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Journal of Universal Surgery and Emergency Medicine Appendicitis but Not Appendicitis; Utility of Ultrasound in Management of Children with Suspected Appendicitis Research Article Caleb Loo 3 , Pourya Pouryahya 1,2,3 1 Casey hospital, Emergency Department, Program of Emergency Medicine, Monash Health 2 Monash Emergency Research Collaborative (MERC), Program of Emergency Medicine, Monash Health 3 Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia Correspondent author: Pouryahya P, Department of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia, Tel: +61 (03) 8768 1869; Email: [email protected] Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-105. Received Date: 13 July, 2020; Accepted Date: 22 July, 2020; Published Date: 28 July, 2020 Keywords: Appendicitis, Acute abdominal pain, Abdominal pain, Emergency medicine, Emergency department, Ultrasound Introduction Abdominal Pain is a common and challenging ED presentation in the paediatric population, with acute appendicitis being one of the differential diagnosis. If missed and left untreated, the appendix can rupture and lead to complications such as peritonitis and pelvic abscess [1]. A few scoring systems and risk stratification tools, such as the Alvarado and Paediatric Appendicitis Scores have been proposed to guide management. However, these scores are not commonly used in the clinical setting [2]. Beside clinical findings and physician gestalt, diagnostic imaging, in particular, ultrasound is often used in these Jou Uni SurEmer Med: JUSEM-105 1 children because of its safe profile. One key radiological finding on ultrasound is the appendix size with the maximum normal diameter of six [6] millimetres. Other radiological findings suggestive of acute appendicitis include hyperaemia of the appendix, thickened appendix wall and peri-appendiceal changes [3]. Despite having multiple radiological criteria, assessment and evaluation of the appendix with Ultrasound is challenging and operator-dependent [4]. Sometimes the appendix cannot be visualised, or its diameter cannot be measured accurately [5], thus its utility is controversial [6]. Point-of-care ultrasound (PoCUS) has also been used as a bed side tool risk stratification tool, however despite having known diagnostic and procedural values, the prevalence of POCUS in ED was found to be low and its prevalence was shown to be proportional to the level of clinical expertise among the operators [7]. Abstract Objective: Undifferentiated abdominal pain in children is a common presentation to Emergency Department (ED). Diagnostic imaging, in particular, ultrasound, in addition to laboratory tests is often used in this cohort. This study aims to assess the utility of ultrasound in suspected appendicitis in management options. Methods: A 5-year retrospective cross-sectional data analysis of children under the age of 16 presented to Monash Health EDs with abdominal pain between June 2014 and June 2019 was conducted. Among 271934 (total) presentations, 20934 presented with abdominal pain (traumatic and non-traumatic) and 1131 patients were highly suspected for appendicitis who were investigated in ED or hospitalised for ongoing investigation and management. Results: 162 (14.3%; 95% CI, 12.3-16.4) patients had ultrasound findings suggestive of appendicitis, with a further 147 (13.0%; 95% CI, 11.0-15.0) admitted to paediatric surgical ward. 111 (9.81%; 95% CI, 8.1-11.5) patients subsequent underwent diagnostic laparoscopy during their admission which 109 (9.63%; 95% CI, 7.9- 11.4) confirmed intraoperative appendicitis. The mean appendix size difference in patients discharged vs admitted and cases that underwent diagnostic laparoscopy vs conservative management were 0.576mm (95% CI, -1.16-2.32). and 0.217 (95% CI, -1.03-1.47) respectively. Given that the P values of the differences are 0.513 and 0.732 respectively (P>0.05), the results are not statistically significant. Conclusions: The appendix size on ultrasound did not show any correlation with the actual pathology or management option. Clinical picture and clinician’s judgement were the main factors in determining management.
Transcript of le Appendicitis but Not Appendicitis; Utility of ...
Appendicitis but Not Appendicitis; Utility of Ultrasound in
Management of Children
with Suspected Appendicitis
1Casey hospital, Emergency Department, Program of Emergency Medicine, Monash Health 2Monash Emergency Research Collaborative (MERC), Program of Emergency Medicine, Monash Health 3Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
Correspondent author: Pouryahya P, Department of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia, Tel: +61 (03) 8768 1869; Email: [email protected]
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-105.
