Surg 2017; 53:S0022-3468(17)30633-4. [PMID: 29103787 DOI: 10.1016/j.jpedsurg.2017.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Standardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis. METHODS All children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients. RESULTS Of 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0h, p<0.001), but postoperative LOS (4.4 vs. 17.4h, p<0.001) and overall LOS (17.1 vs. 31.2h, p<0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode ($8073 vs $8424, p=0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10). CONCLUSIONS Safe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system. LEVEL OF EVIDENCE Prognosis study, Level II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine.
| | - Carolyn M Smith
- Decision Support, Texas Children's Hospital Outcomes and Impact Service, Texas Children's Hospital
| | - Kimberly K Ceyanes
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Bindi J Naik-Mathuria
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Sohail R Shah
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | | | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Monica E Lopez
- Division of Pediatric Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine
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A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis. J Trauma Acute Care Surg 2017; 83:643-649. [PMID: 28459797 DOI: 10.1097/ta.0000000000001551] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy. METHODS We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports. RESULTS Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively). CONCLUSION Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients. LEVEL OF EVIDENCE Diagnostic Test, Level III.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA.
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Carpenter JL, Orth RC, Zhang W, Lopez ME, Mangona KL, Guillerman RP. Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study. Radiology 2017; 282:835-841. [DOI: 10.1148/radiol.2016160175] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer L. Carpenter
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Robert C. Orth
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Wei Zhang
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Monica E. Lopez
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - Kate L. Mangona
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
| | - R. Paul Guillerman
- From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children’s Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.)
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Munden MM, Wai S, DiStefano MC, Zhang W. Limited Abdominal Sonography for Evaluation of Children With Right Lower Quadrant Pain. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:183-186. [PMID: 27925670 DOI: 10.7863/ultra.16.01102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine whether a complete abdominal sonographic examination is necessary in the evaluation of children with right lower quadrant pain that is suspicious for appendicitis in the emergency department and whether performing a limited, more-focused study would miss clinically important disease. METHODS With Institutional Review Board approval, a retrospective study was performed of 704 patients, from ages 5-19 years, presenting to the emergency department with right lower quadrant pain that was suspicious for appendicitis who underwent a complete abdominal sonographic examination. Data were extracted from the complete abdominal sonographic examination to see whether abnormalities were noted in the pancreas, spleen, and left kidney. Patients' medical charts were reviewed to see whether any positive findings in these organs were clinically important. RESULTS Of the 65 studies with a finding that would have been missed with a limited study, only 6 were found to be clinically important. Of those, 5 were managed medically and 1 surgically. The chance of missing a potentially important finding using a limited study with our group of patients was 65 of 704 patients (9.2%), with a 95% confidence interval of 7.2% to 11.7%. The chance of missing an abnormality that was clinically important was 6 of 704 patients (0.85%), with a 95% confidence interval of 0.35% to 1.94%. CONCLUSIONS In children older than 5 years with abdominal pain that is suspicious for appendicitis, performing only a limited abdominal sonographic examination that excludes the pancreas, left kidney, and spleen will yield a miss rate for clinically important disease that is acceptably low to justify the savings of examination time.
