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Roberts K, Moore H, Raju M, Gent R, Piotto L, Taranath A, Ee M, Linke R, Goh DW. Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard. J Pediatr Surg 2024; 59:235-239. [PMID: 37985334 DOI: 10.1016/j.jpedsurg.2023.10.028] [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] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kiera Roberts
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia.
| | - Hamish Moore
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Mahima Raju
- Adelaide Medical School, the University of Adelaide, SA, Australia
| | - Roger Gent
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Lino Piotto
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Ajay Taranath
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Michael Ee
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, SA, Australia
| | - Rebecca Linke
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Paediatrics, University of Adelaide, SA, Australia
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Hwang S, Chung HJ, Park JW, Lee EJ, Lee HN, Kim JH, Jue JH, Choi YH, Jung JY. Factors contributing to uncertainty in paediatric abdominal ultrasound reports in the paediatric emergency department. BMC Emerg Med 2023; 23:120. [PMID: 37817121 PMCID: PMC10566031 DOI: 10.1186/s12873-023-00892-w] [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: 11/08/2022] [Accepted: 10/04/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Abdominal pain, which is a common cause of children presenting to the paediatric emergency department (PED), is often evaluated by ultrasonography (US). However, uncertainty in US reports may necessitate additional imaging. OBJECTIVE In this study, we evaluated factors contributing to uncertainty in paediatric abdominal US reports in the PED. MATERIALS AND METHODS This retrospective cohort study included children younger than 18 years of age who underwent abdominal US in the PED of the study hospital between January 2017 and December 2019. After exclusion, the researchers manually reviewed and classified all US reports as 'certain' or 'uncertain'. Univariate and multivariate logistic regression analyses were performed to identify the factors contributing to uncertain reports. RESULTS In total, 1006 patients were included in the final analysis., 796 patients were tagged as having certain reports, and 210 as having uncertain reports. Children with uncertain reports had a significantly higher rate of undergoing an additional computed tomography (CT) scan (31.0% vs. 2.5%, p < 0.001) and a longer PED median length of stay (321.0 (Interquartile range (IQR); 211.3-441.5) minutes vs. 284.5 (IQR; 191.8-439.5) minutes, p = 0.042). After logistic regression, US performed by a radiology resident (odds ratio, 5.01; 95% confidence interval, 3.63-7.15) was the most significant factor contributing to uncertainty in paediatric abdominal US reports followed by obesity and age. CONCLUSION Several factors contribute to uncertainty in paediatric abdominal US reports. Uncertain radiological reports increase the likelihood of additional CT scans. Measures to improve the clarity of radiological reports must be considered to improve the quality of care for children visiting the PED.
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Affiliation(s)
- Soyun Hwang
- Department of Pediatrics, Yonsei School of Medicine, Severance Children's Hospital, Seoul, Republic of Korea
| | - Hyun Jung Chung
- Department of Pediatrics, Konkuk University Hospital, Seoul, Republic of Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eui Jun Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ha Ni Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin Hee Kim
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jie Hee Jue
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-Ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Zavras N, Vaou N, Zouganeli S, Kasti A, Dimitrios P, Vaos G. The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review. J Clin Med 2023; 12:4811. [PMID: 37510927 PMCID: PMC10381702 DOI: 10.3390/jcm12144811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.
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Affiliation(s)
- Nikolaos Zavras
- Department of Pediatric Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece
| | - Natalia Vaou
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Sofia Zouganeli
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Arezina Kasti
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | | | - George Vaos
- Department of Pediatric Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece
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Papillon S, Candelaria PG, Arthur LG, Pennell C, Aronoff S, Master S, Prasad R, Grewal H. Obesity is not associated with increased resource utilization or morbidity in patients undergoing appendectomy. J Pediatr Surg 2023; 58:648-650. [PMID: 36683000 DOI: 10.1016/j.jpedsurg.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Obesity is a growing public health concern that places patients at risk of morbidity and mortality following surgery. We sought to determine whether obesity influences our resource utilization and postoperative outcomes for patients who present with appendicitis. METHODS Charts were reviewed for patients age 1-18 years identified from a prospective registry who presented with a diagnosis of appendicitis from 2017 to 2020. Patients who underwent appendectomy were eligible. Charts were reviewed for demographics, imaging studies, laboratory studies, length of stay, operative times and thirty-day postoperative adverse events defined as return to the emergency room, re-admission, postoperative abscess or return to the operating room. A multivariate logistic regression analysis was performed to identify differences in resource utilization and outcome. RESULTS A total of 451 patients were identified. There were 126 obese patients (27.9%). Obese patients were not more likely to present with perforated appendicitis and were not more likely to undergo computed tomography scans. All patients underwent laparoscopic appendectomy. Although intraoperative times were significantly longer for Black patients and older patients, BMI did not influence length of surgery. Length of stay was significantly higher for younger patients (p = 0.019). Adverse events were seen in 38 patients (8.4%). There was no association between BMI and adverse events. CONCLUSIONS Within our standardized management pathway, obesity does not influence management or patient outcomes for the treatment of appendicitis. Furthermore, obese patients did not require additional resource utilization. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Stephanie Papillon
- Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134.
