Keeping it simple: CT use slashed in pediatric appendicitis with simple algorithm

A simple diagnostic algorithm for pediatric acute appendicitis decreased the use of imaging, including CT, without reducing diagnostic accuracy, according to a study presented earlier this year at the 9th Annual Academic Surgical Congress and recently published online in Surgery.

The rate of negative appendectomy did slightly increase after implementing the algorithm, but this increase was not significant and not associated with the use of imaging, explained Stephanie F. Polites, MD, of the Mayo Clinic in Rochester, Minn., and colleagues.

“Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis,” wrote the authors. They noted that while both ultrasonography and CT can be used in cases of suspected appendicitis, CT provides better information in cases of complicated appendicitis and its use has been growing in recent years. On the other hand, CT is much more expensive and exposes patients to ionizing radiation.

The diagnostic protocol in the study allowed providers to determine whether the history and physical exam are equivocal or unequivocal for acute appendicitis, and patients with unequivocal findings proceeded directly to pediatric surgery consultation and appendectomy without imaging, according to Polites and colleagues.

To examine the effect of the diagnostic algorithm, Polites and colleagues identified 331 patients 18 years or younger who underwent appendectomy for suspected appendicitis after presenting to the emergency department. A total of 41 percent of patients were identified from the two years prior to the protocol being implemented in January 2010, and the other 59 percent were identified from a three-year post-implementation period.

Results showed CT utilization decreased from 39 percent to 18 percent after implementation. “We suspect that ultrasonography use remained stable and did not increase after implementation because ultrasonography was highly utilized before algorithm implementation; however, it was often used with CT,” wrote Polites and colleagues. “Furthermore, because the algorithm allowed for pediatric surgery consultation without any imaging in patients with an unequivocal history and physical examination, the number of patients who did not undergo any imaging, including ultrasonography, increased after implementation.”

The negative appendectomy rate increased from 9 percent to 11 percent, but the use of CT did not impact the risk of negative appendectomy, according to the authors.

“The results of our study suggest that use of imaging can be decreased most by a diagnostic tool that relies on providers' clinical acumen rather than stringent criteria,” wrote Polites and colleagues. “Furthermore, we feel that acceptance of the algorithm by emergency department providers was improved by respecting their autonomy and clinical judgment.”