Diagnostic accuracy of surgeon performed ultrasound (SPU) for appendicitis in children

Contemporary ultrasound, computed tomography, or magnetic resonance imaging for acute appendicitis diagnosis in children and adolescents: systematic review and meta-analysis

BACKGROUND

Since the last publication of meta-analyses on pediatric acute appendicitis imaging in 2016 and 2018, ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) technology and protocols have improved, and there are new reports on their accuracy.

OBJECTIVE

We determined sensitivity, specificity, and diagnostic odds ratios (DOR) of the US, CT, and MRI for pediatric acute appendicitis, in studies published from 2015 to 2024.

MATERIALS AND METHODS

PubMed, MEDLINE, BVS, OVID, Web of Science, and Trip Database (Jan 2015-May 2024) were searched for studies in patients less than 21 years old with suspected acute appendicitis. Histopathology and clinical follow-up were the reference standard. Those with insufficient data for a 2 × 2 contingency table were excluded. QUADAS-2 directed risk of bias assessment. Data were extracted for meta-analysis.

RESULTS

Our review of 37 articles included 22 conventional US studies (20,897 patients), 4 point-of-care US (POCUS) studies (280), 4 CT studies (1,389), and 13 MRI studies (2,630). Pooled sensitivity, specificity, and DOR were: conventional US: 0.93 (95% CI [0.87, 0.96]), 0.89 (95% CI [0.80, 0.95]), 115.23 (95% CI [-32.88, 263.34]); POCUS: 0.80 (95% CI [0.61, 0.91]), 0.93 (95% CI [0.83, 0.98]), 53.97 (95% CI [-39, 146.94]); CT: 0.96 (95% CI [0.93, 0.97]), 0.98 (95% CI [0.96, 0.98]), 864.43 (95% CI [264.02, 1,464.84]); MRI: 0.96 (95% CI [0.94, 0.97]), 0.98 (95% CI [0.96, 0.99]), 1,030.42 (95% CI [222.05, 1,838.8]). No statistically significant differences were found (P = 0.07). For quantitative synthesis, US and POCUS studies had the highest heterogeneity.

CONCLUSION

All four modalities have high diagnostic accuracy.

REGISTRATION

PROSPERO: CRD42024538086. May 5, 2024. Retrospectively registered. PROSPERO registration name: Ultrasound, computed tomography or magnetic resonance imaging for diagnosing acute appendicitis in children and adolescents.

Balancing Between Negative Appendectomy and Complicated Appendicitis: A Persisting Reality Under the Rule of the Uncertainty Principle

Uncertainty is inherent in medical practice. False-negative decisions can delay treatments and result in adverse outcomes in children with acute appendicitis (AA). On the other hand, false-positive surgery decisions lead to unnecessary appendectomies. Impressive technological advancements, such as magnetic resonance imaging and laparoscopy, have reduced but failed to eliminate the occurrence of erroneous decisions. Furthermore, there seems to be a fundamental limit to further reduction, especially in eliminating the rates of negative appendectomy or, oppositely, complicated appendicitis. What does this mean for the pediatric surgeon? Will we ever be able to eliminate our mistakes? This systematic review emphasizes the importance of understanding the potential abilities and limitations of different diagnostic options, as well as the impact of decisions in the face of uncertainty.

[Clinical Ultrasound (ClinUS) - Concepts and Controversies]

Clinical ultrasound (ClinUS) is the integration of ultrasound diagnostics into the clinical examination. By comparing clinical ultrasound with other models of ultrasound diagnostics, this overview presents a concept that integrates point-of-care ultrasound, comprehensive specialty-specific ultrasound examinations and specialized multiparametric ultrasound. The applications, advantages and challenges of clinical ultrasound and its special features in comparison to other cross-sectional imaging modalities are discussed using the example of gastroenterology and general medicine in particular.

C-Reactive Protein, International Normalized Ratio, and Fibrinogen in Diagnostic Scale of Complicated Acute Appendicitis

Background/Objectives: Differentiating complicated acute appendicitis (CA) and uncomplicated acute appendicitis (UC) is essential to guide clinical management. While CA requires urgent surgical management, UC can be treated with antibiotic therapy in selected cases. However, accurate identification of CA remains a clinical challenge. This study aimed to identify factors associated with CA and to develop a diagnostic severity scale. Methods: In this retrospective study, we included 132 adult patients (>16 years) with a confirmed postsurgical diagnosis of appendicitis, of whom 52 had CA and 80 had UA. Signs, symptoms, comorbidities, laboratory values, and ultrasonographic findings were evaluated to determine predictive factors and construct a diagnostic scale. Results: The factors most significantly associated with CA were elevated plasma concentrations of C-reactive protein (>7.150 mg/dL), fibrinogen (481.5 mg/dL), International Normalized Ratio (INR) (>1.150), and the presence of free fluid periappendicular. The combination of these factors within one scale showed an area under the curve (AUC) of 0.84, with a sensitivity of 78.75% and a specificity of 82.69%. Conclusions: Serum C-reactive protein concentration, fibrinogen, and INR can be employed individually or as part of a scale as important indicators in diagnosing CA.