| | - P Garrett Candelaria
- Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA, USA 19129
| | - L Grier Arthur
- Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134; Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA, USA 19129
| | - Christopher Pennell
- Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134
| | - Stephen Aronoff
- Department of Pediatrics, Temple University Lewis Katz School of Medicine, 3223 N. Broad Street, Philadelphia, PA, USA 19140; Section of Pediatric Infectious Diseases, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134
| | - Sahal Master
- Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134
| | - Rajeev Prasad
- St. Luke's University Health Network, Pediatric Surgery, 701 Ostrum Street, Bethlehem, PA, USA 18015
| | - Harsh Grewal
- Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St. Christopher's Hospital for Children, 160 E. Erie Avenue, Philadelphia, PA, USA 19134; Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA, USA 19129
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Body mass index as a predictor of sonographic visualization of the pediatric appendix. Pediatr Radiol 2022; 52:42-49. [PMID: 34524472 DOI: 10.1007/s00247-021-05176-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/16/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Appendicitis is a common condition that is often confirmed with imaging. Ultrasound (US) is recommended as the first radiologic test in the work-up of appendicitis in children. Increased body mass index (BMI) has been implicated as a limiting factor to the sensitivity of US. This has drastic public health ramifications, as pediatric obesity has been increasing at alarming rates. OBJECTIVE The purpose of this study is to compare age-adjusted BMI z-scores to the frequency of sonographic visualization of the appendix. MATERIALS AND METHODS A retrospective review of 500 consecutive reports of US exams ordered for appendicitis in patients with a documented BMI was performed. Patients were stratified by BMI z-score based on, and the visualization frequency of the appendix was compared to the BMI z-score group. A logistic regression analysis generated the odds of visualization of the appendix by BMI z-score group. Primary home language, ethnicity, sex and insurance status were included in the logistic regression model to assess these characteristics as potential effect modifiers. RESULTS Of the 500 patients, 52.4% were male, 56.4% were Hispanic and 62.0% had government insurance. BMI z-score distribution groups were as follows: 4.2% were <-2, 8.0% were -2 to -1, 49.8% were -1 to 1, 26.4% were 1 to 2 and 11.6% were >2. The visualization frequency was 61.1% for boys and 46.2% for girls (P<0.05). Visualization frequency by BMI z-score group was as follows: 85.7% for <2, 72.5% for -2 to -1, 57.4% for -1 to 1, 47.7% for 1 to 2 and 29.3% for >2. Children with a BMI z-score greater than 2 were less likely to have a US with visualization of the appendix compared to children with a BMI z-score between -1 and 1 (adjusted odds ratio [aOR]: 0.21, 95% CI: 0.11-0.40, P<0.0001). Boys were more likely than girls to have a US with visualization of the appendix (aOR: 1.90, 95% CI: 1.29-2.80, P=0.001). There was no effect from insurance status, ethnicity or primary home language. CONCLUSION Findings show that as the BMI z-score increased, sonographic visualization of the appendix decreased even after adjusting for demographic differences. These findings have implications for pediatric radiology practice in light of the worsening obesity epidemic.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e962-e968. [PMID: 31136455 DOI: 10.1097/pec.0000000000001840] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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Affiliation(s)
- Laurie Malia
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Jesse J Sturm
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Sharon R Smith
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | | | - Brendan Campbell
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Henry Chicaiza
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
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Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children? J Pediatr Surg 2021; 56:2010-2015. [PMID: 33573804 DOI: 10.1016/j.jpedsurg.2021.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasonography (US) is the preferred imaging for suspected pediatric appendicitis. We hypothesize that children with elevated Body-Mass-Index-for-age percentile (BMIP) may be more likely to have an inaccurate or equivocal (IE) US. METHODS After IRB approval, a four-year review was performed on pediatric patients evaluated for appendicitis by US. The CDC BMIP Calculator was used. IE subgroups were analyzed together for comparison against the accurate group. RESULTS 1059 patients were included: median age 11.3 years (IQR: 8.2, 14.6), 506 (47.8%) males. Median BMIP was 65.9 (IQR: 33.9, 89.6). US accurately diagnosed 857 (80.9%), incorrectly diagnosed 76 (7.2%), 126 (11.9%) were equivocal. Overall sensitivity was 0.85, specificity 0.96, PPV 0.93 and NPV 0.91. Obese children (BMIP ≥95%), had higher odds of IE US (OR: 1.86, 95% CI: 1.28, 2.70; p = 0.001). When analyzed by sex, risk increased in obese males (OR: 2.55, 95% CI:1.53, 4.24; p = 0.0003) but normalized in obese females (OR: 1.30, 95% CI:0.74, 2.28; p = 0.35). CONCLUSIONS An elevated BMIP may increase difficulty in visualizing the appendix, resulting in inaccurate or equivocal findings. This risk is seen specifically in obese males. If US findings do not correlate with clinical assessment in obese children with abdominal pain, further evaluation may be warranted.
