Sage Journals: Discover world-class research

Abstract

Introduction

The optimal diagnostic pathway for pediatric acute appendicitis (AA) following an inconclusive or negative ultrasonography (US) is poorly defined, leading to debate over subsequent computed tomography (CT) use. This systematic review and meta-analysis compared negative appendectomy rates in children managed with a US-only pathway vs a pathway involving CT after a non-diagnostic initial US.

Methods

Following PRISMA guidelines (PROSPERO: CRD42024568560), we systematically searched 6 databases, including PubMed and Embase, through July 2024 for longitudinal studies comparing the 2 diagnostic pathways. Two reviewers independently selected studies and extracted data. Risk of bias in included studies was assessed using the ROBINS-I and Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the GRADE framework. A fixed-effects meta-analysis was performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

Results

The pooled analysis demonstrated that a US-only pathway was associated with significantly lower odds of negative appendectomy compared to the US-followed-by-CT pathway (OR 0.44; 95% CI 0.21-0.90; P = 0.02). This protective association was even more pronounced in the subgroup of patients with an initial inconclusive US (OR 0.22; 95% CI 0.05-0.89; P = 0.03).

Conclusion

In children with suspected AA after a non-diagnostic US, a US-only pathway is associated with a significantly lower rate of negative appendectomy. These findings support strategies that prioritize clinical re-evaluation and repeat US to reduce unnecessary surgeries and radiation exposure. However, given the low certainty of evidence, clinical judgment remains paramount.

Keywords

appendicitis pediatrics computed tomography ultrasonography

Get full access to this article

View all access options for this article.

References

Becker

Kharbanda

Bachur

. Atypical clinical features of pediatric appendicitis. Acad Emerg Med. 2007;14(2):124-129. https://pubmed.ncbi.nlm.nih.gov/17192449/

Theilen

Rolle

. [The acute abdomen in children]. Med Klin Intensivmed Notfallmed. 2023;118(8):619-625. https://pubmed.ncbi.nlm.nih.gov/37294351/

Binkovitz

Unsdorfer

KML

Thapa

, et al. Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol. 2015;45(13):1934-1944. https://pubmed.ncbi.nlm.nih.gov/26280637/

di Saverio

Podda

de Simone

, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27. https://pubmed.ncbi.nlm.nih.gov/32295644/

Petroianu

. Diagnosis of acute appendicitis. Int J Surg. 2012;10(3):115-119. https://pubmed.ncbi.nlm.nih.gov/22349155/

ABIM Foundation. Choosing Wisely [Internet]. Philadelphia (PA): ABIM Foundation ; 2012 [cited 2024 Dec 22]. Available from: https://www.choosingwisely.org/

The Alliance for Radiation Safety in Pediatric Imaging. Image Gently [Internet]. Reston (VA): The Alliance for Radiation Safety in Pediatric

Imaging; c2007 [cited 2024 Dec 22]. Available from: https://www.imagegently.org/

Brenner

. Minimising medically unwarranted computed tomography scans. Ann ICRP. 2012;41(3–4):161-169. https://pubmed.ncbi.nlm.nih.gov/23089015/

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906. https://pubmed.ncbi.nlm.nih.gov/33789826/

10.

Higgins

JPT

Thomas

Chandler

Cumpston

Page

Welch

. Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available from www.training.cochrane.org/handbook.

11.

Chaochankit

Boocha

Samphao

. Negative appendectomy rate in patients diagnosed with acute appendicitis. BMC Surg. 2022;22(1):404. https://pubmed.ncbi.nlm.nih.gov/36419019/

12.

Shin

Cho

, et al. Delta neutrophil index as an early predictor of acute appendicitis and acute complicated appendicitis in adults. World J Emerg Surg. 2017;12(1):32. https://pubmed.ncbi.nlm.nih.gov/28747992/

13.

Sugiura

Miyake

Nagai

, et al. Chronological changes in appendiceal pathology among patients who underwent appendectomy for suspected acute appendicitis. World J Surg. 2020;44(9):2965-2973. https://pubmed.ncbi.nlm.nih.gov/32322937/

14.

Ouzzani

Hammady

Fedorowicz

Elmagarmid

. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):1-10. doi:10.1186/s13643-016-0384-4

15.

Sterne

Hernán

Reeves

, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Br Med J. 2016;355:i4919. https://pubmed.ncbi.nlm.nih.gov/27733354/

16.

Wells

Shea

O’Connell

Peterson

Welch

Losos

Tugwell

. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, ON: Ottawa Hospital Research Institute; [cited 2024 Dec 22]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

17.

Guyatt

Oxman

Vist

, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926.

18.

