Appendicitis on CT, not US

[b-real]

Hey guys, had a pediatric pt today that has me questioning getting US in kids suspected of appendicitis. Classic story, periumbilical pain radiating to RLQ, waxing/waning. A/w nausea. Tenderness at McBurney's, + hopping tenderness. Slightly elev white count (in teens), afebrile. Thin kid, good for US, which could not see tip of appendix, but normal caliber of portion seen, compressible, with no evidence of inflammation or free fluid. I was skeptical, since the story was textbook, so I CT'd the pt, which showed a dilated, fluid-filled appendix and surrounding FF. Same radiologist read both studies. Anyone else experience such vast differences b/t US and CT? Maybe has to do with radiologist experience? It has me second-guessing ever getting US on kids.

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[emergentmd]

CT a better test for Appy in kids vs US. US is very tech dependent. If I have a high index of Suspicion and U/S neg, then I go to CT.

 

[txterp98]

I can't unfortunately speak to statistics, but yes, anecdotally, I've had similar cases. I wouldn't derail your approach, though. Minimizing (actually, eliminating) radiation exposure with ultrasound is a good opening gambit for the pediatric population especially if your U/S techs are adequately trained and feel comfortable performing the test. And if negative, moving on to CT is certainly reasonable since your pre-test suspicion was relatively high. Two questions that also go hand-in-hand with your scenario (and I genuinely mean this collegially and not questioning your judgment):

1) Since your pre-test suspicion was this high, would your current practice location/setup allow you to go straight to surgical consultation without imaging?

2) If the CT had also been negative, what would you have done next? (Timed follow-up in 12 hours with strong ER precautions? Consult surgery anyways based on H&P?) The caveat is also in the two permutations of "negative" CT....appendix not visualized vs appendix visualized and felt to be normal.

Great case and pickup, though. Nicely done.

 

[dotcb]

The problems with US for appy in kids are:

#1. They are so frequently non-diagnostic that ordering them is more often than not a waste of time.
2. Surgeons who are not pediatric surgeons are not comfortable with US and prefer CT if it comes to operating on a child.

For years we've continued to order them in the hope to train our US techs and change the practice culture. I have noticed no progress on either front.

My favorite move is when I can get a surgeon to operate on a patient (almost always male) with no imaging.

 

[Crayola227]

If pos U/S means not having to go to CT, obviously that makes sense.

If realistically you need CT for any of the reasons above, then why bother U/S?

I'm probably missing the subtlety here, but only the test that affects management or avoids another test makes sense. If it does neither, it's pointless.

 

[DrBowtie]

If pos U/S means not having to go to CT, obviously that makes sense.

If realistically you need CT for any of the reasons above, then why bother U/S?

I'm probably missing the subtlety here, but only the test that affects management or avoids another test makes sense. If it does neither, it's pointless.

Because people are scared to radiate kids when there's the harmless US available even if US is an inferior test.

US is good for a select population with an appendix in an anterior position. Problem is you can't tell prior to doing the scan.

 

[emergentmd]

Its all standard of care, learn that in your practice. Takes you 30 secs to ask.

In my adult EDs, its CT. 10 yr old with RLQ pain, gets a CT bf surgeon would touch them.
In my Pedi ED, its U/S nondiagnostic then CT. Even if its a waste of time in half the cases, thats standard.

Why? The U/S tech and Rad needs to be comfortable with the images/reads.

 

[Arcan57]

US for appy is the opposite of d-diner. Really useful if positive, pretty meaningless if negative.

 

[TooMuchResearch]

The problems with US for appy in kids are:

#1. They are so frequently non-diagnostic that ordering them is more often than not a waste of time.
2. Surgeons who are not pediatric surgeons are not comfortable with US and prefer CT if it comes to operating on a child.

For years we've continued to order them in the hope to train our US techs and change the practice culture. I have noticed no progress on either front.

My favorite move is when I can get a surgeon to operate on a patient (almost always male) with no imaging.

We had our US techs trained by peds US techs. They're actually pretty good at picking up appy.

 

[Angry Birds]

In pediatric cases where I have a strong suspicion for appendicitis, I'm ordering labs and U/S, then calling the pediatric surgeon to ask them to lay hands on the patient.

In adult cases, no surgeon will take a patient to the OR without a CT scan, despite always saying that (1) appendicitis is a clinical diagnosis, and (2) we ER docs are too stupid since we scan everyone. This latter idea exists amongst surgeons even though their first question when you call them is, "what did the CT scan show?"

