A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children

Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis

OBJECTIVE

Possible childhood appendicitis is a common emergency presentation. The exact value of blood tests is debated. This study sought to determine the diagnostic accuracy of four blood tests (white cell count (WCC), neutrophil(count or percentage), C reactive protein (CRP) and/or procalcitonin) for childhood appendicitis.

DESIGN

A systematic review and diagnostic meta-analysis. Data sources included MEDLINE, EMBASE, Central, Web of Science searched from inception-March 2022 with reference searching and authors contacted for missing/unclear data. Eligibility criteria was studies reporting the diagnostic accuracy of the four blood tests compared to the reference standard (histology or follow-up). Risk of bias was assessed (QUADAS-2), pooled sensitivity and specificity were generated for each test and commonly presented cut-offs. To provide insight into clinical impact, we present strategies using a hypothetical cohort.

RESULTS

67 studies were included (34 839 children, 13 342 with appendicitis), all in the hospital setting. The most sensitive tests were WCC (≥10 000 cells/µL, 53 studies sensitivity 0.85 (95% CI 0.80 to 0.89)) and absolute neutrophil count (ANC) (≥7500 cells/µL, five studies sensitivity 0.90 (95% CI 0.85 to 0.94)). Combination of WCC or CRP increased sensitivity further(≥10 000 cells/µL or ≥10 mg/L, individual patient data (IPD) of 6 studies, 0.97 (95% CI 0.93 to 0.99)).Applying results to a hypothetical cohort(1000 children with appendicitis symptoms, of whom 400 have appendicitis) 60 and 40 children would be wrongly discharged based solely on WCC and ANC, respectively, 12 with combination of WCC or CRP.The most specific tests were CRP alone (≥50 mg/L, 38 studies, specificity 0.87 (95% CI 0.80 to 0.91)) or combined with WCC (≥10 000 cells/µL and ≥50 mg/L, IPD of six studies, 0.93 (95% CI 0.91 to 0.95)).

CONCLUSIONS

The best performing single blood tests for ruling-out paediatric appendicitis are WCC or ANC; with accuracy improved combining WCC and CRP. These tests could be used at the point of care in combination with clinical prediction rules. We provide insight into the best cut-offs for clinical application.

PROSPERO REGISTRATION NUMBER

CRD42017080036.

Factors affecting utilization of CT scan following ultrasound evaluation of suspected appendicitis

CONTEXT

When evaluating a pediatric patient in the emergency department for suspected appendicitis, a provider is often faced with the dilemma of deciding if a computed tomography (CT) scan is warranted when-as is most often the case-ultrasound results do not yield a definitive diagnosis. The potential risks of radiation must be weighed against numerous aspects of a patient's background, physical exam, and already-obtained workup.

OBJECTIVES

This study aims to aid in future decision making of providers in their evaluation of patients with suspected appendicitis, to help facilitate a more comprehensive answer to the "next-steps" in the question of equivocal ultrasound, and to create a pathway utilizing lab results, physical exam findings, and pertinent positives and negatives in patient history to facilitate a more objective decision-making process for ordering a CT scan.

METHODS

A retrospective chart review was performed for patients who were evaluated for possible appendicitis at our institution between October 2016 and October 2017 and whose ultrasound results were equivocal. We determined what factors led to increased frequency of obtaining CT scans.

RESULTS

Statistical analysis showed that several factors were independently associated with the increased likelihood of having a CT scan performed. When considered in combination with the other parameters, it was found that older children, males, report of right lower quadrant (RLQ) pain, and presence of RLQ tenderness on physical exam were all associated with a significantly higher likelihood of having a CT scan performed.

CONCLUSIONS

When combined with present algorithms and protocols already in use, this information can assist the provider in making prudent decisions for their patients with the potential for reduced provider bias.