Advertisement

A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children

      Background

      A diagnostic algorithm for appendicitis in children was created to reduce computed tomography (CT) use owing to the risk of cancer from radiation exposure and cost of CT. This study evaluates the impact of the algorithm on CT use and diagnostic accuracy of appendicitis.

      Methods

      Patients ≤18 years who underwent appendectomy for suspected appendicitis after presenting to the emergency department for 2 years before and 3 years after algorithm implementation were identified. Clinical characteristics and outcomes, including use of CT and negative appendectomy rate, were compared between the pre- and post-implementation periods. Multivariable analysis was used to determine the impact of CT on negative appendectomy.

      Results

      We identified 331 patients—41% in the pre- and 59% in the post-implementation period. CT utilization decreased from 39% to 18% (P < .001) after implementation. The negative appendectomy rate increased from 9% to 11% (P = .59). Use of CT did not impact the risk of negative appendectomy (P = .64).

      Conclusion

      Utilization of CT was significantly reduced after implementation of a diagnostic algorithm for appendicitis without impacting diagnostic accuracy. Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Birnbaum B.A.
        • Wilson S.R.
        Appendicitis at the millennium.
        Radiology. 2000; 215: 337-348
        • Mathews J.D.
        • Forsythe A.V.
        • Brady Z.
        • Butler M.W.
        • Goergen S.K.
        • Byrnes G.B.
        • 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. 2013; 346: f2360
        • Miglioretti D.L.
        • Johnson E.
        • Williams A.
        • Greenlee R.T.
        • Weinmann S.
        • Solberg L.I.
        • et al.
        The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk.
        JAMA Pediatr. 2013; 167: 700-707
        • Krajewski S.
        • Brown J.
        • Phang P.T.
        • Raval M.
        • Brown C.J.
        Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis.
        Can J Surg. 2011; 54: 43-53
        • Rao P.M.
        • Rhea J.T.
        • Novelline R.A.
        • Mostafavi A.A.
        • McCabe C.J.
        Effect of computed tomography of the appendix on treatment of patients and use of hospital resources.
        N Engl J Med. 1998; 338: 141-146
        • Pena B.M.
        • Taylor G.A.
        • Lund D.P.
        • Mandl K.D.
        Effect of computed tomography on patient management and costs in children with suspected appendicitis.
        Pediatrics. 1999; 104: 440-446
        • Pena B.M.
        • Taylor G.A.
        • Fishman S.J.
        • Mandl K.D.
        Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis.
        Pediatrics. 2002; 110: 1088-1093
        • Drake F.T.
        • Florence M.G.
        • Johnson M.G.
        • Jurkovich G.J.
        • Kwon S.
        • Schmidt Z.
        • et al.
        Progress in the diagnosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program.
        Ann Surg. 2012; 256: 586-594
        • McDonald G.P.
        • Pendarvis D.P.
        • Wilmoth R.
        • Daley B.J.
        Influence of preoperative computed tomography on patients undergoing appendectomy.
        Am Surg. 2001; 67: 1017-1021
        • Partrick D.A.
        • Janik J.E.
        • Janik J.S.
        • Bensard D.D.
        • Karrer F.M.
        Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children.
        J Pediatr Surg. 2003; 38: 659-662
        • Saucier A.
        • Huang E.Y.
        • Emeremni C.A.
        • Pershad J.
        Prospective evaluation of a clinical pathway for suspected appendicitis.
        Pediatrics. 2014; 133: e88-e95
        • Russell W.S.
        • Schuh A.M.
        • Hill J.G.
        • Hebra A.
        • Cina R.A.
        • Smith C.D.
        • et al.
        Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy.
        Pediatr Emerg Care. 2013; 29: 568-573
        • Antevil J.L.
        • Rivera L.
        • Langenberg B.J.
        • Hahm G.
        • Favata M.A.
        • Brown C.V.
        Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation.
        J Am Coll Surg. 2006; 203: 849-856
        • Bachur R.G.
        • Hennelly K.
        • Callahan M.J.
        • Chen C.
        • Monuteaux M.C.
        Diagnostic imaging and negative appendectomy rates in children: effects of age and gender.
        Pediatrics. 2012; 129: 877-884
        • Mariadason J.G.
        • Wang W.N.
        • Wallack M.K.
        • Belmonte A.
        • Matari H.
        Negative appendectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendectomy.
        Ann R Coll Surg Engl. 2012; 94: 395-401
        • Martin A.E.
        • Vollman D.
        • Adler B.
        • Caniano D.A.
        CT scans may not reduce the negative appendectomy rate in children.
        J Pediatr Surg. 2004; 39: 886-890
        • Kosloske A.M.
        • Love C.L.
        • Rohrer J.E.
        • Goldthorn J.F.
        • Lacey S.R.
        The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation.
        Pediatrics. 2004; 113: 29-34
        • Bendeck S.E.
        • Nino-Murcia M.
        • Berry G.J.
        • Jeffrey Jr., R.B.
        Imaging for suspected appendicitis: negative appendectomy and perforation rates.
        Radiology. 2002; 225: 131-136
        • Wagner P.L.
        • Eachempati S.R.
        • Soe K.
        • Pieracci F.M.
        • Shou J.
        • Barie P.S.
        Defining the current negative appendectomy rate: for whom is preoperative computed tomography making an impact?.
        Surgery. 2008; 144: 276-282
        • McGory M.L.
        • Zingmond D.S.
        • Nanayakkara D.
        • Maggard M.A.
        • Ko C.Y.
        Negative appendectomy rate: influence of CT scans.
        Am Surg. 2005; 71: 803-808
        • Adibe O.O.
        • Amin S.R.
        • Hansen E.N.
        • Chong A.J.
        • Perger L.
        • Keijzer R.
        • et al.
        An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children.
        J Pediatr Surg. 2011; 46: 192-196
        • Garcia Pena B.M.
        • Cook E.F.
        • Mandl K.D.
        Selective imaging strategies for the diagnosis of appendicitis in children.
        Pediatrics. 2004; 113: 24-28
        • Sivit C.J.
        • Applegate K.E.
        Imaging of acute appendicitis in children. Seminars in Ultrasound.
        CT and MRI. 2003; 24: 74-82
        • Dennett K.V.
        • Tracy S.
        • Fisher S.
        • Charron G.
        • Zurakowski D.
        • Calvert C.E.
        • et al.
        Treatment of perforated appendicitis in children: what is the cost?.
        J Pediatr Surg. 2012; 47: 1177-1184