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8
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Evaluating Changes in Diagnostic Accuracy of Ultrasound for Appendicitis: Does Practice Make Perfect? J Emerg Med 2020; 59:563-572. [PMID: 32732135 DOI: 10.1016/j.jemermed.2020.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US. OBJECTIVES The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US. METHODS We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience. RESULTS A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps < 0.001). Higher body mass index was significantly associated with equivocal US (p < 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22). CONCLUSIONS An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.
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Kim JY. Imaging Findings of Gastrointestinal Emergency in Infants and Young Children. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:794-805. [PMID: 36238180 PMCID: PMC9432212 DOI: 10.3348/jksr.2020.81.4.794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/15/2022]
Abstract
급성 복증(acute abdomen)은 갑자기 발생하는 심한 복부 통증으로 즉각적인 수술적 치료를 필요로 할 수도 있는 상태를 말한다. 소아 환자의 급성 복증의 원인은 다양하며, 수술적 치료를 해야 하는 질환부터 투약 치료를 받아야 하거나 임상적 관찰 만을 요하는 질환까지 다양하게 분류될 수 있다. 이러한 급성 복증의 환자에서 영상 검사의 역할은 가능하다면 복통의 원인이 되는 질환을 밝혀서 수술적 치료를 해야 하는 환자와 투약 치료를 해야 하는 환자를 구분해 주는 것이다. 장중첩증과 충수돌기염이 소아 환자에서 수술적 치료를 필요로 하는 급성 복증의 가장 흔한 원인 질환이므로, 급성 복통을 호소하는 영아에서는 장중첩증을, 좀 더 나이가 많은 소아에서는 충수돌기염을 영상 검사를 이용해 배제해 주는 것이 중요하다. 이 논문에서는 영유아 환자의 급성 복통을 유발할 수 있는 질환 중 특징적 영상 소견을 보이는 장중첩증, 충수돌기염, 중장 염전, 메켈 게실 및 중복낭종에 대해 소개하고자 한다
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Affiliation(s)
- Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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10
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Lee EJ, Lee YJ, Park JH. Usefulness of Ultrasonography in the Diagnosis of Peptic Ulcer Disease in Children. Pediatr Gastroenterol Hepatol Nutr 2019; 22:57-62. [PMID: 30671374 PMCID: PMC6333589 DOI: 10.5223/pghn.2019.22.1.57] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 11/21/2022] Open
Abstract
PURPOSE This study was performed to assess the clinical usefulness of transabdominal ultrasonography (TUS) in detecting peptic ulcer disease (PUD) in children. METHODS Twenty-four patients (19 boys, 5 girls; mean age, 10.6±4.5 years [range, 3.0-17.9 years]) who were admitted to the hospital for acute abdomen or gastrointestinal bleeding and diagnosed with PUD by endoscopy and who underwent TUS were included. Clinical data were retrospectively collected by reviewing patient medical records. Gastric ulcer (GU) was suspected when the gastric wall exceeded 8 mm in thickness and had lost its five-layer structure on TUS. Duodenal ulcer (DU) was suspected if the duodenal wall thickness exceeded 5 mm. RESULTS Sensitivity of TUS in diagnosing PUD was 66.7% for GU and 38.9% for DU. Mean age and body weight of the 11 patients suspected with PUD on TUS were 10.9±4.4 years and 38.1±17.2 kg, respectively. For 13 patients without suspected PUD, they were 12.1±4.1 years and 39.6±17.0 kg, respectively. There was a significant difference in height, weight, and body mass index between patients who were suspected to have PUD and those who were not suspected on TUS (p=0.014, 0.008, and 0.005, respectively). A significant difference in the sensitivity of TUS in diagnosing PUD was found between patients under 30 kg and those over 30 kg (88.9% and 20.0%, respectively; p=0.003). CONCLUSION TUS investigation of the stomach and duodenum is an efficient method for PUD detection in children with low body weight. TUS can be used in preliminary diagnostic work-up before further invasive tests.
