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Rodriguez-Takeuchi S, Sousa-Plata K, Man C, Vidarson L, Rayner T, Mohanta A, Amirabadi A, Schuh S, Doria AS. Characterization and quantification of fluid in the abdomen by ultrasound and magnetic resonance imaging in children with clinical suspicion of appendicitis. Abdom Radiol (NY) 2024; 49:1031-1041. [PMID: 38195800 DOI: 10.1007/s00261-023-04133-3] [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: 04/12/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE While regarded as a secondary sign of pediatric appendicitis, the frequency of physiologic intra-abdominal fluid in children with suspected but absent appendicitis is unknown. Ex vivo: to assess the validity of US/MRI measurements of free fluid. In vivo: in suspected pediatric appendicitis, to assess the amount of abdominal fluid by US and MRI, determine performance characteristics of US in fluid detection and identify fluid volume ranges in confirmed appendicitis. METHODS Ex vivo: criterion validity of US and MRI for fluid volume measurements was tested using tissue-mimicking phantoms filled with different volumes of distilled water. In vivo: all participants from a previous prospective study of suspected appendicitis were evaluated by US; MRI was performed after equivocal USs. Qualitative and quantitative analyses of abdominal fluid and correlation of fluid presence with appendicitis were performed. RESULTS Ex vivo: no difference was found between phantom-fluid amount and measured volume using the formula for volume of an ellipsoid for US (P=0.19) or MRI (P=0.08). In vivo: intra-abdominal fluid was present in 212/591 (35.9%) patients; 75/212 patients with fluid (35.4%) had appendicitis, 60 (28.3%) had alternate diagnoses, and 77 (36.3%) had physiologic fluid. Sensitivity and specificity of US for fluid detection were 84% (95% CI 71-93) and 65% (95% CI 52-77), respectively. In children with versus without appendicitis, the respective ranges of fluid volume were 0.7-1148.8 ml and 0.8-318 ml. CONCLUSION The volume of an ellipsoid formula is a valid method for quantifying intra-abdominal fluid. The sole presence of intra-abdominal fluid on US does not support the diagnosis of pediatric appendicitis.
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Affiliation(s)
- Sara Rodriguez-Takeuchi
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Department of Diagnostic Imaging, Fundacion Valle de Lili, Cali, Colombia
| | - Karen Sousa-Plata
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Carina Man
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Logi Vidarson
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Tammy Rayner
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Arun Mohanta
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Suzanne Schuh
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Department of Medical Imaging, University of Toronto, Toronto, ON, M5G 1X8, Canada.
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Ata NA, Trout AT, Dillman JR, Tkach JA, Ayyala RS. Technical and Diagnostic Performance of Rapid MRI for Evaluation of Appendicitis in a Pediatric Emergency Department. Acad Radiol 2024; 31:1102-1110. [PMID: 37863782 DOI: 10.1016/j.acra.2023.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 10/22/2023]
Abstract
RATIONALE AND OBJECTIVES Rationale MRI is increasingly used for diagnosis of pediatric appendicitis in the emergency care setting. Scan and room time are important to optimize workflow, especially in situations with limited MRI availability and accessibility. To describe our process to optimize and implement a rapid, non-contrast, free-breathing MRI protocol for appendicitis and to characterize the accuracy for diagnosis. MATERIALS AND METHODS Initial MRI protocol implemented for suspected appendicitis included five respiratory-triggered axial and coronal single shot fast spin echo (SSFSE) and radial T2W sequences with and without fat suppression (FS). This protocol was reassessed based on image quality. Subsequently, the coronal and axial T2W SSFSE FS sequence were removed. A three-sequence exam comprised the rapid MRI appendicitis protocol used for the remainder of the study. All examinations were performed on a 1.5 T scanner. For all examinations, the following information was obtained: scan time, diagnosis of appendicitis (by radiology report), surgery and pathology reports, and alternative diagnoses documented in radiology reports. MRI examination scan durations were compared between the five-sequence and three-sequence protocols, with Mann-Whitney U test, and proportions of false diagnoses were compared to Fisher's exact test. RESULTS 216 examinations were performed; 21 and 195 performed with five- and three-sequence protocol, respectively. The median duration of the five-sequence protocol was 20 (16.9-23.5) minutes vs.11 (9.5-13) minutes for the three sequence protocol (p < 0.0001). The majority (n = 157, 80.5% of 195) of examinations were performed in a goal time of< 15 min. 23 examinations took longer than 20 min (n = 12, n = 11 for the three- and five-sequence protocols, respectively) were due to repeat sequences or addition of non-standard sequences (requested by interpreting radiologist). 27 (90%) of the 30 reported positive cases were confirmed by pathology. There were three false-positive diagnoses (all three-sequence protocol exams) and one false-negative diagnosis (five-sequence protocol exam). Alternative diagnoses, including pancreatitis, omental infarct, masses, and ovarian pathology, were made in 42 (19%) cases. CONCLUSION A three-sequence, non-contrast, free- breathing MRI examination can be performed in less than 15 min in the emergency department and has high diagnostic accuracy for acute appendicitis in children and young adults.
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Affiliation(s)
- Nadeen Abu Ata
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, Ohio, 45229, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.)
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, Ohio, 45229, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (A.T.T.)
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, Ohio, 45229, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.)
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, Ohio, 45229, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.)
| | - Rama S Ayyala
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, Ohio, 45229, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.); Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (N.A.A., A.T.T., J.R.D., J.A.T., R.S.A.).
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3
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [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: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Greene AC, Mankarious MM, Patel A, Matzelle-Zywicki M, Kwon EG, Reyes L, Tsai AY, Santos MC, Moore MM, Kulaylat AN. Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess? Surgery 2023; 174:703-708. [PMID: 37365084 DOI: 10.1016/j.surg.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Computed tomography scans have been used when cross-axial imaging is required to evaluate pediatric post-appendectomy abscesses. To reduce a source of radiation exposure, our institution converted to using contrast-enhanced magnetic resonance imaging to replace computed tomography scans in this clinical context. Our aim is to evaluate the performance of magnetic resonance imaging compared to computed tomography scans and associated clinical outcomes in this patient population. METHODS A contrast-enhanced comprehensive magnetic resonance imaging protocol was implemented to evaluate a post-appendectomy abscess in 2018. A retrospective chart review was performed from 2015 to 2022 for pediatric patients (<18 years old) with prior appendectomy and subsequent cross-sectional imaging to evaluate for an intraabdominal abscess. Patient characteristics and clinical parameters between the 2 modalities were abstracted and compared using standard univariate statistics. RESULTS There were a total of 72 post-appendectomy patients who received cross-axial imaging, which included 43 computed tomography scans and 29 magnetic resonance imaging during the study interval. Patient demographics were comparable between cohorts and rates of perforated appendicitis at the index operation (computed tomography: 79.1% vs magnetic resonance imaging: 86.2%). Missed abscess rate, abscess size, management technique, drainage culture results, readmission, and reoperation were similar between imaging modalities. Median request to scan time was longer for magnetic resonance imaging than computed tomography (191.5 vs 108 minutes, P = .04). The median duration of a comprehensive magnetic resonance imaging scan was 32 minutes (interquartile range 28-50.5 minutes). CONCLUSION Contrast-enhanced magnetic resonance imaging provides an alternative cross-sectional imaging modality to computed tomography scans to evaluate pediatric post-appendectomy abscesses.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/AliciaGreeneDO
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/MarcMMankarious
| | - Akshilkumar Patel
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Madeline Matzelle-Zywicki
- The Pennsylvania State University College of Medicine, Hershey, PA. https://twitter.com/maddie_mzywicki
| | - Eustina G Kwon
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA. https://twitter.com/eustina_k
| | - Lilia Reyes
- Division of Pediatric Emergency Medicine, Penn State Children's Hospital, Hershey, PA
| | - Anthony Y Tsai
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA. https://twitter.com/antsai
| | - Mary C Santos
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA
| | - Michael M Moore
- Department of Radiology, Nemours Children's Hospital, Wilmington, DE
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA.
