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Having recently attended a pediatric ER conference I learned about this protocol for r/o appy in peds.
Ultrasound followed by MRI if results are equivocal instead of CT. I had never heard of this, but I can see this starting to gain traction in the community. I'm curious about people's practices for imaging kids for r/o appy.
How many people are using MRI as a follow up exam for nondiagnostic ultrasounds? Are you experiencing any barriers to this protocol? What do you think?http://pediatrics.aappublications.org/content/pediatrics/early/2014/02/25/peds.2013-2128.full.pdf
 

shoal

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definately not. in the community. standard of practice here is us then ct. our us techs arent very seasoned at appy us either. negative scan, i call surgery then usually its a ct.

to get a mri in the 3-10 yr group, it may take sedation and thats almost impossible to arrange at my hospital as id be the one doing it.


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gro2001

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Having recently attended a pediatric ER conference I learned about this protocol for r/o appy in peds.
Ultrasound followed by MRI if results are equivocal instead of CT. I had never heard of this, but I can see this starting to gain traction in the community. I'm curious about people's practices for imaging kids for r/o appy.
How many people are using MRI as a follow up exam for nondiagnostic ultrasounds? Are you experiencing any barriers to this protocol? What do you think?http://pediatrics.aappublications.org/content/pediatrics/early/2014/02/25/peds.2013-2128.full.pdf
That was our practice in residency, but that was at one of the pediatric Meccas. There was a clear, written protocol that was agreed upon by Peds EM, Peds surgery and Peds Radiology, so never any push back at all. It went something like this:

High suspicion -> Call peds surgery straight away -> usually US -> if US non diagnostic, usually MRI, or if sedation not available (middle of night, for example) then sometimes CT, sometimes obs depending on labs, serial exams, etc.

Moderate suspicion -> US (but order MRI at the same time) -> if US non diagnostic, reassess, if clinically improved and labs all good (no high WBC count, etc) either DC with strict return instructions/mandatory return in 24 hours for re-eval, obs a little more or call surgery consult that would often recommend DC as above.

Low suspicion -> US -> if non diagnostic, reassess and either upgrade to MRI or downgrade to DC with return instructions.


I think the standard is going to vary significantly depending on the resources available. With the best possible set up (ready availability of MRIs, anesthesia available for sedation, skilled US techs, etc) I think its the best possible protocol from the patient's perspective. However, if resources are less available, then the standard may be US -> CT, or straight to CT, or US -> serial exams, or US -> transfer to peds center. The most important thing is to have institutional agreement on what to do, and to have your surgeons on board.

PS: I only clicked your link after I wrote up this post, and it turns out that this is the Mecca I was talking about. Oops.
 
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WilcoWorld

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Highly suspicious --> Surgical consult.

Moderately suspicious: US, CT if US negative.

Low suspicion: US, reexamine, dc with return precautions/repeat exam the next day.

I'd be willing to do an MRI if I a) have concern for api and b) I expect the kid to be able to do an MRI without sedation. However, I worry about indication creep leading to a bunch of kids who have low-likelihood of api getting sedated for an MRI.
 
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If I have a suspicion for appy, I'll order US and start kid drinking at same time, that way if US non-diagnostic, I can get CT and kid has already had PO contrast. I discuss upfront with parents that US may or may not show appy and that we also may need to do CT. I tell them about the radiation and if they prefer to not do CT, then I arrange for transfer to Peds ER. Some just prefer to be transferred before US, which I think is fair. Our techs are decent at US, but certainly nowhere near as good as Peds ER US techs. But I figure the more we order them, the better they'll get, hopefully!
 

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I have no ability to get MRI in ED for this. Typically it's US (always cannot see appendix) then either followed by CT or D/C home with 12 hours of obs and return.

I think 12 hours of obs and return is preferable on non-toxic kids, with no fever, and normal labs.
 

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We transfer to peds hospital for moderate-high suspicion where they do the US/MRI protocol. Our surgeons don't do kids so makes since to transfer prior to irradiating.
 

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We have MRI available and have not really run into an issue with kids needing sedation for it. I almost never order the US. If I'm suspicious enough, they get MRI. If not, they get labs and serial exams to see if my suspicion increases enough to get an MRI. If not, they get 24 hour recheck. US is great in the community if you're trying to spare radiation or avoid transfer. I find US to be a waste of time and money in the setting of readily available MRI and enough suspicion to warrant imaging, at least with the rate of "appendix could not be visualized" scans I see.
 

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For y'all doing MRI, will ped surg read it and make a call or do they wait for rads? And do y'all have 24/7 MRI staff, or are you getting the on call to come in? What's the turnaround time work up -> OR?
 

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We have a "Children's Hospital" inside our hospital. We staff the peds ER (and have a few dedicated peds people). Our protocol is US and if non-diagnostic c/s to peds surgery. They usually want the CT after they see the patient.

