COMMENTARY |
The Diagnosis of Appendicitis: An Evolving Paradigm
Children’s Hospital and
University of Colorado Health Science Center
Denver, CO 80218
Abbreviations: US, ultrasound • CT, computed tomography
More than 250 000 Americans, 1/4 to 1/3 of which are children, undergo appendectomy annually for the presumptive diagnosis of acute appendicitis.1 Although appendicitis evidence-based guidelines reduce variability and control costs without sacrificing quality,2 sadly, they are used by only a fraction of practicing physicians.3 In the recent past patient and societal costs for the 
15% "negative" appendectomy and the 33% perforative appendicitis rates were substantial.1 In an effort to enhance outcomes, the last decade has witnessed a renewed focus on improving diagnostic sensitivity, and Pediatrics has been the forum for the publication of several of these important reports.4–8
Body imaging as a diagnostic adjunct for appendicitis has enhanced sensitivity, specificity, and accuracy. Ultrasound (US) is portable, fast, free of irradiation exposure, and of modest incremental cost; however, it is of limited use in obese adolescents, and it is highly user-dependent.9 Computed tomography (CT) as an adjunct for the diagnosis of acute appendicitis was first described 10 years ago.10 Its immediate impact was substantial, reducing negative appendectomy rates to 4.1% and perforative rates to 14.7%.11 However, the product of this improved diagnostic accuracy was an explosive and indiscriminant increase in the number of CT and US studies done, often in deference to an initial clinical evaluation by the surgical team responsible for eventual disease treatment. Cost analyses suggested that such imaging was justified4; however, such assessments did not include the risk of exposure of the child to the CT dose of ionizing radiation, especially when done with adult dosage.12,13 Alarmingly, at the current frequency of pediatric head and body CT examinations, it is projected that 500 annual radiation-induced cancer deaths will result.13
The report of Garcia Peña et al6 suggests that diagnostic CT should be applied by a patient risk-stratification protocol. Their hypothetical data suggest that such guidelines will limit this alarming increase in abdominal CT examinations with a minimal decrement in diagnostic accuracy. However, their report falls short of prospectively proving the utility of such a diagnostic algorithm. In contrast, the retrospective study of Kosloske et al7 suggests that an equally sensitive and specific diagnostic strategy is an initial clinical evaluation and decision by the responsible faculty surgeon, supplemented by selective application of body imaging and intervals of patient observation. What is less clear from their analysis is how often a radiographic study became the determining factor for operation. When these 2 series are compared, Kosloske et al did 0.83 US or CT studies per patient, whereas the original and protocol-driven series of Garcia Peña et al performed 3 and 2 times those numbers, respectively. The risk and cost implications are obvious.
Of more contemporary importance is the potential impact of hospital volume on disease outcomes,14 including the diagnosis of appendicitis. Smink et al,8 using the negative appendectomy rate as a diagnostic outcome assessment tool, reports that high-volume hospitals are associated with a lower negative appendectomy rate. Of concern is the age of the data set (1997) and the arbitrary nature of parameters chosen to stratify institutions into "lowest volume" (<1 appendectomy per month) to "highest volume" (>3 appendectomies per week) without concomitantly assessing individual surgeon volumes. These data are of particular interest when such criteria are applied to the 2 other reports.6,7 One institution is "medium volume," at which 3 surgeons average 1.4 appendectomies per week and diagnostic accuracy heavily depends on personal physician assessment. The other is from a "high-volume" institution at which 6 to 8 surgeons did twice as many procedures (2.8 appendectomies per week) with diagnostic accuracy driven by institution-specific resources. Interestingly, surgeon volumes and diagnostic outcomes are equivalent between the 2 reports.
What is the take-home message for the diagnosis and treatment of this common pediatric malady? 1) Use concomitant pediatrician/surgeon evaluation for any patient suspected of having acute appendicitis. 2) An operation should be performed when the clinical diagnosis is unequivocal. 3) A period of hydration and serial clinical reexamination, after a short interval (not to exceed several hours), should be performed in the face of diagnostic uncertainty. If appendicitis is the diagnosis, appendectomy should follow; if uncertain, an imaging diagnostic care guideline should be instituted. US is preferred for thin adolescent females whose differential diagnosis includes tube-ovarian pathology and in institutions at which US expertise exists. Focused CT is preferred otherwise. The pediatric CT must use appropriate radiation dosage and informed consent that defines potential long-term risks. 4) Experienced clinicians and institutions produce optimal patient outcomes.
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FOOTNOTES |
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Received for publication Jul 2, 2003; Accepted Jul 7, 2003.
Reprint requests to (M.M.Z.) Children’s Hospital, 1056 E 19th Ave, Denver, CO 80218
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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