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5
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Schuh S, Man C, Marie E, Alhashmi GHA, Halevy D, Wales PW, Singer-Harel D, Finkelstein A, Sweeney J, Doria AS. Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis-A prospective cohort study. Am J Emerg Med 2023; 71:217-224. [PMID: 37453161 DOI: 10.1016/j.ajem.2023.06.026] [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: 02/14/2023] [Revised: 05/29/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). STUDY DESIGN prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. RESULTS 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. CONCLUSION this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
| | - Carina Man
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Eman Marie
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | | | - Dan Halevy
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Paul W Wales
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada
| | - Aya Finkelstein
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Judith Sweeney
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Andrea S Doria
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
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Arora V, Kaur T, Singh K. The role of magnetic resonance imaging in acute abdominal pain in paediatric age group. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00709-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The purpose of this study is to evaluate the utility of magnetic resonance imaging in the assessment of acute atraumatic abdominal pain as the first line cross sectional modality in children, so as to prevent excessive radiation exposure from computed tomography scan and to review the magnetic resonance imaging features of common acute abdominal and pelvic conditions.
Results
30 patients (0–18 years) underwent rapid unenhanced magnetic resonance imaging. The results of our study indicated that for the diagnosis of causes for acute abdominal pain, magnetic resonance imaging had sensitivity of 92% (95% confidence interval 73.8–97.6%) and a specificity of 80% (95% confidence interval 28.4–99.5%). The positive predictive value was 95.8% (95% confidence interval 79.9–99.3%) and negative predictive value was 67% (95% confidence interval 33.1–89.0%) which had a highly significant statistical association (p < 0.001).
Conclusion
Unenhanced magnetic resonance imaging is an excellent option for the initial, detailed evaluation of acute abdominal emergencies in pediatric patients because it can diagnose the whole range of presenting abnormalities which include the causes of abdominal pain warranting surgical and nonsurgical management.
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Figueiro Longo MG, Jaimes C, Machado F, Delgado J, Gee MS. Pediatric Emergency MRI. Magn Reson Imaging Clin N Am 2022; 30:533-552. [PMID: 35995478 DOI: 10.1016/j.mric.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
There is an overall increase in the use of imaging in the pediatric emergency room setting, which is accompanied by a reduction in computed tomography examinations performed mainly due to the increased awareness of the risks of ionizing radiation. Advances in MRI technology have led to shortened scan time, decreased motion sensitivity, and improved spatial resolution. With increased access to MRI in the emergency room setting, the goal of this article is to review major applications of MR in pediatric emergency room patients.
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Affiliation(s)
- Maria Gabriela Figueiro Longo
- Division of Pediatric Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Fedel Machado
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jorge Delgado
- Division of MSK Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael S Gee
- Division of Pediatric Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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8
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James NC, Ahmadian R, Mckee JQ, Sarangarm D, Bussmann SC, Williamson S, Upham BD. Magnetic Resonance Imaging Availability Reduces Computed Tomography Use for Pediatric Appendicitis Diagnosis. Pediatr Emerg Care 2022; 38:e219-e224. [PMID: 32898123 DOI: 10.1097/pec.0000000000002222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine if introducing magnetic resonance imaging (MRI) as an imaging option for children with suspected appendicitis and an inconclusive ultrasound reduces computed tomography (CT) use. METHODS This is a retrospective cohort study of patients aged 5 to 18 years who presented to a pediatric emergency department (ED) with suspected appendicitis. Rates of CT use 1 year before and 1 year after MRI availability are compared. Secondary outcomes include missed and negative appendectomies, imaging charges, time to antibiotics and surgery, time to radiology read, ED length of stay, and test characteristics of MRI and CT. RESULTS Of the 981 patients screened, 499 patients met inclusion criteria. There was an absolute reduction of CT use of 25% from 38% in year 1 to 13% in year 2 (95% confidence interval, 18% to 33%). Advanced imaging charges were $371 higher in year 2 (MRI) than year 1 (CT), and median time to radiologist reads was longer in MRIs than CTs (129 versus 62 minutes; difference 53 minutes, 95% confidence interval, 23 to 74 minutes). All other secondary outcomes, including ED length of stay and test characteristics, were statistically similar. CONCLUSIONS Introducing MRI for as an imaging option for children with suspected appendicitis and an inconclusive ultrasound markedly reduced CT use, but did result in a small increase in imaging charges and time to preliminary radiology read.
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Affiliation(s)
- Natasha C James
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of New Mexico
| | | | - Jason Q Mckee
- Division of Pediatric Surgery, Department of Surgery
| | | | | | - Susan Williamson
- Department of Radiology, University of New Mexico, Albuquerque, NM
| | - Bryan D Upham
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of New Mexico
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9
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [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: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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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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11
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Sawyer DM, Mushtaq R, Vedantham S, Shareef F, Desoky SM, Arif-Tiwari H, Gilbertson-Dahdal DL, Udayasankar UK. Performance of overnight on-call radiology residents in interpreting unenhanced abdominopelvic magnetic resonance imaging studies performed for pediatric right lower quadrant abdominal pain. Pediatr Radiol 2021; 51:1378-1385. [PMID: 33688988 PMCID: PMC8266720 DOI: 10.1007/s00247-021-05009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/22/2020] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominopelvic magnetic resonance imaging (MRI) is increasingly being used to evaluate children with abdominal pain suspected of having acute appendicitis. At our institution, these examinations are preliminarily interpreted by radiology residents, especially when performed after hours. OBJECTIVE To determine the accuracy of preliminary reports rendered by radiology residents in this setting. MATERIALS AND METHODS Three hundred seventy-seven pediatric abdominopelvic MRI examinations were included. The preliminary (resident) and final (attending) radiology reports were coded as diagnosing acute appendicitis or no acute appendicitis. The concordance between resident and attending radiologist interpretations was calculated. Additionally, both resident and attending reports were compared to available surgical pathology or clinical follow-up data. RESULTS Overall concordance rate for the diagnosis of acute appendicitis was 97.1%. Concordance for verified cases of acute appendicitis was 93.4%. Concordance rates did not differ by residents' postgraduate year levels. When compared against surgical pathology or clinical follow-up data, residents demonstrated 91.2% sensitivity and 97.6% specificity. There was no statistically significant difference in the sensitivity or specificity of resident or attending radiologist interpretations. CONCLUSION Radiology residents demonstrate high concordance with attending pediatric radiologists in their interpretations of pediatric abdominopelvic MRI for acute appendicitis. The diagnostic performances of residents and attendings were comparable.