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Affiliation(s)
- Eun Joo Lee
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Yeoun Joo Lee
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Hong Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
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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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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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13
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Schoel L, Maizlin II, Koppelmann T, Onwubiko C, Shroyer M, Douglas A, Russell RT. Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. J Surg Res 2018; 230:131-136. [PMID: 30100029 DOI: 10.1016/j.jss.2018.04.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/23/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Data from the American College of Surgeons National Surgical Quality Improvement Program identified our hospital as an outlier for preoperative computed tomography (CT) use in the diagnosis of acute appendicitis in children. We performed a quality improvement project to reduce this utilization in favor of ultrasound-based diagnoses (ultrasonography [US]) through creation and implementation of an evidence-based appendicitis algorithm. METHODS Over a 2-y period (1 y preceding and 1 y following institution of the algorithm), the clinical information of all pediatric patients operated on for suspicion of acute appendicitis following imaging studies in our institution was collated. Basic characteristics were compared before and after protocol implementation using the chi-square test for categorical variables and the nonparametric, independent sample test of medians for numerical variables. Imaging modalities used and clinical outcomes were compared using chi-square analysis. RESULTS A total of 227 patients (117 preprotocol and 110 postprotocol implementation) were evaluated in our emergency department and operated on for suspicion of acute appendicitis. There were no differences in age, sex, race, or body mass index between the two periods. There were also no differences in length of stay (P = 0.27), acute and perforated appendicitis rates (P = 0.59), negative appendectomy rates (P = 0.40), or postoperative complications (P = 0.19). There was a significant reduction in the utilization of CT, from 65.8% to 22.0%, with a concurrent increase in the utilization of US (P < 0.001). CONCLUSIONS With the implementation of a standardized, multidisciplinary algorithm, CT utilization was decreased and concurrently US utilization was increased without sacrificing diagnostic accuracy or patient outcomes.
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Affiliation(s)
- Leah Schoel
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Ilan I Maizlin
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Tal Koppelmann
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Chinwendu Onwubiko
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Michelle Shroyer
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Ann Douglas
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama.
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Alerhand S, Meltzer J, Tay ET. Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis. ULTRASOUND (LEEDS, ENGLAND) 2017; 25:166-172. [PMID: 29410692 PMCID: PMC5794046 DOI: 10.1177/1742271x16689693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/21/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. OBJECTIVE To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. METHODS We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. RESULTS In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). CONCLUSION Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.
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Affiliation(s)
| | | | - Ee Tein Tay
- Icahn School of Medicine at Mount Sinai, NY, USA
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Imler D, Keller C, Sivasankar S, Wang NE, Vasanawala S, Bruzoni M, Quinn J. Magnetic Resonance Imaging Versus Ultrasound as the Initial Imaging Modality for Pediatric and Young Adult Patients With Suspected Appendicitis. Acad Emerg Med 2017; 24:569-577. [PMID: 28207968 DOI: 10.1111/acem.13180] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND While ultrasound (US), given its lack of ionizing radiation, is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time-intensive and operator dependent and results in frequent inconclusive studies, thus necessitating further imaging and admission for observation or repeat clinical visits. A rapid focused magnetic resonance imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to computed tomography but without radiation and offers a potential alternative to US. OBJECTIVE In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the emergency department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost-effective than US as the initial imaging modality in the ED diagnosis of appendicitis. METHODS A prospective randomized cohort study of consecutive patients was conducted in patients 2 to 30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the predetermined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (minutes) between triage, order placement, start of imaging, end of imaging, image result, and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging, and repeat ED visits) were recorded. RESULTS Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45 of 82 (55%) of patients were in the US-first group, and 37 of 82 (45%) patients were in the rapid MRI-first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. Eleven of 45 (24%) of US-first patients had inconclusive studies, resulting in follow-up rapid MRI and five return ED visits contrasted with no inconclusive studies or return visits (p < 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference = 100 minutes; 95% confidence interval [CI] = 35-169 minutes) and increased ED charges (mean difference = $4,887; 95% CI = $1,821-$8,513). CONCLUSIONS In the diagnosis of appendicitis, US-first imaging is more time-efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first-line imaging modality for appendicitis in patients 2 to 30 years of age.
