Appendicitis: Improving Diagnostic Accuracy

10 February, 2011 by: colinparker

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Appendicitis is the most common surgical condition in children, and an important condition not to miss.  Can we use clinical features, scoring systems, blood tests or radiological investigations to improve our diagnostic accuracy?

In this episode we put the diagnostic process under the microscope and try to figure out the most helpful symptoms, signs and tests to confirm or exclude appendicitis.

Outline: Tests for Appendicitis

[CP] hello, disclaimer, introduction

Review Article:

Bundy 2007 JAMA

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.
Does this child have appendicitis? JAMA. 2007; 298(4):438-51. Review. PubMed PMID:17652298

[CP] overview (including methods)

[KB] appendicitis symptoms

[SF] appendicitis signs

[CP] results: symptoms

[KB] results: signs

[SF] results: WBC count & differential

[CP] results: CRP & ESR

[ALL] comments re blood tests especially WBC

Passing mention of O’Shea 1988 Pediatric Emergency Care

[CP] Scoring systems: Alvarado Score (still with reference to Bundy)

[CP] Alvarado 1986 Annals of Emergency Medicine

[SF] Scoring sytems: (Samuel) Paediatric Appendicitis Score (still with reference to Bundy)

[SF] Samuel 2002 J Pediatric Surgery

[KB] Scoring systems: Low-Risk decision rule: (with reference to Bundy)

[KB] Kharbanda 2005 Pediatrics

Passing mention of Schneider 2007 (Annals of Emergency Medicine) prospective evaluation of scoring systems (still with reference to Bundy):

[SF] Clinical gestalt (as indicated by imaging ordered)

[CP] Comparison with Adult data

[KB] Limitations in the Literature

Imaging Tests for suspected appendicitis

[CP] introduction (rule-out vs rule-in strategies, unnecessary when diagnosis obviously appendicitis or obviously not)

[KB] UltraSound with Graded Compression – Sim 1989 J National Med Association

[SF] CT for Appendicitis: Callahan 2002 Radiology

[CP] Contrast or not: Kaiser 2004 Radiology

[SF] An Argument for Ultrasound: Strouse 2010 Radiology

[KB] Routine Ultrasound & Limited CT: Toorenvliet 2010 World J Surgery

[ALL] Comments re: Imaging in suspected appendicitis
(where does Australia sit on the UK – USA spectrum – U/S vs CT?)

What’s new?

[SF] calprotectin (S100A8/A9): Bealer & Colgin 2010 Academic Emergency Medicine – featured in Journal Watch top 10 most read articles in EM in 2010

Bottom Line

[KB] Acheson & Banerjee 2010 Arch Dis Child Education & Practice Edition

[ALL] When to do blood tests?

[ALL] When to get imaging?

[ALL] When to get Surgical review?

[ALL] Discharge advice – when appendicitis unlikely but not excluded

[CP] Summary, goodbye

ADHD Corner: Brief Synopsis

For those with short attention spans, here is the abridged version.

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