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Affiliation(s)
- David M. Sawyer
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Raza Mushtaq
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Srinivasan Vedantham
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Faryal Shareef
- Creighton University of Arizona Health Alliance, Phoenix, AZ USA
| | - Sara M. Desoky
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | | | - Unni K. Udayasankar
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
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12
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Koberlein GC, Trout AT, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Falcone RA, Garber MD, Joseph MM, Nguyen JC, Safdar NM, Karmazyn B. ACR Appropriateness Criteria ® Suspected Appendicitis-Child. J Am Coll Radiol 2020; 16:S252-S263. [PMID: 31054752 DOI: 10.1016/j.jacr.2019.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 12/29/2022]
Abstract
Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - George C Koberlein
- Research Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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13
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James K, Duffy P, Kavanagh RG, Carey BW, Power S, Ryan D, Joyce S, Feeley A, Murphy P, Andrews E, McEntee MF, Moore M, Bogue C, Maher MM, O' Connor OJ. Fast acquisition abdominal MRI study for the investigation of suspected acute appendicitis in paediatric patients. Insights Imaging 2020; 11:78. [PMID: 32548771 PMCID: PMC7297877 DOI: 10.1186/s13244-020-00882-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/13/2020] [Indexed: 02/08/2023] Open
Abstract
Objectives To assess the diagnostic accuracy of fast acquisition MRI in suspected cases of paediatric appendicitis presenting to a tertiary referral hospital. Materials and methods A prospective study was undertaken between May and October 2017 of 52 children who presented with suspected appendicitis and were referred for an abdominal ultrasound. All patients included in this study received both an abdominal ultrasound and five-sequence MRI consisting of axial and coronal gradient echo T2 scans, fat-saturated SSFSE and a diffusion-weighted scan. Participants were randomised into groups of MRI with breath-holds or MRI with free breathing. A patient satisfaction survey was also carried out. Histopathology findings, where available, were used as a gold standard for the purposes of data analysis. Statistical analysis was performed, and p values < 0.05 were considered statistically significant. Results Ultrasound had a sensitivity and specificity of 25% and 92.9%, respectively. MRI with breath-hold had a sensitivity and specificity of 81.8% and 66.7%, respectively, whilst MRI with free breathing was superior with sensitivity and specificity of 92.3% and 84.2%, respectively. MRI with free breathing was also more time efficient (p < 0.0001). Group statistics were comparable (p < 0.05). Conclusions The use of fast acquisition MRI protocols, particularly free breathing sequences, for patients admitted with suspected appendicitis can result in faster diagnosis, treatment and discharge. It also has a statistically significant diagnostic advantage over ultrasound. Additionally, the higher specificity of MR can reduce the number of negative appendectomies performed in tertiary centres.
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Affiliation(s)
- Karl James
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Patrick Duffy
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Richard G Kavanagh
- Department of Radiology, Cork University Hospital, Cork, Ireland.,Department of Radiology, University College Cork, Cork, Ireland
| | - Brian W Carey
- Department of Radiology, Cork University Hospital, Cork, Ireland.,Department of Radiology, University College Cork, Cork, Ireland
| | - Stephen Power
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - David Ryan
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, University College Cork, Cork, Ireland
| | - Aoife Feeley
- School of Medicine, University College Cork, Cork, Ireland
| | - Peter Murphy
- PET/CT-MRI Unit, Cork University Hospital, Cork, Ireland
| | - Emmet Andrews
- Department of Surgery, Cork University Hospital, Cork, Ireland
| | - Mark F McEntee
- Department of Radiography, University College Cork, Cork, Ireland
| | - Michael Moore
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Conor Bogue
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Michael M Maher
- Department of Radiology, Cork University Hospital, Cork, Ireland.,Department of Radiology, University College Cork, Cork, Ireland
| | - Owen J O' Connor
- Department of Radiology, Cork University Hospital, Cork, Ireland. .,Department of Radiology, University College Cork, Cork, Ireland.
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14
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Heye P, Saavedra JSM, Victoria T, Laje P. Accuracy of unenhanced, non-sedated MRI in the diagnosis of acute appendicitis in children. J Pediatr Surg 2020; 55:253-256. [PMID: 31706612 DOI: 10.1016/j.jpedsurg.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Children with suspected appendicitis generally undergo an ultrasound (most commonly) or a CT scan (rarely) as the first imaging study. At our hospital, patients with non-diagnostic ultrasound or CT scan results undergo a non-contrast (unenhanced), non-sedated MRI. We aimed to determine the accuracy of this study for this purpose in a large cohort of children. METHODS A retrospective review of all unenhanced, non-sedated MRIs done for suspected appendicitis was performed from January 2014 to December 2018. MRI reports were correlated with pathology reports in cases that underwent appendectomy, and with clinical outcomes if no operation was done (clinical follow up: 30d). No patient was treated for appendicitis non-operatively. RESULTS Three hundred fifty unenhanced, non-sedated MRIs were done and reviewed with median age: 12 (3 to 18) years. Sixty-five (18.6%) MRIs were positive for appendicitis, and 62 of those underwent appendectomy (3 excluded clinically). Pathology was positive in 59/62 cases. 256 (73.1%) MRIs were negative for appendicitis. Six cases underwent appendectomy (persistent symptoms). Pathology was positive in 2/6 cases. The overall diagnostic accuracy was: sensitivity 96.7% (95% CI: 88.6-99.6), specificity 97.7% (95% CI: 95.0-99.1), PPV: 90.8% (95% CI: 81.6-95.6; false positives 6/65), and NPV: 99.2% (95% CI: 97.0-99.8; false negatives 2/254). Twenty-nine (8.3%) MRIs were non-diagnostic. None of those 29 cases had appendicitis (4 negative pathology, 25 excluded clinically). CONCLUSIONS The unenhanced, non-sedated MRI is highly accurate for the diagnosis of appendicitis in children. It should be considered as an alternative to CT in the work-up of patients with suspected appendicitis to eliminate the risks associated with ionizing radiation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Pascal Heye
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pablo Laje
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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15
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Alvarado Scores Predict Additive Value of Magnetic Resonance Imaging in Workup of Suspected Appendicitis in Children. J Surg Res 2019; 244:42-49. [PMID: 31279262 DOI: 10.1016/j.jss.2019.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/03/2019] [Accepted: 06/07/2019] [Indexed: 11/17/2022]
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16
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Naffaa L, Barakat A, Baassiri A, Atweh LA. Imaging Acute Non-Traumatic Abdominal Pathologies in Pediatric Patients: A Pictorial Review. J Radiol Case Rep 2019; 13:29-43. [PMID: 31558965 DOI: 10.3941/jrcr.v13i7.3443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The dilemma of acute non-traumatic abdominal pathologies in the pediatric population depends on the age of the patients and symptoms. Surgical etiologies in patients younger than 2 years of age include intussusception, pyloric stenosis, malrotation and midgut volvulus. In older patients, considerations become closer to differential etiologies in adults including acute appendicitis. Ultrasound and fluoroscopic examinations remain the mainstay for diagnosis that may even be therapeutic such as contrast/air enemas in intussusception reduction. There is an increasing role for CT in appendicitis and renal colic especially in assessing complications; however, it is less favored because it incurs radiation to the patient. This article summarizes the imaging approach to pediatric patients with acute abdominal pathologies presenting to the emergency department, and how imaging is instrumental in guiding diagnosis and treatment, with emphasis on radiation safety, in the context of providing typical imaging findings of each pathology in this pictorial review.
