Variation in imaging outcomes associated with individual sonographers and radiologists in pediatric acute appendicitis: a retrospective cohort of 9271 examinations

CAR/CETARS/CSAR Practice Guideline on Imaging the Adult Patient With Right Lower Quadrant Pain

In 2023, the Canadian Society of Abdominal Radiology (CSAR) and Canadian Emergency, Trauma, and Acute Care Radiology Society (CETARS) received Canadian Association of Radiologists (CAR) member feedback that there was an unmet educational need for guidance in the imaging investigation of right lower quadrant (RLQ) pain. Members requested specific guidance on how to handle controversial scenarios including which test to order when, specifics of imaging protocols, and managing pregnant patients who have RLQ pain-all from a Canadian perspective. After conducting an exhaustive literature review, the working group agreed that a Canadian-specific set of guidelines was warranted. The management recommendations presented in this guideline were discussed as a group to achieve expert consensus. As the workup for RLQ pain can vary considerably in the paediatric population, the scope of this paper was restricted to adults (18 years of age or older). Whenever possible, the best evidence was used to inform the clinical guidance, and where gaps existed, the guidelines reflect consensus among experts in the field. The result is a framework to aid in this process of managing patients with RLQ pain across various clinical scenarios while addressing current questions and controversies, particularly those most relevant to the Canadian healthcare system.

Partial visualization of appendix on ultrasound: What does it mean in the child with suspected appendicitis?

BACKGROUND

Visualization of the entire appendix, including the tip, is thought, but has not been demonstrated, to be important for exclusion of appendicitis by ultrasound.

OBJECTIVE

To determine if incomplete visualization of the appendix has negative clinical ramifications including missed appendicitis.

METHODS

Under IRB approval we retrospectively reviewed right lower quadrant ultrasound reports from January 2017 to December 2020 to identify examinations with impressions of full visualization of the normal appendix, non-visualization of the appendix with and without secondary findings of appendicitis, and partial visualization of the appendix. Electronic health records were reviewed for follow-up imaging within 48 h, and surgery with pathology reports (if available).

RESULTS

12,193 examinations were included. 4171 (34.2 %) had full visualization of a normal appendix, 5369 (44.0 %) had non-visualization with no secondary findings, and 234 (1.9 %) had non-visualization with secondary findings, The frequencies of appendicitis in these three groups were 34 (0.8 %), 283 (5.3 %), and 127 (54.3 %) respectively. The appendix was partially visualized in 338 (2.8 %) patients with secondary findings present in 53 (15.6 %). Partial visualization without secondary findings had a similar frequency (4.9 %, 14/285) of appendicitis to non-visualized appendix without secondary findings (p = 0.797) and a higher frequency than full visualization of a normal appendix (p < 0.0001). Partial visualization with secondary findings had similar rates (54.7 %, 29/53) to non-visualized appendix with secondary findings (p = 0.953).

CONCLUSION

Partial visualization of the appendix with ultrasound (with and without secondary findings) is associated with similar frequencies of appendicitis as non-visualization of appendix (with and without secondary findings).

Predictors of Clinical Outcomes in Pediatric Appendicitis: Role of the Individual Sonographer and Radiologist When Using a First-Line Ultrasound Approach

OBJECTIVE

To determine if differences between individual sonographers and radiologists performing and interpreting appendix ultrasound affect clinically important outcomes in children with suspected acute appendicitis.

METHODS

Patients <18 years of age who presented to our emergency department (ED) with suspected acute appendicitis and underwent an appendix ultrasound were identified. Sonographers who performed fewer than 100 examinations and radiologists who interpreted fewer than 100 examinations during the study period were excluded. Multivariable logistic regression was performed to assess the effect of sonographer, radiologist, clinical variables, and system factors on key clinical outcomes, including hospital admission and appendectomy.

RESULTS

In all, 9,283 appendix ultrasounds (mean age, 9.9 ± 4.2 years; 5,400 [58.2%] boys) performed by 31 sonographers (mean number of examinations, 299 ± 140 [range, 115-610]) and interpreted by 31 radiologists (mean number of examinations, 299 ± 157 [range, 101-845]) were included. Mean admission frequency per sonographer was 34.0% ± 3.3% (range, 27.8%-42.6%) and per radiologist was 33.5% ± 3.9% (range, 23.7%-41.6%). Mean appendectomy frequency per sonographer was 20.3% ± 2.6% (range, 14.9%-27.0%) and per radiologist was 20.3% ± 3.1% (range, 15.2%-28.7%). Significant multivariable predictors of hospital admission included temperature (P < .0001), white blood cell count (P < .0001), male sex (P = .002), imaging performed at the main hospital (versus satellite hospital) (P = .001), abdominal tenderness with ultrasound transducer compression (P < .0001), presence of rebound tenderness (P = .001), and presence of acute appendicitis by ultrasound (P < .0001), but not sonographer or radiologist. Predictors of appendectomy included weight (P < .0001), white blood cell count (P < .0001), male sex (P = .0004), abdominal tenderness with ultrasound transducer compression (P < .0001), and the presence of acute appendicitis by ultrasound (P < .0001), but not sonographer or radiologist.

CONCLUSION

Differences in individual sonographers and radiologists did not predict clinically important outcomes in children undergoing ultrasound in the ED for suspected acute appendicitis.