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Affiliation(s)
| | - Shannon Wai
- Rady Children's Hospital, San Diego, California, USA
| | | | - Wei Zhang
- Texas Children's Hospital, Houston, Texas, USA
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Karmazyn B. Imaging is Usually Not Necessary When Clinical Scores for the Diagnosis of Appendicitis Are Low. Radiology 2017; 282:304-305. [DOI: 10.1148/radiol.2017161977] [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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Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams. Pediatr Radiol 2016; 46:1539-45. [PMID: 27282824 DOI: 10.1007/s00247-016-3645-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/29/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, borderline appendiceal enlargement or questionable inflammatory changes can confound interpretation and lead to equivocal exams. OBJECTIVE The purpose of this study was to determine which findings on equivocal US exams are most predictive of appendicitis. MATERIALS AND METHODS All US exams performed for suspected pediatric appendicitis from July 1, 2013, through July 9, 2014, were initially interpreted using a risk-stratified scoring system. Two blinded pediatric radiologists independently reviewed US exams designated as equivocal and recorded the following findings: increased wall thickness, loss of mural stratification, peri-appendiceal fat inflammation, peri-appendiceal fluid, appendicolith and maximum appendiceal diameter. A third pediatric radiologist resolved discrepancies. US features were correlated with the final diagnosis via multivariate analysis. RESULTS During the study period, 162/3,750 (4.3%) children had US exams initially interpreted as equivocal (mean age 9.8 +/- 3.8 years). Five outpatients were lost to follow-up. Forty-eight of the remaining 157 (30.6%) children had an operative diagnosis of appendicitis. Findings significantly associated with appendicitis were loss of mural stratification (odds ratio [OR] = 6.7, P=0.035), peri-appendiceal fat inflammation (OR = 10.0, P<0.0001) and appendicolith (OR = 15.8, P=0.025). While appendiceal diameter tended to be larger in patients with appendicitis, the difference was not statistically significant. CONCLUSION Loss of mural stratification, peri-appendiceal fat inflammation and an appendicolith are significant predictors of appendicitis in children with otherwise equivocal US exams. While maximum appendiceal diameter is not statistically associated with appendicitis in our study, mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal limit of 6 mm is too sensitive.
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Cundy TP, Sierakowski K, Manna A, Cooper CM, Burgoyne LL, Khurana S. Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study. ANZ J Surg 2016; 87:271-276. [PMID: 27599307 DOI: 10.1111/ans.13744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. METHODS Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. RESULTS Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. CONCLUSION Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyra Sierakowski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Alexandra Manna
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Celia M Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Laura L Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Gale HI, Gee MS, Westra SJ, Nimkin K. Abdominal ultrasonography of the pediatric gastrointestinal tract. World J Radiol 2016; 8:656-667. [PMID: 27551336 PMCID: PMC4965350 DOI: 10.4329/wjr.v8.i7.656] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/11/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.
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Coca Robinot D, Liébana de Rojas C, Aguirre Pascual E. Abdominal emergencies in pediatrics. RADIOLOGIA 2016; 58 Suppl 2:80-91. [PMID: 27041066 DOI: 10.1016/j.rx.2016.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 02/02/2016] [Accepted: 02/20/2016] [Indexed: 11/17/2022]
Abstract
Abdominal symptoms are among the most common reasons for pediatric emergency department visits, and abdominal pain is the most frequently reported symptom. Thorough history taking and physical examination can often reach the correct diagnosis. Knowing the abdominal conditions that are most common in each age group can help radiologists narrow the differential diagnosis. When imaging tests are indicated, ultrasonography is usually the first-line technique, enabling the diagnosis or adding relevant information with the well-known advantages of this technique. Nowadays, plain-film X-ray studies are reserved for cases in which perforation, bowel obstruction, or foreign body ingestion is suspected. It is also important to remember that abdominal pain can also occur secondary to basal pneumonia. CT is reserved for specific indications and in individual cases, for example, in patients with high clinical suspicion of abdominal disease and inconclusive findings at ultrasonography. We review some of the most common conditions in pediatric emergencies, the different imaging tests indicated in each case, and the imaging signs in each condition.
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Affiliation(s)
- D Coca Robinot
- Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - C Liébana de Rojas
- Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, España
| | - E Aguirre Pascual
- Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, España
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Frickmann H, Jungblut SA. Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report. Mil Med Res 2016; 3:20. [PMID: 27350895 PMCID: PMC4922061 DOI: 10.1186/s40779-016-0088-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed. CASE PRESENTATION A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis. CONCLUSIONS Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.
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Affiliation(s)
- Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany ; Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
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