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dectomy (5%) and perforation (17%) were achieved without the potential costs and radiation exposure of excess
imaging. Pediatrics 2004;113:29 34; appendicitis, appendectomy, pediatric surgeon, CT, computed tomography.
ABBREVIATIONS. CT, computed tomography; US, ultrasound;
WBC, white blood cell.
cute appendicitis is the most common surgical emergency in children and adolescents in
the United States. In 1999, an estimated
59 000 children 15 years old were diagnosed with
appendicitis.1 Despite its frequency, however, the
diagnosis of appendicitis in a child is sometimes
difficult. Recent reports recommended imaging, particularly computed tomography (CT) with rectal contrast, as the optimal diagnostic study in both adults2
and children.3,4 One protocol used imaging (usually
both ultrasound [US] and CT scan with rectal contrast) in 78.5% of children with possible appendicitis.3,5 CT scanning was calculated as cost-effective in
children based on a negative appendectomy rate of
23%.6 Because in our west Texas pediatric surgical
practice we rely on a clinically based strategy with
selective use of imaging, and because we considered
a 23% rate of negative appendectomy to be unacceptably high, we undertook the present study. We reviewed the outcomes of 356 children and adolescents
referred to us for possible appendicitis over a 3-year
period and calculated the accuracy of our diagnostic
strategy compared with the accuracy of imaging.
METHODS
The pediatric surgeon authors (A.M.K., J.F.G., and S.R.L.) practice in a west Texas city of 204 000 population, with a referral area
consisting of 62 primarily rural counties in west Texas and eastern
New Mexico. The total population served is 1.4 million. No other
pediatric surgeon practiced in this area during the study period.
Children and adolescents with possible appendicitis were referred
to the pediatric surgeon by a pediatrician, a family practitioner, or
an emergency department physician. Patients were treated at 2
hospitals: Texas Tech University Hospital, a 325-bed teaching
hospital with an 88-bed pediatric hospital located on one floor,
and Covenant Childrens Hospital, a 73-bed pediatric hospital that
is a separate wing of a 400-bed community hospital. The study
was approved by the institutional review boards of both hospitals.
Residents in general surgery (Post-Graduate Year 4 or Post-Graduate Year 2) assisted the 3 pediatric surgeons in the diagnosis and
treatment of all patients. The diagnostic call, however, was
made by the attending pediatric surgeon. Radiographic studies
were performed by general radiologists at each hospital; there
were no specialty-trained pediatric radiologists at either institution.
The strategy for diagnosis of appendicitis (Fig 1), agreed on by
29
not referred and thus were excluded from this patient population.)
Incidental appendectomies performed as part of another procedure were excluded. A standardized data collection tool was used
that included age, gender, duration of symptoms, county of residence, imaging (US or 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, and pathologic diagnosis. Pathologic criteria for acute appendicitis were mucosal and intramural inflammation. The presence
of advanced appendicitis, eg, right lower quadrant peritonitis
with or without gross appendiceal perforation was based on the
surgeons operative note. The presence of perforation was based
on the pathologists 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.
Two reviewers (including A.M.K.) performed 95% of chart reviews, and 2 individuals (including A.M.K.) performed all the
data entry. Outliers were double-checked by a second review of
the original record. The data were entered into a computer program (Epi Info 2002, Centers for Disease Control and Prevention,
Atlanta, GA) for analysis. Significance tests were performed to
compare differences between groups. Means were tested by using
the Student t or the Kruskal-Wallace test. 2 tests were used for
comparison of categorical variables. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated by standard epidemiologic methods.7 Accuracy was calculated by number of patients with correct diagnoses/total number
of patients. Reports from US or CT which were diagnostically
equivocal were not included in the calculation of accuracy. The
study did not attempt to analyze separate aspects of the pediatric
surgical evaluation (history, physical examination, WBC count,
differential count, or urinalysis) for determination of rank of importance in the diagnostic process.
30
RESULTS
No. of Patients
Gastroenteritis
Constipation
Abdominal pain
Viral syndrome
Ovarian cyst
Pneumonia
Pharyngitis/strep
Mesenteric lymphadenitis
Pancreatitis
Pyelonephritis/urinary tract infection
Other*
Total
54
31
23
9
7
6
4
2
2
2
6
146
* 1 each: abdominal wall strain, diabetic ketoacidosis, dysmenorrhea, infectious mononucleosis, vomiting (unspecified), and not
recorded.
ARTICLES
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31
TABLE 2.
