The Diagnosis of Appendicitis

in Children: Outcomes of a
Strategy Based on Pediatric
Surgical Evaluation

Ann M Kosloske, C Lance Love, James E Rohrer, Jane F

Goldthorn, Stuart R Lacey.
Departments of Surgery, Pediatrics, and Health Services Research, Texas Tech University,
Health Sciences Center, Lubbock, Texas; and Covenant Children's Hospital, Lubbock,
Texas.
Introduction
Appendicitis most common surgical
emergency in children and adolescents in USA
( 59.000 children in 1999)
Diagnosis in a child is sometimes difficult
Reports recommended imaging, particularly
computed tomography (CT) with rectal contrast,
as the optimal diagnostic study
CT scanning was calculated as cost-effective in
children based on a negative appendectomy
rate of 23% in Texas (unacceptable) CT scan
was undertaken accurate diagnostic tool
This study is to review the needs for the imaging
Methods

356
children & adolescents

January 1999 through December 2001

3 pediatric surgeons
Ann M Kosloske
Jane F Goldthorn
Stuart R Lacey
Methods
West Texas city : 204 000 population

2 hospitals

Texas Tech Covenant

University Hospital
325-bed teaching
hospital with an 88-
bed pediatric
hospital located on
one floor
Children's Hospital
73-bed pediatric
hospital that is a
separate wing of a
400-bed community
hospital
Methods
Strategy:
Methods
Standardized data collection tool:
age, gender, duration of symptoms, county of
residence, imaging (US / CT scan), physician
ordering imaging studies, results of imaging
studies (positive, negative, or equivocal),
interval (hours) from arrival to pediatric surgical
consultation, interval (hours) from arrival to
appendectomy, operative diagnosis, &
pathologic diagnosis.
Pathologic criteria for acute appendicitis:
mucosal and intramural inflammation
Methods
The presence of advanced appendicitis
(appendiceal perforation) was based on
the surgeon's operative note.
The presence of perforation was based on
the pathologist's report.
In children who did not have appendicitis,
the discharge diagnosis was recorded.
Children who improved under observation
were discharged; those who did not return
to the hospital were presumed not to have
appendicitis.
Methods
All data were entered into a computer
program (Epi Info 2002, Centers for
Disease Control and Prevention, Atlanta,
GA) for analysis.
Significance tests were performed
Means were tested by Student-t, Kruskal-
Wallace test, 2 tests.
Sensitivity, specificity, positive predictive
value, and negative predictive value were
calculated by standard epidemiologic
methods
RESULTS
Mean age : 9.6 years ( 3.83 years; 1-18 years)
144 females & 212 males was diagnosed
220 (62%) underwent appendectomy: 209 (95%)
had pathologic confirmation of appendicitis, 11
(5%) had a normal (negative) appendix.
Of the 209 children with appendicitis, 139 (66%)
had acute appendicitis, 34 (16%) had advanced
appendicitis without perforation, 36 (17%) had
advanced appendicitis with perforation.
There were no significant changes from year to
year across the 3-year period in the proportion
of patients with perforation or with a negative
appendix.
RESULTS
RESULTS
Duration of symptoms before arrival at the
hospital was significantly longer for children with
advanced/perforated appendicitis than for those
with early acute appendicitis (58.2 vs 26.0 hours;
P 0.0001).
Median time from arrival at the hospital to
appendectomy in children diagnosed with
appendicitis at the initial pediatric surgical
evaluation: 5 hours.
Median time to appendectomy in the 25 children
who had appendectomy after a period of
observation: 18 hours.
RESULTS
117 (33%) imaging studies (67 US and 50
CT scans) were ordered by the referring
physician before pediatric surgical
evaluation. 60 (17%) were ordered by the
pediatric surgeon.
US alone was performed in 96 patients;
CT scan alone was performed in 54
patients, and both US and CT scan were
performed in 16 patients.
RESULTS
Sensitivity, specificity, positive predictive
value, negative predictive value and
accuracy of the protocol, US, & CT was
listed below.
RESULTS

Table 3 above shows comparison of

previous protocols used in the diagnosis of
appendicitis with present study in all
aspects including % of negative
appendectomy
DISCUSSION
In many centers, imaging for appendicitis has
become routine.
CT scan with rectal contrast as the gold
standard for diagnosis of appendicitis have
appeared in every literature
Few reports have questioned the accuracy or
wisdom of CT scanning for appendicitis.
Parents of a child with possible appendicitis may
request a CT scan because they have read
about it in the lay press as the definitive test.
Evaluation by a pediatric surgeon early in the
course of a child with possible appendicitis has
rarely been emphasized.
RESULTS
This study, however, support a diagnostic
strategy based primarily on the clinical
acumen of a pediatric surgeon rather than
imaging have high sensitivity (99%),
specificity (93%), accuracy (97%) and low
negative appendectomy rate (5%)
RESULTS
Because a missed diagnosis often leads to
perforation and complications, rates of
negative appendectomy of 12% to 18%
are considered acceptable in children.
This clinically based approach, with its low
rate of negative appendectomy (5%), may
be more cost-effective than other
diagnostic strategies (the cost of imaging
(US + CT, in 1997 dollars) was reported as
$907 per patient)
CONCLUSION
Improved technology does not always
translate into improved diagnosis and
patient outcomes
Physicians or pediatric surgeons clinical
jugdement is still the primary basis for
diagnosing appendicitis
One should consider the advantages of
using imaging especially CT in children not
only the cost effectiveness, but also for the
lifetime radiation risk cancer (10x higher
than adults)
End of session