Received Date: 13 July, 2020; Accepted Date: 22 July, 2020; Published Date: 28 July, 2020
Keywords: Appendicitis, Acute abdominal pain,
Abdominal pain, Emergency medicine, Emergency
department, Ultrasound
Introduction
Abdominal Pain is a common and challenging ED presentation in the paediatric population, with acute appendicitis being one of the differential diagnosis. If missed and left untreated, the appendix can rupture and lead to complications such as peritonitis and pelvic abscess [1]. A few scoring systems and risk stratification tools, such as the Alvarado and Paediatric Appendicitis Scores have been proposed to guide management. However, these scores are not commonly used in the clinical setting [2]. Beside clinical findings and physician gestalt, diagnostic imaging, in particular, ultrasound is often used in these
Jou Uni SurEmer Med: JUSEM-105 1
children because of its safe profile. One key radiological finding on ultrasound is the appendix size with the maximum normal diameter of six [6] millimetres. Other radiological findings suggestive of acute appendicitis include hyperaemia of the appendix, thickened appendix wall and peri-appendiceal changes [3]. Despite having multiple radiological criteria, assessment and evaluation of the appendix with Ultrasound is challenging and operator-dependent [4]. Sometimes the appendix cannot be visualised, or its diameter cannot be measured accurately [5], thus its utility is controversial [6]. Point-of-care ultrasound (PoCUS) has also been used as a bed side tool risk stratification tool, however despite having known diagnostic and procedural values, the prevalence of POCUS in ED was found to be low and its prevalence was shown to be proportional to the level of clinical expertise among the operators [7]. This study aims to compare the appendix sizes to the clinical outcomes of children presenting to ED with abdominal pain and high pre-test probability for appendicitis based on clinical
Abstract
Objective: Undifferentiated abdominal pain in children is a common presentation to Emergency Department
(ED). Diagnostic imaging, in particular, ultrasound, in addition to laboratory tests is often used in this cohort.
This study aims to assess the utility of ultrasound in suspected appendicitis in management options.
Methods: A 5-year retrospective cross-sectional data analysis of children under the age of 16 presented to
Monash Health EDs with abdominal pain between June 2014 and June 2019 was conducted. Among 271934
(total) presentations, 20934 presented with abdominal pain (traumatic and non-traumatic) and 1131 patients
were highly suspected for appendicitis who were investigated in ED or hospitalised for ongoing investigation
and management.
Results: 162 (14.3%; 95% CI, 12.3-16.4) patients had ultrasound findings suggestive of appendicitis, with a
further 147 (13.0%; 95% CI, 11.0-15.0) admitted to paediatric surgical ward. 111 (9.81%; 95% CI, 8.1-11.5)
patients subsequent underwent diagnostic laparoscopy during their admission which 109 (9.63%; 95% CI, 7.9-
11.4) confirmed intraoperative appendicitis. The mean appendix size difference in patients discharged vs
admitted and cases that underwent diagnostic laparoscopy vs conservative management were 0.576mm (95%
CI, -1.16-2.32). and 0.217 (95% CI, -1.03-1.47) respectively. Given that the P values of the differences are 0.513
and 0.732 respectively (P>0.05), the results are not statistically significant.
Conclusions: The appendix size on ultrasound did not show any correlation with the actual pathology or
management option. Clinical picture and clinician’s judgement were the main factors in determining
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-105.
This study aims to compare the appendix sizes to the clinical outcomes of children presenting to ED with abdominal pain and high pre-test probability for appendicitis based on clinical findings and physician gestalt.
Methods
This was a retrospective cross-sectional study of children under 16 years old presenting to any of three Monash Health EDs between June 2014 and June 2019. Monash Health, located in south-east Melbourne, is the largest health network in Victoria, Australia, with approximately 230,000 annual presentations across three hospitals: Monash Medical Centre (tertiary including Monash Children with paediatric medical and surgical wards), Dandenong Hospital and Casey Hospital (district hospital with paediatric medical wards). This study was approved by the Monash Health and Monash University Human Research and Ethics Committees (RES-19-0000- 536Q).
Selection
Eligible cases for this study were those under age 16 on presentation during the study period who presented for the first time and were investigated for appendicitis in emergency department including ultrasound. Cases where the diagnosis of appendicitis was made in the outpatient setting prior to ED arrival were excluded. Cases were identified through the ED medical records (Symphony, EMIS Health, Leads, UK) between June 2014 and June 2019 by electronically filtering for patients under 16 years old on presentation who presented with abdominal pain and investigated for appendicitis, referred to paediatric surgical team or admitted to paediatric surgical unit. Data obtained included patients age and gender, presenting complaint, provisional diagnosis, imaging tests performed and results, ED discharge outcome and management.
Cases who had ultrasound requested on their admission period were also identified and clinical information was obtained from Carestream (Carestream Radiography Software, Carestream Health, Inc, Rochester, NY). The results, including visualisation of appendix, appendix size and presence of secondary signs to suggest appendicitis were identified and subsequently analysed.
Analysis
Patients who were investigated during their ED stay with USS as well as the ones who were admitted to the paediatric surgical ward with high suspicion for appendicitis were initially identified.
Statistical Analysis was carried out using Microsoft Excel and IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) to explore the significance of the difference between the mean appendix size of the different patient groups. An independent T-test was carried out on the data with a 95% confidence interval for the mean difference.