Epidemiologic Measures of Pediatric Surgical Protocol and of Imaging Techniques for
Diagnosis of Appendicitis in This Series
Basis of
Diagnosis
No. of
Patients
Sensitivity
(%)
Specificity
(%)
PPV
(%)
NPV
(%)
Accuracy
(%)
Pediatric surgical
protocol
US
CT scan
356
99.5
92.5
95.0
99.3
96.6
112
70
76.5
87.2
88.4
80.0
88.6
93.2
76.0
66.7
81.9
90.3
Study
Basis of
Diagnosis
No. of
Patients
Age*
(y)
Sensitivity
(%)
Specificity
(%)
PPV
(%)
NPV
(%)
Accuracy
(%)
Negative
Appendix
(%)
Rao8
Weyant et al9
Pen a et al3
Present study
CT scan
CT scan
US CT
Clinical selective
imaging
100
625
139
356
28
35
321
9.6
98
96
94
99
98
16
94
92
98
90
90
95
98
NS
97
99
98
88
94
97
13
12
12
5
mous influence on practice. Few reports have questioned the accuracy or wisdom of CT scanning for
appendicitis.9,12 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.13
Evaluation by a pediatric surgeon early in the course
of a child with possible appendicitis has rarely been
emphasized.
Our data, however, support a diagnostic strategy
based primarily on the clinical acumen of a pediatric
surgeon rather than imaging. Our sensitivity (99%),
specificity (93%), diagnostic accuracy (97%), and
negative appendectomy rate (5%) compare favorably
with recent reports of imaging-based strategies in
both adults and children (Table 3). Our rate of perforated appendicitis (17%) compares favorably to
other large pediatric series since 1995, the rates of
which have ranged from 15.5% to 47%.4,14 18 Many
different factors are associated with the perforation
rate, which in general varies inversely with age and
directly with duration of illness. Surprisingly, our
large proportion of children (40%) from rural counties did not have an increased rate of perforation
compared with local children, despite their longer
duration of symptoms.
Because appendicitis is an evolving pathologic
process, and because early appendicitis may be impossible to differentiate from other causes of abdominal pain in children, clinical reevaluation after a
period of observation and supportive care may be
necessary. Cost analyses, however, may be biased
toward testing to make the diagnosis at first encounter; if appendicitis can be ruled out (by testing), the
patient may be sent home from the emergency department. In an urban setting, this strategy may be
successful, especially if intravenous fluid resuscitation has been completed during the period of testing.
In our rural west Texas population, however, discharge home from the emergency department was
rarely an option.
The 25 children who underwent appendectomy
32
versity childrens hospital (Childrens Hospital, Boston, MA) depended on a coterie of pediatric
radiologists with special interest and expertise in the
radiographic diagnosis of pediatric appendicitis.3 6
The cost of imaging (US CT, in 1997 dollars) was
reported as $907 per patient.6 Other tertiary centers
have chosen opposite strategies with successful outcomes. One large, urban, university childrens hospital (Childrens Hospital Medical Center, Cincinnati, OH), for example, used a clinical, evidencebased pathway for appendicitis in which pediatric
surgical evaluation was conducted before any tests
were ordered. Imaging was done in doubtful cases.
Quality of care, using as indicators the rates of appendiceal perforation (25%) and negative appendectomy (12%), was unchanged with this pathway, and
hospital costs were reduced significantly.19 A diagnostic strategy that depends on the clinical acumen
of a pediatric surgeon may be more generalizable
than one that requires the technologic skill and expertise unique to pediatric radiologists.
Improved technology does not always translate
into improved diagnosis and patient outcomes. Weyant et al9 studied 625 patients with appendicitis but
found no correlation between CT findings and
pathologically proven appendiceal disease. A population-based study from the state of Washington analyzed 63 707 appendectomies performed during a
12-year period (19871998), during which great improvements in CT, US, and laparoscopy occurred.
Contrary to expectation, however, the incidence of
negative appendectomies (15.5%) and perforation
(25.8%) did not change with the availability of advanced diagnostic testing.21
A limitation of our investigation is its retrospective
format. Despite our preference that imaging studies
be ordered by the pediatric surgeon, a CT scan,
which some authors now consider as the definitive
imaging study,4 was ordered in 50 (14%) of 356 children by the referring physician before pediatric surgical evaluation. We could not determine retrospectively whether such prereferral imaging was helpful
or superfluous in making the diagnosis of appendicitis; however, the data suggest that it may have been
superfluous, because the accuracy of diagnosis of
appendicitis was no better with prereferral imaging
(94%) than without it (95%).
Because the children in our study population were
prescreened by another physician before referral,
they were more likely to have appendicitis than an
unscreened population of children with the initial
presentation of abdominal pain. Selection thus
would account for our relatively high proportion of
children with confirmed appendicitis (62%). Selection by prescreening, however, does not affect the
study outcomes, ie, the perforation rate or negative
appendectomy rate, because the denominator of
these outcomes is the number of children who actually undergo operation. Further, selection by prescreening does not affect the epidemiologic measures
(sensitivity, specificity, positive predictive value,
negative predictive value, and accuracy), because
these measures are based on correct diagnoses, not
on the proportion of subjects with appendicitis. A
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The charges issues has become a focus of healthcare advocates, who have
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charges, they ask the uninsured to pay the full rates and then pursue them
aggressively to collect.
Lagnado L. Hospitals urged to end harsh tactics for billing uninsured. Wall Street Journal, July 7, 2003
Submitted by Student
34
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