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Affiliation(s)
- Lena Naffaa
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Andrew Barakat
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amro Baassiri
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lamya Ann Atweh
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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17
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Jiang J, Wu Y, Tang Y, Shen Z, Chen G, Huang Y, Zheng S, Zheng Y, Dong R. A novel nomogram for the differential diagnosis between advanced and early appendicitis in pediatric patients. Biomark Med 2019; 13:1157-1173. [PMID: 31559834 DOI: 10.2217/bmm-2019-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To develop a nomogram for differential diagnosis between advanced and early pediatric appendicitis (PA). Patients & methods: We retrospectively studied 669 PA patients. Patient characteristics and 24 serum markers were subjected to univariate and multivariate analysis, based on which the nomogram was constructed. Results: Fibrin degradation product, CRP and Na+ differed significantly between the advanced and early PA. The value of area under the receiver operating characteristic curve (AUC) was 0.8602, which was greater than that of a single serum marker. Furthermore, the nomogram showed better discriminative ability than the biomarker alone. Notably, validation indicated high stability and reproducibility. Conclusion: The nomogram is superior to the serum marker alone, and may hold promise in clinical application.
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Affiliation(s)
- Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Ying Wu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yue Tang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yanlei Huang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
| | - Yijie Zheng
- Department of Medical Scientific Affairs, Wuxi Diagnosis, Wuxi Apptec, Shanghai, PR China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect, Shanghai 201102, PR China
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18
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Sams C, Ayyala RS, Swenson DW. Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population. BJR Open 2019; 1:20190016. [PMID: 33178945 PMCID: PMC7592479 DOI: 10.1259/bjro.20190016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/17/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.
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Affiliation(s)
- Cassandra Sams
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - Rama S Ayyala
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - David W. Swenson
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
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19
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Abstract
BACKGROUND Acute pelvic pain in women may be due to gynecological, gastrointestinal, and urinary tract disorders. Ectopic pregnancy (EP), pelvic inflammatory disease (PID), and ruptured ovarian cysts are the most common gynecological causes for acute pelvic pain and their diagnosis can be challenging. METHODS Patient history, clinical examination, and blood tests as well as patient age and potential pregnancy status help to establish the correct diagnosis. While sonography (US) remains the primary imaging modality of choice, computed tomography (CT) plays an important role in patients with indeterminate US evaluation and for treatment planning. CONCLUSION Diagnostic imaging is pivotal to differentiate potentially life- and fertility-threatening conditions from those that can be treated conservatively. Profound knowledge of the most common gynecological pathologies allows prompt and correct radiological diagnosis and assists in proper treatment planning.
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20
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Absolute neutrophil count as a diagnostic guide for the use of MRI in the workup of suspected appendicitis in children. J Pediatr Surg 2019; 54:1359-1364. [PMID: 30001891 DOI: 10.1016/j.jpedsurg.2018.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE To assess the additive value of magnetic resonance imaging (MRI) in the setting of an equivocal US (Eq-US) with or without an elevated absolute neutrophil count (ANC). METHODS Single-institution, retrospective review of children ages 5-18 years who presented to the ER with suspected appendicitis from 9/2015 to 8/2016. US, ANC, and MRI results were reviewed. Imaging was identified as positive/suspicious, normal, or equivocal and ANC <8000/mm3 was defined as normal. RESULTS 738 patients with a median age of 11 years (IQR 8-14) met inclusion criteria. US was equivocal in 61.4%. Among 304 (67.1%) patients with an Eq-US and normal ANC, only 5 (1.6%) had acute appendicitis. In contrast, 28 of 149 patients (18.8%) with Eq-US and elevated ANC had appendicitis. MRI was performed in 125 patients with Eq-US and was positive/suspicious in 2.9% (2/69) with normal ANC and 25.0% (14/56) with elevated ANC. MRI had 94.7% sensitivity and 100% specificity for acute appendicitis in patients with an Eq-US. CONCLUSIONS MRI has high sensitivity and specificity for diagnosing acute appendicitis in children. Patients with Eq-US plus a normal ANC have a very low likelihood of appendicitis and do not typically require further imaging. MRI may have utility for children with Eq-US and elevated ANC. LEVEL OF EVIDENCE Level III.
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21
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Lala SV, Strubel N, Nocera N, Bittman ME, Fefferman NR. Visualization of the normal appendix in children: feasibility of a single contrast-enhanced radial gradient recalled echo MRI sequence. Pediatr Radiol 2019; 49:770-776. [PMID: 30783687 DOI: 10.1007/s00247-019-04352-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 01/03/2019] [Accepted: 02/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assessment for appendicitis is limited by exam time and patient cooperation. The radially sampled 3-dimensional (3-D) T1-weighted, gradient recalled echo sequence (radial GRE) is a free-breathing, motion robust sequence that may be useful in evaluating appendicitis in children. OBJECTIVE To compare the rate of detection of the normal appendix with contrast-enhanced radial GRE versus contrast-enhanced 3-D GRE and a multi-sequence study including contrast-enhanced radial GRE. MATERIALS AND METHODS This was a retrospective study of patients ages 7-18 years undergoing abdominal-pelvic contrast-enhanced MRI between Jan. 1, 2012, and April 1, 2016. Visualization of the appendix was assessed by consensus between two pediatric radiologists. The rate of detection of the appendix for each sequence and combination of sequences was compared using a McNemar test. RESULTS The rate of detection of the normal appendix on contrast-enhanced radial GRE was significantly higher than on contrast-enhanced 3-D GRE (76% vs. 57.3%, P=0.003). The rate of detection of the normal appendix with multi-sequence MRI including contrast-enhanced radial GRE was significantly higher than on contrast-enhanced 3-D GRE (81.3% vs. 57%, P<0.001). There was no significant difference between the rate of detection of the normal appendix on contrast-enhanced radial GRE alone and multi-sequence MRI including contrast-enhanced radial GRE (76% vs. 81.3%, P=0.267). CONCLUSION Contrast-enhanced radial GRE allows superior detection of the normal appendix compared to contrast-enhanced 3-D GRE. The rate of detection of the normal appendix on contrast-enhanced radial GRE alone is nearly as good as when the contrast-enhanced radial GRE is interpreted with additional sequences.
