Diagnostic Algorithm in the Pediatric Appendicitis; A Prospective Clinical Study

Year 2022, Volume: 10 Issue: 2, 89 - 96, 01.09.2022

Süleyman Arif Bostancı , Altan Güneş , Doğuş Güney , Gökhan Demirtaş , Can Öztorun , Ahmet Ertürk , Sabri Demir , Elif Erten , Müjdem Nur Azılı , Emrah Şenel

https://doi.org/10.21765/pprjournal.1136049

Abstract

Aim: We compare the diagnostic approaches: surgeon prediction, surgeon prediction plus ultrasound imagining (US) as the first-line imaging modality, and magnetic resonance imagining (MRI) as the second-line imaging for suspected pediatric appendicitis.
Methods: Three hundred sixty-one patients with a clinically suspected appendicitis were prospectively divided into three groups by the type of diagnostic approach.
Results: A total of 51 patients were diagnosed via only the surgeon prediction. Of the patients, 254 only underwent a US examination, and 56 patients underwent both US and MRI. Considering the diagnostic groups, the accuracy of both the “surgeon prediction only” and “surgeon prediction + US + MRI” groups was 100%. The “surgeon prediction + US” group revealed a sensitivity value of 62,4% with an accuracy rate of 59,8%. The sensitivity and specificity of US were 61,0%, 65,5%, respectively. These values were 100% for MRI. The sensitivity, specificity of our institutional algorithm were 100,0%, 94,4%, and the positive-negative predictive values were 94,7%, 100%.
Conclusions: To diagnose appendicitis in children, surgeon’s assessment, prudence, and clinical evaluation should be the first method of diagnosis. US is a useful method to support surgeons in ensuring an accurate diagnosis, and MRI can be trusted as an additional method to verify a correct diagnosis.

Keywords

acute apandicitis, children, magnetic resonance imagining, ultrasound

Çocuklarda Apandisit Tanı Algoritması; Prospektif Klinik Çalışma

Abstract

Amaç: Akut apandisit (AA), çocuklarda tanısı birçok hastalıkla karışabilmektedir. Bu da gecikmiş tedaviye neden olmaktadır. Görüntüleme yöntemleri hekimlere tanıda yardımcı olabilmektedir. Çalışmamızda AA tanısını koymada yaklaşımlar neler olabiliri değerlendiriyoruz. Tanısal yaklaşımları üç gruba ayırdık. Bunlar: birinci basamakta sadece cerrahın muayenesi, ikinci basamak olarak cerrahın muayenesi ile birlikte Ultrason (US), üçüncü basamakta da şüpheli kalınan durumlarda Manyetik rezonans görüntülemenin (MRG) kullanılmasıydı.
Yöntem: Klinik olarak apandisit şüphesi olan üç yüz altmış bir hasta, tanısal yaklaşım tipine göre prospektif olarak üç gruba ayrıldı.
Bulgular: Toplam 51 hastaya sadece cerrah öngörüsü ile tanı konuldu. Hastaların 254'üne sadece US incelemesi yapıldı ve 56 hastaya hem US hem de MRG yapıldı. Tanı grupları dikkate alındığında hem “sadece cerrahın muayenesi” hem de “Cerrahın muayenesi + US + MRI” gruplarının doğruluğu %100 idi. “Cerrahın muayenesi + US” grubu, %59,8 doğruluk oranı ile %62,4'lük bir duyarlılık değeri ortaya koydu. US'nun duyarlılığı ve özgüllüğü sırasıyla %61,0, %65,5 idi. Bu değerler MRG için %100 idi. Kurumsal algoritmamızın duyarlılığı, özgüllüğü %100,0, %94,4, pozitif-negatif tahmin değerleri %94,7, %100 idi.
Sonuç: Çocuklarda apandisit tanısı için cerrahın değerlendirmesi ve klinik değerlendirmesi ilk tanı yöntemi olmalıdır. US, cerrahları doğru tanı koymada desteklemek için yararlı bir yöntemdir ve MRG, doğru tanıyı doğrulamak için ek bir yöntem olarak güvenilir olabilir.