MRI for anyone from the ED usually takes 6+ hours. It is staffed 24 hours a day, it is often just full/busy.
 

GeneralVeers

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It's interesting that we spend so much time and effort on something that in most of the world is a non-surgical disease. Probably we should just be putting these kids on IV antibiotics and admitting overnight.

Appendicitis really should be treated primarily non-surgically at least in adults.
 

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We have 24/7 tech and radiologist coverage for MRI. Turn around time is probably faster than ultrasound, slower than CT. Positive scan generally means admission for antibiotics and OR the next day.
 
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gro2001

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It's interesting that we spend so much time and effort on something that in most of the world is a non-surgical disease. Probably we should just be putting these kids on IV antibiotics and admitting overnight.

Appendicitis really should be treated primarily non-surgically at least in adults.
I agree that treatment of appendicitis should (and likely in the future, will) switch to a more non-surgical role, but I doubt the amount of 'effort' we spend on it will decrease a huge amount. Untreated appendicitis is bad, but so is starting all kids with abdominal pain on antibiotics. So even if tomorrow all the surgeons agreed that abx treatment is the appropriate first line therapy, we would still have the problem of trying to figure out who to admit for abx and who to discharge.
 

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It's interesting that we spend so much time and effort on something that in most of the world is a non-surgical disease. Probably we should just be putting these kids on IV antibiotics and admitting overnight.

Appendicitis really should be treated primarily non-surgically at least in adults.
that's the norm in japan, admit, abx, wait to see what happens
 

MSmentor018

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Having recently attended a pediatric ER conference I learned about this protocol for r/o appy in peds.
Ultrasound followed by MRI if results are equivocal instead of CT. I had never heard of this, but I can see this starting to gain traction in the community. I'm curious about people's practices for imaging kids for r/o appy.
How many people are using MRI as a follow up exam for nondiagnostic ultrasounds? Are you experiencing any barriers to this protocol? What do you think?http://pediatrics.aappublications.org/content/pediatrics/early/2014/02/25/peds.2013-2128.full.pdf
never done that protocol. we have a algorithm in conjunction with peds surg. labs, kub, u/s. if strong suspect, then transfer for overnight obs/serial exam by surgeon. they absolutely do not want a ct for this disease
 

GeneralVeers

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I think given the evidence, if I had uncomplicated appendicitis, I would choose antibiotic therapy over surgery for myself. Surgery has potential complications, not to mention adhesions, and the surgical scar.
 

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never done that protocol. we have a algorithm in conjunction with peds surg. labs, kub, u/s. if strong suspect, then transfer for overnight obs/serial exam by surgeon. they absolutely do not want a ct for this disease
What does the KUB add?
 
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RustedFox

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I think given the evidence, if I had uncomplicated appendicitis, I would choose antibiotic therapy over surgery for myself. Surgery has potential complications, not to mention adhesions, and the surgical scar.
I agree with this: hit me up with Zosyn, and see just how I do. Adhesions and resultant SBO do not make me all warm and fuzzy.
 

VA Hopeful Dr

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I agree with this: hit me up with Zosyn, and see just how I do. Adhesions and resultant SBO do not make me all warm and fuzzy.
Is that really that big of a problem with lap appys though? I'm not an EM doc, but it seems to me that a quick surgery (usually home within 24 hours) would be preferable to several days of IV antibiotics and pain medications.
 
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RustedFox

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From my surgical buddies; yes - as soon as you put steel thru the peritoneum... you've got reason for an adhesion.
 

VA Hopeful Dr

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From my surgical buddies; yes - as soon as you put steel thru the peritoneum... you've got reason for an adhesion.
Well duh, but how often is that a problem from getting your appendix out? Are you seeing lots of obstructions from people with that as their only abdominal surgery?

When the articles about nonoperative treatment of appendicitis were coming out, most surgeons I know said (and still say) that they would want theirs taken out.
 
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gro2001

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You know, appendicitis can cause adhesions by itself. There isn't really a body of literature on how commonly it does that (as in most places, appendicitis still = surgery) but if this really does become the norm we might see that medically treated appendicitis causes comparable number of adhesions as a laparoscopic appendectomy. Certainly ruptured appendix does, but I suspect routine appendicitis does too.
 
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RustedFox

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Well duh, but how often is that a problem from getting your appendix out? Are you seeing lots of obstructions from people with that as their only abdominal surgery?

When the articles about nonoperative treatment of appendicitis were coming out, most surgeons I know said (and still say) that they would want theirs taken out.
Of course they say that; they're surgeons. You can train a monkey to do surgery - but you can't train a surgeon to NOT do surgery.
 