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Affiliation(s)
- Shailee V Lala
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA.
| | - Naomi Strubel
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Nicole Nocera
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Mark E Bittman
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
| | - Nancy R Fefferman
- Department of Radiology, New York University School of Medicine, 660 First Ave., New York, NY, 10016, USA
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22
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Anderson KT, Bartz-Kurycki MA, Austin MT, Kawaguchi AL, Kao LS, Lally KP, Tsao K. Hospital type predicts computed tomography use for pediatric appendicitis. J Pediatr Surg 2019; 54:723-727. [PMID: 29925468 DOI: 10.1016/j.jpedsurg.2018.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Kathryn Tinsley Anderson
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX.
| | - Marisa A Bartz-Kurycki
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Mary T Austin
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Akemi L Kawaguchi
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Lillian S Kao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kevin P Lally
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
| | - Kuojen Tsao
- McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice (C-STEP), Houston, TX
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Janos S, Schooler GR, Ngo JS, Davis JT. Free-breathing unsedated MRI in children: Justification and techniques. J Magn Reson Imaging 2019; 50:365-376. [DOI: 10.1002/jmri.26644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Sara Janos
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Gary R. Schooler
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Jennifer S. Ngo
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
| | - Joseph T. Davis
- Department of Radiology; Duke University Medical Center; Durham North Carolina USA
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Roh AT, Xiao Z, Cheng JY, Vasanawala SS, Loening AM. Conical ultrashort echo time (UTE) MRI in the evaluation of pediatric acute appendicitis. Abdom Radiol (NY) 2019; 44:22-30. [PMID: 30066168 DOI: 10.1007/s00261-018-1705-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) sequences with conical k-space trajectories are able to decrease motion artifacts while achieving ultrashort echo times (UTE). We assessed the performance of free-breathing conical UTE MRI in the evaluation of the pediatric pelvis for suspected appendicitis. METHODS Our retrospective review of 84 pediatric patients who underwent MRI for suspected appendicitis compared three contrast-enhanced sequences: free-breathing conical UTE, breath-hold three-dimensional (3D) spoiled gradient echo (BH-SPGR), and free-breathing high-resolution 3D SPGR (FB-SPGR). Two radiologists performed blinded and independent evaluations of each sequence for image quality (four point scale), anatomic delineation (four point scale), and diagnostic confidence (five point scale). Subsequently, the three sequences were directly compared for overall image quality (- 3 to + 3 scale). Scores were compared using Kruskal-Wallis and Wilcoxon signed-rank tests. RESULTS UTE demonstrated significantly better perceived signal-to-noise ratio (SNR) and fewer artifacts than BH-SPGR and FB-SPGR (means of 3.6 and 3.4, 3.4 and 3.2, 3.1 and 2.7, respectively; p < 0.0006). BH-SPGR and FB-SPGR demonstrated significantly better contrast than UTE (means of 3.6, 3.4, and 3.2, respectively; p < 0.03). In the remaining categories, UTE performed significantly better than FB-SPGR (p < 0.00001), while there was no statistical difference between UTE and BH-SPGR. Direct paired comparisons of overall image quality demonstrated the readers significantly preferred UTE over both BH-SPGR (mean + 0.5, p < 0.00001) and FB-SPGR (mean + 1.2, p < 0.00001). CONCLUSIONS In the evaluation of suspected appendicitis, free-breathing conical UTE MRI performed better in the assessed metrics than FB-SPGR. When compared to BH-SPGR, UTE demonstrated superior perceived SNR and fewer artifacts.
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Affiliation(s)
- Albert T Roh
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Zhibo Xiao
- Radiology, First Affiliated Hospital, Chongqing, China
| | - Joseph Y Cheng
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | | | - Andreas M Loening
- Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Abstract
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.
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MRI for Pediatric Appendicitis in an Adult-Focused General Hospital: A Clinical Effectiveness Study-Challenges and Lessons Learned. AJR Am J Roentgenol 2018; 212:180-187. [PMID: 30383407 DOI: 10.2214/ajr.18.19825] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The objective of our study was to determine the feasibility and accuracy of MRI for pediatric appendicitis in an adult-predominant general hospital setting where non-pediatric-trained radiologists routinely interpret the studies. MATERIALS AND METHODS MRI was performed in pediatric patients with equivocal ultrasound (US) findings and persistent clinical concern for appendicitis. Neither IV contrast material nor a sedative was administered. Our MRI protocol evolved early during the study period, quickly settling on three sequences (total scanning time, 11 minutes). The clinical reference standard for statistical analysis was appendicitis diagnosed on operative or pathology report; 95% Clopper-Pearson CIs were calculated. RESULTS Between 2012 and 2016, 528 pediatric patients (mean age, 9.9 years; age range, 1-17 years) underwent MRI after US evaluation yielded equivocal findings: 10.4% (55/528) of patients were found to have surgically proven or pathologically proven appendicitis. Sensitivity and specificity of MRI for appendicitis were 96.4% and 98.9%, respectively. Positive and negative predictive values were 91.2% and 99.6%. A normal appendix and abnormalities not involving the appendix were identified on MRI in 21.6% (114/528) of patients. CONCLUSION Our data show that unenhanced MRI for suspected appendicitis in pediatric patients is clinically effective when performed in a nonpediatric hospital setting with nonpediatric radiologists, emergency physicians, and surgeons.
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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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Zens TJ, Rogers AP, Riedesel EL, Leys CM, Ostlie DJ, Woods MA, Gill KG. The cost effectiveness and utility of a "quick MRI" for the evaluation of intra-abdominal abscess after acute appendicitis in the pediatric patient population. J Pediatr Surg 2018; 53:1168-1174. [PMID: 29673611 DOI: 10.1016/j.jpedsurg.2018.02.078] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study. MATERIALS AND METHODS Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared. RESULTS There was no difference in age or weight (p>0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p<0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT. CONCLUSION Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA. TYPE OF STUDY Retrospective Case-Control Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tiffany J Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Andrew P Rogers
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Erica L Riedesel
- Division of Pediatric Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | | | - Michael A Woods
- Division of Interventional Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Kara G Gill
- Division of Pediatric Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI.
