Purpose or Case Report: In the past Computed Tomography (CT), has been the preferred diagnostic modality in appendicitis diagnosis. Due to increasing radiation and cancer concerns, ultrasound (US) has been promoted as a safer alternative. Despite the US benefits, some pediatric providers have reluctance to use US due to its lower appendicitis sensitivity. Attempting to increase the use and efficacy of US in suspected appendicitis, our US department performed three annual interventions consisting of lectures and hands-on sonographer training during 2012-2014. Additionally, a clinical pathway for appendicitis diagnosis was developed in 2014 to promote US as the primary diagnostic modality in acute appendicitis evaluation.
Methods & Materials: We examined the use and efficacy of US in pediatric appendicitis diagnosis after our interventions in 2012-2014. 437 2-18 year old patients who presented to our 7 ED facilities from 8/1/15-4/30/16 were evaluated for the sequence of imaging exams chosen and the respective outcomes, as well as pediatric age-weight percentile, Pediatric Appendicitis Score, WBC, temperature, symptoms duration, age, sex, and surgical outcomes. Data from an additional 260 patients collected from 03/01/2012-11/31/2012 were analyzed in order to evaluate US use before and after educational interventions.
Results: US used as the primary diagnostic modality was 69% in 2012 and 96% in 2015 (Chi-square=100, p<.00001). Overall, US specificity and sensitivity to acute appendicitis was 98% and 67% respectively in 2012, and 95% and 73% in 2015-16. In the 2015 cohort, use of an US dictation template developed by the Safe and Sound campaign (WA) ranking suspected appendicitis (1-4, Normal-High appendicitis suspicion) improved sensitivity (69% without template, 78% with template) when used by the radiologist. In ambiguous cases in 2015 (16%), primarily where US was not able to clearly image the appendix and lower right quadrant abdominal pain remained, physicians used supplemental CT. Primary US and supplemental CT combined yielded 95% specificity and 89% sensitivity overall.
Conclusions: Our lectures, hands-on training and US pathway promotion successfully increased primary US usage in acute appendicitis evaluation. However, there are a small number of cases where supplemental CT is still necessary. We are currently analyzing our data to determine exactly which patients need this additional imaging.