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Çocuklarda Direkt Batın Grafisi ile Ultrason Bulgularının Apandisit Tanısındaki Değeri

Year 2015, Volume: 9 Issue: 1, 22 - 26, 01.04.2015

Abstract

Amaç: Karın ağrısı çocukluk çağında en sık hastaneye başvuru nedenlerinden biridir. Bu çalışmada, apandisit ön tanısıyla başvuran çocuklarda, ayakta direkt batın grafisi (ADBG) ve ultrasonografinin (US), apandisit tanısı koymaya katkılarının değerlendirilmesi amaçlanmıştır.Gereç ve Yöntemler: 2010 yılı içerisinde polikliniğimize apandisit ön tanısıyla başvuran hastaların ADBG ve US bulguları değerlendirildi. Bu hastalardan apandisit tanısı alanlar 1.grup, opere edilip, patolojik incelemesi normal bulunan olgular, gözlem için yatan ve ayaktan takip edilen hastalar 2. grup olarak adlandırıldı. ADBG’de apandisit tanısını düşündüren; sağ alt kadranda hava-sıvı seviyesi, yaygın hava-sıvı seviyesi, fekalit varlığı, properitoneal yağ gölgesinde silinme, sağdan uzaklaşan skolyoz, diyafram altı serbest hava, apendiks içinde gaz bulguları değerlendirildi. US’de; çekum ile ilişkili, kör sonlanan, US probu ile komprese edilemeyen ve anteroposterior çapı ≥ 6 mm ölçülen tübüler yapı patolojik apendiks olarak kabul edildi. Bu bulgulara ek olarak; apendikolit, mezenter eko artışı, apse varlığı, sağ altta bağırsakların bir araya toplanması gibi apandisit tanısını destekleyen bulgular da değerlendirildi.Bulgular: Bir yıllık sürede polikliniğimize apandisit ön tanısıyla 744 hasta başvurdu. 1. grupta 350 hasta, 2. grupta 394 hasta mevcuttu. Grupların yaş ortalamaları benzerdi (p>0,05). Hastaların %87.5’ine ADBG, %78.5’ine US yapılmıştı. US’lerin %59.4’ü hastanemizde, %40.6’sı başka bir merkezde yapılmıştı. 1. grupta ADBG’de apandisit tanısını düşündüren bulgulardan sağ altta hava-sıvı seviyesi %46.8, sağdan uzaklaşan skolyoz %10.5, fekalit %4.7 ve yağ gölgesinde silinme %4.1 oranında saptandı. ADBG’nin apandisit tanısındaki duyarlılığı %56.3, spesifikliği %66.9 bulundu. US ile 180 olguda apendiks çapı değerlendirilmişti, apendiks çapının ≥6mm saptanması durumunda %86.4 ve komprese edilememe varlığında %72.1 duyarlılıkla apandisit tanısı koyulabildiği bulundu. 1. grupta %16.2 apendikolit, %5.5 apse, bunlara ek olarak %37.5 oranında mezenter eko artışı saptandı. Tüm US sonuçları değerlendirildiğinde duyarlılık %66.9, spesifiklik %66.1 olarak bulundu.Sonuç: ADBG apandisitli olguların sadece yarısında pozitif bir bulgu verebilmektedir. Çocuk yaş grubunda apandisit tanısı koymada US duyarlılığı en yüksek radyolojik tetkiklerden biri olmakla birlikte, bu duyarlılık yüksek oranda kullanıcıya bağımlıdır. Sonuç olarak sadece radyolojik incelemelere dayanılarak apandisit tanısının koyulması veya ekarte etmesinin mümkün olmadığı, bu nedenle tüm radyolojik bulguların klinik bulgularla birlikte değerlendirilerek tanıya gidilmesinin daha uygun olacağı kanısındayız.