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D'Souza N, Marsden M, Bottomley S, Nagarajah N, Scutt F, Toh S. Cost-effectiveness of routine imaging of suspected appendicitis. Ann R Coll Surg Engl 2018; 100:47-51. [PMID: 29046077 PMCID: PMC5838669 DOI: 10.1308/rcsann.2017.0132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction The misdiagnosis of appendicitis and consequent removal of a normal appendix occurs in one in five patients in the UK. On the contrary, in healthcare systems with routine cross-sectional imaging of suspected appendicitis, the negative appendicectomy rate is around 5%. If we could reduce the rate in the UK to similar numbers, would this be cost effective? This study aimed to calculate the financial impact of negative appendicectomy at the Queen Alexandra Hospital and to explore whether a policy of routine imaging of such patients could reduce hospital costs. Materials and methods We performed a retrospective analysis of all appendicectomies over a 1-year period at our institution. Data were extracted on outcomes including appendix histology, operative time and length of stay to calculate the negative appendicectomy rate and to analyse costs. Results A total of 531 patients over 5 years of age had an appendicectomy. The negative appendicectomy rate was 22% (115/531). The additional financial costs of negative appendicectomy to the hospital during this period were £270,861. Universal imaging of all patients with right iliac fossa pain that could result in a 5% negative appendicectomy rate would cost between £67,200 and £165,600 per year but could save £33,896 (magnetic resonance imaging), £105,896 (computed tomography) or £132,296 (ultrasound) depending on imaging modality used. Conclusions Negative appendicectomy is still too frequent and results in additional financial burden to the health service. Routine imaging of patients with suspected appendicitis would not only reduce the negative appendicectomy rate but could lead to cost savings and a better service for our patients.
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Affiliation(s)
- N D'Souza
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
| | - M Marsden
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine , London , UK
| | - S Bottomley
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
| | - N Nagarajah
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
| | - F Scutt
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
| | - S Toh
- Department of General Surgery, Queen Alexandra Hospital , Portsmouth , UK
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Martin JF, Mathison DJ, Mullan PC, Otero HJ. Secondary imaging for suspected appendicitis after equivocal ultrasound: time to disposition of MRI compared to CT. Emerg Radiol 2017; 25:161-168. [PMID: 29249008 DOI: 10.1007/s10140-017-1570-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 12/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to compare MRI to CT as a secondary imaging modality for children age 5 years and older with suspected appendicitis after an equivocal abdominal ultrasound in terms of (1) the time to ED disposition decision, (2) surgery consultation rate, and (3) imaging test accuracy. METHODS We retrospectively studied children with suspected appendicitis and equivocal ultrasound results who underwent MR or CT as secondary imaging in a pediatric emergency department over two-consecutive 9-month periods. No oral or intravenous contrast was utilized for MRI. No sedation was utilized for any modality. Time of disposition is the time to admission or discharge order. RESULTS Twenty-five patients underwent CT and 30 underwent MRI, with no significant difference in the median time from ultrasound to disposition between the CT (5.9 h, IQR 4.5, 8.4) and the MRI (5.9 h, IQR 4.6, 6.9) groups (p = 0.65). Fifteen patients had appendicitis. Of the 40 negative or equivocal studies, surgery was consulted for 79% in the CT and 48% in the MRI group (odds ratio 4.12, 95% CI 1.02-16.67). Diagnostic accuracy was as follows: MRI: sensitivity of 90%, specificity of 97.1%, positive predictive value of 90%, and negative predictive value of 97.1%. Abdominal CT: sensitivity of 88%, specificity of 98.6%, positive predictive value of 95.7%, and negative predictive value of 95.8%. CONCLUSION MRI is a feasible alternative to CT for secondary imaging in acute appendicitis for showing comparable ED throughput metrics and diagnostic accuracy, with added benefits of reduced radiation and avoidance of intravenous contrast.
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Affiliation(s)
- James F Martin
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - David J Mathison
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - Paul C Mullan
- Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Boulevard, Philadelphia, PA, 20910, USA.
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Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis. Radiology 2017; 286:1022-1029. [PMID: 29156146 DOI: 10.1148/radiol.2017162755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose To establish, in a large cohort, the diagnostic performance of a staged algorithm involving ultrasonography (US) followed by conditional unenhanced magnetic resonance (MR) imaging for the imaging work-up of pediatric appendicitis. Materials and Methods A staged imaging algorithm in which US and unenhanced MR imaging were performed in pediatric patients suspected of having appendicitis was implemented at the authors' institution on January 1, 2011, with US as the initial modality followed by unenhanced MR imaging when US findings were equivocal. A search of the radiology database revealed 2180 pediatric patients who had undergone imaging for suspected appendicitis from January 1, 2011, through December 31, 2012. Of the 2180 patients, 1982 (90.9%) were evaluated according to the algorithm. The authors reviewed the electronic medical records and imaging reports for all patients. Imaging reports were reviewed and classified as positive, negative, or equivocal for appendicitis and correlated with surgical and pathology reports. Results The frequency of appendicitis was 20.5% (407 of 1982 patients). US alone was performed in 1905 of the 1982 patients (96.1%), yielding a sensitivity of 98.7% (386 of 391 patients) and specificity of 97.1% (1470 of 1514 patients) for appendicitis. Seventy-seven patients underwent unenhanced MR imaging after equivocal US findings, yielding an overall algorithm sensitivity of 98.2% (400 of 407 patients) and specificity of 97.1% (1530 of 1575 patients). Seven of the 1982 patients (0.4%) had false-negative results with the staged algorithm. The negative predictive value of the staged algorithm was 99.5% (1530 of 1537 patients). Conclusion A staged algorithm of US and unenhanced MR imaging for pediatric appendicitis appears to be effective. The results of this study demonstrate that this staged algorithm is 98.2% sensitive and 97.1% specific for the diagnosis of appendicitis in pediatric patients. © RSNA, 2017.
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Affiliation(s)
- Elizabeth H Dibble
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - David W Swenson
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Claudia Cartagena
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Grayson L Baird
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Thaddeus W Herliczek
- From the Department of Diagnostic Imaging (E.H.D., D.W.S., C.C., G.L.B., T.W.H.) and Lifespan Biostatistics Core (G.L.B.), The Warren Alpert Medical School of Brown University/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
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Rosenbaum DG, Askin G, Beneck DM, Kovanlikaya A. Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging. Pediatr Radiol 2017; 47:1483-1490. [PMID: 28578474 DOI: 10.1007/s00247-017-3900-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/01/2017] [Accepted: 05/09/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated. OBJECTIVE To assess the performance of MRI in differentiating perforated from non-perforated appendicitis. MATERIALS AND METHODS A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected. RESULTS Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%. CONCLUSION Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between perforated and non-perforated cases. These results may help guide management decisions as MRI assumes a greater role in the work-up of pediatric appendicitis.
