Evaluation of Acute Appendicitis in Children Using Bedside
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Evaluation of Acute Appendicitis in Children using Bedside Ultrasound Amanda Bates Appendicitis Epidemiology Most common cause of emergent abdominal surgery in children Rare in very young children More common in males than females Most common in children age 10-20yrs Classic presentation of anorexia, vomiting, & periumbilical pain migrating to RLQ occurs in only half of all patients Perforation = surgical emergency Diagnosing Appendicitis in the ED Clinical diagnosis HPI – anorexia, periumbilical pain migrating to RLQ, fever, nausea/vomiting PE – Rovsing sign, Obturator sign, Iliopsoas sign, rebound/guarding, RLQ tenderness Cannot reliably exclude appendicitis from ddx when classic symptoms are absent Multiple pediatric clinical scoring systems Alvarado Score Pediatric appendicitis score Refined Low-Risk Appendicitis Score Diagnosing Appendicitis in the ED Unique challenges with pediatric population May not be able to communicate clearly/verbalize where pain is located Symptoms may be nonspecific Clinical presentation varies by age Children <5yrs: abdominal pain (diffuse vs. RLQ), diarrhea, fever, N/V, lethargy, irritability Children 5-12yrs: abdominal pain, N/V, limp/R hip pain, trouble walking, diarrhea, anorexia Children >12yrs: may present similarly to adults Diagnosing Appendicitis in the ED Differential for abdominal complaints in children Infants: necrotizing enterocolitis, volvulus, colic, gastroenteritis, constipation, testicular torsion Toddlers: intussusception, volvulus, testicular torsion, gastroenteritis, constipation, UTI Young children: torsion, gastroenteritis, constipation, UTI Adolescents: torsion, ectopic/intrauterine pregnancy, DKA, IBD, PID, gastroenteritis Diagnosing Appendicitis in the ED Can dx with CT or ultrasound Concern with exposing children to radiation limits use of CT ACEP guidelines for pediatric population Recommend ultrasound as initial imaging modality Ultrasound can confirm but not exclude appendicitis CT can definitively confirm or exclude appendicitis Ultrasound Technique Pain control High frequency linear array probe Place on point of maximal tenderness Graded compression to displace bowel gas Visualize in longitudinal and transverse planes Identifying the Appendix Find ascending colon – no peristalsis, contains gas and fluid – follow to the cecum & identify terminal ileum Appendix should be at cecal tip ~1cm below ileum Use psoas muscle and iliac vessels as landmarks Identifying the Appendix Normal anatomy Psoas Image: http://www.minnisjournals.com.au/ajum/article/Appendicitis-21 Diagnosing Appendicitis Criteria include: tubular structure, blind ending, noncompressible, >6mm in diameter, nonperistalsing Transverse view – “target sign” Doppler can show increased flow to wall of appendix +/- appendicolith – hyperechoic, cause shadowing + sonographic McBurney’s Limitations in visualizing the appendix: variations in anatomy, perforation, pain, habitus, bowel gas Acute Appendicitis - Longitudinal Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874 Acute Appendicitis - Transverse Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874 Acute Appendicitis Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874 Evaluation by EM Physicians Evaluation by EM Physicians Participating pediatric attendings/fellows trained with 30 min lecture & 30 min of hands on practice 150 scans, 50 cases of verified acute appendicitis Verified by surgical pathology or phone follow up 1 false negative, 5 false positives Limitations: single center study, convenience sample EM sonographers demonstrated high specificity in identifying acute appendicitis Study found reduction in CT use and decreased ED LOS CT rate dec from 44.2% to 27.3% LOS 154 min vs. 288 min for radiology US and 487 min for CT Evaluation by EM Physicians Evaluation by EM Physicians 13 peds EM sonographers 1 faculty physician trained 12 fellows (no prior experience scanning bowel) with 45 min lecture & 5 practice exams 264 scans, 85 cases of verified acute appendicitis Verified by surgical pathology or phone follow up 13 false positive studies Limitations: single center, lead sonographer performed 43% of study imaging Ultimately POCUS performed by EM physicians had high specificity, especially in sonographers with more scanning experience Conclusion Ultrasound can be used to confirm acute appendicitis in children, a population in which it’s advisable to limit exposure to radiation with CT scans CT definitive test if US equivocal/appendix not visualized Bedside ultrasound performed by trained EM physicians can have high specificity comparable to CT or formal US studies References Clinical Policy: Evaluation and Management of Suspected Appendicitis. American College of Emergency Physicians. http://www.acep.org/Clinical---PracticeManagement/Clinical-Policy--Evaluation-and-Management-of-SuspectedAppendicitis. Accessed October 17, 2015 Appendicitis. Medscape. http://emedicine.medscape.com/article/773895overview. Accessed October 17, 2015 Wessen DE. Acute Appendicitis in Children. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2015 Focus On: Ultrasound for Appendicitis. American College of Emergency Physicians. http://www.acep.org/Continuing-Education-top-banner/Focus-On--Ultrasound-forAppendicitis. Accessed October 17, 2015 Abdomen and Retroperitoneum. Ultrasound Cases. http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874. Accessed October 17, 2015 References Polites SF, Mohamed MI, et al. A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children. Surgery. 2014; 156:2 Elikashvili I, Tay ET, Tsung JW. The Effect of Point-of-care Ultrasonography of Emergency Department Length of Stay and Computed Tomography Utilization in Children with Suspected Appendicitis. Academic Emergency Medicine. 2014; 163-170 Sivitz AB, Cohen SG, Tejani C. Evaluation of Acute Appendicitis by Pediatric Emergency Physician Sonography. Annals of Emergency Medicine. 2014; 64:4 SonoTutorial: Appendicitis assessment by ultrasound. SonoSpot: Topics in Bedside Ultrasound. https://sonospot.wordpress.com/2014/04/10/sonotutorial-appendicitisassessment-by-ultrasound-foamed-foamus/.
