Emergency Physician-Performed Bedside Ultrasound in the Evaluation of Acute Appendicitis in a Pediatric Population

Abstract

Background/Objective Many pediatric emergency departments in the United States have adopted a staged ultrasound and CT pathway for the diagnosis of acute appendicitis. However, most algorithms only include radiology-performed ultrasound (RUS) and not emergency physician- performed bedside ultrasound (BUS). Our objective was to determine if emergency physician-performed BUS provides sufficient diagnostic accuracy for acute appendicitis in a pediatric population, thereby limiting additional cost and/or delays in disposition. Methods This is a single-center prospective study of pediatric patients with concern for and requiring further work-up for acute appendicitis. Each patient had a focused bedside ultrasound (BUS) performed by an emergency physician with training in BUS. Diagnostic accuracy was compared with surgical pathology standard, as well as radiology- performed ultrasound (RUS), computed tomography (CT), and clinical follow-up. Results Among46 enrolledpatients, 12were diagnosed with acute appendicitis (26%). There were no negative laparotomies in those who had surgery. There was one case of missed appendicitis at 4-week follow-up. BUS had a sensitivity of 100% (95% Cl: 72% to 100%) and. a specificity of 81% (61% to 93%) when the app6ndix'was visualized (37). This resulted in positive likelihood ratio of5.2 and a negative likelihood ratio ofo. In the cases where the appendix was not visualized on BUS (9), 1 patient was diagnosed with appendicitis, and the other 8 patients were negative for appendicitis. In RUS both the sensitivity and specificity was 100% when the appendix was visualized. The sensitivity and specificity of CT in our studywas 90% and 100% respectively. Conclusions Emergency physicians can perform bedside ultrasound with high accuracy for acute appendicitis in a pediatric population. When the appendix is not visualized by ultrasound, a staged ultrasound and CT pathway should be considered.