Diagnostic performance of standardized ultrasound protocol for detecting perforation in pediatric appendicitis

POCUS for Infectious Enteritis-A Retrospective Case Series Analysis

INTRODUCTION

The abdominal pain associated with diarrhea can be difficult to distinguish from appendicitis. We present a case series of all children found on pediatric emergency department point-of-care ultrasound (POCUS) to have right-sided bowel wall edema.

METHODS

Over the study period June 2020 through September 2023, POCUS images were collected by a pediatric emergency physician with 6 years of experience with POCUS. Children found to have small bowel wall edema on POCUS were identified, and hospital charts were reviewed.

RESULTS

One hundred thirteen children were found on POCUS to have right-sided small bowel wall edema. Thirty-one (27%) were referred by their pediatrician or urgent care provider to evaluate for appendicitis. Seventy-eight children (69%) provided stool samples. Of those, 58% resulted Campylobacter , 8% Salmonella , and 8% Shigella . Forty (35%) were discharged after POCUS without further evaluation. One child in our case series was subsequently diagnosed with uncomplicated appendicitis. To date, no child in the series has subsequently been diagnosed with inflammatory bowel disease.

CONCLUSIONS

Enteritis can initially be difficult to distinguish on clinical grounds from acute appendicitis. Bowel wall edema on POCUS in a child without sonographic signs of appendicitis strongly suggests bacterial enteritis. Early POCUS demonstrating enteritis without signs of appendicitis may decrease hospital resource usage.

Characterization and quantification of fluid in the abdomen by ultrasound and magnetic resonance imaging in children with clinical suspicion of appendicitis

PURPOSE

While regarded as a secondary sign of pediatric appendicitis, the frequency of physiologic intra-abdominal fluid in children with suspected but absent appendicitis is unknown. Ex vivo: to assess the validity of US/MRI measurements of free fluid. In vivo: in suspected pediatric appendicitis, to assess the amount of abdominal fluid by US and MRI, determine performance characteristics of US in fluid detection and identify fluid volume ranges in confirmed appendicitis.

METHODS

Ex vivo: criterion validity of US and MRI for fluid volume measurements was tested using tissue-mimicking phantoms filled with different volumes of distilled water. In vivo: all participants from a previous prospective study of suspected appendicitis were evaluated by US; MRI was performed after equivocal USs. Qualitative and quantitative analyses of abdominal fluid and correlation of fluid presence with appendicitis were performed.

RESULTS

Ex vivo: no difference was found between phantom-fluid amount and measured volume using the formula for volume of an ellipsoid for US (P=0.19) or MRI (P=0.08). In vivo: intra-abdominal fluid was present in 212/591 (35.9%) patients; 75/212 patients with fluid (35.4%) had appendicitis, 60 (28.3%) had alternate diagnoses, and 77 (36.3%) had physiologic fluid. Sensitivity and specificity of US for fluid detection were 84% (95% CI 71-93) and 65% (95% CI 52-77), respectively. In children with versus without appendicitis, the respective ranges of fluid volume were 0.7-1148.8 ml and 0.8-318 ml.

CONCLUSION

The volume of an ellipsoid formula is a valid method for quantifying intra-abdominal fluid. The sole presence of intra-abdominal fluid on US does not support the diagnosis of pediatric appendicitis.

Acute care diagnostics in children for general radiologists - not alone in the hospital at night

BACKGROUND

Radiologic care for children and adolescents during night and weekend shifts is challenging. This is especially true when a dedicated pediatric radiology front or background service is not available.

METHODS

The purpose of this review is to present the approach, the most relevant diagnoses, and their differential diagnoses based on four common example cases - abdominal pain, respiratory/chest pain, headache, and refusal to walk. Essentials such as clinical classification (e. g., disease dynamics) and practical instructions (e. g., necessity of acute cross-sectional imaging) are presented.

RESULTS AND CONCLUSION

For the abdomen, appendicitis ranks first among acute diseases. Other important diseases are intussusception and volvulus. Far more frequently, however, gastroenteritis is the cause of abdominal pain. Usually no imaging is required in this case. In unclear clinical situations, ultrasound may be indicated. In suspected pulmonary infections, chest imaging is limited to inconclusive cases and suspicion of complications such as pleural empyema. Major emergencies include (spontaneous) pneumothorax and aspiration. Headache is a common symptom. Immediate imaging is only necessary in cases of suspected acute inflammatory (meningitis/encephalitis) or vascular disease (e. g., hemorrhage due to vascular malformations). MRI is the primary imaging modality in these cases. Restricted walking/refusal to walk is a classic nonspecific sign, particularly of acute musculoskeletal disease, especially in younger children. Clinical examination is essential to narrow down the field of investigation. Besides the frequent and symptomatic coxitis fugax, the rare but serious (septic) arthritis/osteomyelitis must not be overlooked.

KEY POINTS

· Radiological care of children and adolescents is challenging, especially during night and weekend shifts.. · However, in close cooperation with the referring colleagues/clinics, the appropriate approach can be effectively determined even if the symptoms are not clear.. · The selection of the optimal imaging method is based on guidance and guidelines, but also on the condition of the child/adolescent.. · A silent or whimpering child is cause for alarm..

CITATION FORMAT

· Beer M, Mentzel H, Steinborn M et al. Acute care diagnostics in children for general radiologists - not alone at night in the hospital. Fortschr Röntgenstr 2023; 195: 205 - 216.

The utility of sonographic signs to diagnose simple and complicated appendicitis in children

BACKGROUND

Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children.

METHODS

Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant).

RESULTS

A total of 934 USS were included, with median age 10.7 [8.0-13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90-0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57-0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004).

CONCLUSION

Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.

Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines

BACKGROUND

Use of clinical practice guidelines (CPGs) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis.

METHODS

We characterized key decision points and content areas from CPGs developed from 2000 to 2019 that were identified using publicly available platforms and manual search/personal communications.

RESULTS

Twenty-seven CPGs were reviewed with content saturation achieved after reviewing eight. We found 16 key elements spanning from triage to postoperative care. Elements with high accord among CPGs included use of laparoscopy and delay of postoperative imaging for abscess screening until postoperative day seven. For simple appendicitis, all CPGs endorsed antibiotic cessation, diet advancement, and early activity, and 11 CPGs included same-day discharge. Elements with heterogeneity in decision-making included antibiotic selection/duration for perforated appendicitis, criteria defining perforation, and utility of postoperative laboratory evaluations.

CONCLUSIONS

Development of an evidence-based CPGs for pediatric appendicitis requires attention to a finite number of key decision points and content areas. Existing literature demonstrates improved patient outcomes with CPG implementation.

Imaging of Acute Abdominal Pain in the Pediatric Population

Acute abdominal pain is a common complaint in pediatrics. Although age and location of pain can help focus differential diagnosis, imaging plays an essential role in clinical evaluation. In this review, we discuss the optimal imaging approach to pediatric patients with acute abdominal pain and important imaging findings in the most common causes of abdominal pain in the pediatric population. [Pediatr Ann. 2020;49(9):e380-e388.].