271934 presentations were recorded during the study period, of which 20934 had abdominal pain (Traumatic and non- traumatic). Out of the 20934 presentations with abdominal pain, 10346 paediatric referrals were matched with 1636 emergency department presentations using Microsoft Excel. The patients were matched by hospital identification number and time of presentation. This process yielded 1361 patients. 79 patients who were over 16 years old were excluded, 64 patients who were diagnosed with appendicitis on external ultrasound were excluded and 87 patients who were transferred from Dandenong Hospital or Casey Hospital to Monash Medical Centre ED for paediatric surgery review had their two separate presentations merged into one. This resulted in 1131 patients (Figure 1).
Jou Uni SurEmer Med: JUSEM-105 2
Figure 6: Postsurgical photograpgh showing wide excision of
mass located in retromolar área.
Discussion
These type of tumours are very rare they comprise only 5% of
neoplasms and are seen in 0.4-2.6 for every 100,000 cases around
the world, the mucoepidermoid tumour affects parotid and minor
salivary glans in adults and is mostly seen in women and Young
adults, most tof the cases arise in the the parotid gland with this
ccase accounting for only 2-4% of the cases because it was seen in
the submandibular gland, this patient is currently under treatment
he was performed two sugeries for removal of ganglions locanated
in neck and in the submandbullary gland, highes prevalence for this
type of tumour is around the fifth decade of life and they can be
asymptomatic like in this case with the patient having few to no
symptoms. It has a puripotent cell origin and as we mention can
be classidief into three stages [3].
References
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Figure 1: Study Flowchart As a subgroup analysis after chart review, patients were divided into different groups based on imaging (USS in ED, USS after hospitalisation on the wards or no imaging) or operative intervention (Diagnostic laparoscopy +/- appendectomy Vs conservative management).
To identify any poor outcomes or re-presentation, 2-week time frame post discharge was used and data was obtained from the Electronic Medical Record (EMR).
Results
Among 1131 patients (500 Female: 44.2%) with abdominal pain concerning for appendicitis during the study period with a median age of 11 (interquartile range 9-13 years), 880 (77.8%; 95% CI, 75.4-80.2) were admitted to paediatric surgical ward for ongoing management and investigation with 529 (46.8%; 95% CI, 43.9-49.7) underwent diagnostic laparoscopy. 464 (41.0; 95% CI, 38.2- 43.9) had confirmed appendicitis intraoperatively. 306 (27.1%; 95% CI, 24.5-29.6) patients were investigated further with ultrasound performed during their ED stay. (Table 1)
Demographic No of Patients (%)
Female 500 (44.2)
Diagnostic Laparoscopy 529 (46.8)
Table 1: Demographics
Jou Uni SurEmer Med: JUSEM-105 3
162 (14.3%; 95% CI, 12.3-16.4) patients had ultrasound findings suggestive of appendicitis, with a further 147 (13.0%; 95% CI, 11.0-15.0) admitted to paediatric surgical ward. 111 (9.81%; 95% CI, 8.1-11.5) patients subsequently underwent diagnostic laparoscopy during their admission which 109 (9.63%; 95% CI, 7.9-11.4) confirmed intraoperative appendicitis.
36 (3.18; 95% CI, 2.16-4.21) patients were managed conservatively on the ward. 15 (1.32%; 95% CI, 0.660-2.00) were discharged home, 3 (0.265%; 95% CI, 0.00-0.565) of those subsequently re-presented with 2 (0.177%; 95% CI, 0.00-0.422) diagnosed intraoperatively with acute appendicitis and the last 1 (0.0884%; 95% CI, 0.00-0.262%) case managed conservatively as non-specific abdominal pain without further re-presentation.
22 (1.95%; 95% CI, 1.14-2.75) patients had a normal appendix on ultrasound. 11 (0.973%; 95% CI, 0.401-1.55) were discharged home with 1 re-presentation who was managed conservatively as non-specific abdominal pain. 11 (0.973%; 95% CI, 0.401-1.55) patients with normal USS findings were admitted for ongoing management, were observed in the ward and discharged home without any re-presentations or poor outcomes.
The appendix was not visualised in 90 (7.965%; 95% CI, 6.38-9.54) cases. Of those, 33 (2.92%; 95% CI, 1.94-3.90) were discharged home with no re-presentations. 57 (5.04%; 95% CI, 3.77-6.32) were admitted, with 13 (1.15%; 95% CI, 0.528-1.77) undergoing diagnostic laparoscopic and 11 (0.973%; 95% CI, 0.401-1.55) having confirmed appendicitis intraoperatively. The remaining 44 (3.89%; 95% CI, 2.76-5.02) cases were observed in the ward and discharged home with 1 re-presentation who was managed as non- specific abdominal pain conservatively without any poor outcome.
Ultrasound was equivocal in 16 (1.41%; 95% CI, 0.726-2.10) patients. 6 (0.530% 95% CI, 0.107-0.954) were discharged home with no re-presentations. 10 (0.884%; 95% CI, 0.339-1.43) were admitted, with 1 (0.0884%; 95% CI, 0.00-0.262) confirmed appendicitis intraoperatively. 9 (0.795%; 95% CI, 0.278-1.31) were observed in the ward and were discharged with no re-presentations.