Periappendiceal Abscess Masquerading as Pyosalpinx: A Case Report and Mini Literature Review of Acute Appendicitis Misdiagnosis

A 17-year-old patient presented to the emergency department of the General Hospital of Trikala, Greece, reporting hypogastric pain accompanied by a fever of up to 38°C. The pain, progressively increasing in intensity, had been present for about a week, with the fever onset occurring 24 hours prior. Based on clinical examination, transvaginal ultrasound, and computed tomography findings, an incorrect diagnosis of pyosalpinx was made, and intravenous treatment with broad-spectrum antibiotics was initiated. However, the lack of improvement in the patient's clinical and laboratory findings after two days led to the decision to perform a laparotomy. Intraoperatively, a periappendiceal abscess was found, with a bilateral secondary extension of inflammation to the uterus, fallopian tubes, ovaries, and pelvic peritoneum. The inflamed appendix was resected from its retrocecal position, and the pelvic abscess was drained. The postoperative course was uneventful. This case report highlights an atypical presentation of acute appendicitis with abscess, which was preoperatively misdiagnosed as pyosalpinx. The main factors contributing to the misdiagnosis of acute appendicitis and the subsequent delay in medical care are discussed, emphasizing that early and accurate diagnosis is crucial in preventing adverse outcomes and ensuring effective treatment.

MaskAppendix: Backbone-Enriched Mask R-CNN Based on Grad-CAM for Automatic Appendix Segmentation

BACKGROUND

A leading cause of emergency abdominal surgery, appendicitis is a common condition affecting millions of people worldwide. Automatic and accurate segmentation of the appendix from medical imaging is a challenging task, due to its small size, variability in shape, and proximity to other anatomical structures.

METHODS

In this study, we propose a backbone-enriched Mask R-CNN architecture (MaskAppendix) on the Detectron platform, enhanced with Gradient-weighted Class Activation Mapping (Grad-CAM), for precise appendix segmentation on computed tomography (CT) scans. In the proposed MaskAppendix deep learning model, ResNet101 network is used as the backbone. By integrating Grad-CAM into the MaskAppendix network, our model improves feature localization, allowing it to better capture subtle variations in appendix morphology.

RESULTS

We conduct extensive experiments on a dataset of abdominal CT scans, demonstrating that our method achieves state-of-the-art performance in appendix segmentation, outperforming traditional segmentation techniques in terms of both accuracy and robustness. In the automatic segmentation of the appendix region in CT slices, a DSC score of 87.17% was achieved with the proposed approach, and the results obtained have the potential to improve clinical diagnostic accuracy.

CONCLUSIONS

This framework provides an effective tool for aiding clinicians in the diagnosis of appendicitis and other related conditions, reducing the potential for diagnostic errors and enhancing clinical workflow efficiency.

Misdiagnosis of Acute Appendicitis Cases in the Emergency Room

Acute appendicitis (AA) is one of the most frequent surgical emergencies, especially in pediatric populations, with its misdiagnosis in emergency settings presenting significant health risks. This misdiagnosis leads to various complications, such as delayed treatment or unnecessary surgeries. Factors such as age, gender, and comorbidities contribute to diagnostic errors, leading to complications such as peritonitis and increased negative appendectomy rates. This underscores the importance of accurate clinical assessment and awareness of common pitfalls, such as cognitive biases and over-reliance on laboratory tests. This review delves into the prevalence of AA misdiagnosis, its health burden, and the challenges inherent in the diagnostic process. It scrutinizes the effectiveness of different diagnostic approaches, including clinical assessment and imaging techniques. The treatment paradigms for AA are also explored, focusing on surgical interventions and the potential of conservative treatments using antibiotics. The review underscores the criticality of precise diagnosis in preventing adverse outcomes and ensuring effective treatment.

Point of Care Ultrasound in Pediatric Surgery across the European Region-European Pediatric Surgery Association Endorsed Survey

INTRODUCTION

 Our purpose was to assess the state of training, clinical practice, and barriers to use point-of-care ultrasound (POCUS) in pediatric surgery in Europe.