Higgins

JPT

Thompson

. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558. https://pubmed.ncbi.nlm.nih.gov/12111919/

19.

Ahmad

Manson

. Diagnostic performance of a staged pathway for imaging acute appendicitis in children. Pediatr Emerg Care. 2021;37(12):E1197-e1201. https://pubmed.ncbi.nlm.nih.gov/31913249/

20.

Anderson

Putnam

Pham

, et al. Negative appendectomy rates do not increase with reduced computed tomography use in pediatric appendicitis. J Am Coll Surg. 2016;223(4):e158. https://journals.lww.com/journalacs/fulltext/2016/10002/negative_appendectomy_rates_do_not_increase_with.348.aspx

21.

Elikashvili

Tay

Tsung

. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 2014;21(2):163-170. https://pubmed.ncbi.nlm.nih.gov/24673672/

22.

Ramarajan

Krishnamoorthi

Gharahbaghian

Pirrotta

Barth

Wang

. Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis? J Clin Ultrasound. 2014;42(7):385-394. https://pubmed.ncbi.nlm.nih.gov/24700515/

23.

Schuh

Chan

Langer

, et al. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med. 2015;22(4):406-414. https://pubmed.ncbi.nlm.nih.gov/25808065/

24.

Polites

Mohamed

Habermann

, et al. A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children. Surgery. 2014;156(2):448-454. https://pubmed.ncbi.nlm.nih.gov/24953265/

25.

Fugazzola

Ceresoli

Agnoletti

, et al. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition). World J Emerg Surg. 2020;15(1):19. https://pubmed.ncbi.nlm.nih.gov/32156296/

26.

Fazel

Krumholz

Wang

, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009;361(9):849-857. https://pubmed.ncbi.nlm.nih.gov/19710483/

27.

Samei

Segars

, et al. Patient-specific radiation dose and cancer risk estimation in CT: part II. Application to patients. Med Phys. 2010;38(1):408-419. https://pmc.ncbi.nlm.nih.gov/articles/PMC3021563/

28.

Bachur

Dayan

Bajaj

, et al. The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis. Ann Emerg Med. 2012;60(5):582-590.e3. https://pubmed.ncbi.nlm.nih.gov/22841176/

29.

Paterson

Frush

. Dose reduction in paediatric MDCT: general principles. Clin Radiol. 2007;62(6):507-517. https://pubmed.ncbi.nlm.nih.gov/17467387/

30.

Pauwels

EKJ

Bourguignon

. Radiation dose features and solid cancer induction in pediatric computed tomography. Med Princ Pract. 2012;21(6):508-515. https://pubmed.ncbi.nlm.nih.gov/22472997/

31.

Brenner

Hall

. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. https://pubmed.ncbi.nlm.nih.gov/18046031/

32.

Brenner

Elliston

Hall

Berdon

. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289-296. https://pubmed.ncbi.nlm.nih.gov/11159059/

33.

Larson

Rader

Forman

Fenton

. Informing parents about CT radiation exposure in children: it’s OK to tell them. AJR Am J Roentgenol. 2007;189(2):271-275. https://pubmed.ncbi.nlm.nih.gov/17646450/

34.

Kutanzi

Lumen

Koturbash

Miousse

. Pediatric exposures to ionizing radiation: carcinogenic considerations. Int J Environ Res Publ Health. 2016;13(11):1057. https://pmc.ncbi.nlm.nih.gov/articles/PMC5129267/

35.

Balthazar

Rofsky

Zucker

. Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates. Am J Gastroenterol. 1998;93(5):768-771. https://pubmed.ncbi.nlm.nih.gov/9625125/

36.

Kaffas

Vo-Phamhi

Griffin

Hoyt

. Critical advances for democratizing ultrasound diagnostics in human and veterinary medicine. Annu Rev Biomed Eng. 2024;26(1):49-65. https://pubmed.ncbi.nlm.nih.gov/38166185/

37.

van den Heuvel

TLA

Graham

Smith

de Korte

Neasham

. Development of a low-cost medical ultrasound scanner using a monostatic synthetic aperture. IEEE Trans Biomed Circuits Syst. 2017;11(4):849-857. https://pubmed.ncbi.nlm.nih.gov/28715339/

38.

Clevert

Beyer

Nieß

Schlenker

. Ultrasound—New techniques are extending the applications. Dtsch Arztebl Int. 2023;120(4):41-47. https://pubmed.ncbi.nlm.nih.gov/28715339/

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.16 MB

Complementary Computed Tomography to Inconclusive Ultrasonography in Children with Suspected Acute Appendicitis: A Systematic Review and Meta-Analysis

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Get full access to this article

References

Supplementary Material