Ultrasonography as an adjunct in the diagnosis of acute appendicitis: a 4-year experience

Evaluating Changes in Diagnostic Accuracy of Ultrasound for Appendicitis: Does Practice Make Perfect?

BACKGROUND

Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US.

OBJECTIVES

The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US.

METHODS

We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience.

RESULTS

A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps < 0.001). Higher body mass index was significantly associated with equivocal US (p < 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22).

CONCLUSIONS

An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.

Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children

PURPOSE

Our objective was to increase ultrasound reliability for diagnosing appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.

METHODS

A retrospective review of ultrasound use in patients diagnosed with appendicitis in our ED from 1/1/2011 to 6/30/2014 established a baseline cohort. From 8/1/2014 to 7/31/2015 a diagnostic algorithm that prioritized ultrasound over CT was used in our ED, and a standardized template was implemented for the reporting of appendicitis-related ultrasound findings by our radiologists.

RESULTS

Of 627 patients diagnosed with appendicitis in the ED during the retrospective review, 46.1% (n=289) had an ultrasound. After implementation of the diagnostic algorithm and standardized ultrasound report, 88.4% (n=236) of 267 patients diagnosed with appendicitis had an ultrasound (p<0.01). The frequency of indeterminate results decreased from 44.3% to 13.1%, and positive results increased from 46.4% to 66.1% in patients with appendicitis (p<0.01). The sensitivity of ultrasound (indeterminate counted as negative) increased from 50.6% to 69.2% (p<0.01).

CONCLUSIONS

Ultrasound reliability for the diagnosis of appendicitis in children can be improved through standardized results reporting. However, these changes should be made as part of a multidisciplinary quality improvement initiative to account for the initial learning curve necessary to increase experience.

LEVEL OF EVIDENCE

Level II, Study of Diagnostic Test.

Clinical and Ultrasonographic Diagnosis of Acute Appendicitis

Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.

Evaluation of an imaging protocol using ultrasound as the primary diagnostic modality in pediatric patients with superficial soft tissue infections of the face and neck

OBJECTIVE

To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT).

METHODS

Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared.

RESULTS

Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates.

CONCLUSION

Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance.

Laparoscopic Appendectomy in Children: Preliminary Study in Pediatric Hospital Albert Royer, Dakar

Appendiceal pathology's management has benefited in recent years from the advent of laparoscopic surgery. This study is to make a preliminary assessment of laparoscopic management of acute and complicated appendicitis in children after a few months of practice at the University Hospital Albert Royer, Dakar. This is a retrospective study of 22 cases of patients, all operated on by the same surgeon. The parameters studied were age, sex, clinical data and laboratory features, radiological data, and results of surgical treatment. The mean age of patients was 9.5 years with a male predominance. The series includes 14 cases of acute appendicitis and 8 complicated cases. Appendectomy anterograde is practiced in 81% of cases. Appendectomy was associated with peritoneal wash in 17 patients including 9 cases of acute appendicitis. Drainage of Douglas pouch is performed in 2 patients with complicated appendicitis; the average production was 300 cc of turbid liquids and any complications were not founded. An abscess of Douglas pouch is noted in 2 patients with complicated appendicitis undrained. These Douglas abscesses were treated medically. No conversion of laparotomy was performed in the series. After an average of 8 months no other problems were noted.

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study

PURPOSE

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis.

METHODS

Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes.

RESULTS

Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis.

CONCLUSION

Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.

Integration of ultrasound findings with Alvarado score in children with suspected appendicitis

BACKGROUND

The aim of this study was to investigate the integration of ultrasound (US) findings with Alvarado score in diagnosing or excluding acute appendicitis.

METHODS

Data were analyzed in 122 pediatric patients with suspected appendicitis who had undergone US. The US findings were classified into four groups, and the patients were classified into three groups according to Alvarado score. US results and Alvarado score were compared.

RESULTS

Alvarado score was a good predictor of appendicitis for scores ≥7.

CONCLUSION

In the case of non-visualization of the appendix without a high Alvarado score, appendicitis can be safely ruled out.

Acute abdominal pain in childhood and adolescence: assessing the impact of sonography on diagnosis and treatment

PURPOSE

To assess the impact of ultrasonography on defining the diagnostic and therapeutic pathways for pediatric patients admitted to the emergency department for acute abdominal pain.

METHODS

We performed a retrospective study of all patients aged <16 years with acute abdominal pain who underwent ultrasound examination at our Diagnostic Imaging Department from October 2010 to March 2012. We investigated for each patient the pathway following ultrasound examination and definitive diagnosis. The impact of ultrasonography was defined based on the frequency with which the information resulting from this examination confirmed or denied the diagnostic suspicion made by the emergency physician on the basis of clinical and laboratory findings.