 

[dotcb]

In cases where there appears to be an obvious appendicitis (male, RLQ TTP, incr WBC, no urinary sxs, <72hrs of pain), more often than not - I've found surgeons willing to operate without imaging.

Certainly if you don't ask, they won't.

 

[Angry Birds]

In cases where there appears to be an obvious appendicitis (male, RLQ TTP, incr WBC, no urinary sxs, <72hrs of pain), more often than not - I've found surgeons willing to operate without imaging.

Certainly if you don't ask, they won't.

Wow, I've never seen this, although my experience is limited to residency or my single year as an attending.

And I have definitely asked... But, I'm saying the first question out of their mouths is "what does the CT scan show?"

 

[shoal]

I've had surgeons take kids to the or multiple times with negative us but positive story, exam, labs without a CT... Just ask

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[WilcoWorld]

I find this varies with gender, surgeon, time of day and day of the week.

At 1pm on a Tuesday a healthy young male can have his appendix removed if anyone but Dr. Crispy is on call - Dr. Crispy believes that all appendicitis patients require radiation therapy to decrease disease burden before an appendix can be safely removed.

At 3pm on a Friday a healthy young woman can have her appendix removed if Dr. Goodheart is on call and the US ruled-in appendicitis.

At 2am on a Saturday noone can have their appendix removed without a CT.

 

[Angry Birds]

Shoal - I've seen that with pediatric patients, but not with adults. But, it may just be at my shop and due to my limited experience.

I find this varies with gender, surgeon, time of day and day of the week.

At 1pm on a Tuesday a healthy young male can have his appendix removed if anyone but Dr. Crispy is on call - Dr. Crispy believes that all appendicitis patients require radiation therapy to decrease disease burden before an appendix can be safely removed.

At 3pm on a Friday a healthy young woman can have her appendix removed if Dr. Goodheart is on call and the US ruled-in appendicitis.

At 2am on a Saturday noone can have their appendix removed without a CT.

Haha, this is so true. I love how practice patterns differ so much based on if the doctor is (1) on the floor, (2) in the call room, (3) in the call room asleep, (4) at home, (5) at home and asleep, (6) at home, asleep, and it being a night, (7), at home, asleep, and it being a weekend night.

This one time I had a radiology attending trying to convince me to do a plain CT scan to r/o cauda equina instead of doing a CT myelogram in a patient who couldn't get an MRI. She said, "Our CT scans are so good now that we really don't miss anything." This was in the middle of the night, so I told her (being a junior resident at the time), "I'm not an expert but I do believe that the indicated test is a CT myelogram and I think the patient needs one." I spoke with my attending and then wrote in the chart "Dr. XYZ refuses to come in for a CT myelogram..." The radiology attending must have been looking at the chart at home, because she called fifteen minutes later saying, "I'm not refusing, I'm on the way..."

 

[emergentmd]

In pediatric cases where I have a strong suspicion for appendicitis, I'm ordering labs and U/S, then calling the pediatric surgeon to ask them to lay hands on the patient.

In adult cases, no surgeon will take a patient to the OR without a CT scan, despite always saying that (1) appendicitis is a clinical diagnosis, and (2) we ER docs are too stupid since we scan everyone. This latter idea exists amongst surgeons even though their first question when you call them is, "what did the CT scan show?"

My pedi surg will admit and obs but not take to OR with neg U/S.
Adults? forget about it. I could give them a 21 yr Male no med prob with fever, wbc 19, RLQ pain and still want a CT. Neg CT gets them home and follow up tomorrow.

Again..... what we are taught in residency is very different than as an attending. Many similar instances like this.

 

[Groove]

I have absolutely no problem CT'ing a kid if I have a suspicion of appy. I always talk with the parents first about risks vs benefits and will almost always offer US first and if I CT, I always have them sign a consent form.

 

[engineeredout]

When I'm at my home institution (all adult, no in house Peds), almost always get a CT. The general thought, which I tend to agree with, is that our us techs don't perform it enough and our in house radiologists don't read them frequently enough to make it worth the time to end up with a non diagnostic test.

Now when we rotate through the Peds hospitals, it's almost always ultrasound, hardly ever CT. Similar to what was mentioned above, surgery frequently would rather admit and obs rather than CT with a negative us

 

[DrBowtie]

I have absolutely no problem CT'ing a kid if I have a suspicion of appy. I always talk with the parents first about risks vs benefits and will almost always offer US first and if I CT, I always have them sign a consent form.

I'm curious what your consent speech is and what data you're using.

 

[Angry Birds]

I think consent forms are fine in certain circumstances but they are, in a way, ethically dubious.

