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Clinical Assessment, Limited Imaging Diagnose Appendicitis

Do we really need ultrasound and computed tomography for all suspected appendicitis?

Two groups of investigators evaluated the increasingly standard use of ultrasound (US) and computed tomography (CT) in the diagnosis of appendicitis in children.

In 959 children, Garcia Peña and colleagues compared a standard approach (US followed, if negative, by CT) with two hypothetical models applied retroactively. In actual treatment, the children underwent 958 US and 637 CT exams; appendicitis was correctly diagnosed in 94.0%; and 5.8% had unnecessary appendectomies.

In the two hypothetical models, children were grouped into low-, medium-, and high-risk groups based on physical examination and laboratory study results. In the first model, low-risk patients were discharged after negative US results and had surgery if US results were positive. All high-risk patients underwent CT, and medium-risk patients received the standard evaluation. This strategy would have correctly diagnosed 93.8% of cases and resulted in unnecessary surgeries in 5.9%, 225 fewer US exams, and 36 fewer CT exams.

In the second model, low-risk children were admitted for observation without imaging, high-risk patients had appendectomy without imaging, and medium-risk patients had the standard evaluation. This strategy would have correctly diagnosed 92.4% of cases and resulted in unnecessary surgeries in 9.7%, 368 fewer US exams, and 261 fewer CT exams. The percentage of missed or delayed diagnoses (0.04%) was the same in all standard and hypothetical approaches.

Kosloske and colleagues used a diagnostic plan similar to the second hypothetical model for 356 children with suspected appendicitis. They performed appendectomies in 195 patients after clinical and laboratory examinations. Patients with equivocal findings were admitted for observation; 25 of these patients subsequently had appendectomies. Overall, 95.0% received correct diagnoses, and 5.0% had unnecessary surgery.

Comment: Careful physical examination and analysis of laboratory data continue to accurately direct the surgical treatment of most children with suspected appendicitis. Relying on clinical evaluation can speed surgery and reduce costs without adverse outcomes.

— F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 1, 2004

Citation(s):

Garcia Peña BM et al. Selective imaging strategies for the diagnosis of appendicitis in children. Pediatrics 2004 Jan; 113:24-8.

• Original article (Subscription may be required)
• Medline abstract (Free)

Kosloske AM et al. The diagnosis of appendicitis in children: Outcomes of a strategy based on pediatric surgical evaluation. Pediatrics 2004 Jan; 113:29-34.

• Original article (Subscription may be required)
• Medline abstract (Free)