METHODS

 An electronic survey was disseminated among European pediatric surgeons utilizing the European Pediatric Surgery Association network and other existing networks.

RESULTS

 There were 186 respondents from 27 European countries and 7 non-European countries. In most countries (86.6%; N = 161), the initial ultrasound for acute admissions is performed by radiologists, with 1 to 6 hours turnover in 62.9% (N = 117) of urgent cases. Ultrasound by pediatric surgeons (point-of-care ultrasound/POCUS) is performed by 48.4% (N = 90) of respondents, with 29% (N = 54) using it at least once per week. The most common indications for POCUS include abdominal focused abdominal sonography in trauma (53.8%; N = 100), diagnosis of appendicitis (41.9%; N = 78), and intussusception (44.6%; N = 84). In malrotation-volvulus, 28.5% (N = 53) used ultrasound for its diagnosis, while 27.5% (N = 51) would not see an indication here. Training in POCUS occurred informally for 55.4% (N = 103) of participants, while 31.2% (N = 58) attended formal training courses. Almost all respondents wanted to attain further POCUS training (89.3%; N = 166), only 7% (N = 13) did not think this would be useful. For 73.1% (N = 136), POCUS is not currently part of the pediatric surgery training curriculum in their country. Perceived barriers to POCUS use include a lack of training opportunities (26.3% [N = 49]) and a paucity of portable ultrasound machines (17.8% [N = 33]).

CONCLUSION

 There is a wide spectrum of POCUS use in pediatric surgery across Europe. For those surgeons who practice POCUS, it is most used for the diagnosis of abdominal conditions. There are differing views among clinicians concerning the most useful applications of POCUS. The extent to which ultrasound is taught during pediatric surgery training differs substantially across European curricula.

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons in paediatric patients

BACKGROUND/PURPOSE

Bedside point-of-care ultrasound scans are a cheap, quick and safe diagnostic tool. There is increasing evidence for the use of point-of-care surgeon-performed ultrasound scans in adults, however there are fewer studies of its use in children. This systematic review aims to provide an up-to-date summary of the evidence behind surgeon-performed ultrasound scans in paediatric surgery.

METHODS

The PubMed database was used to conduct this systematic review between the dates 1 Jan 1980 to 1 June 2020 (last search: 1 June 2020). Seven primary research studies were included in this review.

RESULTS

There is good evidence for the use of ultrasound scans in appendicitis and hypertrophic pyloric stenosis. Training times are easily achievable and transferable within a surgical department.

CONCLUSIONS

Although the use of surgeon-performed bedside ultrasound scans has been described in appendicitis and hypertrophic pyloric stenosis, more research is required to embed this into clinical practice, particularly in low volume centres such as district general hospitals. A robust training programme is also recommended to incorporate ultrasound scans into clinical practice.

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study

BACKGROUND

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.

METHODS

A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.

RESULTS

Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.

CONCLUSIONS

Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

Classification systems of acute appendicitis as an indicator for paediatric surgical consultation of children with acute abdominal pain

AIM

This study examined if the classification systems for acute appendicitis could be applied in the emergency department as an indicator for surgical consultation, in order to reduce unnecessary paediatric surgery admission.

METHODS

The Alvarado Score (ALS) and the Pediatric Appendicitis Score (PAS) were applied. The decisions for hospitalisation and treatment were made independent of the scores.

RESULTS

In total, 307 children with abdominal pain suggestive of acute appendicitis were included. We used a cut-off point of 7 and divided the patients into groups; the group with score ≥ 7 points was considered the positive ALS and/or PAS group, and the group with score < 7 points was the negative ALS and/or PAS group. The same process for cut-values set at 6 points was followed. The joint probabilities for the 7-point-thresholds were: ALS-sensitivity 84%, PAS-sensitivity 85%, ALS-specificity 92%, PAS-specificity 92%, ALS-positive predictive value (PPV) 83%, PAS-PPV 84% and 93% negative predictive value (NPV) for both scores. Considering the 6-point-thresholds, we estimated: 94% sensitivity for both scores, 74% ALS-specificity, 84% PAS-specificity, 66% ALS-PPV, 73% PAS-PPV, 91% ALS-NPV and 97% PAS-NPV.

CONCLUSION

The scoring systems provided acceptable prediction of patients with and without appendicitis. They may be of use in the emergency department, as assistive diagnostic-tools, in order to reduce paediatric surgery consultations, admissions and treatment costs.