In total, 726 out of 20934 (3.46%; 95% CI, 61.4-67.0) children presenting to the ED with abdominal pain had appendicitis either after imaging or intraoperatively (Figure 2).
Figure 2: Outcome flowchart
Jou Uni SurEmer Med: JUSEM-105 4
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-
105.
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Appendix Size
The mean appendix size of children who had an abnormal appendix on ultrasound was 8.96mm (95% CI 8.45-9.47). Children who were discharged had a mean appendix size of 8.44mm (95% CI, 6.74-10.1) and patients who were admitted had a mean appendix size of 9.02mm (95% CI, 8.45-9.47). Children who underwent diagnostic laparoscopy +/- appendectomy had a mean appendix size of 9.07mm (95% CI, 8.58-9.56) and children who were managed conservatively had a mean appendix size of 8.86mm (95% CI, 7.22- 10.5).
The mean appendix size difference in patients discharged vs admitted and cases that underwent diagnostic laparoscopy vs conservative management were 0.576mm (95% CI, -1.16-2.32). and 0.217 (95% CI, -1.03-1.47) respectively. Given that the P values of the differences are 0.513 and 0.732 respectively (P>0.05), the results are not statistically significant.
The mean appendix size of the children who had a normal appendix on ultrasound was 4.25mm (95% CI, 3.53-4.97). The mean appendix size difference of children with normal appendix vs abnormal appendix is 4.71mm (95% CI, 2.85-6.57) with a P value of 0.00. This result is statistically significant. (Table 2, Graph 1)
Patient Group Mean Appendix Size(mm)
95% CI Lower Limit
95% CI Upper Limit
Abnormal Appendix
Surgical Rx 9.07 8.58 9.56
0.217 -1.03 1.47 0.732 Conservative Rx 8.86 7.22 10.5
Table 2: Comparison of appendix size on ultrasound in different groups
Test characteristics of Ultrasound
From the 290 ultrasounds performed in the ED, we found that the appendix was not visualised in 90 (31.0%; 95% CI, 25.7-36.4)
patients. Excluding this group as well as the group with equivocal and inconclusive ultrasound findings, the measured sensitivity
and specificity of ultrasound were calculated as 100% (95% CI, 97.1-100) and 50.8% (95% CI, 41.6-60.0) respectively. Positive and
negative predictive values of 67.9% (95% CI, 63.9-71.7) and 100% as well as a likelihood ratio of 2.03 (95% CI, 1.70-2.44) were also
demonstrated. (Table 3)
Ultrasound Appendicitis No appendicitis Total
Abnormal 127 60 187
Normal 0 62 62
Totals 127 122 249
Table 3: Cross Tabulation Done with True Positive and Negative Ultrasounds
Subgroup analysis
We also conducted a subgroup analysis of 122 (10.8%; 95% CI, 8.98-12.6) patients who had an ultrasound performed in the paediatric surgical ward. 25 (2.21%; 95% CI, 1.35-3.07) cases were suggestive of appendicitis, appendix wasn’t visualised in 50 (4.42%; 95% CI, 3.22-5.62) patients, 40 (3.54%; 95% CI, 2.46-4.61) patients had a normal sized appendix and 7 (0.619%; 95% CI, 0.162-1.08) patients had inconclusive and equivocal results. Of the 25 confirmed appendicitis cases on the wards, 19 (1.68%; 95% CI, 0.931-2.43) underwent diagnostic laparoscopy, of which 18 (1.59%; 95% CI, 0.862-2.32) had appendicitis confirmed intraoperatively. 6 (0.531%; 95% CI, 0.107-0.954) patients were managed conservatively on the wards and were discharged home with no re-presentations or poor outcome. (Figure 3)
Figure 3: Admitted patients’ outcome
Jou Uni SurEmer Med: JUSEM-105 6
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Discussion
In our study 726 out of 20934 (3.47%; 95% CI, 3.22-3.72) children presenting to the ED with abdominal pain had appendicitis confirmed either intraoperatively or on diagnostic imaging (Ultrasound). Looking at the appendix sizes of the two groups managed surgically or conservatively, given that the confidence interval of the difference in means crosses zero, demonstrates that the difference is not statistically significant and thus, appendix size in ultrasound alone might not be a reliable factor to guide management.
In our study, 25% of children were admitted to the paediatric surgical ward and 16.7% patients had appendicitis confirmed after diagnostic laparoscopy despite normal appendix size in ultrasound. This could be due to the high pre-test suspicion of appendicitis of children undergoing ultrasound imaging.
Our study demonstrated a very good negative predictive value in Ultrasound. However, in about one third of patients (31%), the appendix could not be visualised which emphasises the importance of clinical judgement as a reliable diagnostic and risk stratification tool.
We also found that expectedly, the decision of surgical or conservative management was mainly based on the clinical pictures and progression of the disease regardless of Ultrasound findings.