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Affiliation(s)
- Daniel G Rosenbaum
- Division of Pediatric Radiology, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 E. 68th St, New York, NY, 10065, USA.
| | - Gulce Askin
- Division of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, NY, USA
| | - Debra M Beneck
- Department of Pathology, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Arzu Kovanlikaya
- Division of Pediatric Radiology, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 E. 68th St, New York, NY, 10065, USA
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Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging. Pediatr Surg Int 2017; 33:1007-1012. [PMID: 28674919 DOI: 10.1007/s00383-017-4121-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Preoperative determination of perforated versus acute appendicitis can be difficult. We compared CT and MRI performance in diagnosing perforated appendicitis, and created diagnostic criteria. METHODS We retrospectively reviewed all pediatric patients who underwent appendectomy within one day of CT or MRI between 1/1/2013 and 1/16/2016. True diagnosis was determined by pathology report. Findings on CT/MRI were grouped into "hard" findings (abscess, pneumoperitoneum, extruded fecalith, appendiceal wall with visible hole) and "soft" findings (extensive/diffuse inflammation/free fluid, phlegmon). Correlation of white blood cell count (WBC), temperature, peritoneal signs, and symptom duration >72 h with perforation was assessed using logistic regression. Significant correlates were incorporated in clinical criteria. RESULTS 135 patients underwent appendectomy after CT/MRI. Fifty patients underwent MRI and 85 CT. Using hard and/or soft findings, MRI was 86.7% sensitive and 74.3% specific, compared to 68.4% (p = 0.19) and 92.4% (p = 0.025) for CT. WBC > 15, temperature >38.0 °C, and peritoneal signs predicted perforation. Diagnostic accuracy of MRI was highest using imaging findings alone. Accuracy of CT was improved by mandating at least one of the previous three clinical correlates, resulting in 68.4% sensitivity and 93.9% specificity. CONCLUSIONS MRI trended toward more sensitive and CT was more specific for complicated appendicitis. CT specificity is improved by our algorithm.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA
| | - Sohail R Shah
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030, USA.
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Didier RA, Hopkins KL, Coakley FV, Krishnaswami S, Spiro DM, Foster BR. Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis. Pediatr Radiol 2017. [PMID: 28631157 DOI: 10.1007/s00247-017-3897-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated. OBJECTIVE To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis. MATERIALS AND METHODS We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy. RESULTS Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative. CONCLUSION Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.
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Affiliation(s)
- Ryne A Didier
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Katharine L Hopkins
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Fergus V Coakley
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sanjay Krishnaswami
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.,Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - David M Spiro
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Bryan R Foster
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Kim JR, Suh CH, Yoon HM, Jung AY, Lee JS, Kim JH, Lee JY, Cho YA. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: A systematic review and meta-analysis. J Magn Reson Imaging 2017; 47:767-778. [PMID: 28815859 DOI: 10.1002/jmri.25825] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/10/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To evaluate in pediatric patients the diagnostic performance of magnetic resonance imaging (MRI) for suspected appendicitis and its negative appendectomy rate. MATERIALS AND METHODS The study involved diagnostic accuracy studies that used MRI for pediatric patients with suspected appendicitis. Various field strengths and sequences were used in each included study. The diagnostic accuracy of MRI in pediatric patients with suspected appendicitis and negative appendectomy rate were assessed. A search of MEDLINE and EMBASE databases was performed until January 10, 2017. Two reviewers assessed the methodological quality of the articles using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Pooled sensitivity and specificity for appendicitis diagnosis were calculated using hierarchical logistic regression modeling. Meta-regression was performed to explore factors affecting study heterogeneity. The pooled negative appendectomy rate was analyzed. RESULTS Thirteen original articles with 1946 patients were included. The summary sensitivity and specificity were 97% (95% confidence interval [CI], 95-98%) and 97% (95% CI, 93-98%), respectively; the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.97-0.99). In meta-regression, use of diffusion-weighted imaging (P < 0.01) and age (P < 0.01) affected heterogeneity, but there was no difference according to intravenous contrast agent use (P = 0.95). The pooled negative appendectomy rate of MRI was 4.5% (95% CI, 1.9-7.1%). CONCLUSION MRI shows excellent diagnostic performance for appendicitis in pediatric patients regardless of the use of intravenous contrast media. Therefore, nonenhanced-only MRI protocols might be appropriate for pediatric patients with suspected appendicitis. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:767-778.
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Affiliation(s)
- Jeong Rye Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology, Namwon Medical Center, Jeollabuk-do, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Leelakanok N, Phelps AS, Zapala MA, Kato K, Ohliger M, Li Y, Courtier J. Assessing 3D T2 FSE sequence for identification of the normal appendix: working toward a single-sequence MR appendicitis protocol. Emerg Radiol 2017; 24:653-660. [DOI: 10.1007/s10140-017-1538-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/11/2017] [Indexed: 12/29/2022]
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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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Diagnostic utility of intravenous contrast for MR imaging in pediatric appendicitis. Pediatr Radiol 2017; 47:398-403. [PMID: 28108797 DOI: 10.1007/s00247-016-3775-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/23/2016] [Accepted: 12/23/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is increasingly employed as a diagnostic modality for suspected appendicitis in children. However, there is uncertainty as to which MRI sequences are sufficient for safe, timely and accurate diagnosis. Several recent studies have described different MRI protocols, including exams both with and without the use of intravenous contrast. OBJECTIVE We hypothesized that intravenous contrast may be useful in some patients but could be safely omitted in others. MATERIALS AND METHODS All MRI examinations (n=112) performed at our institution for evaluating appendicitis in children were retrospectively reevaluated. Exams were reread by pediatric radiologists under three conditions: With postcontrast images, Without postcontrast images, and Without/With - selective use of postcontrast sequences only when needed for diagnostic certainty. Samples were scored as positive, negative or equivocal for appendicitis. Findings were compared to pathological or clinical follow-up in the medical record. RESULTS Without the use of intravenous contrast yielded more equivocal results (12.4%) compared to With contrast (3.4%). By selectively using postcontrast sequences, the Without/With group yielded fewer equivocal results (1.1%) compared to Without while also reducing contrast use 79.8% compared to the With contrast group. No significant differences in conditional sensitivity or conditional specificity were detected among the three groups. CONCLUSION MRI diagnosis of acute appendicitis can be performed without contrast for most patients; injection of contrast can be reserved for only those patients with equivocal non-contrast imaging.
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Keller C, Wang NE, Imler DL, Vasanawala SS, Bruzoni M, Quinn JV. Predictors of Nondiagnostic Ultrasound for Appendicitis. J Emerg Med 2017; 52:318-323. [PMID: 27692650 DOI: 10.1016/j.jemermed.2016.07.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 06/29/2016] [Accepted: 07/20/2016] [Indexed: 02/08/2023]
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Nah SA, Ong SS, Lim WX, Amuddhu SK, Tang PH, Low Y. Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children. J Pediatr 2017; 182:164-169.e1. [PMID: 28010937 DOI: 10.1016/j.jpeds.2016.11.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/19/2016] [Accepted: 11/23/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain. STUDY DESIGN We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted. RESULTS Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal ultrasound imaging had computed tomography imaging confirming appendicitis. There were 51 patients with a partially visualized appendix. The segment of appendix that could be seen was normal in 34 patients, none of whom had appendectomy. The remaining 17 had appendectomy, in whom the appendix seemed to be inflamed in 13 and equivocal in 4, all with histologically confirmed appendicitis. Overall, 232 children underwent appendectomy; 58 had no ultrasound imaging done, and 5 had a histologically normal appendix (overall negative appendectomy rate, 2.2%). Only 35 of 1359 patients (0.03%) had computed tomography scans. CONCLUSION In patients with a nonvisualized appendix on ultrasound imaging and no evidence of secondary inflammatory changes, the likelihood of appendicitis is less than 2%. Generous use of ultrasonography as an adjunct to clinical examination can achieve low negative appendectomy rates without underdiagnosis of acute appendicitis.
