US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs

Abstract

This study evaluated the additional value of secondary signs in the diagnosing of appendicitis in children with ultrasound. From May 2005 to June 2006, 212 consecutive paediatric patients with suspected appendicitis were examined. Ultrasonographic depiction of the appendix was classified into four groups: 1, normal appendix; 2, appendix not depicted, no secondary signs of appendicitis; 3, appendix not depicted with one of the following secondary signs: hyperechoic mesenteric fat, fluid collection, local dilated small bowel loop; 4, depiction of inflamed appendix. We classified 96 patients in group 1, 41 in group 2, 13 in group 3, and 62 in group 4. Prevalence of appendicitis was 71/212 (34%).Negative predictive values of groups 1 and 2 were 99% and 100%, respectively. Positive predictive values of groups 3 and 4 were 85% and 95%, respectively. In groups 3 and 4, hyperechoic mesenteric fat was seen in 73/75 (97.3%), fluid collections and dilated bowel loops were seen in 12/75 (16.0%) and 5/75 (6.6%), respectively. This study shows that in case of nonvisualization of the appendix without secondary signs, appendicitis can be safely ruled out. Furthermore, secondary signs of appendicitis alone are a strong indicator of acute appendicitis.

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

“…49,50 Despite previously reported inverse association between the use of diagnostic US and negative appendectomy rate in children, 26,51,52 this pathway was associated with a higher negative appendectomy rate than that reported in the two key U.S.-wide studies by Bachur and colleagues and other authors. 26,44,53 This difference may be in part explained by the high rate of hemorrhagic ovarian cysts (six of 14 negative appendectomies), which may mimic appendicitis on US 54 and one case of successfully managed ovarian torsion that required urgent operative management.…”

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

“…Some studies have included the presence or combination of secondary signs into their criteria to give a more accurate and meaningful diagnosis and creating four possible findings: unequivocally positive (appendix is seen and inflamed), probably positive (appendix was poorly seen or not visualised and secondary signs are present), probably negative (appendix was poorly seen or not seen and no secondary signs) and unequivocally negative (appendix seen and normal) 3, 38, 39, 55. With recent studies demonstrating that up to 46% of ultrasound studies do not visualise the appendix, the value of sonographers recognising that secondary signs are reliable diagnostic corollaries could facilitate better clinical outcomes and decrease the need for potential harm in the form of radiation exposure from CT and or unnecessary surgical procedures from negative appendicectomies 47, 53, 56…”

“…During 2013–2014 in Australia, almost 29,000 appendicectomies were performed, comprising approximately 10% of all emergency surgery 1. Since the 1980s, ultrasound has been commonly used to diagnose appendicitis with a range of reported sensitivities (71.2–99%) and specificities (91.3–98.2%) 2, 3, 4, 5, 6, 7, 8, 9. There is currently some debate about the best imaging modality or combination of modalities to accurately and cost‐effectively diagnose the condition.…”

“…Definitive sonographic criteria or techniques that improve accuracy and assist diagnosis would be of particular benefit in these cases. Secondary signs of appendicitis are well established with a recent investigation of their predictive value identifying potential diagnostic use in the absence of an identifiable appendix 3, 34, 35. The purpose of this review is to examine appendiceal sonography, established sonographic criteria, paediatric‐specific techniques and the predictive value of secondary signs.…”

The Diagnosis of Acute Appendicitis in Pediatric Patients; the Influence of Abdominal Wall Fat Thickness on the Accuracy of Ultrasonography

“…Bununla birlikte, USG'nin tanısal sınırlılı-lığı erişkin hastalara göre pediatrik hastalarda çok daha azdır. 8 Ancak yine de vücut yapısı, karın ağrısı olan çocuklarda USG'nin tanı değerini etkileyebilmektedir.…”