Weekly Article: May 28 2013

Dear All, 

Happy Memorial Day -and here is your article of the week. 

I was actually looking for something in the theme of my last weekly article... about refugees and their emergency care in the US, but it turns out, there is barely anything published; an open field it seems for anyone interested. 

So then I went to a question I keep asking myself:

- A patient presents with abdominal pain and you are concerned about acute appendicitis. You order an U/S but the appendix is not visualized, so you end up having to do a CT abd/pelvis and therefore are back to the same problem of radiation and time spent in the ED with delay of care. However, we always have something in the report about fluid in the pelvis, lymphadenopathy .... but what do those mean?  A potential answer could be found in the following article Appendix Not Seen (abstract below): 

In this retrospective study, 241 U/Ss could not visualize the appendix of which 8.8% had acute appendicitis by pathology. The specificity of moderate-to-large amounts of free fluid is 98%, phlegmon at 100%, pericecal inflammatory fat changes at 98%, and any free fluids with prominent lymph nodes at 81%. The odds ratio of appendicitis increases from 0.56 to 0.64 to 2.3 and 17.5, respectively, when there were 2 and 3 ultrasonographic inflammatory markers identified.

How can this change my practice? Especially in boys, with very high clinical suspicion of appendicitis, you can consider avoiding the CT if the child has multiple secondary findings.... if you can convince surgery of this, and there are no signs of peritonitis/abscess I guess. 

Happy Read, 

Rasha 

ABSTRACT:

Pediatr Emerg Care. 2013 Apr;29(4):435-9. doi: 10.1097/PEC.0b013e318289e8d5.

Appendix not seen: the predictive value of secondary inflammatory sonographic signs.

Estey A, Poonai N, Lim R.

Source

Department of Paediatrics, University of Alberta, Edmonton, Alberta, Canada.

Abstract

BACKGROUND:

Acute appendicitis is the most prevalent emergency surgical diagnosis in children. Although traditionally a clinical diagnosis, the diagnosis of acute appendicitis is uncertain in approximately 30% of pediatric patients. In attempts to avoid a misdiagnosis and facilitate earlier definitive care, imaging modalities such as ultrasonography have become important tools. In many pediatric studies, the absence of a visualized appendix with no secondary sonographic features has been reported as a negative study result, and a study where the appendix is not seen but demonstrates secondary features is often deemed equivocal. With ultrasound appendiceal detection rates reported at 60% to 89%, the dilemma of the nonvisualized appendix or equivocal study is frequently faced by clinicians.

OBJECTIVE:

This study aimed to assess the value of the nonvisualized appendix on ultrasound and the association of secondary sonographic findings in pediatric patients with acute right lower quadrant pain undergoing ultrasound, in whom acute appendicitis was a diagnostic consideration.

METHODS:

Retrospective case review of 662 consecutive children (age < 18 years) presenting to a pediatric emergency department with clinically suspected appendicitis, who had graded compression sonographic studies during the 24-month study period, was performed.

RESULTS:

The appendix could not be visualized in 241 studies (37.7%). An alternate diagnosis was identified via sonography in 47 patients (19.5%). Twenty-five patients (12.9%) were taken for surgery where 17 (8.8%) had acute appendicitis confirmed via pathology. The specificity of moderate-to-large amounts of free fluid is 98%, phlegmon at 100%, pericecal inflammatory fat changes at 98%, and any free fluids with prominent lymph nodes at 81%. The odds ratio of appendicitis increases from 0.56 to 0.64 to 2.3 and 17.5, respectively, when there were 2 and 3 ultrasonographic inflammatory markers identified.

CONCLUSIONS:

Although uncommonly seen, large amounts of free fluid, phlegmon, and pericecal inflammatory fat changes were very specific signs of acute appendicitis. In the absence of a distinctly visualized appendix, the presence of multiple secondary inflammatory changes provides increasing support of a diagnosis of acute appendicitis.