Pediatric appendicitis work up

[Zebra Hunter]

Going into residency, I was a firm believer in minimizing radiation of children, especially in suspected appendicitis cases. Decent but not slam dunk story? They got an U/S and blood work. If it was negative and work up was normal, they got d/c'd with good return precautions. If appendicitis was not visualized, I would call surgery to come evaluate them (which they never did, and instead would say "just order the damn CT"). If it was positive, well that was obviously a slam dunk admit to surgery case (in my mind, at least).

Nearly 2 years through my training, I've come to the realization that U/S for r/o appendicitis is a gigantic time sink that most of the time just delays care. Just to get a tech to come do the exam at night can take up to 2-3hrs. About 1/3rd-4th of the time, the appendix is not visualized. For the positive cases, about half of the time the surgeon will ask for a CT, anyways (where I work, at least), especially on females. And I now understand why they ask for them, as I have now seen 3 cases in the last 6 months that have had an U/S "positive for acute appendicitis" that have had a negative CT scan, and were eventually d/c'd w/o requiring surgery. Also, for those negative appendicitis cases by U/S, the U/S is such a limited tool in the evaluation of abdominal pain. One of those cases that had a positive U/S but negative CT for appendicitis was found to have terminal ileitis and had a father w/ a hx of Crohn's. Another was found to have a R sided distal ureteral stone. And having read the limited available literature behind our fear of radiation for CT scans (or lack thereof, odds ratio of ~1.003...that could be just due to random chance, or the obvious confounder that kids more likely to get cancer are more likely to get CT scans) and the significant lack of evidence for the linear no-threshold model of radiation exposure that fear is based on, I think that a reasonable conclusion to come to is that initially getting a CT scan on a suspected peds appendicitis case really is not that unreasonable.

I've had long debates with fellow residents and attendings on the subject. In my opinion, the threat of a misdiagnosis and possible unnecessary surgery largely outweighs the theoretical risk of radiation. Some look at me like I'm absolutely insane for holding these opinions, some understand the argument but disagree, and a very few actually agree.

Maybe my thinking is wrong on this subject, but I'd like to know what y'all think and what your workup usually entails.

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[deleted109597]

So, if you've got a robust US program that can quickly and reliably scan for these, then sure. If not, waiting for the US takes longer than getting the CT. And if they're being called in, they're likely to do a ****ty and fast exam so they can go back home. I hate to say it, but it's true.
Risk of appy>>>>>>>>>unnecessary surgery>>>>>>>>>CT radiation. But serial exams aren't bad either.
You can use the Alvarado score (sort of), but each site's surgeons are specific to their personal preference. So do that.
While I don't like doing any study without a reason (CT, US, or even CBC), the risks are a bit overblown. Don't do it for obviously negative cases, but it's not like you're ordering serial CTs on these kids. At least, I hope you're not.

 

[Venko]

I feel that you should work with your system to establish a protocol that all folks can get behind.

Our situation is different than yours as we have a technician in house and radiology in house. So we do ultrasound and visualized and negative pts are considered negative. If a kiddo has poorly or inadequately visualized or positive study, peds surgery usually admits for serial exams or ultrasound.

This works here with our resources. Interestingly, our visualization rates for professional sonographers from radiology are between 45-55 percent at place as large and specialized as ours. I think it underscores the difficulty that ultrasound has for this diagnosis in other places.






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[kemper6036]

A lot of this is institution specific. Some centers do large numbers of ultrasound exams on children (children hospitals for instance) and i would give much more weight to one of their exams calling an acute appy compared to my smaller place where they do a fraction of exams a specialized center does. The "operator dependent" aspect of US is well documented. The point about being called in and doing a rushed exam in the middle of the night is probably accurate as well.

A lot of depends on your surgeons also. There are some of us who are more comfortable accepting a higher rate of negative appendectomy and will take a classic story of appendicitis to the OR without imaging. Others will want a CT no matter what

Like Venko mentioned above, probably best to come up with an institutional specific protocol to avoid confusion and middle of the night awkward phone calls while doing the right thing for the patient

 

[brk81144]

Working in the community I can tell you that our techs don't do enough to get comfortable with finding the appendix to make it a worthwhile study. If I need to rule out appy we usually just call the local Children's hospital and have them seen in the ER to avoid doing unnecessary CTs.

I always ask myself what I would do if it were my child and even a theoretical risk of cancer is enough to stop me from doing the CT unless circumstances dictate it... acute abdomen, significantly abnormal vital signs, etc

 

[tsbqb]

Anyone doing MRI (at any hour but esp in the middle of the night) routinely?

 

[shoal007]

the closest peds er shop is 1.5 hrs away... I order a fair amount of CTs on kids (1/ mo perhaps). Ive yet to have a visualized appendix by US here. MRI is off the table. labs, story, exam... still worrisome = CT. i do shared decision making with the family (CT or repeat exam in 12-24hr. most choose CT. remember sensitivity of CT is only 98%. Ive seen one appy on a ct neg pt with positive pathology.

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[fahimaz7]

Going into residency, I was a firm believer in minimizing radiation of children, especially in suspected appendicitis cases. Decent but not slam dunk story? They got an U/S and blood work. If it was negative and work up was normal, they got d/c'd with good return precautions. If appendicitis was not visualized, I would call surgery to come evaluate them (which they never did, and instead would say "just order the damn CT"). If it was positive, well that was obviously a slam dunk admit to surgery case (in my mind, at least).