RESULTS

In 497/729 patients (69 %), ultrasound examination did not determine variations in the diagnostic and therapeutic pathways, either because it confirmed the outcome of clinical examination and laboratory tests, or because, even addressing in the opposite direction to these, the emergency physician did not consider its result because of being particularly alarmed or sufficiently reassured by clinical examination and laboratory tests. In the remaining 232/729 cases (31 %), ultrasound examination determined an increase or a reduction of the provided care and attention (subsequently proved justified in the vast majority of cases) in spite of what was initially assessed based on clinical examination and laboratory tests.

CONCLUSIONS

The results of our retrospective study demonstrated that ultrasonography was a valuable tool in the management of pediatric patients with acute abdominal pain together with clinical examination and laboratory tests.

Management of Complicated Appendicitis in the Pediatric Population: When Surgery Doesn't Cut It

The management of complicated appendicitis in children has evolved significantly over the last century. What initially was a surgeon's dilemma is becoming the interventional radiologist's task because image-guided percutaneous drainage of abscesses from a ruptured appendix obviates the need for urgent surgery and allows for selective interval appendectomy at the surgeon's discretion (versus conservative nonoperative management in selected cases). This paradigm shift places the onus on the interventional radiologist to recognize when the procedure is emergently indicated and to be cognizant of the special needs of a pediatric patient.

Ultrasonography (US) in the assessment of pediatric non traumatic gastrointestinal emergencies

Background

Non traumatic gastrointestinal emergencies in the children and neonatal patient is a dilemma for the radiologist in the emergencies room and they presenting characteristics ultrasound features on the longitudinal and axial axis. The most frequent emergencies are : appendicitis, intussusceptions, hypertrophic pyloric stenosis, volvulus due to intestinal malrotation. The aim of this article is to familiarize the reader with the US features.

Methods

A retrospective analysis of 200 ultrasound examinations performed in neonatal and children patients with fever, abdominal pain, leukocytosis, vomiting and diarrhea were evaluated.

Results

Of 200 exame 50 cases of intussusceptions, 100 cases of appendicitis, 20 cases associated with abscess;10 gangrenous appendicitis with absence a color Doppler , and 10 cases of perforated appendicitis at tomography computer integration and 10 cases of volvulus was found.

Conclusions

Ultrasonography (US) is therefore rapidly becoming an important imaging modality for the evaluation of acute abdominal pain, particularly in pediatric patients, where satisfactory examination is often not achievable for the attending clinicians. US provides excellent anatomic detail on the longitudinally and axial axis .

Managing radiation exposure in children--reexamining the role of ultrasound in the diagnosis of appendicitis

PURPOSE

To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children.

METHODS

A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate.

RESULTS

Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%).

CONCLUSIONS

US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.

Reevaluating the sonographic criteria for acute appendicitis in children: a review of the literature and a retrospective analysis of 246 cases

RATIONALE AND OBJECTIVES

There has been little rigorous evaluation of the sonographic criteria for acute appendicitis in children. Our clinical experience has called the traditional diagnostic criteria into question. We set out to review the literature, evaluate the most commonly applied diagnostic criteria for acute appendicitis, and identify those criteria that best predict the presence of disease.

MATERIALS AND METHODS

A critical review of the literature concerning the sonographic diagnosis of acute appendicitis was performed. Based on diagnostic criteria identified in that review, two independent, blinded pediatric radiologists retrospectively reviewed 246 right lower quadrant ultrasound examinations in which the appendix was identified with attention to commonly described diagnostic criteria for acute appendicitis. Multivariate and classification and regression tree analysis were performed to identify criteria that predict appendicitis.

RESULTS

In a multivariate analysis, inflammation of the periappendiceal fat is the only finding that statistically significantly predicts acute appendicitis (OR = 68.93, P < .0001). Other criteria such as diameter, noncompressibility, hyperemia, the presence of an appendicolith, and loss of stratification of the appendiceal wall do not independently predict appendicitis.

CONCLUSION

Periappendiceal fat infiltration is the most important diagnostic criterion for acute appendicitis in children. Strict application of other criteria such as diameter should be avoided.

Abdominal pain in children

Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.

Effect of the Alvarado score on the diagnostic accuracy of right iliac fossa pain in an emergency

Acute appendicitis is among the commonest surgical diseases faced by an emergency clinician. A prompt diagnosis is mandatory to reduce morbidity and mortality, which may be difficult for junior doctors who first see the patient in the emergency department. This study was conducted to assess the efficacy of Alvarado score as a tool to improve the accuracy of diagnosis of appendicitis. We did a prospective pre- and post-test study in 381 patients with right iliac fossa pain in the emergency department of BP Koirala Institute of Health Sciences. Alvarado scoring was used for the post-test study. We found that the Alvarado scoring system is an effective diagnostic method, which decreases overdiagnosis of appendicitis in the emergency department, and at the same time reduces the risk of missing acute appendicitis cases. It is inexpensive and easy to implement by junior doctors with good results.

