Skip to main content
SpringerLink
Log in

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting

  • Original Article
  • Published:
Pediatric Surgery International Aims and scope Submit manuscript

A Letter to the Editor to this article was published on 12 June 2019

A Letter to the Editor to this article was published on 02 February 2019

Abstract

Background

Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting.

Materials and methods

All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported.

Results

Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively.

Conclusion

These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Doria AS, Moineddin R, Kellenberger CJ et al (2006) US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241(1):83–94

    Article  Google Scholar 

  2. Scholer SJ, Pituch K, Orr DP, Dittus RS (1996) Clinical outcomes of children with acute abdominal pain. Pediatrics 98(4 Pt 1):680–685

    CAS  PubMed  Google Scholar 

  3. Mostbeck G, Adam EJ, Nielsen MB et al (2016) How to diagnose acute appendicitis: ultrasound first. Insights Imaging 7(2):255–263

    Article  Google Scholar 

  4. Al-Khayal KA, Al-Omran MA (2007) Computed tomography and ultrasonography in the diagnosis of equivocal acute appendicitis. A meta-analysis. Saudi Med J 28(2):173–180

    PubMed  Google Scholar 

  5. Puylaert JB (1986) Acute appendicitis: US evaluation using graded compression. Radiology 158(2):355–360

    Article  CAS  Google Scholar 

  6. Estey A, Poonai N, Lim R (2013) Appendix not seen: the predictive value of secondary inflammatory sonographic signs. Pediatr Emerg Care 29(4):435–439

    Article  Google Scholar 

  7. Jaremko JL, Crockett A, Rucker D, Magnus KG (2011) Incidence and significance of inconclusive results in ultrasound for appendicitis in children and teenagers. Can Assoc Radiol J 62(3):197–202

    Article  Google Scholar 

  8. Kearl YL, Claudius I, Behar S et al (2016) Accuracy of magnetic resonance imaging and ultrasound for appendicitis in diagnostic and non-diagnostic studies. Acad Emerg Med 23(2):179–185

    Article  Google Scholar 

  9. Keller C, Wang NE, Imler DL, Vasanawala SS, Bruzoni M, Quinn JV (2017) Predictors of nondiagnostic ultrasound for appendicitis. J Emerg Med 52(3):318–323

    Article  Google Scholar 

  10. Nah SA, Ong SS, Lim WX, Amuddhu SK, Tang PH, Low Y (2017) Clinical relevance of the nonvisualized appendix on ultrasonography of the abdomen in children. BioMed Res Int 182:164–169.e161

    Google Scholar 

  11. Ross MJ, Liu H, Netherton SJ et al (2014) Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 21(5):538–542

    Article  Google Scholar 

  12. Crady SK, Jones JS, Wyn T, Luttenton CR (1993) Clinical validity of ultrasound in children with suspected appendicitis. Ann Emerg Med 22(7):1125–1129

    Article  CAS  Google Scholar 

  13. Wiersma FTB, Bloem JL, Allema JH, Holscher HC (2009) US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol 19(2):455–461

    Article  Google Scholar 

  14. Cohen B, Bowling J, Midulla P et al (2015) The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg 50(6):923–927

    Article  Google Scholar 

  15. Shah BR, Stewart J, Jeffrey RB, Olcott EW (2014) Value of short-interval computed tomography when sonography fails to visualize the appendix and shows otherwise normal findings. J Ultrasound Med 33(9):1589–1595

    Article  Google Scholar 

  16. Srinivasan A, Servaes S, Pena A, Darge K (2015) Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol. Emerg Radiol 22(1):31–42

    Article  Google Scholar 

  17. Alter SM, Walsh B, Lenehan PJ, Shih RD (2017) Ultrasound for diagnosis of appendicitis in a community hospital emergency department has a high rate of non-diagnostic studies. J Emerg Med 52(6):833–838

    Article  Google Scholar 

  18. Larson DB, Trout AT, Fierke SR, Towbin AJ (2015) Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roentgenol 204(4):849–856

    Article  Google Scholar 

  19. Anandalwar SP, Callahan MJ, Bachur RG et al (2015) Use of white blood cell count and polymorphonuclear leukocyte differential to improve the predictive value of ultrasound for suspected appendicitis in children. J Am Coll Surg 220(6):1010–1017

    Article  Google Scholar 

  20. Pastore V, Cocomazzi R, Basile A, Pastore M, Bartoli F (2014) Limits and advantages of abdominal ultrasonography in children with acute appendicitis syndrome. Afr J Paediatr Surg 11(4):293–296

    Article  Google Scholar 

  21. Fallon SC, Orth RC, Guillerman RP et al (2015) Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol 45(13):1945–1952

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA

    Jenny M. Held & Christian S. McEvoy

  2. Department of Emergency Medicine, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA

    Jonathan D. Auten

  3. Department of Radiology, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA

    Stephen L. Foster

  4. Department of Pediatric Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA

    Robert L. Ricca

Authors
  1. Jenny M. Held
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christian S. McEvoy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jonathan D. Auten
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stephen L. Foster
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Robert L. Ricca
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study design was completed by JH and RR. The data collection and manuscript preparation were performed by JH, JA, and CM. Data analysis was performed by CM. Critical revisions were performed by all the authors.

Corresponding author

Correspondence to Jenny M. Held.

Ethics declarations

Conflict of interest

The authors have no financial conflicts of interest to disclose.

Disclosure

The views expressed are those of the authors and do not necessarily reflect the official policy of the Department of the Navy, Department of Defense, or the United States Government. In addition, the authors are military service members. This work was prepared as part of official duties. Title 17, USC, Section 105 provides that Copyright protection under this title is not available for any work of the US Government. Title 17, USC, Section 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties. Research data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol; number NMCP.2015.0037.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Held, J.M., McEvoy, C.S., Auten, J.D. et al. The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting. Pediatr Surg Int 34, 1287–1292 (2018). https://doi.org/10.1007/s00383-018-4350-1

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00383-018-4350-1

Keywords

Search

Navigation