Imaging Before Appendectomy
Samuel R. Reid, MDJoseph D. Losek, MD
Emergency Department
Children’s—St Paul
St Paul, MN 55102, USA
To the Editor.—
We read with interest the article by Garcia Peña et al1 and commend their work to improve the diagnostic accuracy for, and the clinical outcomes of, appendicitis. Without a reproducible definition for an "equivocal" presentation of appendicitis, however, it is difficult to know the true effect of their imaging protocol on outcome. All we know is that this group of patients had a "history, physical examination, or laboratory evaluation concerning but not classic for acute appendicitis." Such a definition is open to fairly broad interpretation and calls into question any quantitative analysis that relies on it. Why, for instance, did the percentage of "equivocal" presentations for appendicitis jump from 56% to 70% of patients with suspected appendicitis from the preprotocol time period to the postprotocol time period? One explanation could be that radiographic studies were ordered on patients who actually had unequivocal presentations of appendicitis. The tendency to order a test on unequivocal cases "just to be sure" would bias the result. We suggest that the authors present a table to convince us that the pre- and postprotocol groups were similar with respect to variables other than age and gender, e.g. What percentage had normal white blood cell counts? What percentage had tenderness other than in the right lower quadrant?, etc. Although we do not doubt the direction of the study’s result, without a reproducible definition for "equivocal" presentations of appendicitis, the magnitude of the effect of the study protocol is unclear.
REFERENCE
- Garcia Peña BA, Taylor GA, Fishman SJ, et al. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis.
Pediatrics.2002; 110
:1088
–1093
[Abstract/Free Full Text]
Barbara M. Garcia Peña, MD, MPH
Department of Emergency Medicine
Miami Children’s Hospital
Miami, FL 33155
In Reply.—
We appreciate the comments of Drs Reid and Losek regarding our article.1 We chose to define "equivocal" patients as having a "history, physical examination or laboratory evaluation that was concerning, but not classic for appendicitis." However, in addition, these patients had to have also undergone ultrasonography (US) or computed tomography (CT) or had to have been admitted to the hospital for an observation period. Hence, those children with "classic" presentations for appendicitis would have proceeded directly to the operating room and would not have been included in the "equivocal" population. As discussed in the article, the percentage of children with "unequivocal" presentations for appendicitis decreased from 40% before the protocol to 30% after the protocol. This difference may have been caused by several factors. Over the past few years, the trend in pediatric appendicitis has been moving toward imaging the majority of children, even those who would probably have been labeled in the past as "classic" presentations. This is attributable to a variety of factors. The previously acceptable negative appendectomy rates of 15% to 20% are becoming obsolete. Many surgeons are now striving for a negative appendectomy rate of 10%. The accuracy of US and CT have become so high with little to no risk that many surgeons are requesting imaging in the majority of their patients. Also, many parents are requesting that imaging be performed on their children before appendectomy. This increased use of imaging is seen in the significant decrease in the negative appendectomy rate in our investigation.
As suggested by the authors, we retrospectively reviewed the signs and symptoms of the children before and after the protocol. However, one must remember that the definition of equivocal was not based on one specific variable but on the history, physical examination, and laboratory results. Interestingly, these data are quite variable. For example, the percentage of children who had anorexia was 66.4% preprotocol and 76.3% postprotocol (P < .05). Conversely, the percentage of patients who did not have right lower quadrant tenderness preprotocol was 7.2% and those postprotocol was 1.7% (P < .05). The percentage of patients with diarrhea, fever, and a white blood cell count >10 000 mm3 between the 2 groups was not statistically significant. Hence, our results of improved patient management with our imaging protocol remain valid and strongly support the use of US and CT for children with signs and symptoms equivocal for acute appendicitis.
REFERENCE
- Garcia Peña BM, Taylor GA, Fishman SJ, et al. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics.2002; 110 :1088 –1093
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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