In the case of a pediatric patient, I think ultrasound should always be first. Positive ultrasound = surgery without ct scan.

I don't think consenting the parents is appropriate since it's the child who suffers by getting radiation.

Edit: I think I read your post incorrectly. I just saw that you offer ultrasound first. I think that's correct but I don't think it should be offered as a choice. First ultrasound then discuss ct scan after that. Just my opinion.

 

[Crayola227]

I guess my point is that if your suspicion is very high, and a positive or negative US doesn't mean you avoid CT because you *know* the surgeon wants it if U/S is positive, and that if negative you want CT, then US is just a waste of healthcare dollars.

If the U/S is going to determine whether you do CT or skip it, great, it may affect management and you may avoid radiation.

Again, I guess it has more to do with what happens at your institution, pre-test probability, predictive value.

I only mean to say if there's 0 chance U/S avoids CT, and isn't offering information additional to the CT, seriously what is the point?

 

[Groove]

Much of this is region/city specific and I think your hospital and local guidelines/treatment patterns should be taken into strong consideration. That being said... my overall point is that it's far worse to miss an appendicitis in a child than it is to expose them to radiation in efforts to rule out an emergency when all appropriate steps have been taken to avoid the risk in the first place. At the end of the day, the kid is in my ED for rule out of a surgical/medical emergency and if my clinical suspicion is strong enough and the US is equivocal or non diagnostic, then they get a CT. Assuming you can't get get creative with an MRI in a well behaved child who's going to lay still for 20 mins (good luck). Sure, consent doesn't protect you, but I think it's absolutely appropriate before scanning children. Most radiology dept's have pediatric protocols to minimize the radiation.

If you have a pediatric surgeon who can come see the pt before CT? Great. If you have no peds surgeon and a local peds hospital where surgery is available and want to send them for obs and r/o appy on a not so clear cut case? Great. If you have none of the above and need to rule out an appendicitis when you're looking at an US report saying equivocal/neg but after examining the kid, your spidy sense is slapping you in the head... pick the more sensitive test. After all, the missed appendicitis is much more likely to harm or kill the kid than the CT scan.

I'm not some cavalier, gung ho, scan every kid with belly pain. However, I've seen some people go to extraordinary methods to avoid any and all radiation in children to the point of delaying the diagnosis.

 

[shookwell]

I always ultrasound kids with any suspicion for appendicitis.

If positive -> kid goes to OR.

If negative and I have low suspicion => either discharge with close follow up or admit to peds for serial exams, depending on how low my suspicion is and how reliable the parents are

If negative and I have high suspicion => wait for surgical residents to stop talking, then discuss case with surgery attending. Either surgeon agrees to go to OR or I have to CT.

 

[Angry Birds]

I always ultrasound kids with any suspicion for appendicitis.

If positive -> kid goes to OR.

If negative and I have low suspicion => either discharge with close follow up or admit to peds for serial exams, depending on how low my suspicion is and how reliable the parents are

If negative and I have high suspicion => wait for surgical residents to stop talking, then discuss case with surgery attending. Either surgeon agrees to go to OR or I have to CT.

Co-signed. This is my algorithm too.

 

[Gadofosveset]

A positive ultrasound is positive. There's no need for a confirmatory CT. For anyone to insist on a confirmatory ct is nonsense... It offers no increase in diagnostic certainty.

I guess my point is that if your suspicion is very high, and a positive or negative US doesn't mean you avoid CT because you *know* the surgeon wants it if U/S is positive, and that if negative you want CT, then US is just a waste of healthcare dollars.

If the U/S is going to determine whether you do CT or skip it, great, it may affect management and you may avoid radiation.

Again, I guess it has more to do with what happens at your institution, pre-test probability, predictive value.

I only mean to say if there's 0 chance U/S avoids CT, and isn't offering information additional to the CT, seriously what is the point?

 

[Crayola227]

A positive ultrasound is positive. There's no need for a confirmatory CT. For anyone to insist on a confirmatory ct is nonsense... It offers no increase in diagnostic certainty.

Someone above asserted that sometimes, especially for peds cases, a surgeon will insist on CT, for anatomy? I dunno. I just try to diagnose stuff without pissing anyone off and I usually have no idea what the surgeon wants, they are not of my kind (j/k)

 

[docdragon]

Someone above asserted that sometimes, especially for peds cases, a surgeon will insist on CT, for anatomy?

Please refer concept to Gomer blog for development of quips regarding need for definition of the anatomy of the ileocecal junction.

