The impact of ultrasound in suspected acute appendicitis

Pediatric Appendicitis Score or Ultrasonography? In Search of a Better Diagnostic Tool in Indian Children with Lower Abdominal Pain

OBJECTIVES

To prospectively assess the performance of pediatric appendicitis score (PAS) in diagnosing acute appendicitis in the children with lower abdominal pain and correlated with ultrasound findings; and to assess the impact of the PAS on clinical outcome and its efficacy in differentiating between complicated and uncomplicated appendicitis.

METHODS

A prospective study was done which included cases of lower abdominal pain. Appendectomy was done for PAS ≥ 6, and diagnosis was confirmed on histopathology. A receiver operator characteristic (ROC) curve was created to assess the PAS performance. The sensitivity, specificity, and accuracy of ultrasonography in diagnosing appendicitis were assessed, and analysis of agreement between ultrasonography and PAS score was done by kappa statistics.

RESULTS

Of 260 cases with lower abdominal pain, 205 were suspected of having appendicitis. One hundred fifty-nine had PAS ≥ 6. There were 2/159 (1.26%) cases of negative appendectomies and 2/46 (4.34%) cases of missed appendicitis. The mean PAS was significantly higher in patients with appendicitis than in those without appendicitis. The area under the ROC curve was 0.9925. Sensitivity, specificity, and positive and negative predictive value of PAS were 98.74%, 95.65%, 95.7% and 95.65%, respectively. Complicated appendicitis had significantly more PAS, fever, and cough tenderness than uncomplicated appendicitis. The sensitivity and specificity of ultrasonography were 86.79% and 17.39%, respectively. Agreement between ultrasonography-proven appendicitis and PAS-dependent appendicitis was weak.

CONCLUSION

PAS has high efficacy in diagnosing acute appendicitis. Clinical outcome was more favorable with the use of PAS. Ultrasonography should be used judiciously and in combination with clinical judgment.

Two-dimensional shear wave elastography can improve the diagnostic accuracy of ultrasonography in acute appendicitis

AIM

We aimed to evaluate the effectiveness of combining 2-dimensional shear wave elastography (2D-SWE) with ultrasonography (US) in diagnosing acute appendicitis in patients with suspected acute appendicitis.

METHODS

Clinical and laboratory findings, gray-scale US and 2D-SWE imaging features, operation information, and pathology results of 48 patients diagnosed with acute appendicitis who presented with right lower quadrant pain were prospectively evaluated. We compared the findings to the US and SWE imaging features of 79 asymptomatic patients.

RESULTS

Mean Alvarado score and appendix diameter were statistically significantly higher for acute appendicitis (p < 0.001). In patients with acute appendicitis, mesenteric lymphadenopathy and fat stranding were also more frequent (p < 0.001). The mean velocity and kPa values for appendix and mesenteric fat were statistically significantly higher in acute appendicitis (p < 0.001).

CONCLUSION

In the diagnosis of acute appendicitis, 2D-SWE increases the diagnostic performance of gray-scale US in the differentiation of inflamed and normal appendixes.

A Correlation of Blood Panel Results and Histologically Confirmed Appendicitis

Background

Appendicitis is the most common indication for emergency surgery in the world. There is no one laboratory or radiological test that is used to diagnose it. Various routine and novel blood markers have been identified, however none have proved to be conclusive. The aim of this study was to combine routine blood markers to increase the sensitivity and specificity in diagnosing histologically confirmed appendicitis.

Methods

We retrospectively reviewed the theatre logs for the calendar year of 2015 to identify all of the appendectomies which were performed. We reviewed all of the admission bloods for the patients - including their white blood cell (WBC) count, their neutrophil count, and their C-Reactive protein (CRP) value. We also reviewed all of the histology to identify the inflamed appendices, and analysed all of this information together.