References

  • Kosloske AM, C. Lance Love, James E. Rohrer, Jane F. Goldthorn, Stuart R.Lacey. The Diagnosis of appendicitis in children: Outcomes of a strategy based on pediatric surgical evaluation. Pediatrics 2004;113:29-34.
  • Ergün E, Bilaloğlu P, Koşar U, Ünlübay D, Temel S. Akut apandisit tanısında opaksız spiral BT incelemenin yeri, US ve cerrahi sonuçları ile korelasyonu. Tanısal ve Girişimsel Radyoloji 2002; 8:231-6.
  • Paajanen H, Somppi E. Early childhood appendicitis is still a diffi cult diagnosis. Acta Paediatr 1996;85:459–62.
  • Rothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis and management. Ann Emerg Med 2000;36:39–51.
  • Parks NA, Schroeppel TJ. Update on imaging for acute appendicitis. Surg Clin N Am 2011;91:141-54.
  • van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 2008;249:97-106.
  • Shimkin PM. Radiology of acute appendicitis. Am J Roentgenol 1978;130:1001-4.
  • Turkyılmaz Z, Sonmez K, Konus O, Demiroğulları B, Karabulut R, Can Başaklar A, et al. Diagnostic value of plain abdominal radiographics in acute appendicitis in children. East Afr Med J 2004;81:104-7.
  • Phillpott JW, Swischuk LE, John SD. Appendicitis in the era of ultrasound: Are plain radiographs stil useful? Emerg Radiol 1997;4:68-71.
  • Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: A continuing diagnostic challenge. Pediatr Emerg Care 2000;16:160-2.
  • Gaitini D, Beck-Razi N, Mor-Yosef D, Fischer D, Ben Itzhak O, Krausz MM, et al. Diagnosing acute appendicitis in adults: Accuracy of color doppler sonography and mdct compared with surgery and clinical follow-up. AJR Am J Roentgenol 2008;190;1300-6.
  • Han HB, Hoepner FU, van Kalle T, Macdonald EBM, Prantl F, Spitzer IM, et al. Sonography of acute appendicitis in children: 7 years experience. Pediatr Radiol 1998;28:147-51.
  • Rodriguez DP, Vargas S, Callahan MJ, Zurakowski D, Taylor GA. Appendicitis in young children: Imaging experience and clinical outcomes. Am J Roentgenol 2006;186:1158-64.
  • Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology 2002;223:633-8.

The Value of Plain Abdominal X-Ray and Ultrasound Imaging in Childhood Appendicitis

Year 2015, Volume: 9 Issue: 1, 22 - 26, 01.04.2015

Abstract

Objective: Abdominal pain is one of the most common causes of hospitalization in childhood. Here we aimed to evaluate the contribution of positive fi ndings in the upright abdominal x-ray and ultrasound imaging for the diagnosis of acute appendicitis in children admitted with abdominal pain.Material and Methods: The upright abdominal x-ray and ultrasound images of children who presented to our outpatient clinic with suspected acute appendicitis in 2010 were analyzed retrospectively. The patients were divided into 2 groups. The children with a fi nal diagnosis of acute appendicitis constituted group 1, while the patients who were operated on for suspected appendicitis and where the pathology examination was negative for appendicitis and children who required only observation in the hospital or as outpatient for suspected appendicitis made up group 2. Findings accepted to suggest a diagnosis of acute appendicitis on plain x-ray were air-fl uid level at the right lower quadrant, diffuse air-fl uid evels, presence of fecalith, blurring or loss of the properitoneal fat stripe, lumbar scoliosis with a left convexity, free air under the diaphragm,
and gas shadow in the appendix. The criterion for the diagnosis of appendicitis by US was detection of a non-compressible, fl uid-fi lled
and blind-ended tubular intestinal segment in connection with the cecum that was more than 6 mm in diameter. Furthermore, fi ndings that
support the diagnosis of appendicitis such as presence of an appendicolith, increased periappendiceal mesenteric echogenicity, presence
of abscess and conglomeration of intestinal loops to the right lower quadrant were also evaluated.
Results: A total of 744 patients presented at our outpatient clinic for suspected acute appendicitis during the year 2010. Group I
consisted of 350 and group II of 394 children. The mean age was comparable between the groups (p>0.05). Upright abdominal x-ray
was available for 87.5% and ultrasound imaging for 78.5% the patients. Only 59.4% of the ultrasound examinations were carried out by
our institution’s radiology department while the rest (40.6%) were performed elsewhere. In group I, the fi ndings on plain abdominal x-ray
suggestive of acute appendicitis were as follows; air-fl uid levels at right lower quadrant (46.8%), lumbar scoliosis with left-sided convexity
(10.5%), presence of fecalith (4.7%), and blurring of the right properitoneal fat shadow (4.1%). The sensitivity of plain abdominal x-ray
for acute appendicitis was 56.3% with a specifi city of 66.9%. The diameter of the appendix could be measured only in 180 patients with
ultrasound imaging. An appendix diameter ≥ 6 mm could be used to diagnose appendicitis with 86.4% sensitivity while unresponsiveness
to compression could predict acute appendicitis with a sensitivity of 72.1%. In group I, appendicolith, abscess and increased mesenteric
echogenity on ultrasound imaging were found in 16.2%, 5.5% and 37.5% of the patients respectively. The total sensitivity and specifi city
of ultrasound imaging were 66.9% and 66.1% respectively.
Conclusion: Only half of the children with acute appendicitis have a positive fi nding on plain x-ray. Although variability exists depending on
the experience of the radiologist, ultrasound imaging is one of the most sensitive imaging modalities for the diagnosis of childhood acute
appendicitis. In conclusion, we believe that acute appendicitis cannot be diagnosed by relying solely on imaging features and correlation of
the imaging features with clinical parameters is essential.