More seriously, a pediatric ultrasound that doesn't clearly show the whole appendix is simply non-diagnostic. Thus, your pre-test probability and repeat exams should absolutely bias your ensuing decisions. I prefer a surgical consult before CT because observation and clinical decision-making are reasonable alternatives to CT in the right context.

In a parallel world, one of my colleagues signed an adult patient out to me pending U/S and completion of surgical consult one morning. The patient had a classic story and exam but a negative CT (as read by VRAD, with somewhat more description added after callback). Exam was classic, reliable patient, high probability of appy on U/S, congenial surgeon. Surgery revealed a distal appy without proximal involvement.

I remain curious, though. Someday, will appys be treated with antibiotics only, much like tonsillitis, until the third or fifth episode? The data is growing.

 

[TysonCook]

What is your pre-test probability?
What is the sensitivity of US for Appy?
May be a useless test at that point in the game...

If great story, labs, exam etc all match... +/- US.... if US negative=obs, US Positive or indeterminate=OR.
We rarely ever CT kids anymore.

 

[link2swim06]

Please refer concept to Gomer blog for development of quips regarding need for definition of the anatomy of the ileocecal junction.

More seriously, a pediatric ultrasound that doesn't clearly show the whole appendix is simply non-diagnostic. Thus, your pre-test probability and repeat exams should absolutely bias your ensuing decisions. I prefer a surgical consult before CT because observation and clinical decision-making are reasonable alternatives to CT in the right context.

In a parallel world, one of my colleagues signed an adult patient out to me pending U/S and completion of surgical consult one morning. The patient had a classic story and exam but a negative CT (as read by VRAD, with somewhat more description added after callback). Exam was classic, reliable patient, high probability of appy on U/S, congenial surgeon. Surgery revealed a distal appy without proximal involvement.

I remain curious, though. Someday, will appys be treated with antibiotics only, much like tonsillitis, until the third or fifth episode? The data is growing.

I think this is pretty much the standard of care in Europe. I have seen a few of the surgeons where I work "offer" antibiotics only.

I always find it a little bizarre that they go straight to the OR for the appendicitis yet the perforated diverticulitis with small abscess I had last night was "IV antibiotics and admit to medicine" per surgery. I sometimes wonder if there is less push for antibiotics because an appendectomy is a straight forward procedure for general surgeons and the patients are typically healthy otherwise. (v.s. the old lady with diverticulitis who has 14 medical comorbids).

 

[JayDoc06]

Don't scan kids. If basic eval including Ultrasound Is equivocal, they just need observation not a CT. They will either get better or disease will declare itself.

 

[ERDude]

Don't scan kids. If basic eval including Ultrasound Is equivocal, they just need observation not a CT. They will either get better or disease will declare itself.

Not remotely practical in most (non-children's) community EDs.

 

[Birdstrike]

They will either get better or disease will declare itself.

The same could be said for any horrendous disease.

"Sir, you don't need a test for tapeworms. That's the GREAT thing about those suckers. They will either get better, or declare themselves."

Lol. I like it though.


(Just messing witcha)

 

[JayDoc06]

Not remotely practical in most (non-children's) community EDs.

Our "community" ED physicians do a pretty good job on this. Not sure what you mean. Are community ED physicians not as good?

 

[WilcoWorld]

Our "community" ED physicians do a pretty good job on this. Not sure what you mean. Are community ED physicians not as good?

No. But a lot of admitting services at community hospitals will balk at admitting any kid that might actually need a hospital. It sounds like you probably don't work at such a place. But I accept a lot of transfers where admitting services refused to admit because it was conceivable that, if several things changed, and all of the kid's labs changed to very different results, then the kid might need a specialist that isn't on call locally.

 

[Daiphon]

No. But a lot of admitting services at community hospitals will balk at admitting any kid that might actually need a hospital. It sounds like you probably don't work at such a place. But I accept a lot of transfers where admitting services refused to admit because it was conceivable that, if several things changed, and all of the kid's labs changed to very different results, then the kid might need a specialist that isn't on call locally.

Murphy's Law... gotta respect it.

I work in a quaternary center that takes a lot of these, and a boondock joint that sends a lot. It's annoying, sure, but 1) I understand it being on both sides, and 2) it's usually in the best interests of the kid.

I grumble, I write a quick level 5 facilitated transfer note, and I move on.

-d

 

[WilcoWorld]

Murphy's Law... gotta respect it.

I work in a quaternary center that takes a lot of these, and a boondock joint that sends a lot. It's annoying, sure, but 1) I understand it being on both sides, and 2) it's usually in the best interests of the kid.

I grumble, I write a quick level 5 facilitated transfer note, and I move on.

-d

That's what I do as well.