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Affiliation(s)
- Daniel Imler
- Department of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - Christine Keller
- Department of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - Shyam Sivasankar
- Department of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - Nancy Ewen Wang
- Department of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - Shreyas Vasanawala
- Department of Radiology (Pediatric Radiology); Stanford University School of Medicine; Stanford CA
| | - Matias Bruzoni
- Department of Surgery (Pediatric Surgery); Stanford University School of Medicine; Stanford CA
| | - James Quinn
- Department of Emergency Medicine; Stanford University School of Medicine; Stanford CA
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16
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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17
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Evaluation for suspected acute appendicitis in the emergency department setting: a comparison of outcomes among three imaging pathways. Clin Imaging 2016; 40:788-92. [PMID: 27317225 DOI: 10.1016/j.clinimag.2016.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 02/17/2016] [Accepted: 02/21/2016] [Indexed: 11/23/2022]
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18
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Repplinger MD, Weber AC, Pickhardt PJ, Rajamanickam VP, Svenson JE, Ehlenbach WJ, Westergaard RP, Reeder SB, Jacobs EA. Trends in the Use of Medical Imaging to Diagnose Appendicitis at an Academic Medical Center. J Am Coll Radiol 2016; 13:1050-6. [PMID: 27053160 DOI: 10.1016/j.jacr.2016.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/11/2016] [Accepted: 02/19/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To quantify the trends in imaging use for the diagnosis of appendicitis. METHODS A retrospective study covering a 22-year period was conducted at an academic medical center. Patients were identified by International Classification of Diseases-9 diagnosis code for appendicitis. Medical record data extraction of these patients included imaging test used (ultrasound, CT, or MRI), gender, age, and body mass index (BMI). The proportion of patients undergoing each scan was calculated by year. Regression analysis was performed to determine whether age, gender, or BMI affected imaging choice. RESULTS The study included a total of 2,108 patients, including 967 (43.5%) females and 599 (27%) children (<18 years old). CT use increased over time for the entire cohort (2.9% to 82.4%, P < .0001), and each subgroup (males, females, adults, children; P < .0001 for each). CT use increased more in females and adults than in males and children, but differences in trends were not statistically significant (male versus female, P = .8; adult versus child, P = .1). The percentage of patients who had no imaging used for the diagnosis of appendicitis decreased over time (P < .0001 overall and for each subgroup), and no difference was found in trends between complementary subgroups (male versus female, P = .53; adult versus child, P = .66). No statistically significant changes were found in use of ultrasound or MRI over the study period. With increasing BMI, CT was more frequently used. CONCLUSIONS Of those diagnosed with appendicitis at an academic medical center, CT use increased more than 20-fold. However, no statistically significant trend was found for increased use of ultrasound or MRI.
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Affiliation(s)
- Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Andrew C Weber
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Victoria P Rajamanickam
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elizabeth A Jacobs
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 2015; 45:1934-44. [PMID: 26280637 DOI: 10.1007/s00247-015-3432-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/08/2015] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ultrasonography is considered the most appropriate initial imaging study in the evaluation of acute appendicitis in children but has recently come under criticism with reports of low specificity and high indeterminate study rates, particularly when used in obese patients and patients early in the course of their disease, or when performed by sonographers with limited experience. OBJECTIVE To (1) assess the impact of patient factors (gender, age, body mass index, and symptom duration) and system factors (call status or year of exam) on pediatric appendiceal US accuracy and indeterminate study rate, (2) assess the impact of indeterminate study results on follow-up CT and negative laparotomy rates and (3) present strategies to reduce the rate of indeterminate US studies and improve accuracy. MATERIALS AND METHODS We retrospectively reviewed all US reports performed for the assessment of acute appendicitis in children <18 years old at Mayo Clinic Rochester from January 2010 to June 2014. RESULTS A total of 790 US examinations were performed in 452 girls (57%) and 338 boys (43%). The prevalence of appendicitis was 18.5% (146/790). There were 109 true-positive, 440 true-negative, 17 false-positive, 6 false-negative, 218 equivocal and 41 technically inadequate US studies. A definitive interpretation was made in 72% of the studies, with an accuracy, sensitivity and specificity of 0.960, 0.948 and 0.963, respectively. No patient or system factors significantly affected US accuracy. Indeterminate studies (28%) had significantly higher CT utilization (46% vs. 11%) and normal appendectomy rates (6.9% vs. 3.5%). CONCLUSION US should be the initial imaging study of choice for pediatric appendicitis. When a definitive interpretation was given, the accuracy was 96%, was independent of patient and system factors and resulted in reduced follow-up CTs and negative laparotomies. Accuracy can be increased by requiring the presence of periappendiceal inflammatory changes prior to interpreting a mildly distended appendix as positive for acute appendicitis. The indeterminate study rate can be reduced by not requiring visualization of the normal appendix for the exclusion of acute appendicitis.