Evidence-based appendicitis: the initial work-up

In this article we provide an evidence-based review of appendicitis, which is one of the most challenging conditions to diagnose in patients presenting with abdominal pain. Almost all clinicians are faced with the diagnostic work-up of these patients, and missing the diagnosis can result in patient decompensation. We review the literature from the initial description of McBurney's point to the clinical presentation, as well as the most appropriate imaging testing. Additionally, we review the usefulness of specific diagnostic laboratory tests. The use of computed tomography scans has reduced negative appendectomy rates when combined with a physical examination, and assists in ruling out appendicitis. Computed tomography scans with no contrast or just rectal contrast are becoming the standard in many institutions. It is essential that when the diagnosis of abdominal pain of unclear etiology is suspected, the clinician's discussion with the patient is well documented on the patient's chart.

Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department

OBJECTIVES

Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs).

METHODS

A convenience sample of children, 4-18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve.

RESULTS

Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of <or=4 were discharged home without further investigations, the sensitivity was 97.6% with a NPV of 97.7%. When a PAS of >or=8 determined the need for appendectomy, the score's specificity was 95.1% with a PPV of 85.2%. Using this strategy, the negative appendectomy rate would have been 8.8%, the missed appendicitis rate would have been 2.4%, and 41% of imaging investigations would have been avoided.

CONCLUSIONS

The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores of <or=4 help rule out appendicitis, while scores of >or=8 help predict appendicitis. Patients with a PAS of 5-7 may need further radiologic evaluation.

Appendicitis score for children with suspected appendicitis. A randomized clinical trial

BACKGROUND/PURPOSE

Appendicectomy is often performed without certainty of diagnosis. We have previously constructed and validated a diagnostic score for acute appendicitis in children. The purpose of this prospective study was to determine whether diagnosis by using the appendicitis score may improve clinical outcomes for children with suspected appendicitis.

METHODS

A total of 126 children with suspected appendicitis were randomly assigned to either the appendicitis-score group or the no-score group. The attending general surgeon indicated a provisional diagnosis, a differential diagnosis and a provisional disposition on admission at 3 h and, if necessary, at 6, 9 and 12 h. The decision to operate was based on a clinical assessment in the no-score group and on the use of the diagnostic scoring system in the appendicitis-score group. The main outcome measures were the diagnostic accuracy (primary endpoint), the rate of unnecessary appendicectomies and adverse events between the two groups.

RESULTS

The diagnostic accuracy was significantly greater in the appendicitis-score group compared with that in the no-score group (92% vs 80%; P = 0.04). A significantly higher rate of unnecessary appendicectomies was observed in the no-score group compared with that in the appendicitis-score group (29% vs 17%; P = 0.05). In the appendicitis-score group, the sensitivity was 100%, specificity was 88%, positive predictive value was 83% and negative predictive value was 100%, compared to sensitivity of 96%, specificity of 67%, positive predictive value of 70% and negative predictive value of 96% observed in the no-score group. There were no differences in terms of the length of hospital stay, rate of complications and appendiceal histology between the two groups. The only case with missed appendicitis was in the no-score group.

CONCLUSION

The use of the appendicitis score can reduce the unnecessary appendicectomy rate in general surgeons treating children with suspected appendicitis.

Current management of appendicitis

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.

US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis

PURPOSE

To perform a meta-analysis to evaluate the diagnostic performance of ultrasonography (US) and computed tomography (CT) for the diagnosis of appendicitis in pediatric and adult populations.

MATERIALS AND METHODS

Medical literature (from 1986 to 2004) was searched for articles on studies that used US, CT, or both as diagnostic tests for appendicitis in children (26 studies, 9356 patients) or adults (31 studies, 4341 patients). Prospective and retrospective studies were included if they separately reported the rate of true-positive, true-negative, false-positive, and false-negative diagnoses of appendicitis from US and CT findings compared with the positive and negative rates of appendicitis at surgery or follow-up. Clinical variables, technical factors, and test performance were extracted. Three readers assessed the quality of studies.

RESULTS

Pooled sensitivity and specificity for diagnosis of appendicitis in children were 88% (95% confidence interval [CI]: 86%, 90%) and 94% (95% CI: 92%, 95%), respectively, for US studies and 94% (95% CI: 92%, 97%) and 95% (95% CI: 94%, 97%), respectively, for CT studies. Pooled sensitivity and specificity for diagnosis in adults were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies.

CONCLUSION

From the diagnostic performance perspective, CT had a significantly higher sensitivity than did US in studies of children and adults; from the safety perspective, however, one should consider the radiation associated with CT, especially in children.