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Affiliation(s)
- Shireen Anne Nah
- Pediatric Surgery, KK Women's and Children's Hospital, Singapore.
| | - Sophie Sihui Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wei Xiang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Phua Hwee Tang
- Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Yee Low
- Pediatric Surgery, KK Women's and Children's Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
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Abstract
Pelvic inflammatory disease (PID) is an ascending infection of the female genital tract caused by the spread of bacteria from the vagina to the pelvic reproductive organs and occasionally the peritoneum. The most common causative organisms are sexually transmitted. PID is a significant source of morbidity among reproductive age women both as a cause of abdominal pain and as a common cause of infertility. Its clinical presentation is often nonspecific, and the correct diagnosis may first come to light based on the results of imaging studies. MRI is well suited for the evaluation of PID and its complications due to its superior soft tissue contrast and high sensitivity for inflammation. MRI findings in acute PID include cervicitis, endometritis, salpingitis/oophoritis, and inflammation in the pelvic soft tissues. Acute complications include pyosalpinx, tuboovarian abscess, peritonitis, and perihepatitis. Hydrosalpinx, pelvic inclusion cysts and ureteral obstruction may develop as chronic sequela of PID. The pathophysiology, classification, treatment, and prognosis of PID are reviewed, followed by case examples of the appearance of acute and subclinical PID on MR images.
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Focused CT using a height-adjusted metric and the umbilicus as a landmark for children undergoing evaluation for appendicitis. Pediatr Radiol 2017; 47:294-300. [PMID: 28062934 DOI: 10.1007/s00247-016-3756-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/14/2016] [Accepted: 11/10/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Confirmation of appendicitis in children often requires CT. A focused CT scan that is limited to the lower abdomen/pelvis might help to reduce radiation exposure. OBJECTIVE To determine the position of the appendix relative to the umbilicus and derive a height-adjusted threshold for a focused CT that would identify most appendices. MATERIALS AND METHODS We conducted a retrospective study of children younger than 18 years who underwent a CT scan for suspected appendicitis. A pediatric radiologist determined the distance from the most cephalad portion of the appendix to the center of the umbilicus. This distance was divided by the child's height to create a ratio for each child. We then assessed the largest of these distance/height ratios ("height constants") as potential height-adjusted thresholds that, when multiplied by any patient's height, would yield the superior threshold for the focused CT scan. Radiation reduction was calculated as percentage decrease in scan length compared to a complete abdominopelvic CT. RESULTS Of 270 patients whose entire appendix was identified on CT, all were identified within 10.5 cm above the umbilicus. A focused CT using a height constant of 0.07 identified 100% of the appendices visualized on the complete CT scan and resulted in an estimated mean percentage radiation reduction of 27% (standard deviation [SD] +/-4.7). If a height constant of 0.03 was used, 97% of appendices were identified and the estimated radiation reduction was 43% (SD +/-4.3). CONCLUSION A height-adjusted focused abdominopelvic CT scan might reduce radiation exposure without sacrificing the diagnostic accuracy of the complete CT scan.
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Otero HJ, Crowder L. Imaging Utilization for the Diagnosis of Appendicitis in Stand-Alone Children's Hospitals in the United States: Trends and Costs. J Am Coll Radiol 2017; 14:603-608. [PMID: 28223114 DOI: 10.1016/j.jacr.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the imaging utilization patterns for the diagnosis of appendicitis among children's hospitals in the United States over the last 10 years (2005-2014). METHODS All patients with a primary discharge diagnosis of appendicitis included in a large administrative database of 45 pediatric institutions in the United States between 2005 and 2014 were selected. Demographics, imaging utilization, and costs were described. RESULTS In all, 96,786 children with appendicitis (59% boys, 41% girls; mean age: 9.9 years) were studied. The average length of stay decreased from 5.0 days in 2005 to 3.4 days in 2014 (P < .01). The percentage of patients undergoing CT increased between 2005 and 2007 from 59.1% to 62.6%, respectively, followed by a decrease from 62.6% to 32.7% in 2014 (r2 = 0.93). Radiograph utilization decreased from 14.2% in 2005 to 3.6% in 2014 (r2 = 0.93), and ultrasound and MRI increased from 25% and 0.03% in 2005 to 61% and 1.0% in 2014 (r2 = 0.97 and 0.64), respectively. The mean total hospital costs increased from $11,700 in 2005 to $16,500 in 2014; imaging costs increased only slightly from $3,205 to $3,259. The imaging fraction of hospital costs decreased from 27.5% to 19.8%. CONCLUSION There has been a significant decrease in utilization of CT and radiographs for the management of appendicitis in children, and ultrasound has continued to increase. Imaging costs have remained stable in comparison to rising hospital costs, generating a drop in the fraction of costs related to imaging.
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Affiliation(s)
- Hansel J Otero
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC.
| | - Lauren Crowder
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC
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Ultrasound, computed tomography or magnetic resonance imaging - which is preferred for acute appendicitis in children? A Meta-analysis. Pediatr Radiol 2017; 47:186-196. [PMID: 27815615 DOI: 10.1007/s00247-016-3727-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/04/2016] [Accepted: 10/04/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is no established consensus about the relative accuracies of US, CT and MRI in childhood appendicitis. OBJECTIVE To compare, through meta-analysis, the accuracies of US, CT and MRI for clinically suspected acute appendicitis in children. MATERIALS AND METHODS PubMed, Embase, Web of Science and the Cochrane Library were searched. After study selection, data extraction and quality assessment, the sensitivity, specificity and the area under the curve of summary receiver operating characteristic were calculated and compared. RESULTS Twenty-seven articles including 29 studies met the inclusion criteria, including 19 studies (9,170 patients) of US, 6 studies (928 patients) of CT and 4 studies (990 patients) of MRI. The analysis showed that the area under the receiver operator characteristics curve of MRI (0.995) was a little higher than that of US (0.987) and CT (0.982; P > 0.05). CONCLUSION US, CT and MRI have high diagnostic accuracies of clinically suspected acute appendicitis in children overall with no significant difference.
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Abstract
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Cox AD, Virues-Ortega J, Julio F, Martin TL. Establishing motion control in children with autism and intellectual disability: Applications for anatomical and functional MRI. J Appl Behav Anal 2016; 50:8-26. [DOI: 10.1002/jaba.351] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 04/20/2016] [Indexed: 11/09/2022]
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Ogunmefun G, Hardy M, Boynes S. Is magnetic resonance imaging a viable alternative to ultrasound as the primary imaging modality in the diagnosis of paediatric appendicitis? A systematic review. Radiography (Lond) 2016. [DOI: 10.1016/j.radi.2016.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
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Affiliation(s)
- Charity C Glass
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115
| | - Shawn J Rangel
- Department of Surgery, Children׳s Hospital Boston, Harvard Medical School, 300 Longwood Ave. Fegan-3, Boston, MA 02115.
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