Our study demonstrated a lower confirmed appendicitis rate of 3.47% (95% CI, 3.22-3.72) compared to the study by Lee et.al which showed a rate of 7.4% (95% CI 5.2-9.6) (8). However, the study by Lee et. al looked at ED presentations for 1 month, which might be a contributing factor to this difference.
Limitations Whilst follow up of discharged patients has significant limitations, attrition bias is not likely, since repeat presentations are generally to the same health network in our region (our network covers a very large geographical area). In addition, hospitals generally notify each other of unexpected deaths following recent discharges.
The decision was made within the limits of our funding and ethics approval, not to attempt contacting the group of patients who had no further presentations after their initial visit. It is
unlikely, but not impossible, that there were patients missed by this approach.
Given the retrospective nature of the study, the results are hypothesis generating and require prospective evaluation to assess any clinical applicability of the abnormal results in this population.
Conclusions
Ultrasound findings might have some diagnostic value but did not show any added value in terms of influencing management. Additionally, the appendix size on ultrasound did not show any correlation with the actual pathology or management option. The patient’s clinical picture and clinician’s judgement were the main factors in determining management.
References 1. Stringer MD (2017) Acute appendicitis. Journal of Paediatrics and
Child Health.;53: 1071-1076. 2. Macco S, Vrouenraets BC, Castro SMD (2016) Evaluation of scoring
systems in predicting acute appendicitis in children. Surgery 160: 1599-1604.
3. Quigley AJ, Stafrace S (2013) Ultrasound assessment of acute appendicitis in paediatric patients: methodology and pictorial overview of findings seen. Insights into Imaging 4:741-751.
4. Gongidi P, Bellah RD (2017) Ultrasound of the pediatric appendix. Pediatric Radiology 47: 1091–1100.
5. Benabbas R, Hanna M, Shah J, Sinert R (2017) Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of- care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Academic Emergency Medicine 24: 523-551.
6. Tyler PD, Carey J, Stashko E, Levenson RB, Shapiro NI, et al. (2019) The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department. The Journal of Emergency Medicine 56:191-196.
7. Pourya Pouryahya, Alastair D McR Meyer, Mei Ping Melody Koo (2019) Prevalence and Utility of Point-Of-Care Ultrasound in the Emergency Department: a prospective observational study. Australasian Journal of Ultrasound in Medicine. AJUM12172 22: 273-278.
8. Lee WH, O'Brien S, Skarin D, Cheek JA, Deitch J, Nataraja R, et al. (2019) Pediatric Abdominal Pain in Children Presenting to the Emergency Department. Vol. Publish Ahead of Print, Pediatric Emergency Care. Pediatric Emergency Care.
Jou Uni SurEmer Med: JUSEM-105 7
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Copyright: ©2020 Loo C, Pouryahya P. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
with Suspected Appendicitis
1Casey hospital, Emergency Department, Program of Emergency Medicine, Monash Health 2Monash Emergency Research Collaborative (MERC), Program of Emergency Medicine, Monash Health 3Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
Correspondent author: Pouryahya P, Department of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia, Tel: +61 (03) 8768 1869; Email: [email protected]
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-105.
Received Date: 13 July, 2020; Accepted Date: 22 July, 2020; Published Date: 28 July, 2020
Keywords: Appendicitis, Acute abdominal pain,
Abdominal pain, Emergency medicine, Emergency
department, Ultrasound
Introduction
Abdominal Pain is a common and challenging ED presentation in the paediatric population, with acute appendicitis being one of the differential diagnosis. If missed and left untreated, the appendix can rupture and lead to complications such as peritonitis and pelvic abscess [1]. A few scoring systems and risk stratification tools, such as the Alvarado and Paediatric Appendicitis Scores have been proposed to guide management. However, these scores are not commonly used in the clinical setting [2]. Beside clinical findings and physician gestalt, diagnostic imaging, in particular, ultrasound is often used in these
Jou Uni SurEmer Med: JUSEM-105 1
children because of its safe profile. One key radiological finding on ultrasound is the appendix size with the maximum normal diameter of six [6] millimetres. Other radiological findings suggestive of acute appendicitis include hyperaemia of the appendix, thickened appendix wall and peri-appendiceal changes [3]. Despite having multiple radiological criteria, assessment and evaluation of the appendix with Ultrasound is challenging and operator-dependent [4]. Sometimes the appendix cannot be visualised, or its diameter cannot be measured accurately [5], thus its utility is controversial [6]. Point-of-care ultrasound (PoCUS) has also been used as a bed side tool risk stratification tool, however despite having known diagnostic and procedural values, the prevalence of POCUS in ED was found to be low and its prevalence was shown to be proportional to the level of clinical expertise among the operators [7]. This study aims to compare the appendix sizes to the clinical outcomes of children presenting to ED with abdominal pain and high pre-test probability for appendicitis based on clinical
Abstract
Objective: Undifferentiated abdominal pain in children is a common presentation to Emergency Department
(ED). Diagnostic imaging, in particular, ultrasound, in addition to laboratory tests is often used in this cohort.
