Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure. MATERIALS AND METHODS: We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports. RESULTS: Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%. CONCLUSION: Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.

Low-risk criteria for pelvic radiography in pediatric blunt trauma patients.

CONTEXT: The American College of Surgeons recommends that any patient with blunt trauma undergoes radiographic evaluation, including a radiograph of the pelvis. Studies have questioned the use of such routine pelvic radiographs (PXR) in pediatrics. Selective elimination of PXR would save time, money and unshielded radiation exposure to the gonads. OBJECTIVE: To determine if a defined set of historical and clinical factors could predict low risk for pelvic fracture and incorporate these factors into a clinical decision guideline. DESIGN, SETTING, AND PATIENTS: A retrospective chart review of all blunt trauma patients 25 years or younger in whom a PXR was obtained from January 2002 to June 2006 presenting to an urban level 1 trauma center. A total of 579 patients underwent 580 trauma evaluations. MAIN OUTCOME MEASURES: Variables including sex, mechanism of injury, Glascow Coma Score, Pediatric Trauma Score, fall height, lower extremity injury, blood on rectal examination, blood at meatus, and clinical need for computed tomography (CT) were compared with outcomes of pelvic fracture and pelvic fracture requiring surgical intervention. RESULTS: There were 22 pelvic fractures identified, resulting in a fracture rate of 4%. The negative predictive value for pelvic fracture was 98.3% (95% confidence interval [95% CI], 96.9%-99.2%) if no lower extremity injury was present, 99% (95% CI, 98.2%-99.6%) if physical examination of the pelvis was normal, and 99.5% (95% CI, 98.6%-99.9%) if there was no need for abdominopelvic CT. The negative predictive value was 100% (95% CI, 98.8%-100%) if any one of these 3 factors is present. CONCLUSIONS: Using the clinical findings of (1) lack of lower extremity injury, (2) lack of an abnormal physical examination of the pelvis, and (3) no need for abdominopelvic CT, pelvic fracture can be reliably excluded. Pelvic radiography can be eliminated in the evaluation of these patients, potentially decreasing time expenditure, radiation exposure, and cost.