Abstract 474 Health Services Research: Quality Platform, Saturday, 5/1

Background: Focused computed tomography with rectal contrast (CTRC) has been shown to be 98% accurate in the diagnosis of appendicitis in adults.

Objective: To determine the accuracy and effect of ultrasonography (US) and CTRC on the diagnosis and management of appendicitis in children.

Methods: Design: Prospective cohort study. Subjects: Children 3-21 years with right lower quadrant pain suspected of having appendicitis. Setting: Emergency department (ED) of a large, urban pediatric teaching hospital. Imaging algorithm: The consulting surgeon evaluated all children with suspected appendicitis. Those children with unequivocal clinical presentations for appendicitis underwent appendectomy without imaging studies. Those children with equivocal clinical findings comprised the study cohort and were initially evaluated with pelvic US. If the US was definitive for appendicitis, laparotomy was performed. If the US was normal or inconclusive, helical CT of the pelvis was obtained using rectal contrast. Management decisions: Surgeons were asked to estimate the likelihood of appendicitis and management plans (discharge home from the ED, admit for inpatient observation, or proceed to operating room [OR] for appendectomy) before imaging, after US and after CTRC. Outcomes were determined by pathology in children who underwent appendectomy and by clinical follow-up in those managed nonoperatively.

Results: 107 children (age range 3-20 years, mean=11.5±4.4 years) underwent US and 82/107 had CTRC imaging. 16/107 children had surgery after US while 26/82 patients underwent laparotomy after CTRC. CTRC was not performed in 9 children after US due to resolved symptoms or established alternative diagnoses. Appendicitis was proven in 39/107 (36%) patients. Evaluation of each imaging modality demonstrated: (Table) US identified a normal appendix in only 3/65 (4.6%) children without appendicitis. CTRC identified the normal appendix in 49/56 (88%) children without appendicitis. US had no effect on the surgeons' likelihood of appendicitis in 43/107 (40%) children, while CTRC had no effect in 11/82 (13%) children (p<.01). Initial management plans changed in 22/107 (21%) patients after US and included: observation to discharge home (4), observation to OR (13), discharge home to observation (3) and OR to observation (2). Initial management plans changed in 58/82 (71%) of children after CTRC imaging (p<.01) and included: observation to discharge home (34), observation to OR (22), OR to observation (1) and OR to discharge home (1).

Table 1 No caption available.
Full size table

Conclusion: Focused CTRC is 96% accurate in children with negative US and significantly effects management of suspected pediatric appendicitis.