Choosing Wisely:

Don’t do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Rationale and Comments: Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94% in experienced hands. Recognizing that expertise may vary, strategies including improving diagnostic expertise in community-based ultrasound and the development of evidence-based clinical decision rules are realistic goals in improving diagnosis without the use of CT scan.
Sponsoring Organizations:
  • American College of Surgeons
  • Sources:
  • American College of Radiology Appropriateness Criteria
  • Disciplines:
  • Emergency medicine
  • Surgical
  • Pediatric
  • References: • Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, Doria AS. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis-a Markov decision analytic model. Radiology. 2009;250:378-86.
    • Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for diagnosis of appendicitis in children? A meta-analysis. Radiology. 2006;241:83-94.
    • Garcia K, Hernanz-Schulman M, Bennett DL, Morrow SE, Yu C, Kan JH. Suspected appendicitis in children: diagnostic importance of normal abdominopelvic CT findings with nonvisualized appendix. Radiology. 2009;250:531-7.
    • Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011;259:231-9.
    • Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL, Grant TH, Greene FL, Jones B, Katz DS, Lalani T, Miller FH, Small WC, Spottswood S, Sudakoff GS, Tulchinsky M, Warshauer DM, Yee J, Coley BD, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® right lower quadrant pain -- suspected appendicitis. [Internet]. Reston (VA): American College of Radiology (ACR); 2010. 7 p.
    • Frush DP, Frush KS, Oldham KT. Imaging of acute appendicitis in children: EU versus US or US versus CT? A North American perspective. Pediatr Radiolol. 2009;39(5):500-5.
    • Saito JM, Yan Y, Evashwick TW, Warner BW, Tarr PI. Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis. Pediatrics. 2013;131(1):e37-44.
    • Kharbanda AB, Stevenson MD, Macias CG, Sinclair K, Dudley NC, Bennett J, Bajaj L, Mittal MK, Huang C, Bachur RG, Dayan PS, and for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Interrater reliability of clinical findings in children with possible appendicitis. Pediatrics. 2012;129(4):695-700.

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