This study aims to assess the utility of ultrasound in suspected appendicitis in management options.
Methods: A 5-year retrospective cross-sectional data analysis of children under the age of 16 presented to
Monash Health EDs with abdominal pain between June 2014 and June 2019 was conducted. Among 271934
(total) presentations, 20934 presented with abdominal pain (traumatic and non-traumatic) and 1131 patients
were highly suspected for appendicitis who were investigated in ED or hospitalised for ongoing investigation
and management.
Results: 162 (14.3%; 95% CI, 12.3-16.4) patients had ultrasound findings suggestive of appendicitis, with a
further 147 (13.0%; 95% CI, 11.0-15.0) admitted to paediatric surgical ward. 111 (9.81%; 95% CI, 8.1-11.5)
patients subsequent underwent diagnostic laparoscopy during their admission which 109 (9.63%; 95% CI, 7.9-
11.4) confirmed intraoperative appendicitis. The mean appendix size difference in patients discharged vs
admitted and cases that underwent diagnostic laparoscopy vs conservative management were 0.576mm (95%
CI, -1.16-2.32). and 0.217 (95% CI, -1.03-1.47) respectively. Given that the P values of the differences are 0.513
and 0.732 respectively (P>0.05), the results are not statistically significant.
Conclusions: The appendix size on ultrasound did not show any correlation with the actual pathology or
management option. Clinical picture and clinician’s judgement were the main factors in determining
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-105.
This study aims to compare the appendix sizes to the clinical outcomes of children presenting to ED with abdominal pain and high pre-test probability for appendicitis based on clinical findings and physician gestalt.
Methods
This was a retrospective cross-sectional study of children under 16 years old presenting to any of three Monash Health EDs between June 2014 and June 2019. Monash Health, located in south-east Melbourne, is the largest health network in Victoria, Australia, with approximately 230,000 annual presentations across three hospitals: Monash Medical Centre (tertiary including Monash Children with paediatric medical and surgical wards), Dandenong Hospital and Casey Hospital (district hospital with paediatric medical wards). This study was approved by the Monash Health and Monash University Human Research and Ethics Committees (RES-19-0000- 536Q).
Selection
Eligible cases for this study were those under age 16 on presentation during the study period who presented for the first time and were investigated for appendicitis in emergency department including ultrasound. Cases where the diagnosis of appendicitis was made in the outpatient setting prior to ED arrival were excluded. Cases were identified through the ED medical records (Symphony, EMIS Health, Leads, UK) between June 2014 and June 2019 by electronically filtering for patients under 16 years old on presentation who presented with abdominal pain and investigated for appendicitis, referred to paediatric surgical team or admitted to paediatric surgical unit. Data obtained included patients age and gender, presenting complaint, provisional diagnosis, imaging tests performed and results, ED discharge outcome and management.
Cases who had ultrasound requested on their admission period were also identified and clinical information was obtained from Carestream (Carestream Radiography Software, Carestream Health, Inc, Rochester, NY). The results, including visualisation of appendix, appendix size and presence of secondary signs to suggest appendicitis were identified and subsequently analysed.
Analysis
Patients who were investigated during their ED stay with USS as well as the ones who were admitted to the paediatric surgical ward with high suspicion for appendicitis were initially identified.
Statistical Analysis was carried out using Microsoft Excel and IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA) to explore the significance of the difference between the mean appendix size of the different patient groups. An independent T-test was carried out on the data with a 95% confidence interval for the mean difference.
271934 presentations were recorded during the study period, of which 20934 had abdominal pain (Traumatic and non- traumatic). Out of the 20934 presentations with abdominal pain, 10346 paediatric referrals were matched with 1636 emergency department presentations using Microsoft Excel. The patients were matched by hospital identification number and time of presentation. This process yielded 1361 patients. 79 patients who were over 16 years old were excluded, 64 patients who were diagnosed with appendicitis on external ultrasound were excluded and 87 patients who were transferred from Dandenong Hospital or Casey Hospital to Monash Medical Centre ED for paediatric surgery review had their two separate presentations merged into one. This resulted in 1131 patients (Figure 1).
Jou Uni SurEmer Med: JUSEM-105 2
Figure 6: Postsurgical photograpgh showing wide excision of
mass located in retromolar área.
Discussion
These type of tumours are very rare they comprise only 5% of
neoplasms and are seen in 0.4-2.6 for every 100,000 cases around
the world, the mucoepidermoid tumour affects parotid and minor
salivary glans in adults and is mostly seen in women and Young
adults, most tof the cases arise in the the parotid gland with this
ccase accounting for only 2-4% of the cases because it was seen in
the submandibular gland, this patient is currently under treatment
he was performed two sugeries for removal of ganglions locanated
in neck and in the submandbullary gland, highes prevalence for this
type of tumour is around the fifth decade of life and they can be
asymptomatic like in this case with the patient having few to no
symptoms. It has a puripotent cell origin and as we mention can
be classidief into three stages [3].