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Michailidou M, Sacco Casamassima MG, Goldstein SD, Gause C, Karim O, Salazar JH, Yang J, Abdullah F. The impact of obesity on laparoscopic appendectomy: Results from the ACS National Surgical Quality Improvement Program pediatric database. J Pediatr Surg 2015; 50:1880-4. [PMID: 26255898 DOI: 10.1016/j.jpedsurg.2015.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Childhood obesity is a worsening epidemic. Little is known about the impact of elevated BMI on perioperative and postoperative complications in children who undergo laparoscopic surgery. The purpose of this study was to examine the effects of obesity on surgical outcomes in children using laparoscopic appendectomy as a model for the broader field of laparoscopic surgery. STUDY DESIGN Using the Pediatric National Surgical Quality Improvement Program (NSQIP) data from 2012, patients aged 2-18years old with acute uncomplicated and complicated appendicitis who underwent laparoscopic appendectomy were identified. Children with a body mass index (BMI)≥95th percentile for their age and gender were considered obese. Primary outcomes, including overall morbidity and wound complications, were compared between nonobese and obese children. Multivariate regression analysis was conducted to identify the impact of obesity on outcome. RESULTS A total of 2812 children with acute appendicitis who underwent appendectomy were included in the analysis; 22% were obese. Obese children had longer operative times but did not suffer increased postoperative complications when controlling for confounders (OR 1.3, 95% CI: 0.83-0.072 for overall complications, OR 1.3, 95% CI: 0.84-1.95 for wound complications). CONCLUSIONS Obesity is not an independent risk factor for postoperative complications following laparoscopic appendectomy. Although operative times are increased in obese children, obesity does not increase the likelihood of 30-day postoperative complications.
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Affiliation(s)
- Maria Michailidou
- Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria G Sacco Casamassima
- Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth D Goldstein
- Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Colin Gause
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Omar Karim
- Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose H Salazar
- Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric, Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jingyan Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago & Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Dillman JR, Gadepalli S, Sroufe NS, Davenport MS, Smith EA, Chong ST, Mazza MB, Strouse PJ. Equivocal Pediatric Appendicitis: Unenhanced MR Imaging Protocol for Nonsedated Children-A Clinical Effectiveness Study. Radiology 2015; 279:216-25. [PMID: 26458209 DOI: 10.1148/radiol.2015150941] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine retrospectively the clinical effectiveness of an unenhanced magnetic resonance (MR) imaging protocol for evaluation of equivocal appendicitis in children. MATERIALS AND METHODS Institutional review board approval was obtained. Pediatric patients (≤18 years old) underwent unenhanced MR imaging and contrast material-enhanced computed tomography (CT) of the appendix between December 2013 and November 2014 and December 2012 and November 2013, respectively, within 24 hours after an abdominal ultrasonographic examination with results equivocal for appendicitis. Pertinent MR imaging and CT reports were reviewed for visibility of the appendix, presence of appendicitis and appendiceal perforation, and establishment of an alternative diagnosis. Surgical reports, pathologic reports, and 30-day follow-up medical records were used as reference standards. Diagnostic performance with MR imaging and CT was calculated with 95% confidence intervals (CIs) for diagnosis of appendicitis and appendiceal perforation. The Fisher exact test was used to compare proportions; the Student t test was used to compare means. RESULTS Diagnostic performance with MR imaging was comparable to that with CT for equivocal pediatric appendicitis. For MR imaging (n = 103), sensitivity was 94.4% (95% CI: 72.7%, 99.9%) and specificity was 100% (95% CI: 95.8%, 100%); for CT [n = 58], sensitivity was 100% (95% CI: 71.5%, 100%), specificity was 97.9% (95% CI: 88.7%, 100%). Diagnostic performance with MR imaging and CT also was comparable for detection of appendiceal perforation, with MR imaging (n = 103) sensitivity of 90.0% (95% CI: 55.5%, 99.8%) and specificity of 85.7% (95% CI: 42.1%, 99.6%) and CT (n = 58) sensitivity of 75.0% (95% CI: 19.4%, 99.4%) and specificity of 85.7% (95% CI: 42.1%, 99.6%). The proportion of examinations with identifiable alternative diagnoses was similar at MR imaging to that at CT (19 of 103 [18.4%] vs eight of 58 [13.8%], respectively; P = .52). The proportion of appendixes seen at MR imaging and at CT also was similar (77 of 103 [74.8%] vs 50 of 58 [86.2%], respectively; P = .11). CONCLUSION Unenhanced MR imaging is sensitive and specific for the diagnosis of equivocal appendicitis in nonsedated pediatric patients.