A Healthcare Physician Can Be Trained to Perform Intestinal Ultrasound in Children With Inflammatory Bowel Disease

OBJECTIVES

Training healthcare physicians to perform intestinal ultrasound (IUS) during outpatient visits with equal accuracy as radiologists could improve clinical management of IBD patients. We aimed to assess whether a healthcare-physician can be trained to perform IUS, with equal accuracy compared with experienced radiologists in children with iBD, and to assess inter-observer agreement.

METHODS

Consecutive children, 6 to 18 years with IBD or suspicion of IBD, who underwent ileo-colonoscopy were enrolled. iUS was performed independently by a trained healthcare-physician and a radiologist in 1 visit. Training existed of an international training curriculum for IUS. Operators were blinded for each other's IUS, and for the ileocolonoscopy. Difference in accuracy of IUS by the healthcare-physician and radiologist was assessed using areas under the ROC curve (AUROC). Inter-observer variability was assessed in terminal ileum (TI), transverse colon (TC) and descending-colon (DC), for disease activity (ie, bowel wall thickness [BWT] >2 mm with hyperaemia or fat-proliferation, or BWT >3 mm).

RESULTS

We included 73 patients (median age 15, interquartile range [IQR]:13-17, 37 [51%] female, 43 [58%] with Crohn disease). AUROC ranged between 0.71 and 0.81 for the healthcare-physician and between 0.67 and 0.79 for radiologist (P  > 0.05). Inter-observer agreement for disease activity per segment was moderate (K: 0.58 [SE: 0.09], 0.49 [SE: 0.12], 0.52 [SE: 0.11] respectively for TI, TC, and DC).

CONCLUSIONS

A healthcare- physician can be trained to perform IUS in children with IBD with comparable diagnostic accuracy as experienced radiologists. The interobserver agreement is moderate. Our findings support the usage of IUS in clinical management of children with IBD.

Diagnostic accuracy of ultrasound in diagnosing acute appendicitis in pregnancy: a systematic review and meta-analysis

BACKGROUND

Lack of timely diagnosis of acute appendicitis (AA) can lead to perforation and peritonitis, which might be associated with complications such as miscarriage, preterm delivery, fetal loss, and even maternal mortality. The aim of the present systematic review and meta-analysis was to evaluate the accuracy of ultrasonography (US) for diagnosing AA in pregnant patients.

METHODS

We performed the present systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Using a pre-designed standard datasheet, the two authors summarized the data of each study independently. Pregnant women with diagnosed or suspected AA, who have undergone ultrasonography, as well as using CT scan or surgery as the standard method, were included.

RESULTS

A total of 8 studies consisting of 1593 patients were included. The main analysis showed that the overall sensitivity and specificity were 77.6% and 75.3% for US in diagnosing AA in pregnancy. The sensitivity of US in the first, second, and third trimesters of pregnancy were 69%, 63%, and 51%, respectively. While the corresponding figures for specificity were 85%, 85%, and 65%. There was a significant difference in the diagnostic performance of US between the first two trimesters and the third one. The DORs in these three trimesters were 36, 26, and 1.92, respectively.

CONCLUSIONS

Ultrasound evaluation showed a low diagnostic accuracy for acute appendicitis in pregnant women, especially during the third trimester. These patients should be diagnosed early and accurately to prevent both complications and unnecessary operations. It can be recommended to consider alternative imaging, mostly after negative or uncertain US.

Non-radiologist-performed abdominal point-of-care ultrasonography in paediatrics - a scoping review

BACKGROUND

Historically, US in the paediatric setting has mostly been the domain of radiologists. However, in the last decade, there has been an uptake of non-radiologist point-of-care US.

OBJECTIVE

To gain an overview of abdominal non-radiologist point-of-care US in paediatrics.

MATERIALS AND METHODS

We conducted a scoping review regarding the uses of abdominal non-radiologist point-of-care US, quality of examinations and training, patient perspective, financial costs and legal consequences following the use of non-radiologist point-of-care US. We conducted an advanced search of the following databases: Medline, Embase and Web of Science Conference Proceedings. We included published original research studies describing abdominal non-radiologist point-of-care US in children. We limited studies to English-language articles from Western countries.

RESULTS

We found a total of 5,092 publications and selected 106 publications for inclusion: 39 studies and 51 case reports or case series on the state-of-art of abdominal non-radiologist point-of-care US, 14 on training of non-radiologists, and 1 each on possible harms following non-radiologist point-of-care US and patient satisfaction. According to included studies, non-radiologist point-of-care US is increasingly used, but no standardised training guidelines exist. We found no studies regarding the financial consequences of non-radiologist point-of-care US.