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You know, appendicitis can cause adhesions by itself. There isn't really a body of literature on how commonly it does that (as in most places, appendicitis still = surgery) but if this really does become the norm we might see that medically treated appendicitis causes comparable number of adhesions as a laparoscopic appendectomy. Certainly ruptured appendix does, but I suspect routine appendicitis does too.
How many have you seen from diverticulitis (without perforations?)
I would say it's significantly less.
 
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RustedFox

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I have never seen an SBO that wasn't caused by:

1.) Surgical adhesions.
2.) Hernia.
3.) Malignancy.

"Uncomplicated appy" is nowhere, anywhere, even close in this galaxy.
 
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BoardingDoc

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I have never seen an SBO that wasn't caused by:

1.) Surgical adhesions.
2.) Hernia.
3.) Malignancy.

"Uncomplicated appy" is nowhere, anywhere, even close in this galaxy.
How many SBOs have you seen in patients who have only had a lap appy without any of your other 3? Granted I haven't been doing this as long, but I've seen zero.
 

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What if they're constipated at baseline (pretty much every peds patient I see) but now have appendicitis?

As far as therapeutic testing, I prefer a udip. Definitely some parents aren't happy w/o imaging though.
Sterile pyuria is common with appendicitis. A dirty udip does not rule out an appy either.

Edit: Actually, in just the last week I've had a case of RLQ pain w/ sterile pyuria that ended up being appendicitis and a patient with a gigantic stool ball that also ended up having appendicitis.
 
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Sterile pyuria is common with appendicitis. A dirty udip does not rule out an appy either.

Edit: Actually, in just the last week I've had a case of RLQ pain w/ sterile pyuria that ended up being appendicitis and a patient with a gigantic stool ball that also ended up having appendicitis.
I prefer a urine to axr bc of the lack of radiation, as well as the possibility to diagnose Uti's (in girls) and the (remote) possibility of dka. If I'm concerned about an apply I work it up.
 

GeneralVeers

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Is that really that big of a problem with lap appys though? I'm not an EM doc, but it seems to me that a quick surgery (usually home within 24 hours) would be preferable to several days of IV antibiotics and pain medications.
Maybe I'm crazy, but I'd like to avoid being cut open and having parts ripped out. Not to mention avoiding general anesthesia. If the two approaches are comparable in outcomes, I would pick antibiotics every time.
 
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Is that really that big of a problem with lap appys though? I'm not an EM doc, but it seems to me that a quick surgery (usually home within 24 hours) would be preferable to several days of IV antibiotics and pain medications.
Who said anything about "several days of IV antibiotics"?

Otherwise, mostly feel the data is equivocal or not applicable.

HH
 

MSmentor018

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What if they're constipated at baseline (pretty much every peds patient I see) but now have appendicitis?

As far as therapeutic testing, I prefer a udip. Definitely some parents aren't happy w/o imaging though.
great question, they all seem to have a poo ball on kub at the rlq. it's clinical gestault + labs. if neg crp/esr/wbc/fever and kid's running around. I send home with good instructions.
 

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I have never seen an SBO that wasn't caused by:

1.) Surgical adhesions.
2.) Hernia.
3.) Malignancy.

"Uncomplicated appy" is nowhere, anywhere, even close in this galaxy.
2% of SBO are in a virgin belly. Don't use the "fallacy of anecdote" ("I've never seen it, so I don't believe it."). Now, the hernia and malignancy can be in a virgin belly, of course, but that was not your intent.
 

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I think given the evidence, if I had uncomplicated appendicitis, I would choose antibiotic therapy over surgery for myself. Surgery has potential complications, not to mention adhesions, and the surgical scar.
I've been thinking about this; what are you, a bikini model? Why would the scar proper even concern you?
 

BoardingDoc

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Maybe I'm crazy, but I'd like to avoid being cut open and having parts ripped out. Not to mention avoiding general anesthesia. If the two approaches are comparable in outcomes, I would pick antibiotics every time.
They don't appear to be. http://jama.jamanetwork.com/article.aspx?articleid=2320315

Also, a 2014 study in Annals of Surgery quotes a rate of SBO following open appy of approx 1%. For a lap appy it's 0.4%. The rate of uncomplicated appendicitis is likely even lower as the 0.4% figure includes patients who perforated or had a seemingly normal appearing appending and who underwent more extensive laparascopic exploration.

If 0.4% is too high a chance, I get that argument, but I'd also then want to know what percentage of people who are treated with antibiotics later go on to fail treatment and subsequently burst. I'm not aware of data covering this aspect, but I wouldn't be surprised if that number was close to 0.4%.
 

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2% of SBO are in a virgin belly. Don't use the "fallacy of anecdote" ("I've never seen it, so I don't believe it."). Now, the hernia and malignancy can be in a virgin belly, of course, but that was not your intent.
Good point. I'm willing to also bet that a large percentage of that 2% is due to Crohn's in a virgin belly.

