Advanced Web Ranking 9.2 Serial
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Advanced Web Ranking 9.2 Serial Number
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Abstract Objectives The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. Methods This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis.
Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. Results Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval CI = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%).
The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p. Serial US clinical diagnostic pathway.
PAS = pediatric appendicitis score; RLQ = right lower quadrant; US = ultrasound. Study Setting and Population The study took place at a Canadian pediatric hospital with about 250 trauma team activations in our ED annually, of which 125 have an Injury Severity Score of 12. We chose a consecutive sample of previously healthy children 4 to 17 years old with abdominal pain and right lower quadrant abdominal tenderness, as defined by an initial PAS ≥ 2 points, who in the opinion of the ED staff physician/fellow required imaging (US represents the initial imaging at our institution) for suspected appendicitis. This PAS cutoff reflects a conservative imaging practice of some physicians to ensure that appendicitis is not missed.
Table 1. Characteristics of Patients With and Without Appendicitis Characteristic Appendicitis ( n = 111) No Appendicitis ( n = 183) p-value. BMI = body mass index; IQR = interquartile range; PAS = pediatric appendicitis score. Age (yr), mean ± SD 10 ± 3.2 10.6 ± 3.8 0.14 Sex (% male) 72 (64.9%) 71 (38.8%).
Table 2. Diagnostic Performance of Initial and Interval Ultrasound Ultrasound Appendicitis No Appendicitis Total Initial Positive 89 10 99 Equivocal 21 102 123 Negative 1 71 72 Total 111 183 294 Interval Positive 12 1 13 Equivocal 5 12 17 Negative 0 10 10 Total 17 23 40 Interval US The interval US confirmed or ruled out appendicitis in 22 of the 40 (55.0%) children who had equivocal initial US interpretation, with one false-positive interval US. The sensitivity of the interval US was 71% (12 of 17), the specificity was 44% (10of 23), and the equivocal rate was 45.0% (18 of 40). Discussion To the best of our knowledge, this is the first study to demonstrate that the serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in very few CTs. This approach appears to be most useful in children with equivocal initial US in whom appendicitis was diagnosed or ruled out by the combination of the clinical reassessment and interval US/surgical consultation in virtually all study patients. Recently, Kulik et al.
examined the performance of six unique clinical decision rules in 4,200 children with suspected appendicitis. The authors concluded that although the PAS and the Alvarado scores were the best validated, neither score met the current performance benchmarks. With respect to the key diagnostic strategies, Ramarajan et al. conducted a retrospective review of an appendicitis pathway where children with equivocal initial US underwent clinical examinations and those with persistent abdominal pain had CT scans.
Although this pathway avoided many CTs that would have been done otherwise, 37% of children still had CT scans. The authors recommended further prospective study be done to investigate alternative diagnostic approaches in this population. These results were subsequently retrospectively confirmed by Krishnamoorthi and colleagues and prospectively by Santillanes and colleagues. In a key study, Kharbanda and colleagues have recently validated and refined a clinical pathway to identify children at low risk of acute appendicitis. A study from Spain prospectively evaluated a modified clinical practice guiding score consisting of a clinical examination, laboratory result, and tissue harmonic US when necessary. Although the overall accuracy of this approach was high, the authors did not mention to what extent these methods contributed to the overall guideline success. In contrast, our diagnostic pathway used a low-risk imaging method with the frequently utilized clinical reassessment and showed that children with equivocal initial US and persistent concern about appendicitis on reassessment are candidates for interval US and surgical consultation, and those without ongoing symptoms on reassessment can be discharged.
Ultrasound is highly operator-dependent and frequently cannot visualize the appendix. Our study had a high rate of equivocal US that was comparable to that found in our recent study of appendicitis and higher than that reported in a multisite study by Bachur et al. who found a 14% equivocal US rate.
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This difference may be in part explained by the difference in the criteria for equivocal US. For example, during our prospective application of previously published criteria we have classified US with incomplete or no visualization of the appendix with no secondary signs of appendicitis as equivocal, whereas Bachur and colleagues classified these as negative. Our study highlights that a combination of US and clinical reassessment is very helpful in diagnosing appendicitis and that the reassessment represents a powerful tool in identifying children at high risk of appendicitis. Indeed, clinical reassessment was used to exclude appendicitis in the majority of patients with equivocal US, and children no longer judged to be at risk of appendicitis were identified after relatively brief observation.