Ultrasonography in the diagnosis of appendicitis: evaluation by meta-analysis

Objective

We wanted to review the usefulness of ultrasonography (US) for the diagnosis of appendicitis and to evaluate the diagnostic accuracy of US according to patients' and researchers' characteristics.

Materials and Methods

The relevant Korean articles published between 1985 and 2003 were included in this study if the patients had clinical symptoms of acute appendicitis. The histopathologic findings were the reference standard and the data were presented for 2×2 tables. Articles were excluded if patients had no sonographic signs of appendicitis according to graded-compression US. Two reviewers independently extracted the data on study characteristics. The Hasselblad method was used to obtain the combined estimates of sensitivity and specificity for the performance of US.

Results

Twenty-two articles (2,643 patients) fulfilled all inclusion criteria. The estimate of đ calculated by combining the sensitivity and specificity was 2.0054 (95% confidence interval [CI]: 1.8553, 2.1554) by a random effects model. The overall sensitivity and specificity (95% CI) were 86.7% (85.4 to 88.0), and 90.0% (88.9 to 91.2), respectively. According to the subgroup meta-analysis by patients' characteristics, the đ estimate (95% CI) of dominantly younger age, male, and highly clinical suggestive group for US was 2.2388 (1.8758 to 2.6019), 2.7131 (2.2493 to 3.1770), and 2.4582 (1.7387 to 3.1777), respectively. Also, according to subgroup meta-analysis by researchers' characteristics, the đ value (95% CI) for US done by diagnostic radiologists and gray-scale was 2.0195 (1.7942 to 2.2447) and 2.2630 (1.8444 to 2.6815).

Conclusion

This evidence suggests that US may be useful for the diagnosis of acute appendicitis, especially when patients are younger age, male, and highly clinical suggestive.

Abdominal pain in children

Abdominal pain and gastrointestinal symptoms such as vomiting or diarrhea are common chief complaints in young children who present in emergency departments. It is the emergency physician's role to differentiate between a self-limited process such as viral gastroenteritis or constipation and more life-threatening surgical emergencies. Considering the difficulties inherent in the pediatric examination, it is not surprising that appendicitis, intussusception, and malrotation with volvulus continue to be among the most elusive diagnoses. This article reviews both the self-limited and more life-threatening gastrointestinal conditions that may present in the emergency department.

CT Evaluation of Appendicitis and Its Complications: Imaging Techniques and Key Diagnostic Findings

OBJECTIVE

This article reviews various CT protocols for appendicitis, identifies key CT findings for diagnosing appendicitis, discusses unusual manifestations such as chronic and recurrent appendicitis, and profiles imaging features that differentiate appendicitis from other inflammatory and neoplastic ileocecal conditions. Patients were studied with helical CT.

CONCLUSION

CT is a highly accurate, noninvasive test for appendicitis, but the optimal CT technique is controversial. Major complications of appendicitis (perforation, abscess formation, peritonitis, bowel obstruction, septic seeding of mesenteric vessels, gangrenous appendicitis) and their management are discussed. Abdominal CT is a well-established technique in the study of acute abdominal pain and has shown high sensitivity and specificity for diagnosing and differentiating appendicitis, providing an accurate diagnosis in the early stages of disease.

Modern imaging of Crohn's disease using bowel ultrasound

Technological advancement of ultrasound (US) equipments and understanding of bowel appearances with high resolution US during the last decade has led to consideration of this imaging procedure as an important tool for inflammatory bowel diseases assessment. In particular, Crohn's disease (CD) for its pathologic characteristics (that is, inflammatory infiltration of the entire bowel wall with possible extension to the surrounding mesentery) is the disease entity which has mainly taken advantage from this non-invasive, radiation-free technique. Beside correctly defining anatomic location and extension of CD lesions within the bowel in the majority of cases, US also shows perigut abnormalities and may demonstrate complications such as fistulas and abscesses. With the help of Power Doppler function, some additional information may be obtained about the local activity of the disease which is particularly useful in the presence of strictures. New US technologies (such as those using intravenous bolus contrast agents or oral nonabsorbable anechoic solutions) may further improve diagnostic capability of US in this context, thus probably revolutioning the diagnostic approach to this disease in the near future, particularly during follow-up in CD of the small bowel.

Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts

Acute appendicitis is the most common condition presenting with right lower quadrant pain requiring acute surgical intervention in childhood. The clinical diagnosis of acute appendicitis is often not straightforward and can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed non-operatively. Complications usually result from perforation and include abscess formation, peritonitis, sepsis, bowel obstruction and death. Cross-sectional imaging with sonography and computed tomography (CT) have proven useful for the evaluation of suspected acute appendicitis in children. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to precisely delineate gynecologic disease. The principal advantages of CT are its operator independency with resultant higher diagnostic accuracy, enhanced delineation of disease extent in perforated appendicitis, and improved patient outcomes including decreased negative laparotomy and perforation rates.