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Affiliation(s)
- Jonathan R Dillman
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Samir Gadepalli
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Nicole S Sroufe
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Matthew S Davenport
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Ethan A Smith
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Suzanne T Chong
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Michael B Mazza
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
| | - Peter J Strouse
- From the Section of Pediatric Radiology, Department of Radiology (J.R.D., E.A.S., P.J.S.), Section of Pediatric Surgery, Department of Surgery (S.G.), Children's Emergency Services, Department of Emergency Medicine (N.S.S.), Division of Abdominal Imaging, Department of Radiology (M.S.D.), and Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109
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Roy H, Burbridge B. To CT or not to CT? The influence of computed tomography on the diagnosis of appendicitis in obese pediatric patients. Can J Surg 2015; 58:181-7. [PMID: 26011850 DOI: 10.1503/cjs.009014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Appendicitis is a common pediatric query. However, obesity often results in nondiagnostic ultrasounds and increased likelihood of abdominal computed tomography (CT). Concern regarding radiation exposure led the Canadian Association of Radiologists to recommend foregoing CT when ultrasounds are nondiagnostic and clinical suspicion is high. We evaluated this recommendation by quantifying the influence of CT on the diagnosis of pediatric appendicitis. METHODS We performed a 2-year retrospective case series of children presenting with suspected appendicitis. We stratified patients by weight (obese v. nonobese) and pediatric appendicitis score (PAS) and examined how often they received abdominal CT, why they received it, and its influence on diagnosis. RESULTS Of 223 patients (84 obese, 139 nonobese), 54 received CT. Obese patients received CTs more frequently than nonobese patients (29% v. 22%). The most common reason for CT was a nondiagnostic ultrasound (75% in obese, 80% in nonobese patients). Sixty-five percent of CTs obtained after nondiagnostic ultrasounds confirmed the initial diagnosis, but the rates were 80% and 50%, respectively, when only obese and only nonobese patients were considered. Obese patients were 4 times more likely to have a CT confirming their initial appendicitis diagnosis. CONCLUSION Because obese patients are more likely than nonobese patients to have a CT that confirms appendicitis, when treating an obese pediatric patient with suspected appendicitis and a nondiagnostic ultrasound, surgeons with a high clinical suspicion should strongly consider foregoing CT and proceeding with treatment.
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Affiliation(s)
- Haven Roy
- The College of Medicine, University of Saskatchewan, Saskatoon, Sask
| | - Brent Burbridge
- The College of Medicine, University of Saskatchewan, Saskatoon, Sask
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Wagenaar AE, Tashiro J, Wang B, Curbelo M, Mendelson KL, Perez EA, Hogan AR, Neville HL, Sola JE. Protocol for suspected pediatric appendicitis limits computed tomography utilization. J Surg Res 2015; 199:153-8. [PMID: 25979562 DOI: 10.1016/j.jss.2015.04.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/11/2015] [Accepted: 04/09/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study. MATERIALS AND METHODS An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation. RESULTS For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively. CONCLUSIONS Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.
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Affiliation(s)
- Amy E Wagenaar
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Bo Wang
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Miosotys Curbelo
- Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | | | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Anthony R Hogan
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Holly L Neville
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
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Kotagal M, Richards MK, Flum DR, Acierno SP, Weinsheimer RL, Goldin AB. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50:642-6. [PMID: 25840079 PMCID: PMC4385196 DOI: 10.1016/j.jpedsurg.2014.09.080] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/17/2014] [Accepted: 09/24/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined. METHODS For patients ≤18 years old undergoing appendectomy, we evaluated diagnostic imaging performed, patient characteristics, hospital type, and imaging/pathology concordance (2008-2012) using data from Washington State's Surgical Care and Outcomes Assessment Program. RESULTS Among 2538 children, 99.7% underwent pre-operative imaging. 52.7% had a CT scan as their first study. After adjustment, age >10 years (OR 2.9 (95% CI 2.2-4.0), Hispanic ethnicity (OR 1.7, 95% CI 1.5-1.9), and being obese (OR 1.7, 95% CI 1.4-2.1) were associated with CT use first. Evaluation at a non-children's hospital was associated with higher odds of CT use (OR 7.9, 95% CI 7.5-8.4). Ultrasound concordance with pathology was higher for males (72.3 vs. 66.4%, p=.03), in perforated appendicitis (75.9 vs. 67.5%, p=.009), and at children's hospitals compared to general adult hospitals (77.3 vs. 62.2%, p<.001). CT use has decreased yearly statewide. CONCLUSIONS Over 50% of children with appendicitis had radiation-based imaging. Understanding factors associated with CT use should allow for more specific QI interventions to reduce radiation exposure. Site of care remains a significant factor in radiation exposure for children.
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Affiliation(s)
- Meera Kotagal
- Department of Surgery, University of Washington, Seattle, WA, USA; Surgical Outcomes Research Center (SORCE), University of Washington, Seattle, WA, USA; CHASE Alliance, University of Washington, Seattle, WA, USA.
| | - Morgan K. Richards
- Department of Surgery, University of Washington, Seattle, WA, USA,Department of General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, WA, USA
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, WA, USA,Surgical Outcomes Research Center (SORCE), University of Washington, Seattle, WA, USA,CHASE Alliance, University of Washington, Seattle, WA, USA
| | - Stephanie P. Acierno
- Department of General and Thoracic Surgery, Mary Bridge Children’s Hospital, Tacoma, WA, USA
| | | | - Adam B. Goldin
- Department of General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, WA, USA
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25
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Pershad J, Waters TM, Langham MR, Li T, Huang EY. Cost-effectiveness of diagnostic approaches to suspected appendicitis in children. J Am Coll Surg 2014; 220:738-46. [PMID: 25667142 DOI: 10.1016/j.jamcollsurg.2014.12.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care. STUDY DESIGN We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters. RESULTS In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio. CONCLUSIONS Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
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Affiliation(s)
- Jay Pershad
- Department of Emergency Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Tao Li
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature review. Clin Pediatr (Phila) 2014; 53:975-87. [PMID: 24803638 DOI: 10.1177/0009922814533406] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards. EVIDENCE REVIEW We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study. RESULTS AND CONCLUSION Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children.