Results

The neutrophil count is the most sensitive of the three blood markers with a score of 82%. It has a specificity of 63%. The CRP value is the most specific of the three blood markers with a value of 67% and a sensitivity of 76%. WBC has a sensitivity of 75% and a specificity of 63%. Combining all of the blood values (i.e. elevated white blood cell count or elevated neutrophil count or elevated CRP) demonstrates a sensitivity of 96% and a specificity of 45%.

Conclusion

Combining routine admission blood markers (WBC, neutrophil count, and CRP) can assist in diagnosing appendicitis in unwell patients with abdominal pain.

Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis

OBJECTIVE

To evaluate the diagnostic accuracy of ultrasonography in pediatric acute appendicitis.

METHODS

In this cross-sectional study, 230 children aged 5-15 years with the diagnosis of acute appendicitis were studied. This study included the evaluation of demographic indices, ultrasound findings at diagnosis, and then comparing the results with the description of the patient's procedure and the pathology report of these patients. Patients who did not undergo ultrasound before surgery or their ultrasound did not include the evaluation of appendicitis or their pathologic report was not available were excluded.

RESULTS

Overall, we have included a total number of 230 children with clinical diagnosis of acute appendicitis among whom there were 121 (52.6%) girls and 109 (47.4%) boys with mean age of 11.44 ± 2.90 years. Preoperative ultrasound report showed that 51.3% were normal and 48.7% had acute appendicitis. 34.8% had normal appendix and 65.2% had a pathological diagnosis of acute appendicitis. The sensitivity and specificity of ultrasound in these children were 58% and 68%, respectively. Positive and negative predictive values ​​were 77% and 46%, respectively. The area under curve (AUC) was 0.853 (CI 95% 0.788-0.917) indicating a test with moderate accuracy.

CONCLUSION

According to the obtained results, abdominal ultrasonography is of acceptable diagnostic accuracy in pediatric patients with acute appendicitis. The use of auxiliary techniques in ultrasound would increase the sensitivity and specificity in the diagnosis of acute appendicitis in children.

Appendicitis: Role of MRI

The diagnosis of pediatric appendicitis can be difficult, with a substantial proportion misdiagnosed based on clinical features and laboratory tests alone. Accordingly, advanced imaging with ultrasound (US), computed tomography (CT), and/or magnetic resonance imaging has become routine for most children undergoing diagnostic evaluation for appendicitis. There is increasing interest in the use of US as the primary imaging modality and reserving CT as a secondary diagnostic modality in equivocal cases. Magnetic resonance imaging, using a rapid protocol, without contrast or sedation, has been found to be highly sensitive and specific in the evaluation of children with acute right lower quadrant pain in a number of studies. Because magnetic resonance imaging has the advantage over CT of not using contrast or ionizing radiation, it may replace CT in many instances, whether after US as part of a stepwise imaging algorithm or as a primary imaging modality. Accessibility and cost, however, limit its more widespread use currently.

Review of bedside surgeon-performed ultrasound in pediatric patients

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.

Sonography of suspected acute appendicitis in children: Evaluation of the progress in performance of senior residents

PURPOSE

The objective of this study was to evaluate the progress in performance of senior residents in diagnosing acute appendicitis.

MATERIAL AND METHODS

Results were collected and compared of ultrasound examinations performed for suspected acute appendicitis by three senior residents and two faculty members over a six-month period in a university hospital setting. A grid with the sonographic findings was completed separately by the residents and the faculty members immediately after each examination. The duration of each examination was reported. The final ultrasound diagnosis was compared to the surgical and pathological results and to the clinical follow-up.

RESULTS

The residents and faculty members performed 171 consecutive ultrasound examinations including 49 children with acute appendicitis and 122 with normal appendices. The accuracy of the diagnosis by the residents was 96%, and was similar to that of the faculty members (kappa=0.90) over the six months. The duration of the resident ultrasound examinations was significantly shorter during the second three-month period (p=0.01). No significant differences in diagnostic accuracy were demonstrated by the residents between the first and second three-month periods (p=0.06).

CONCLUSIONS

The residents performed well when using sonography to diagnose acute appendicitis in children, and were faster during the second three-month period.