Appendix in children with cystic fibrosis: US features

PURPOSE

To evaluate the ultrasonographic (US) appearance of the appendix in children with cystic fibrosis but who were asymptomatic for appendicitis.

MATERIALS AND METHODS

Between March 2001 and March 2002, 31 children (14 boys, 17 girls; mean age, 9.5 years; range, 2-16 years) with cystic fibrosis underwent graded-compression US of the appendix. The recordings were analyzed in consensus by two radiologists specialized in US. The overall appendiceal diameter and change in diameter during graded compression, wall dimensions, contents of material in the lumen, and periappendicular fat were evaluated. The exclusion criterion was abdominal pain at the time of investigation.

RESULTS

In all but one patient, the appendix was visualized with US. The diameter of the appendix ranged from 4.0 to 14.5 mm (mean, 8.3 mm). In 25 patients (83.3%), the appendix measured more than 6.0 mm. In six patients, the diameter of the appendix changed when graded compression was applied. Mucoid material was found in the lumen in 27 of 30 patients. No wall thickening occurred, and concentric layer structures of the wall were intact. No involvement of the neighboring mesenteric or omental fat was encountered.

CONCLUSION

The appendiceal diameter was enlarged in the majority of children examined. The lumen contained mucoid contents. Therefore, the diameter of the appendix alone may not be a parameter for diagnosing appendicitis in patients with cystic fibrosis.

Abdominal surgical emergencies in infants and young children

Surgical emergencies can be missed easily in children, who are not always able to volunteer relevant information. Awareness of the entities discussed in this review might help the EP uncover subtle clues to early diagnoses that might not be initially apparent. Ill-appearing children who have abdominal pain and vomiting should be considered to have ischemic or necrotic bowel until proven otherwise. Possible diagnoses include volvulus, intussusception, and necrotizing enterocolitis. Bilious vomiting, especially in a young infant, should be considered to be an indication of a high bowel obstruction such as midgut volvulus, which warrants immediate surgical consultation. Significant rectal bleeding with abdominal pain can result from intussusception, volvulus, or an inflamed Meckel's diverticulum. Rectal bleeding with unstable vital signs can result from an upper GI bleed (eg, peptic ulcer disease). Painless rectal bleeding can result from a Meckel's diverticulum, polyps, arteriovenous malformation, or a tumor. Examination of the genitalia is imperative, especially in boys, to exclude the possibility of an incarcerated hernia or testicular torsion.

Role of early ultrasound in detecting inflammatory intestinal disorders and identifying their anatomical location within the bowel

BACKGROUND

Although bowel ultrasound is a widely accepted diagnostic tool in bowel diseases, its value as the primary imaging procedure in patients with symptoms/signs suggestive of inflammatory bowel disorders is still unclear.

AIM

To investigate the accuracy of bowel ultrasound compared with barium X-ray studies, computed tomography, endoscopy and bowel surgery in the initial assessment of inflammatory bowel disorders.

METHODS

Four hundred and eighty-seven patients hospitalized consecutively for symptoms or signs suggestive of a bowel disorder between December 1999 and March 2002 were initially enrolled in the study. All patients underwent bowel ultrasound as the first imaging procedure within 36 h of admission; radiographic evaluations, endoscopy and/or surgery were then performed as appropriate and the results of these investigations were used as the gold standard.

RESULTS

Three hundred and thirty-six patients had pathological findings of the bowel detectable at ultrasound as the final diagnosis. The main organic disorders found were Crohn's disease (56%), ulcerative/indeterminate colitis (30%), bowel tumours (5%), appendicitis/diverticulitis (2%) and other inflammatory conditions (8%). The overall sensitivity and specificity of bowel ultrasound were 85% and 95%, respectively, whereas the positive and negative predictive values were 98% and 75%, respectively. Comparisons of ultrasound with X-ray or endoscopic results by disease localization showed that the diagnostic performance of ultrasound was higher for inflammatory conditions of the ileum and sigmoid/descending colon (sensitivity of 92% and 87%, respectively), whereas abnormalities localized in the rectum, duodenum and proximal jejunum were often missed by ultrasound.

CONCLUSIONS

In expert hands, bowel ultrasound is highly predictive of inflammatory disease localized in the ileum or colon, and may well be used as the primary imaging method when Crohn's disease or ulcerative colitis is suspected on a clinical basis.

Surgical evaluation of appendicitis in the new era of radiographic imaging

Appendicitis remains a common disease with over 250,000 cases in the United States per year. Surgical intervention has been the primary treatment for over a century, and clinical evaluation has been the mainstay for diagnosis of acute appendicitis for decades. Appendiceal imaging modalities have become increasingly popular to assist with the diagnosis of appendicitis, and the surgeon is no longer the sole diagnostician for this disease. Radiologists and emergency medical physicians have entered the arena. This review examines the surgical and radiological literature to evaluate the current atmosphere of how surgeons, radiologists, and emergency physicians interact in the diagnosis of appendicitis.

