Diagnostic Accuracy of Non-Radiologist-Performed Ultrasound for Diagnosing Acute Appendicitis in Pediatric Patients: A Systematic Review and Meta-Analysis

Abstract

Background and Objectives: Acute appendicitis is a common cause of abdominal pain requiring surgery in pediatric patients. Given concerns regarding radiation exposure from computed tomography (CT), ultrasound (US) has become the first-line diagnostic modality. In many emergency and resource-limited settings, non-radiologist physicians often perform these examinations. This study aimed to evaluate the diagnostic accuracy of a non-radiologist-performed ultrasound in detecting acute appendicitis in children. Materials and Methods: We conducted a systematic review and meta-analysis according to the PRISMA guidelines. The literature was searched across PubMed, Ovid MEDLINE, EMBASE, the Cochrane Library, and Google Scholar through June 2024. Studies reporting on the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of non-radiologist-performed ultrasounds in pediatric appendicitis were included. Study quality was assessed using the QUADAS-2 tool, and a bivariate random-effects model was used for statistical analysis. Results: Eight studies, with a total of 1006 pediatric patients, were included. The pooled sensitivity and specificity were 0.87 (95% CI, 0.83-0.90) and 0.93 (95% CI, 0.91-0.95), respectively. The area under the SROC curve was 0.783 (95% CI, 0.708-0.853), suggesting moderate-to-good diagnostic accuracy. Substantial heterogeneity was observed across studies, possibly due to differences in operator training and ultrasound techniques. Conclusions: Non-radiologist-performed ultrasound demonstrates moderate-to-good diagnostic accuracy in identifying pediatric appendicitis. These findings support its implementation in emergency or resource-constrained settings and suggest that incorporating structured ultrasound training for non-radiologists may improve timely diagnosis and optimize clinical decision-making in pediatric emergency care.

Keywords: appendicitis; child; systematic review; ultrasonography.

Figure 1

Diagram illustrating the study selection procedure.

Figure 2

Overall quality assessment of included studies using the QUADAS-2 tool. (A) Risk of bias summary bar chart. (B) Applicability concerns summary bar chart. Each domain is presented as a percentage of included studies categorized as low risk (green), high risk (red), or unclear risk (yellow). (C) Traffic light plot for risk of bias across individual studies. (D) Traffic light plot for applicability concerns across individual studies. Each domain is color-coded according to the assessed risk level: low (green), unclear (yellow), or high (red) [8,10,11,12,13,14,15,16].

Figure 3

Forest plot showing sensitivity across included studies. Each study is identified by the first author’s name and year of publication. Horizontal lines represent 95% confidence intervals (CIs) [8,10,11,12,13,14,15,16].

Figure 4

Forest plot showing specificity across included studies. Each study is identified by the first author’s name and year of publication. Horizontal lines represent 95% confidence intervals (CIs) [8,10,11,12,13,14,15,16].

Figure 5

Summary receiver operating characteristic (SROC) curves for diagnostic accuracy. (A) Hierarchical summary receiver operating characteristic (HSROC) curve showing the summary point (blue square), 95% confidence region (dashed ellipse), and 95% prediction region (dotted ellipse). (B) SROC curve based on a bivariate random-effects model, with each study represented by a blue dot labeled with the study’s first author. The red line indicates the model-based summary curve, and the area under the curve (AUC) is 0.783 (95% CI: 0.708–0.853). AUC, area under the curve; CI, confidence interval [8,10,11,12,13,14,15,16].