My intent was to state (and I'll restate it) that the relative likelihood of developing an SBO is radically different between (1) adhesions and (2) other causes. So radically different, that it changes the decision-making.
 

VA Hopeful Dr

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Who said anything about "several days of IV antibiotics"?

Otherwise, mostly feel the data is equivocal or not applicable.

HH
The Finland study quoted above had 3 days of IV ertapenem (odd choice, but whatever) then PO meds, and RustedFox would rather have Zosyn than surgery, though admittedly he didn't specify length of treatment before going to PO meds.
 

gro2001

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How many have you seen from diverticulitis (without perforations?)
I would say it's significantly less.
It would be hard to say. I am not sure how many patients I have seen with diverticulitis who has never had any surgeries, hernias, cancers or any other reason for an SBO. I am sure some, but its hard to say quantitatively what proportion. Seems like by the time your typical patient gets diverticulitis, they've often had a history of one of the above.
 

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Maybe I'm crazy, but I'd like to avoid being cut open and having parts ripped out. Not to mention avoiding general anesthesia. If the two approaches are comparable in outcomes, I would pick antibiotics every time.
I get that, although it appears that even the best data on antibiotics has about 1/3rd of patients eventually needing their appendix out anyway. There is a lot to be said about a one-time cure for a problem, especially in what is a fairly easy procedure to bounce back from.
 

gro2001

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I have never seen an SBO that wasn't caused by:

1.) Surgical adhesions.
2.) Hernia.
3.) Malignancy.

"Uncomplicated appy" is nowhere, anywhere, even close in this galaxy.
Its nowhere close because there is essentially no US experience of medically treated appendicities. Maybe you have never seen "uncomplicated appy cause adhesions" because you have never seen uncomplicated appy that didn't go to surgery.

Also, this is a case of experience being misleading. A tiny proportion of people with appendectomy (~0.5%) as their only surgery end up getting adhesions. You notice them because so many people have had appendectomies. If suddenly no one was getting appendectomies for appendicitis, I expect adhesion rate following appendicitis to drop further, but not to 0%. Maybe from 0.5% to 0.25%.
 

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Everyone is misunderstanding my statement, which I thought I laid out pretty well.

I have never seen a SBO that wasn't caused by these three things. Sure; doesn't mean that they exist, but I haven't seen them. Upon further consideration - I have seen the odd SBO as a result of Crohn's.

I'm saying (clearly, with my last sentence) that the incidence of these items is exceedingly rare, no matter what the history. Sure, we can postulate that I've never seen an "uncomplicated appy adhesion" because of the high rate of appendectomies. Lets say there were some uncomplicated appy ahesions. I'm willing to bet dollars to donuts that they wouldn't even be in the same solar system in terms of frequency as.... adhesions from a lap appy - which we know do at least exist. We postulate that the risk of a non-surgical-appy-adhesion is amazingly low (even more so) because we are comparing it to adhesions from diverticulitis (which, to none of our knowledge, is even a possibility)

So, there's a non-zero risk of adhesions from a lap appy.
There may be a non-zero risk of adhesions from a medically treated appy. We don't know - but we suspect that its so low that its laughably negligible. It may be.... zero.
We all agree that the risk is low.

I'll take as close to zero as I can get. Therefore, I'll take Zosyn and watch-and-wait over the #10 blade and the sevoflurane.
 
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VA Hopeful Dr

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Everyone is misunderstanding my statement, which I thought I laid out pretty well.

I have never seen a SBO that wasn't caused by these three things. Sure; doesn't mean that they exist, but I haven't seen them. Upon further consideration - I have seen the odd SBO as a result of Crohn's.

I'm saying (clearly, with my last sentence) that the incidence of these items is exceedingly rare, no matter what the history. Sure, we can postulate that I've never seen an "uncomplicated appy adhesion" because of the high rate of appendectomies. Lets say there were some uncomplicated appy ahesions. I'm willing to bet dollars to donuts that they wouldn't even be in the same solar system in terms of frequency as.... adhesions from a lap appy - which we know do at least exist. We postulate that the risk of a non-surgical-appy-adhesion is amazingly low (even more so) because we are comparing it to adhesions from diverticulitis (which, to none of our knowledge, is even a possibility)

So, there's a non-zero risk of adhesions from a lap appy.
There may be a non-zero risk of adhesions from a medically treated appy. We don't know - but we suspect that its so low that its laughably negligible. It may be.... zero.
We all agree that the risk is low.

I'll take as close to zero as I can get. Therefore, I'll take Zosyn and watch-and-wait over the #10 blade and the sevoflurane.
And the c. diff?
 

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Psst... you're going to get a dose of Zosyn (or Cipro/Flagyl, or whatever your institution prefers) no matter what, if you show up with RLQ pain and an appy.
So its YOUR fault c. diff is everywhere and not all us primary care people throwing augmentin and levaquin at every case of the sniffles...