Ultrasound of paediatric appendicitis and its secondary sonographic signs: providing a more meaningful finding

Abstract

Sonography is an important clinical tool in diagnosing appendicitis in children as it can obviate both exposure to potentially harmful ionising radiation from computed tomography scans and the need for unnecessary appendicectomies. This review examines the diagnostic accuracy of ultrasound in the identification of acute appendicitis, with a particular focus on the the utility of secondary sonographic signs as an adjunct or corollary to traditionally examined criteria. These secondary signs can be important in cases where the appendix cannot be identified with ultrasound and a more meaningful finding may be made by incorporating the presence or absence of secondary sonographic signs. There is evidence that integrating these secondary signs into the final ultrasound diagnosis can improve the utility of ultrasound in cases where appendicitis is expected, though there remains some conjecture about whether they play a more important role in negative or positive prediction in the absence of an identifiable appendix.

Analysis of the predictive value of clinical and sonographic variables in children with suspected acute appendicitis using decision tree algorithms

“…These cases are made more meaningful with the exclusion, or recognition and evaluation of secondary signs of appendicitis . Secondary signs such as mesenteric inflammation, free fluid and prominent lymph nodes can suggest the presence of an inflamed appendix . The approach to appendicitis ultrasound is changing with increased awareness of secondary sonographic signs within both radiology and emergency medicine as well as review of traditional sonographic criteria.…”

“…8 Secondary signs such as mesenteric inflammation, free fluid and prominent lymph nodes can suggest the presence of an inflamed appendix. 9 The approach to appendicitis ultrasound is changing with Funding: None. Conflict of interest: None.…”

Aeromedical retrieval for suspected appendicitis in rural and remote paediatric patients

“…Differentiating those children with abdominal pain who require surgical treatment from those who could be managed expectantly or medically can be difficult, particularly in the remote and rural context, where access to diagnostic testing is intermittent or delayed. Clinical examination has a high sensitivity and a low specificity, whilst ultrasound has a high positive predictive value and the negative predictive value . Ultrasound is recommended in addition to clinical examination in suspected acute appendicitis in paediatric patients, with CT scanning reserved for follow‐up of equivocal results…”

“…Clinical examination has a high sensitivity and a low specificity, whilst ultrasound has a high positive predictive value and the negative predictive value. [5][6][7] Ultrasound is recommended in addition to clinical examination in suspected acute appendicitis in paediatric patients, with CT scanning reserved for follow-up of equivocal results. 3,8 Ultrasound can reduce the rates of appendicectomy, with one study finding that increased rates of diagnostic imaging were associated with lower negative appendicectomy results (NARs) for all age and gender subgroups, other than children younger than 5 years.…”

Stumped? It could be stump appendicitis

“…Traditional sonographic criteria for diagnosing acute appendicitis have been applied to the appendiceal stump, with a transverse diameter greater than 6 mm, non‐compressibility and wall hyperaemia all being concerning for stump appendicitis. Secondary sonographic signs of acute appendicitis, such as echogenic peri‐appendiceal mesentery, can also indicate stump inflammation …”