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Diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings: a systematic review and meta-analysis

  • Dong Wook Kim
  • Hee Mang Yoon
  • Jeong-Yong Lee
  • Jung Heon Kim
  • Ah Young Jung
  • Jin Seong Lee
  • Young Ah Cho
Original Article

Abstract

Objective

To assess the diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings and the proportion of acute appendicitis on final diagnosis among equivocal CT findings.

Methods

MEDLINE and EMBASE databases were searched until October 21, 2017, for studies investigating diagnostic performance of CT for acute appendicitis in pediatric patients confirmed by histopathologic findings and/or clinical follow-up. Pooled estimates of sensitivity and specificity were calculated using a hierarchical logistic regression modeling. The proportion of true appendicitis among patients with inconclusive CT results was obtained using fixed and random effects meta-analyses.

Results

Twenty-two articles with 3396 patients were included. The pooled sensitivity and specificity were 95% (95% CI, 93−97%) and 94% (95% CI, 90−96%), respectively, and the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.96−0.99). Subgroup analyses revealed a comparable diagnostic performance in the low-dose CT group (sensitivity, 97%; specificity, 96%) and the unenhanced group (sensitivity, 95%; specificity, 95%). Other subgroups (publication year, study design, enrolled population, true appendicitis proportion, CT channel number, and slice thickness) also showed good diagnostic performance. Six studies reporting the true appendicitis proportion among patients with equivocal CT findings had pooled proportion of 17% (95% CI, 9−29%).

Conclusions

CT showed good performance for suspected appendicitis in pediatric patients under various clinical settings, including in cases with dose reduction or absence of IV contrast. The prevalence of true appendicitis among patients with equivocal appendicitis results on CTs was not low; therefore, clinical attention should not be disregarded in this population.

Keywords

Appendicitis Appendix Child X-ray computed tomography 

Abbreviations

CT

Computed tomography

HSROC

Hierarchical summary receiver operating characteristic

QUADAS-2

Quality Assessment of Diagnostic Accuracy Studies-2

Notes

Acknowledgements

This study was supported by a grant (2017-0202) from Asan Medical Center Children’s Hospital, Seoul, Korea.

Author contributions

Chong Hyun Suh, MD (Department of Radiology, Asan Medical Center), assisted in a systematic review and meta-analysis.

Compliance with ethical standards

Conflict of interest

All authors of this manuscript (Dong Wook Kim, Hee Mang Yoon, Jeong-Yong Lee, Jung Heon Kim, Ah Young Jung, Jin Seong Lee, and Young Ah Cho) declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Consent to participate

Informed consent was not required because of the nature of our study, which was a systemic review and meta-analysis.

Supplementary material

10140_2018_1624_MOESM1_ESM.pdf (283 kb)
ESM 1 (PDF 283 kb)

References

  1. 1.
    Callahan MJ, Rodriguez DP, Taylor GA (2002) CT of appendicitis in children. Radiology 224:325–332.  https://doi.org/10.1148/radiol.2242010998 CrossRefPubMedGoogle Scholar
  2. 2.
    Rappaport WD, Peterson M, Stanton C (1989) Factors responsible for the high perforation rate seen in early childhood appendicitis. Am Surg 55:602–605PubMedGoogle Scholar
  3. 3.
    Smith MP, Katz DS, Lalani T, Carucci LR, Cash BD, Kim DH, Piorkowski RJ, Small WC, Spottswood SE, Tulchinsky M, Yaghmai V, Yee J, Rosen MP (2015) ACR appropriateness criteria(R) right lower quadrant pain—suspected appendicitis. Ultrasound Q 31:85–91.  https://doi.org/10.1097/ruq.0000000000000118 CrossRefPubMedGoogle Scholar
  4. 4.
    Parks NA, Schroeppel TJ (2011) Update on imaging for acute appendicitis. Surg Clin North Am 91:141–154.  https://doi.org/10.1016/j.suc.2010.10.017 CrossRefPubMedGoogle Scholar
  5. 5.
    Abo A, Shannon M, Taylor G, Bachur R (2011) The influence of body mass index on the accuracy of ultrasound and computed tomography in diagnosing appendicitis in children. Pediatr Emerg Care 27:731–736.  https://doi.org/10.1097/PEC.0b013e318226c8b0 CrossRefPubMedGoogle Scholar
  6. 6.
    Acosta R, Crain EF, Goldman HS (2005) CT can reduce hospitalization for observation in children with suspected appendicitis. Pediatr Radiol 35:495–500.  https://doi.org/10.1007/s00247-004-1384-4 CrossRefPubMedGoogle Scholar
  7. 7.
    Akhtar W, Ali S, Arshad M, Ali FN, Nadeem N (2011) Focused abdominal CT scan for acute appendicitis in children: can it help in need? J Pak Med Assoc 61:474–476PubMedGoogle Scholar
  8. 8.
    Callahan MJ, Anandalwar SP, MacDougall RD, Stamoulis C, Kleinman PL, Rangel SJ, Bachur RG, Taylor GA (2015) Pediatric CT dose reduction for suspected appendicitis: a practice quality improvement project using artificial Gaussian noise—part 2, clinical outcomes. AJR Am J Roentgenol 204:636–644.  https://doi.org/10.2214/ajr.14.12965 CrossRefPubMedGoogle Scholar
  9. 9.
    Didier RA, Vajtai PL, Hopkins KL (2015) Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatr Radiol 45:181–187.  https://doi.org/10.1007/s00247-014-3109-7 CrossRefPubMedGoogle Scholar
  10. 10.
    Dillman JR, Gadepalli S, Sroufe NS, Davenport MS, Smith EA, Chong ST, Mazza MB, Strouse PJ (2016) Equivocal pediatric appendicitis: unenhanced MR imaging protocol for nonsedated children—a clinical effectiveness study. Radiology 279:216–225.  https://doi.org/10.1148/radiol.2015150941 CrossRefPubMedGoogle Scholar
  11. 11.
    Fefferman NR, Bomsztyk E, Yim AM, Rivera R, Amodio JB, Pinkney LP, Strubel NA, Noz ME, Rusinek H (2005) Appendicitis in children: low-dose CT with a phantom-based simulation technique—initial observations. Radiology 237:641–646.  https://doi.org/10.1148/radiol.2372041642 CrossRefPubMedGoogle Scholar
  12. 12.
    Fefferman NR, Roche KJ, Pinkney LP, Ambrosino MM, Genieser NB (2001) Suspected appendicitis in children: focused CT technique for evaluation. Radiology 220:691–695.  https://doi.org/10.1148/radiol.2203001826 CrossRefPubMedGoogle Scholar
  13. 13.
    Garcia Pena BM, Mandl KD, