Evaluation of Acute Appendicitis in Children using Bedside Ultrasound Amanda Bates.
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Transcript of Evaluation of Acute Appendicitis in Children using Bedside Ultrasound Amanda Bates.
Evaluation of Acute Appendicitis in Children using Bedside UltrasoundAmanda 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
Iliac Vessels
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---Practice-Management/Clinical-Policy--Evaluation-and-Management-of-Suspected-Appendicitis. Accessed October 17, 2015
Appendicitis. Medscape. http://emedicine.medscape.com/article/773895-overview. 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-for-Appendicitis. 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-appendicitis-assessment-by-ultrasound-foamed-foamus/.