CONCLUSION

This scoping review supports the further development of non-radiologist point-of-care US and underlines the need for consensus on who can do which examination after which level of training among US performers. More research is needed on training non-radiologists and on the costs-to-benefits of non-radiologist point-of-care US.

NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis

BACKGROUND

It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis.

STUDY DESIGN

The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results.

RESULTS

Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI.

CONCLUSIONS

Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.

Using Machine Learning to Predict the Diagnosis, Management and Severity of Pediatric Appendicitis

Background: Given the absence of consolidated and standardized international guidelines for managing pediatric appendicitis and the few strictly data-driven studies in this specific, we investigated the use of machine learning (ML) classifiers for predicting the diagnosis, management and severity of appendicitis in children. Materials and Methods: Predictive models were developed and validated on a dataset acquired from 430 children and adolescents aged 0-18 years, based on a range of information encompassing history, clinical examination, laboratory parameters, and abdominal ultrasonography. Logistic regression, random forests, and gradient boosting machines were used for predicting the three target variables. Results: A random forest classifier achieved areas under the precision-recall curve of 0.94, 0.92, and 0.70, respectively, for the diagnosis, management, and severity of appendicitis. We identified smaller subsets of 6, 17, and 18 predictors for each of targets that sufficed to achieve the same performance as the model based on the full set of 38 variables. We used these findings to develop the user-friendly online Appendicitis Prediction Tool for children with suspected appendicitis. Discussion: This pilot study considered the most extensive set of predictor and target variables to date and is the first to simultaneously predict all three targets in children: diagnosis, management, and severity. Moreover, this study presents the first ML model for appendicitis that was deployed as an open access easy-to-use online tool. Conclusion: ML algorithms help to overcome the diagnostic and management challenges posed by appendicitis in children and pave the way toward a more personalized approach to medical decision-making. Further validation studies are needed to develop a finished clinical decision support system.

Acute Appendicitis in Childhood and Adulthood

BACKGROUND

Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment.

CONCLUSION

Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.

Bedside ultrasonography for acute appendicitis: An updated diagnostic meta-analysis

BACKGROUND

Bedside ultrasonography is a promising tool for identification of acute appendicitis. We assessed the accuracy and clinical value of bedside ultrasonography for diagnosis of acute appendicitis in the emergency department.

METHODS

Pubmed, Embase and Cochrane Library were searched from inception to November 2018. The diagnostic accuracy of bedside ultrasonography was compared with that of surgery and/or CT scan, which was used as reference standard. Pooled summary estimates of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) from each included study were estimated using bivariate logistic regression model. Inter-study heterogeneity was examined using I2 statistic. Meta-regression was performed to further investigate the source of heterogeneity. Deeks's funnel plot was used to test publication bias.

RESULTS

Our search yielded 5394 citations, of which 27 satisfied the inclusion criteria. Bivariate analysis yielded a mean sensitivity of 90% (95% CI 82%-0.95%) and specificity of 95% (95% CI 89%-98%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.95-0.98). There was significant inter-study heterogeneity (I2 = 96%, 95% CI 94%-99%). Meta-regression analysis suggested that study region and patient sample size could attribute to the heterogeneity. Deeks's funnel plot did not indicate the existence of publication bias (P = 0.15).

CONCLUSION

Bedside ultrasonography, a radiation-free and noninvasive modality, provides superior diagnostic performance in the diagnosis of acute appendicitis, but its value in different abdominal emergencies warrants further development and research.

Diagnosis of appendicitis in the paediatric emergency department: an update

PURPOSE OF REVIEW

Concern regarding appendicitis is a common reason for presentation to the paediatric emergency department. We review recent progress in the use of biomarkers, imaging and clinical scoring systems in improving diagnostic accuracy in suspected appendicitis in children.

RECENT FINDINGS

Use of ultrasound, often performed at the bedside, is becoming more widespread with a parallel reduction in computed tomography (CT) use. Protocols for image acquisition and interpretation have been shown to improve diagnostic accuracy. Novel biomarkers have been explored and clinical diagnostic algorithms refined but none have achieved the level of diagnostic accuracy required.

SUMMARY

Appendicitis remains a clinical diagnosis. Point of care ultrasound is increasingly available and offers higher diagnostic accuracy than several routinely performed laboratory investigations. Recent publications provide support for increased use of clinician performed ultrasound, increased use of MRI, less use of CT, less emphasis on basic laboratory investigation and a renewed respect for the value of serial examination, particularly early in the course of illness.