Nearly 2 years through my training, I've come to the realization that U/S for r/o appendicitis is a gigantic time sink that most of the time just delays care. Just to get a tech to come do the exam at night can take up to 2-3hrs. About 1/3rd-4th of the time, the appendix is not visualized. For the positive cases, about half of the time the surgeon will ask for a CT, anyways (where I work, at least), especially on females. And I now understand why they ask for them, as I have now seen 3 cases in the last 6 months that have had an U/S "positive for acute appendicitis" that have had a negative CT scan, and were eventually d/c'd w/o requiring surgery. Also, for those negative appendicitis cases by U/S, the U/S is such a limited tool in the evaluation of abdominal pain. One of those cases that had a positive U/S but negative CT for appendicitis was found to have terminal ileitis and had a father w/ a hx of Crohn's. Another was found to have a R sided distal ureteral stone. And having read the limited available literature behind our fear of radiation for CT scans (or lack thereof, odds ratio of ~1.003...that could be just due to random chance, or the obvious confounder that kids more likely to get cancer are more likely to get CT scans) and the significant lack of evidence for the linear no-threshold model of radiation exposure that fear is based on, I think that a reasonable conclusion to come to is that initially getting a CT scan on a suspected peds appendicitis case really is not that unreasonable.

I've had long debates with fellow residents and attendings on the subject. In my opinion, the threat of a misdiagnosis and possible unnecessary surgery largely outweighs the theoretical risk of radiation. Some look at me like I'm absolutely insane for holding these opinions, some understand the argument but disagree, and a very few actually agree.

Maybe my thinking is wrong on this subject, but I'd like to know what y'all think and what your workup usually entails.

Our surgeons will take kids to the OR based on my bedside ultrasound. If it's there it's great. If not, move on with a CT or watchful waiting depending on the concern. I've done door to admission times in <10 minutes based on bedside ultrasound for appendicitis.

 

[littlejuan]

Our surgeons will take kids to the OR based on my bedside ultrasound. If it's there it's great. If not, move on with a CT or watchful waiting depending on the concern. I've done door to admission times in <10 minutes based on bedside ultrasound for appendicitis.

Out of curiosity what are your rates of true appendicitis from positive bedside ultrasound as well as CT appendicitis with negative ultrasound? Do you have those numbers? Are you US fellowship trained?

 

[HooliganSnail]

Working in the community I can tell you that our techs don't do enough to get comfortable with finding the appendix to make it a worthwhile study. If I need to rule out appy we usually just call the local Children's hospital and have them seen in the ER to avoid doing unnecessary CTs.

I always ask myself what I would do if it were my child and even a theoretical risk of cancer is enough to stop me from doing the CT unless circumstances dictate it... acute abdomen, significantly abnormal vital signs, etc

We do the same thing. Usually just call over there, tell them the case, and ask how much they want us to do vs. just sending the kid. I have never had them be anything other than completely willing to help

 

[WilcoWorld]

Our surgeons will take kids to the OR based on my bedside ultrasound. If it's there it's great. If not, move on with a CT or watchful waiting depending on the concern. I've done door to admission times in <10 minutes based on bedside ultrasound for appendicitis.

Out of curiosity what are your rates of true appendicitis from positive bedside ultrasound as well as CT appendicitis with negative ultrasound? Do you have those numbers? Are you US fellowship trained?

My guess is that these are cases where the H&P is strongly suggestive, and the US is more of a confirmation. That's still GREAT, but it needs to be considered in context.

 

[gamerEMdoc]

I always look myself first with an US. If someone has an appy, its not as hard as you'd think to find it. If I find an appy, then Ill order a formal US because surgery always wants a formal study. If I dont see one, it depends. I figure if I dont find it, the tech wont either. If the child has a very convincing exam, then sometimes I just cut to the chase and CT them. If the child's exam is more vague, I may just go the formal ultrasound route and stop there if neg or indeterminate.

If the US doesnt view the appendix and doesnt show secondary signs of appy like free fluid in the RLQ, it again depends on the exam. A really good exam for appendicitis, I'll get a surgical consult for serial exams. But in most cases kids exams are vague and it's not appendicitis. If the ultrasound is indeterminate in those cases I send those children home with return precautions to come back in 8 to 12 hours for repeat examination if the pain persists and follow up with her primary care doctor instead in 24 hours if improving. Return sooner if getting worse. I verbally have that conversation, I put it in writing on the discharge instructions, and I documented in my note.

 

[Venko]

I always look myself first with an US. If someone has an appy, its not as hard as you'd think to find it. If I find an appy, then Ill order a formal US because surgery always wants a formal study. If I dont see one, it depends. I figure if I dont find it, the tech wont either. If the child has a very convincing exam, then sometimes I just cut to the chase and CT them. If the child's exam is more vague, I may just go the formal ultrasound route and stop there if neg or indeterminate.

If the US doesnt view the appendix and doesnt show secondary signs of appy like free fluid in the RLQ, it again depends on the exam. A really good exam for appendicitis, I'll get a surgical consult for serial exams. But in most cases kids exams are vague and it's not appendicitis. If the ultrasound is indeterminate in those cases I send those children home with return precautions to come back in 8 to 12 hours for repeat examination if the pain persists and follow up with her primary care doctor instead in 24 hours if improving. Return sooner if getting worse. I verbally have that conversation, I put it in writing on the discharge instructions, and I documented in my note.

Professional sonographers find the appendix around 50% of the time (Fedko M, Am J Emerg Med. 2014 Apr;32(4):346-8.). As an EUS fellowship trained doc, my belief is that people find a structure they want to call an appendix that fits their view of the patient based on history and exam.

I recognize that there are many very passionate advocates for POCUS for this...but I continue to ask...if it's so easy, why can't professional sonographers find it?

Also so many of the scans I have reviewed are actually segments of bowel that are viewed in oblique planes which make them appear blind ended....


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[gamerEMdoc]

I'll defer to your wisdom on this!