LEVEL OF EVIDENCE

I.

Importance of Clinical Decision Making by Experienced Pediatric Surgeons When Children Are Suspected of Having Acute Appendicitis: The Reality in a High-Volume Pediatric Emergency Department

OBJECTIVE

The aim of the present study was to compare the pediatric appendicitis score (PAS), the Alvarado score (AS), white blood cell count (WBC), absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin level, and ultrasound (US) data, with the appendectomy decisions of pediatric surgeons diagnosing acute appendicitis (AA) in a real-life setting; this was a top-level, high-volume pediatric emergency department (PED) in a developing country.

METHODS

The study was conducted prospectively between January 2012 and June 2013 in the PED of the Tepecik Teaching and Research Hospital in Izmir, Turkey. The study was observational in nature; no attempt was made to influence indications for exploration or the timing thereof. Children aged 4 to 18 years presenting to the PED on suspicion of AA were included. The WBC, ANC, CRP level, and procalcitonin level were measured, and US was performed on all patients on admission. The PAS and AS were calculated. An operative decision was made by each pediatric surgeon who had the results of laboratory and radiological tests. The criterion standard for AA was histopathological assessment.

RESULTS

Upon receiver operating curve (ROC) analysis, the areas under the ROCs (AUROCs) of the WBC, ANC, CRP level, procalcitonin level, US positivity, PAS, AS, and decisions of pediatric surgeons supported by laboratory and US data were 0.734, 0.741, 0.671, 0.675, 0.670, 0.831, 0.794, and 0.910, respectively. When US data were employed only in cases with PASs 4 to 7, the sensitivity increased but specificity decreased. The sensitivity and specificity of pediatric surgical decisions were 100% and 82.50%, respectively. The difference between the PAS AUROC and the pediatric surgeon decision-making AUROC was significant (P = 0.0393; 95% confidence interval, 0.0470-0.226).

CONCLUSIONS

Good pediatric surgical decision making supported by laboratory and US data for those suspected of AA may be the most effective diagnostic tool in a high-volume PED in a developing country.

Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children

INTRODUCTION

Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies.

METHODS

Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated.

RESULTS

530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy.

CONCLUSION

Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions.

Added value of graded compression ultrasound to the Alvarado score in cases of right iliac fossa pain

INTRODUCTION

Acute appendicitis is one of the most common emergencies treated by the general surgeon. Simple appendicitis can progress to perforation, which is associated with a much higher morbidity and mortality, and surgeons have therefore been inclined to operate when the diagnosis is probable rather than wait until it is certain. The aim of this study was to evaluate the sensitivity and specificity of the Alvarado score combined with ultrasounds of the abdomen and pelvis in cases of right iliac fossa pain with suspected acute appendicitis.

METHODS

100 patients admitted to the Department of Surgery at Alexandria Main University Hospital in 2013 complaining of right iliac fossa pain with suspected acute appendicitis were studied prospectively. The demographic information, histopathology, physical examination, laboratory data, Alvarado score, sonography report and histopathological reports of these patients were gathered. The treating surgeon made decisions for surgery or conservative management without any intervention from the research team.

RESULTS

A combination of methods showed that Alvarado alone was 100% sensitive in excluding appendicitis at scores below five and was highly specific at scores above eight (91.9%) with no added value when combining it with ultrasound in those scores. On the other hand, ultrasound was beneficial only in patients with Alvarado scores between five and eight for detecting appendicitis and not excluding it (increasing specificity to 100% and not affecting sensitivity).

CONCLUSION

Ultrasound is a good adjuvant examination in cases with Alvarado scores between five and eight in order to diagnose appendicitis. Negative ultrasound results do not exclude appendicitis and further assessment by other modalities should be performed.

Appendicitis in the Infant Population: A Case Report and Review of a Four-Month Old With Appendicitis

BACKGROUND

Appendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis.

CASE REPORT

A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.