References

  • Kosloske AM, C. Lance Love, James E. Rohrer, Jane F. Goldthorn, Stuart R.Lacey. The Diagnosis of appendicitis in children: Outcomes of a strategy based on pediatric surgical evaluation. Pediatrics 2004;113:29-34.
  • Ergün E, Bilaloğlu P, Koşar U, Ünlübay D, Temel S. Akut apandisit tanısında opaksız spiral BT incelemenin yeri, US ve cerrahi sonuçları ile korelasyonu. Tanısal ve Girişimsel Radyoloji 2002; 8:231-6.
  • Paajanen H, Somppi E. Early childhood appendicitis is still a diffi cult diagnosis. Acta Paediatr 1996;85:459–62.
  • Rothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis and management. Ann Emerg Med 2000;36:39–51.
  • Parks NA, Schroeppel TJ. Update on imaging for acute appendicitis. Surg Clin N Am 2011;91:141-54.
  • van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 2008;249:97-106.
  • Shimkin PM. Radiology of acute appendicitis. Am J Roentgenol 1978;130:1001-4.
  • Turkyılmaz Z, Sonmez K, Konus O, Demiroğulları B, Karabulut R, Can Başaklar A, et al. Diagnostic value of plain abdominal radiographics in acute appendicitis in children. East Afr Med J 2004;81:104-7.
  • Phillpott JW, Swischuk LE, John SD. Appendicitis in the era of ultrasound: Are plain radiographs stil useful? Emerg Radiol 1997;4:68-71.
  • Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: A continuing diagnostic challenge. Pediatr Emerg Care 2000;16:160-2.
  • Gaitini D, Beck-Razi N, Mor-Yosef D, Fischer D, Ben Itzhak O, Krausz MM, et al. Diagnosing acute appendicitis in adults: Accuracy of color doppler sonography and mdct compared with surgery and clinical follow-up. AJR Am J Roentgenol 2008;190;1300-6.
  • Han HB, Hoepner FU, van Kalle T, Macdonald EBM, Prantl F, Spitzer IM, et al. Sonography of acute appendicitis in children: 7 years experience. Pediatr Radiol 1998;28:147-51.
  • Rodriguez DP, Vargas S, Callahan MJ, Zurakowski D, Taylor GA. Appendicitis in young children: Imaging experience and clinical outcomes. Am J Roentgenol 2006;186:1158-64.
  • Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology 2002;223:633-8.
There are 14 citations in total.

Details

Other ID JA55UJ94FA
Journal Section Research Article
Authors

Ahmet Ertürk This is me

Ayşe Karaman This is me

Özlem Balcı This is me

İbrahim Karaman This is me

Yusuf Hakan Çavuşoğlu This is me

İsmet Faruk Özgüner This is me

Beytullah Yağız This is me

Yasemin Taşçi Yıldız This is me

Derya Erdoğan This is me

Publication Date April 1, 2015
Submission Date April 1, 2015
Published in Issue Year 2015 Volume: 9 Issue: 1

Cite

Vancouver Ertürk A, Karaman A, Balcı Ö, Karaman İ, Çavuşoğlu YH, Özgüner İF, Yağız B, Yıldız YT, Erdoğan D. The Value of Plain Abdominal X-Ray and Ultrasound Imaging in Childhood Appendicitis. Türkiye Çocuk Hast Derg. 2015;9(1):22-6.


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