Keywords

akut apandisit, çocuk, manyetik rezonans görüntüleme, ultrasonografi

References

• 1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. American journal of epidemiology. 1990;132(5):910-925.
• 2. Burjonrappa S, Rachel D. Pediatric appendectomy: optimal surgical timing and risk assessment. The American surgeon. 2014;80(5):496-499.
• 3. Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ. The impact of helical computed tomography on the negative appendectomy rate: a multi-center comparison. The Journal of emergency medicine. 2008;34(1):3-6. https//doi.org/10.1016/j.jemermed.2007.05.042
• 4. Raja AS, Wright C, Sodickson AD, et al. Negative appendectomy rate in the era of CT: an 18-year perspective. Radiology. 2010;256(2):460-465. https://doi.org/10.1148/radiol.10091570 5. Smith MP, Katz DS, Lalani T, et al. ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis. Ultrasound quarterly. 2015;31(2):85-91. https://doi.org/10.1016/j.jacr.2018.09.033
• 6. Kaiser S, Mesas-Burgos C, Söderman E, Frenckner B. Appendicitis in children--impact of US and CT on the negative appendectomy rate. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie. 2004;14(4):260-264. https://doi.org10.1055/s-2004-817841
• 7. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158(2):355-360. https://doi.org10.1148/radiology.158.2.2934762
• 8. Kotagal M, Richards MK, Flum DR, Acierno SP, Weinsheimer RL, Goldin AB. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. Journal of pediatric surgery. 2015;50(4):642-646. https://doi.org10.1016/j.jpedsurg.2014.09.080
• 9. Ferguson DM, Anderson KT, Tsao K. Diagnostic Imaging for Pediatric Appendicitis. In: Hunter CJ, ed. Controversies in Pediatric Appendicitis. Cham: Springer International Publishing; 2019:29-45.
• 10. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet (London, England). 2012;380(9840):499-505. https://doi.org10.1016/S0140-6736(12)60815-0
• 11. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ (Clinical research ed.). 2013;346:f2360. https://doi.org10.1136/bmj.f2360
• 12. Anderson KT, Bartz-Kurycki M, Austin MT, et al. Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation. Journal of pediatric surgery. 2017;52(12):1909-1915. https://doi.org10.1016/j.jpedsurg.2017.08.050
• 13. Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis. Radiology. 2018;286(3):1022-1029. https://doi.org10.1148/radiol.2017162755
• 14. Hardin DM, Jr. Acute appendicitis: review and update. American family physician. 1999;60(7):2027-2034.
• 15. Kalliakmanis V, Pikoulis E, Karavokyros IG, et al. Acute appendicitis: the reliability of diagnosis by clinical assessment alone. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2005;94(3):201-206. https://doi.org10.1177/145749690509400305
• 16. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Annals of emergency medicine. 1986;15(5):557-564. https://doi.org10.1016/s0196-0644(86)80993-3
• 17. Samuel M. Pediatric appendicitis score. Journal of pediatric surgery. 2002;37(6):877-881. https://doi.org10.1053/jpsu.2002.32893
• 18. Kelly BS, Bollard SM, Weir A, et al. Improving diagnostic accuracy in clinically ambiguous paediatric appendicitis: a retrospective review of ultrasound and pathology findings with focus on the non-visualised appendix. The British journal of radiology. 2019;92(1093):20180585. https://doi.org10.1259/bjr.20180585
• 19. Kim JR, Suh CH, Yoon HM, et al. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: A systematic review and meta-analysis. Journal of magnetic resonance imaging : JMRI. 2018;47(3):767-778. https://doi.org10.1002/jmri.25825
• 20. Yu YR, Rosenfeld EH, Dadjoo S, et al. Accuracy of surgeon prediction of appendicitis severity in pediatric patients. Journal of pediatric surgery. 2019;54(11):2274-2278. https://doi.org 10.1016/j.jpedsurg.2019.04.007
• 21. Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2013;20(7):697-702. https://doi.org10.1111/acem.12161
• 22. Nielsen JW, Boomer L, Kurtovic K, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template. Journal of pediatric surgery. 2015;50(1):144-148. https://doi.org 10.1016/j.jpedsurg.2014.10.033
• 23. Nordin AB, Sales S, Nielsen JW, Adler B, Bates DG, Kenney B. Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs. The Journal of surgical research. 2018;221:77-83. https://doi.org 10.1016/j.jss.2017.07.002
• 24. Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatric emergency care. 2019. https://doi.org 10.1097/PEC.0000000000001840
• 25. Thieme ME, Leeuwenburgh MM, Valdehueza ZD, et al. Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis. European radiology. 2014;24(3):630-637. https://doi.org10.1007/s00330-013-3044-2
• 26. Dillman JR, Gadepalli S, Sroufe NS, et al. Equivocal Pediatric Appendicitis: Unenhanced MR Imaging Protocol for Nonsedated Children-A Clinical Effectiveness Study. Radiology. 2016;279(1):216-225. https://doi.org10.1148/radiol.2015150941
• 27. Duke E, Kalb B, Arif-Tiwari H, et al. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR. American journal of roentgenology. 2016;206(3):508-517. https://doi.org10.2214/AJR.15.14544
• 28. Moore MM, Kulaylat AN, Hollenbeak CS, Engbrecht BW, Dillman JR, Methratta ST. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatric radiology. 2016;46(6):928-939. https://doi.org10.1007/s00247-016-3557-3
• 29. Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatric radiology. 2012;42(9):1056-1063. https://doi.org10.1007/s00247-012-2412-4
• 30. Petkovska I, Martin DR, Covington MF, et al. Accuracy of Unenhanced MR Imaging in the Detection of Acute Appendicitis: Single-Institution Clinical Performance Review. Radiology. 2016;279(2):451-460. https://doi.org10.1148/radiol.2015150468