Ultrasonography aids decision-making in children with abdominal pain

Combined clinical accuracy of inflammatory markers and ultrasound for the diagnosis of acute appendicitis

Introduction

Acute appendicitis is traditionally a clinical diagnosis where there are a range of diagnostic accuracies reported. The role of ultrasound is to improve specificity and decrease negative appendicectomy rate. It is a simple, non-invasive, easily available technique.The purpose of this study is to determine the diagnostic accuracy of an ultrasound in combination with total leukocyte count, neutrophil percentage and C-reactive protein in diagnosing acute appendicitis.

Methods

This study includes consecutive sampling of suspected patients from January 2021 to February 2022 with the approval of the ethical and research committee. Clinical and personal demographics and characteristics of patients were collected, including age, gender, symptoms and clinical signs. Ultrasonographic findings of fluid-filled appendiceal diameter of more than 6 mm, periappendiceal echogenic mesentry and an appendicolith were primary positive features. Laboratory inflammatory markers of total leukocyte count, neutrophil percentage and C-reactive protein were also included.

Results

A total of 250 patients were included with a mean age of 25 ± 9.79 years. Total leukocyte count showed the highest sensitivity (77.68%), followed by neutrophil percentage (69.96%), C-reactive protein (67.10%) and ultrasound (62.96%). While ultrasound had the best specificity (70.59%), it was followed by C-reactive protein and total leukocyte count (64.71%) and neutrophil percentage (58.82%), respectively. The sensitivity and specificity (99% and 98%) increased significantly when all four tests were combined.

Conclusions

Clinical assessment with laboratory inflammatory markers and ultrasound improves the early diagnosis of appendicitis and decreases the false-positive appendicitis diagnosis, hence saving surgeons' time and relieving patients from unnecessary appendicectomies.

Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children

OBJECTIVES

To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain.

STUDY DESIGN

We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted.

RESULTS

Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal ultrasound imaging had computed tomography imaging confirming appendicitis. There were 51 patients with a partially visualized appendix. The segment of appendix that could be seen was normal in 34 patients, none of whom had appendectomy. The remaining 17 had appendectomy, in whom the appendix seemed to be inflamed in 13 and equivocal in 4, all with histologically confirmed appendicitis. Overall, 232 children underwent appendectomy; 58 had no ultrasound imaging done, and 5 had a histologically normal appendix (overall negative appendectomy rate, 2.2%). Only 35 of 1359 patients (0.03%) had computed tomography scans.

CONCLUSION

In patients with a nonvisualized appendix on ultrasound imaging and no evidence of secondary inflammatory changes, the likelihood of appendicitis is less than 2%. Generous use of ultrasonography as an adjunct to clinical examination can achieve low negative appendectomy rates without underdiagnosis of acute appendicitis.

Ultrasound, computed tomography or magnetic resonance imaging - which is preferred for acute appendicitis in children? A Meta-analysis

BACKGROUND

There is no established consensus about the relative accuracies of US, CT and MRI in childhood appendicitis.

OBJECTIVE

To compare, through meta-analysis, the accuracies of US, CT and MRI for clinically suspected acute appendicitis in children.

MATERIALS AND METHODS

PubMed, Embase, Web of Science and the Cochrane Library were searched. After study selection, data extraction and quality assessment, the sensitivity, specificity and the area under the curve of summary receiver operating characteristic were calculated and compared.

RESULTS

Twenty-seven articles including 29 studies met the inclusion criteria, including 19 studies (9,170 patients) of US, 6 studies (928 patients) of CT and 4 studies (990 patients) of MRI. The analysis showed that the area under the receiver operator characteristics curve of MRI (0.995) was a little higher than that of US (0.987) and CT (0.982; P > 0.05).

CONCLUSION

US, CT and MRI have high diagnostic accuracies of clinically suspected acute appendicitis in children overall with no significant difference.

Negative Appendectomy: Clinical and Economic Implications

Historically, performing a negative appendectomy (NA) was justified to reduce the incidence of perforation. Furthermore, it is also believed that NA is associated with minimal morbidity and cost. The purpose of this study was to evaluate the frequency, clinical characteristics, and economic implications of NA. We reviewed the inpatient admissions on 274,405 patients who underwent nonincidental appendectomy as their primary procedure from the California State Inpatient Databases (2005–2011). Overall, 96.9 per cent had appendicitis (nonperforated = 73.1%, perforated = 23.8% and 3.1%) had NA. NA rates decreased steadily from 4.2 per cent in 2005 to 2.5 per cent in 2011 ( P < 0.01). The rates of appendectomy for perforated appendicitis rates also decreased slightly from 25.3 to 23.3 per cent during this time ( P = <0.01). Multivariate regression showed that female gender, African American race, and public insurance were all associated with increased NA rates. Compared with patients with appendectomy for nonperforated appendicitis, NA was associated with longer length of stay (NA = 3.2 days vs nonperforated = 1.7 days), higher median cost per admission (NA = $8626 vs nonperforated = $7605), and higher morbidity (4.7 vs 1.9%), all P < 0.01. Contrary to classic justification for NA, we did not find an inverse association of appendectomy for perforated appendicitis and NA at the hospital level. In conclusion, NA is associated with substantial clinical and financial burden, while having no apparent impact on lowering the rate of appendectomy for perforated appendicitis.

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis

The purposes of this study were to revisit the utility of ultrasonography (USG) as a primary imaging modality in acute appendicitis (AA) and to establish the role of CT scan as a second-line/problem-solving modality. All cases of suspected AA were referred for urgent USG. USG was done with standard protocol for appendicitis. Limited computed tomographic (CT) scan [NCCT ± CECT (IV contrast only)] was done for the lower abdomen and pelvis where sonographic findings were equivocal. One hundred and twenty-one patients were referred for USG for suspected appendicitis. Eight-four patients underwent surgery for AA based on clinical as well as imaging findings, of whom 76 had appendicitis confirmed at histopathology. Three patients were misdiagnosed (3.6 %) on USG as appendicitis. Of 76 patients of appendicitis confirmed histopathologically, 63 (82.8 %) had features of appendicitis on USG and did not require any additional imaging modality. Of 121 patients, 12 (10 %) needed CT scan because of atypical features on USG. Of these 12 patients, seven had retrocecal appendicitis, and three high-up paracolic appendicitis. USG alone had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81, 88, 92.6, 71.6, and 83 %, respectively. When combined with CT scan in select cases, the sensitivity, specificity, PPV, NPV, and accuracy of combined USG + CT scan were 96 % (P = 0.0014), 89 %, 93 %, 93.5 % (P = 0.0001), and 93 % (P = 0.0484), respectively. Twenty-eight (23 %) patients were given alternative diagnosis on USG. Dedicated appendiceal USG should be used as a primary imaging modality in diagnosing or excluding AA. Appendiceal CT can serve as a problem-solving modality.