Imaging of acute appendicitis in children

Acute appendicitis is the most common acute abdominal condition that results in surgical intervention in childhood. The clinical diagnosis of acute appendicitis in children can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed nonoperatively. Complications associated with delayed diagnosis of this condition include perforation, abscess formation, peritonitis, sepsis, bowel obstruction, infertility, and death. The use of cross sectional imaging has proven useful for the evaluation of suspected acute appendicitis in children. Both graded compression sonography and CT have been widely utilized in the imaging assessment of the condition. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to assess ovarian pathology that can often mimic acute appendicitis in female patients. The principal advantages of CT include less operator dependency than sonography as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in perforated appendicitis.

Imaging in acute abdomen

OBJECTIVE

The present study aims at establishing the exact role and limitation of ultrasound in pediatric acute abdomen.

METHODS

Fifty children less than 14 years of age presenting with acute abdomen were evaluated by US and other imaging modalities. The mean age of presentation was 3 1/2 years. Maximum number of cases were seen in less than two years of age. There were 17 cases of intussusception with US sensitivity and specificity of 88.2% and 100% respectively and positive and negative predictive values of 100% and 94.5% respectively. There were 13 cases of appendicitis. US was diagnostic in 11 with sensitivity and specificity of 91.6% and 97%; the positive and negative predictive values were 91.6% and 97% respectively.

RESULTS

There were two cases each of congenital bands, adhesive intestinal obstruction, malrotation of bowel with volvulus, incarcerated inguinal hernia, hypertrophic pyloric stenosis, duplication cyst and pseudopancreatic cyst, one case each of trichobezoar, Meckel's diverticulum, ureteric calculus and worms as a cause of intestinal obstruction. The sensitivity of US for diagnosing specific cause of acute abdomen was found to be 77.5%. The main limitation of US was in the diagnosis of acute intestinal obstruction such as congenital bands and adhesions.

CONCLUSION

US should now be considered as imaging modality of choice in pediatric acute abdomen. However, at times, plain radiography, conventional contrast studies and CT may be vital to reach the true diagnosis.

Valor da ultra-sonografia abdominal com transdutor multifreqüencial de 5 a 10 mhz no diagnóstico de apendicite

Neste trabalho procura-se estabelecer o valor da ultra-sonografia no diagnóstico de apendicite, com transdutor multifreqüencial de 5 a 10 MHz. Foi realizado estudo transversal de casos consecutivos de 240 pacientes, de abril de 1996 a setembro de 1998, com suspeita de apendicite. Os critérios ecográficos de apendicite foram apêndice não-compressível e com espessura acima de 6,0 mm, com ou sem apendicólito e/ou coleção. O padrão ouro utilizado foram achados cirúrgicos e acompanhamento clínico durante um ano. A prevalência de apendicite foi de 59%. A ultra-sonografia mostrou sensibilidade de 90%, especificidade de 97%, acurácia de 93%, valor preditivo positivo de 98% e valor preditivo negativo de 87%, tendo ocorrido 2,4% de falso-positivos e 13% de falso-negativos. O ultra-som com transdutor multifreqüencial de 5 a 10 MHz mostra-se um método muito eficaz no diagnóstico de apendicite.

Nonenhanced limited CT in children suspected of having appendicitis: prospective comparison of attending and resident interpretations

PURPOSE

To prospectively compare resident and attending radiologic interpretations of nonenhanced limited computed tomographic (CT) scans obtained in children suspected of having appendicitis.

MATERIALS AND METHODS

Seventy-five consecutive children underwent nonenhanced limited CT for suspected appendicitis. The scans were prospectively interpreted by a resident and an attending radiologist, each unaware of the other's interpretation. The probability that the findings indicated a diagnosis of appendicitis, level of certainty in the interpretation, and presence of an alternate diagnosis were statistically analyzed.

RESULTS

Nineteen children (25%) had appendicitis. The area under the receiver operating characteristic curve was not significantly different between residents (0.97 +/- 0.02) and attendings (0.95 +/- 0.04). The percentage agreement between residents and attendings was 91% (kappa = 0.73 +/- 0.095). The average level of certainty tended to be higher for attendings (93% +/- 15) than residents (89% +/- 12). The sensitivity, specificity, and accuracy of resident interpretations were 63%, 96%, and 88%, respectively, compared with those of attending interpretations--95%, 98%, and 97%, respectively. Residents and attendings noted alternate diagnoses in 30% of children without appendicitis.

CONCLUSION

A high level of agreement exists between resident and attending radiologists in the interpretation of nonenhanced limited CT scans in children suspected of having appendicitis. Residents, however, tend to be less confident in their interpretations.