References
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Figure 1: Study Flowchart As a subgroup analysis after chart review, patients were divided into different groups based on imaging (USS in ED, USS after hospitalisation on the wards or no imaging) or operative intervention (Diagnostic laparoscopy +/- appendectomy Vs conservative management).
To identify any poor outcomes or re-presentation, 2-week time frame post discharge was used and data was obtained from the Electronic Medical Record (EMR).
Results
Among 1131 patients (500 Female: 44.2%) with abdominal pain concerning for appendicitis during the study period with a median age of 11 (interquartile range 9-13 years), 880 (77.8%; 95% CI, 75.4-80.2) were admitted to paediatric surgical ward for ongoing management and investigation with 529 (46.8%; 95% CI, 43.9-49.7) underwent diagnostic laparoscopy. 464 (41.0; 95% CI, 38.2- 43.9) had confirmed appendicitis intraoperatively. 306 (27.1%; 95% CI, 24.5-29.6) patients were investigated further with ultrasound performed during their ED stay. (Table 1)
Demographic No of Patients (%)
Female 500 (44.2)
Diagnostic Laparoscopy 529 (46.8)
Table 1: Demographics
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162 (14.3%; 95% CI, 12.3-16.4) patients had ultrasound findings suggestive of appendicitis, with a further 147 (13.0%; 95% CI, 11.0-15.0) admitted to paediatric surgical ward. 111 (9.81%; 95% CI, 8.1-11.5) patients subsequently underwent diagnostic laparoscopy during their admission which 109 (9.63%; 95% CI, 7.9-11.4) confirmed intraoperative appendicitis.
36 (3.18; 95% CI, 2.16-4.21) patients were managed conservatively on the ward. 15 (1.32%; 95% CI, 0.660-2.00) were discharged home, 3 (0.265%; 95% CI, 0.00-0.565) of those subsequently re-presented with 2 (0.177%; 95% CI, 0.00-0.422) diagnosed intraoperatively with acute appendicitis and the last 1 (0.0884%; 95% CI, 0.00-0.262%) case managed conservatively as non-specific abdominal pain without further re-presentation.
22 (1.95%; 95% CI, 1.14-2.75) patients had a normal appendix on ultrasound. 11 (0.973%; 95% CI, 0.401-1.55) were discharged home with 1 re-presentation who was managed conservatively as non-specific abdominal pain. 11 (0.973%; 95% CI, 0.401-1.55) patients with normal USS findings were admitted for ongoing management, were observed in the ward and discharged home without any re-presentations or poor outcomes.
The appendix was not visualised in 90 (7.965%; 95% CI, 6.38-9.54) cases. Of those, 33 (2.92%; 95% CI, 1.94-3.90) were discharged home with no re-presentations. 57 (5.04%; 95% CI, 3.77-6.32) were admitted, with 13 (1.15%; 95% CI, 0.528-1.77) undergoing diagnostic laparoscopic and 11 (0.973%; 95% CI, 0.401-1.55) having confirmed appendicitis intraoperatively. The remaining 44 (3.89%; 95% CI, 2.76-5.02) cases were observed in the ward and discharged home with 1 re-presentation who was managed as non- specific abdominal pain conservatively without any poor outcome.
Ultrasound was equivocal in 16 (1.41%; 95% CI, 0.726-2.10) patients. 6 (0.530% 95% CI, 0.107-0.954) were discharged home with no re-presentations. 10 (0.884%; 95% CI, 0.339-1.43) were admitted, with 1 (0.0884%; 95% CI, 0.00-0.262) confirmed appendicitis intraoperatively. 9 (0.795%; 95% CI, 0.278-1.31) were observed in the ward and were discharged with no re-presentations.
In total, 726 out of 20934 (3.46%; 95% CI, 61.4-67.0) children presenting to the ED with abdominal pain had appendicitis either after imaging or intraoperatively (Figure 2).
Figure 2: Outcome flowchart
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Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM-
105.
Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Appendix Size
The mean appendix size of children who had an abnormal appendix on ultrasound was 8.96mm (95% CI 8.45-9.47). Children who were discharged had a mean appendix size of 8.44mm (95% CI, 6.74-10.1) and patients who were admitted had a mean appendix size of 9.02mm (95% CI, 8.45-9.47). Children who underwent diagnostic laparoscopy +/- appendectomy had a mean appendix size of 9.07mm (95% CI, 8.58-9.56) and children who were managed conservatively had a mean appendix size of 8.86mm (95% CI, 7.22- 10.5).
The mean appendix size difference in patients discharged vs admitted and cases that underwent diagnostic laparoscopy vs conservative management were 0.576mm (95% CI, -1.16-2.32). and 0.217 (95% CI, -1.03-1.47) respectively. Given that the P values of the differences are 0.513 and 0.732 respectively (P>0.05), the results are not statistically significant.
