Choosing Wisely:

Avoid using CT scan as the first-line imaging modality in the evaluation of suspected appendicitis in children. Ultrasound should be done first with a CT scan or MRI considered in equivocal cases.

Rationale and Comments: Although CT is the most accurate radiologic modality for the evaluation of appendicitis, ultrasound should be the preferred initial evaluation in children. This modality is cost effective, avoids radiation exposure, and has excellent accuracy, with a reported sensitivity and specificity of 94% in experienced hands. When the ultrasound is equivocal, decision guidelines based on clinical findings as well as radiologic findings may assist in determining the need for cross-sectional imaging. Other options to consider prior to CT scan may include an evaluation by a surgeon, observation with serial exams, repeat ultrasound after a period of observation, and MRI, which has been shown to have similar diagnostic accuracy as CT.
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Surgery
  • Sources:
  • American College of Radiology guidelines
  • Disciplines:
  • Surgical
  • Pediatric
  • References: • Doria AS, Moineddin R, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241:83-94.
    • Krishnamoorthi R, Ramarajan N, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011;259:231-239.
    • Smith MP, Katz DS, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria right lower quadrant pain--suspected appendicitis. Ultrasound Q. 2015 June;31(2):85-91.
    • Samuel M. Pediatric appendicitis score. J Ped Surg. 2002;37(6):877-881.
    • Nielsen JW, Boomer L, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template. J Pediatr Surg. 2015;50:144-148.
    • Aspelund G, Fingeret A, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 2014 Apr;133(4):586-593.

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