Ultrasound of paediatric appendicitis and its secondary sonographic signs: providing a more meaningful finding

Sonography is an important clinical tool in diagnosing appendicitis in children as it can obviate both exposure to potentially harmful ionising radiation from computed tomography scans and the need for unnecessary appendicectomies. This review examines the diagnostic accuracy of ultrasound in the identification of acute appendicitis, with a particular focus on the the utility of secondary sonographic signs as an adjunct or corollary to traditionally examined criteria. These secondary signs can be important in cases where the appendix cannot be identified with ultrasound and a more meaningful finding may be made by incorporating the presence or absence of secondary sonographic signs. There is evidence that integrating these secondary signs into the final ultrasound diagnosis can improve the utility of ultrasound in cases where appendicitis is expected, though there remains some conjecture about whether they play a more important role in negative or positive prediction in the absence of an identifiable appendix.

Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort

OBJECTIVES

The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site-related variations based on the frequency of its use. Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized.

METHODS

This was a secondary analysis of a prospective, 10-center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician.

RESULTS

Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%).

CONCLUSIONS

Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis

PURPOSE

Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital.

METHODS

We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation.

RESULTS

During the study (2005-2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005-2006 to 51.7% (1,775/3,432) in 2007-2008 (p < 0.0001), hospitalizations decreased from 33 to 30.1% (p = 0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p < 0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p < 0.0001).

CONCLUSIONS

Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2 weeks was very low (2.9%) with no difference between the two study periods (p = 1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.

Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT

OBJECTIVES

To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT.

METHODS

Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30 mAs) (step 2). Standard intravenously enhanced CT (180 mAs) was performed after indeterminate LDCT (step 3).

RESULTS

No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%.

CONCLUSIONS

The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast media.

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

Surgeon-performed ultrasound as a diagnostic tool in appendicitis

PURPOSE

Diagnosing appendicitis may require adjunct studies such as computed tomography or ultrasound (US). Combining a clinical examination with surgeon-performed US (SPUS) may increase diagnostic accuracy and decrease radiation exposure and costs.

METHODS

A prospective study was conducted including children with a potential diagnosis of appendicitis. A surgery resident performed a clinical examination and US to make a diagnosis. Final diagnosis of appendicitis was confirmed by operative findings and pathology. Results were compared with radiology department US (RDUS) and a large randomized trial. Analysis was performed using Fisher exact test.

RESULTS

Fifty-four patients were evaluated and underwent SPUS. Twenty-nine patients (54%) had appendicitis. Overall accuracy was 89%, with accuracy increasing from 85% to 93% between the 2 halves of the study. Radiology department US was performed on 21 patients before surgical evaluation, yielding an accuracy of 81%. Surgeon-performed US on those 21 patients yielded an accuracy of 90%. No statistical differences were found between any groups (P > .05).

CONCLUSION

Accuracy of SPUS was similar to RDUS and that of a large prospective randomized trial performed by radiologists. Furthermore, when the same clinician performs the clinical examination and US, a high level of accuracy can be achieved. With this degree of accuracy, SPUS may be used as a primary diagnostic tool and computed tomography reserved for challenging cases, limiting costs, and radiation exposure.

Sonography in the evaluation of acute appendicitis: are negative sonographic findings good enough?

OBJECTIVE

The purpose of this study was to evaluate the negative predictive value (NPV) of sonography in the diagnosis of acute appendicitis.

METHODS

Right lower quadrant sonograms of 193 patients (158 female and 35 male; age range, 3-20 years) with suspected acute appendicitis over a 1-year period were retrospectively reviewed. Sonographic findings were graded on a 5-point scale, ranging from a normal appendix identified (grade 1) to frankly acute appendicitis (grade 5). Sonographic findings were compared with subsequent computed tomographic (CT), surgical, and pathologic findings. The diagnostic accuracy of sonography was assessed considering surgical findings and clinical follow-up as reference standards.