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Affiliation(s)
| | - Megan B Irby
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA Brenner FIT Program, Brenner Children's Hospital, Winston-Salem, NC, USA
| | - Joseph A Skelton
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA Brenner FIT Program, Brenner Children's Hospital, Winston-Salem, NC, USA Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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27
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Ramarajan N, Krishnamoorthi R, Gharahbaghian L, Pirrotta E, Barth RA, Wang NE. Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis? JOURNAL OF CLINICAL ULTRASOUND : JCU 2014; 42:385-394. [PMID: 24700515 DOI: 10.1002/jcu.22153] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 01/23/2014] [Accepted: 02/20/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT. METHODS Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT. RESULTS Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT. CONCLUSIONS We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.
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Affiliation(s)
- Naresh Ramarajan
- Division of Emergency Medicicine, University of California Los Angeles, 924 Westwood Boulevard, Suite 300, Los Angeles, CA, 90095
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28
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Saucier A, Huang EY, Emeremni CA, Pershad J. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics 2014; 133:e88-95. [PMID: 24379237 DOI: 10.1542/peds.2013-2208] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of a clinical pathway for suspected appendicitis combining the Samuel's pediatric appendicitis score (PAS) and selective use of ultrasonography (US) as the primary imaging modality. METHODS Prospective, observational cohort study conducted at an urban, academic pediatric emergency department. After initial evaluation, patients were determined to be at low (PAS 1-3), intermediate (PAS 4-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up. High-risk patients received immediate surgical consultation. Patients at intermediate risk for appendicitis underwent US. RESULTS Of the 196 patients enrolled, 65 (33.2%) had appendicitis. An initial PAS of 1-3 was noted in 44 (22.4%), 4-7 in 119 (60.7%), and 8-10 in 33 (16.9%) patients. Ultrasonography was performed in 128 (65.3%) patients, and 48 (37.5%) were positive. An abdominal computed tomography scan was requested by the surgical consultants in 13 (6.6%) patients. The negative appendectomy rate was 3 of 68 (4.4%). Follow-up was established on 190 of 196 (96.9%) patients. Overall diagnostic accuracy of the pathway was 94% (95% confidence interval [CI] 91%-97%) with a sensitivity of 92.3% (95% CI 83.0%-97.5%), specificity of 94.7% (95% CI 89.3%-97.8%), likelihood ratio (+) 17.3 (95% CI 8.4-35.6) and likelihood ratio (-) 0.08 (95% CI 0.04-0.19). CONCLUSIONS Our protocol demonstrates high sensitivity and specificity for diagnosis of appendicitis in children. Institutions should consider investing in resources that increase the availability of expertise in pediatric US. Standardization of care may decrease radiation exposure associated with use of computed tomography scans.
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Affiliation(s)
- Ashley Saucier
- Division of Emergency Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, TN 38103.
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Abstract
During the past two decades, the incidence of childhood obesity has increased at alarming rates throughout the world. Obesity is associated with a variety of physiological changes that may impair a patient's response to surgery. With the rising rates of childhood obesity, pediatric surgeons must appreciate differences in the management and outcomes of these patients. Difficult physical examination, elevated inflammatory blood markers, and negative influence of obesity on the detection rate of the appendix on ultrasound have been reported causing diagnostic challenging of appendicitis in obese children. Moreover, obesity is associated with longer hospital stay and higher morbidity and minimal invasive techniques' superior outcomes over open technique in children undergoing appendectomy.
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Affiliation(s)
- Balazs Kutasy
- National Children's Research Center, Our Lady's Children's Hospital, Dublin, Ireland.
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30
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Blanco FC, Sandler AD, Nadler EP. Increased incidence of perforated appendicitis in children with obesity. Clin Pediatr (Phila) 2012; 51:928-32. [PMID: 22511195 DOI: 10.1177/0009922812441659] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.
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Affiliation(s)
- Felix C Blanco
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC 20010, USA.
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31
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Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am 2012; 92:505-26, vii. [PMID: 22595706 DOI: 10.1016/j.suc.2012.03.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.
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Affiliation(s)
- Victoria K Pepper
- Section of Pediatric Surgery, Department of Surgery, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, IL, USA
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