Pediatric appendicitis in "real-time": the value of sonography in diagnosis and treatment

OBJECTIVES

To determine the accuracy of sonography in the diagnosis of clinically equivocal appendicitis, and to identify the factors leading to an inaccurate ultrasound diagnosis. The impact of sonographic findings on clinical management and outcome of children with appendicitis is examined.

METHODS

We performed a retrospective review of 317 children who attended the emergency department (ED) of a children's hospital for acute abdominal pain for which acute appendicitis was the main differential diagnosis. They had ultrasound because the diagnosis was uncertain clinically.

RESULTS

The positive predictive value of ultrasound for appendicitis was 0.92, and the negative predictive value was 0.88. The sensitivity and specificity could not be determined because there were 43 patients with equivocal ultrasound results. The pitfalls hindering the accuracy of ultrasound diagnosis included a high incidence of perforated appendicitis at presentation, the retrocecal appendix, and other technical factors such as abdominal guarding, excessive bowel gas, obesity, inadequate bladder filling, and the uncooperative patient. When ultrasound findings were combined with clinical judgment in clinical management, there were only five cases of non-therapeutic laparotomy and eight cases of delayed surgery due to missed diagnosis in our cohort.

CONCLUSIONS

Ultrasound is a useful for the evaluation of acute abdominal pain in children. However, in the setting of a pediatric hospital ED, the accuracy of ultrasound and its ability to improve early hospital triage may be reduced. Repeated clinical review is still essential and in selected cases, appendiceal CT scan may be required to guide therapeutic decision making.

Suspected appendicitis in children: focused CT technique for evaluation

PURPOSE

To determine the accuracy of a focused computed tomographic (CT) technique with oral and intravenous contrast materials for the diagnosis of appendicitis.

MATERIALS AND METHODS

Ninety-three abdominal-pelvic contrast material-enhanced CT scans obtained during 6 years in 54 girls and 39 boys (age range, 1-18 years) with right lower quadrant pain were retrospectively reviewed. The detected abnormal findings were recorded as being in the region above the upper pole of the right kidney, between the upper pole of the right kidney and the lower pole of the right kidney (RLP), or below the iliac crest. Sensitivity, specificity, and positive and negative predictive values were calculated. chi(2) analysis was performed to determine whether there were significant differences among patient groups according to region of detected disease.

RESULTS

Fifty-five scans were abnormal: 38 showed appendicitis; and 17, other diseases. No scans, except two that showed pneumonia, had key findings above the RLP. Nineteen scans showed key findings between the RLP and the iliac crest. Thirty-three scans had diagnostic findings only below the iliac crest. The sensitivity (97%), specificity (93%), positive predictive value (90%), and negative predictive value (98%) of interpretation with all images for the diagnosis of appendicitis were the same as those of interpretation with only the focused images.

CONCLUSION

CT performed to diagnose appendicitis can be limited to the region below the RLP.

Avaliação ultra-sonográfica da apendicite aguda

OBJETIVO: A apendicite aguda é a mais comum urgência cirúrgica abdominal. Na tentativa de aumentar a acurácia diagnóstica a ultra-sonografia abdominal tem sido observada como método sensível e específico. O presente estudo tem por objetivo avaliar a ultra-sonografia do abdome no diagnóstico de apendicite aguda. MÉTODO: Um total de 138 pacientes submetidos a tratamento cirúrgico com suspeita diagnóstica admitidos no Hospital Municipal Djalma Marques foi estudado no período de janeiro de 1997 a dezembro de 1998. Todos os exames foram realizados na mesma instituição e havia 87 pacientes do sexo masculino (63,0%) e 51 do sexo feminino (37,0%) com idade variando de 11 a 81 anos (média de 28,4 anos). RESULTADOS: Dos 134 casos com diagnóstico comprovado cirurgicamente, o estudo ultra-sonográfico foi positivo em 114 (sensibilidade de 85,0%). O apêndice foi visualizado como imagem longitudinal ou transversal maior do que 7mm em 75 dos 114 achados positivos (65,8%). CONCLUSÕES: Os autores concluem que a ultra-sonografia abdominal é um instrumento valioso no diagnóstico de apendicite aguda.

When appendicitis is suspected in children

Acute appendicitis is the most common condition requiring emergent abdominal surgery in childhood. The clinical diagnosis of acute appendicitis is often not straightforward because approximately one-third of children with the condition have atypical clinical findings. The delayed diagnosis of this condition has serious consequences, including appendiceal perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death. Cross-sectional imaging with ultrasonography (US) and computed tomography (CT) have proved useful for the evaluation of suspected acute appendicitis. There has been a great deal of variability in the utilization of these modalities for such diagnosis in the pediatric population. The principal advantages of US are its lower cost, lack of ionizing radiation, and ability to assess vascularity through color Doppler techniques and to provide dynamic information through graded compression. The principal advantages of CT include less operator dependency than US, as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in a perforated appendix.

Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography

OBJECTIVE

The purpose of this investigation is to determine the sensitivity, specificity, and accuracy of unenhanced limited CT of the abdomen in children with suspected appendicitis and compare these results with graded compression sonography.

MATERIALS AND METHODS

Seventy-six children underwent unenhanced limited CT over a 11-month period for evaluation of suspected appendicitis. A historical cohort of 86 consecutive children who had undergone graded compression sonography was identified. Results were correlated with surgical, pathologic, chart, and clinical follow-up data. The sensitivity, specificity, accuracy, rate of alternate diagnosis, time to perform examinations, and charge at our institution were determined for unenhanced limited CT and sonography.

RESULTS

Sensitivity, specificity, and accuracy for unenhanced limited CT were 97%, 100%, 99%, respectively, and were 100%, 88%, 91%, respectively, for sonography. Alternate diagnoses were suggested in 35% and 28% children without appendicitis who had unenhanced limited CT and sonography, respectively. Unenhanced limited CT required 5 min and sonography required 20-30 min to perform. The charge at our institution was $408 for unenhanced limited CT and $295 for sonography.

CONCLUSIONS

CT can be performed rapidly in children without IV, oral, or rectal contrast medium. Unenhanced limited CT and sonography are highly sensitive, specific, and accurate in the evaluation of children with suspected appendicitis.

Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT

OBJECTIVE

The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population.

SUBJECTS AND METHODS

Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up.

RESULTS

Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]).

CONCLUSION

Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.

Evaluation of suspected appendicitis in children and young adults: helical CT

PURPOSE

To evaluate the accuracy of helical computed tomography (CT) for the diagnosis of appendicitis in children and to assess the utility of CT in establishing alternative diagnoses.

MATERIALS AND METHODS

The medical records of 154 children (median age, 12 years; age range, 1-20 years) who were suspected to have appendicitis and who underwent CT were reviewed. The gastrointestinal tract was opacified in 151 of 154 patients: Only orally administered contrast material was used in 126 patients; only rectally administered contrast material, in 21 patients; and both oral and rectal contrast material, in four patients. CT findings were correlated with surgical and histopathologic findings or with clinical follow-up findings.

RESULTS

Sixty-four CT scans were interpreted as positive for appendicitis and included 58 true-positive and six false-positive scans. Ninety scans were interpreted as negative and included 87 true-negative and three false-negative scans. CT had a sensitivity of 95% and a specificity of 94% for the diagnosis of appendicitis. In addition, in 32 (34%) of 93 patients without appendicitis, an alternative diagnosis was established on the basis of CT findings.

CONCLUSION

Helical CT is useful in a pediatric population to diagnose or exclude appendicitis and to establish an alternative diagnosis.

An economic evaluation of sonographic examination of children with suspected appendicitis

BACKGROUND/PURPOSE

Appendicitis is the most common surgical emergency presenting in the pediatric population. Approximately one third of these patients present with equivocal signs and symptoms frequently resulting in inpatient observation or additional diagnostic investigation. Although sonographic examination of patients with suspected appendicitis has been shown to be a highly accurate diagnostic modality, the cost effectiveness of this technology in the pediatric population has not been addressed. The economic value of this examination can be evaluated using a structured decision analysis.

METHODS

The authors constructed a decision analysis model of treatment strategies for 2 groups of patients with a suspected diagnosis of acute appendicitis. Patients were categorized as either presenting with a "definitive acute abdomen" or "equivocal examination." Data drawn from published literature reports of the sensitivity and specificity of ultrasound, institution-specific cost data, and expert judgment were used to construct 2 decision trees. These data were used to determine the least costly diagnostic strategy for each group of patients, and sensitivity analysis performed to assess the robustness of the conclusions.

RESULTS

The use of ultrasonography in patients with "an acute abdomen" is not cost efficient and results in average additional cost of $234 per patient. In patients with equivocal diagnoses who are discharged from the emergency room after a negative ultrasound examination finding results in an average cost savings of $260 when compared with admission and observation. Patients who are discharged without examination incur an average additional cost of $373 as a result of the high cost of a missed diagnosis resulting in a perforated appendix.

CONCLUSION

The use of ultrasonography can be recommended for children with suspected appendicitis and equivocal examinations who are discharged from the emergency room after a negative examination result.

Acute appendicitis in children: emergency department diagnosis and management

Early diagnosis of appendicitis in infants and children can prevent perforation, abscess formation, and postoperative complications, and can decrease cost by shortening hospitalizations. This article reviews the epidemiology, physiology, and age-specific clinical presentation of childhood appendicitis. The accuracy of diagnostic adjuncts is reviewed, as are strategies for avoiding misdiagnosis and improving emergency department evaluation and management.