RESULTS

Forty-nine patients (25.4%) had appendicitis on sonography, and 144 (74.6%) had negative sonographic findings. Computed tomographic scans were obtained in 51 patients (26.4%) within 4 days after sonography. These included 39 patients with negative and 12 with positive sonographic findings. Computed tomography changed the sonographic diagnosis in 10 patients: from negative to positive in 3 cases and positive to negative in 7. Forty-three patients (22.2%) underwent surgery. The surgical findings were positive for appendicitis in 37 (86%) of the 43 patients who had surgery. Patients with negative sonographic findings who, to our knowledge, did not have subsequent CT scans or surgery were considered to have negative findings for appendicitis. Seven patients with negative sonographic findings underwent surgery and had appendicitis; therefore, 137 of 144 patients with negative sonographic findings did not have appendicitis. On the basis of these numbers, the NPV was 95.1%.

CONCLUSIONS

Sonography has a high NPV and should be considered as a reasonable screening tool in the evaluation of acute appendicitis. Further imaging could be performed if clinical signs and symptoms worsen.

Management of acute appendicitis: an imaging strategy in children

The pre-operative diagnosis of acute appendicitis (AA) has markedly changed during the last couple of decades due to the advent of modern imaging technology. Nowadays, the use of imaging has dramatically changed the way we approach children admitted to emergency room for abdominal pain with suspected AA. This change is mainly manifested in our diagnostic strategy.

[Acute appendicitis. Modern diagnostics--surgical ultrasound]

Acute appendicitis is one of the most common acute surgical conditions of the abdomen. Nevertheless, the indications for appendectomy are associated with a high preoperative rate of false diagnoses. Although the rate of unnecessary appendectomies is comparatively high (20-30%) it is considered acceptable because the rate of perforated appendices is 7-30%. With good availability and lack of radiation exposure, ultrasound is the slice imaging modality of first choice. The sensitivity of ultrasonic detection of appendicitis lies between 55 and 98% and the specificity between 78 and 100%. Computed tomography (CT) has a significantly higher sensitivity for detecting acute appendicitis compared to ultrasound both in infancy and adulthood but the specificity shows no significant differences. CT is, therefore, the imaging modality of choice in cases of relevant differential diagnosis that cannot be visualized adequately or inconclusively by sonography especially in obese and critically ill patients. Comparison of ultrasound and magnet resonance imaging (MRI) revealed a significant advantage for MRI regarding accuracy, sensitivity and negative predictive value. In contrast, specificity and positive predictive value showed no significant differences. Currently MRI is only an alternative imaging modality to ultrasound in cases of undetermined and inconclusive ultrasonic findings especially in childhood and pregnancy. The value of ultrasound in the diagnosis of acute appendicitis is increasing and, particularly in the hands of experienced investigators, is an important imaging modality which delivers important and decision-making findings. Nevertheless, the final decision for appendectomy depends on the findings of the physical examination.

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

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

Ultrasound in the surgical intensive care unit

PURPOSE OF REVIEW

Critically ill patients are subjected to a variety of diagnostic and therapeutic procedures. It is desirable to make these interventions as timely, safe, and effective as possible. Bedside ultrasound and echocardiography are tools that allow for diagnosis of many conditions, without subjecting the patient to radiation, dye, and the risks of transport. In addition, ultrasound guidance of procedures may improve safety and efficacy. This review analyzes the literature on ultrasound and echocardiography use in the ICU.

RECENT FINDINGS

There is evidence supporting the use of bedside echocardiography and ultrasound for the diagnosis of chest, abdominal, and other pathologic conditions in the ICU. There is also evidence to support ultrasound guidance of vascular access and other procedures. There are multiple reports of novel uses of bedside echocardiography and ultrasound in the ICU.

SUMMARY

There is substantial literature supporting ultrasound and bedside limited echocardiography in the critical care setting. In addition, there are frequent reports of new applications for these technologies in the literature. The role of ultrasound and bedside limited echocardiography in the critical care setting is likely to expand in the future and become a part of daily care in every surgical intensive care unit.