The mean appendix size of the children who had a normal appendix on ultrasound was 4.25mm (95% CI, 3.53-4.97). The mean appendix size difference of children with normal appendix vs abnormal appendix is 4.71mm (95% CI, 2.85-6.57) with a P value of 0.00. This result is statistically significant. (Table 2, Graph 1)
Patient Group Mean Appendix Size(mm)
95% CI Lower Limit
95% CI Upper Limit
Abnormal Appendix
Surgical Rx 9.07 8.58 9.56
0.217 -1.03 1.47 0.732 Conservative Rx 8.86 7.22 10.5
Table 2: Comparison of appendix size on ultrasound in different groups
Test characteristics of Ultrasound
From the 290 ultrasounds performed in the ED, we found that the appendix was not visualised in 90 (31.0%; 95% CI, 25.7-36.4)
patients. Excluding this group as well as the group with equivocal and inconclusive ultrasound findings, the measured sensitivity
and specificity of ultrasound were calculated as 100% (95% CI, 97.1-100) and 50.8% (95% CI, 41.6-60.0) respectively. Positive and
negative predictive values of 67.9% (95% CI, 63.9-71.7) and 100% as well as a likelihood ratio of 2.03 (95% CI, 1.70-2.44) were also
demonstrated. (Table 3)
Ultrasound Appendicitis No appendicitis Total
Abnormal 127 60 187
Normal 0 62 62
Totals 127 122 249
Table 3: Cross Tabulation Done with True Positive and Negative Ultrasounds
Subgroup analysis
We also conducted a subgroup analysis of 122 (10.8%; 95% CI, 8.98-12.6) patients who had an ultrasound performed in the paediatric surgical ward. 25 (2.21%; 95% CI, 1.35-3.07) cases were suggestive of appendicitis, appendix wasn’t visualised in 50 (4.42%; 95% CI, 3.22-5.62) patients, 40 (3.54%; 95% CI, 2.46-4.61) patients had a normal sized appendix and 7 (0.619%; 95% CI, 0.162-1.08) patients had inconclusive and equivocal results. Of the 25 confirmed appendicitis cases on the wards, 19 (1.68%; 95% CI, 0.931-2.43) underwent diagnostic laparoscopy, of which 18 (1.59%; 95% CI, 0.862-2.32) had appendicitis confirmed intraoperatively. 6 (0.531%; 95% CI, 0.107-0.954) patients were managed conservatively on the wards and were discharged home with no re-presentations or poor outcome. (Figure 3)
Figure 3: Admitted patients’ outcome
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Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
Discussion
In our study 726 out of 20934 (3.47%; 95% CI, 3.22-3.72) children presenting to the ED with abdominal pain had appendicitis confirmed either intraoperatively or on diagnostic imaging (Ultrasound). Looking at the appendix sizes of the two groups managed surgically or conservatively, given that the confidence interval of the difference in means crosses zero, demonstrates that the difference is not statistically significant and thus, appendix size in ultrasound alone might not be a reliable factor to guide management.
In our study, 25% of children were admitted to the paediatric surgical ward and 16.7% patients had appendicitis confirmed after diagnostic laparoscopy despite normal appendix size in ultrasound. This could be due to the high pre-test suspicion of appendicitis of children undergoing ultrasound imaging.
Our study demonstrated a very good negative predictive value in Ultrasound. However, in about one third of patients (31%), the appendix could not be visualised which emphasises the importance of clinical judgement as a reliable diagnostic and risk stratification tool.
We also found that expectedly, the decision of surgical or conservative management was mainly based on the clinical pictures and progression of the disease regardless of Ultrasound findings.
Our study demonstrated a lower confirmed appendicitis rate of 3.47% (95% CI, 3.22-3.72) compared to the study by Lee et.al which showed a rate of 7.4% (95% CI 5.2-9.6) (8). However, the study by Lee et. al looked at ED presentations for 1 month, which might be a contributing factor to this difference.
Limitations Whilst follow up of discharged patients has significant limitations, attrition bias is not likely, since repeat presentations are generally to the same health network in our region (our network covers a very large geographical area). In addition, hospitals generally notify each other of unexpected deaths following recent discharges.
The decision was made within the limits of our funding and ethics approval, not to attempt contacting the group of patients who had no further presentations after their initial visit. It is
unlikely, but not impossible, that there were patients missed by this approach.
Given the retrospective nature of the study, the results are hypothesis generating and require prospective evaluation to assess any clinical applicability of the abnormal results in this population.
Conclusions
Ultrasound findings might have some diagnostic value but did not show any added value in terms of influencing management. Additionally, the appendix size on ultrasound did not show any correlation with the actual pathology or management option. The patient’s clinical picture and clinician’s judgement were the main factors in determining management.
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5. Benabbas R, Hanna M, Shah J, Sinert R (2017) Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of- care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Academic Emergency Medicine 24: 523-551.
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Citation: Loo C, Pouryahya P (2020) Appendicitis but Not Appendicitis; Utility of ultrasound in management of children with suspected appendicitis. JUSEM- 105.
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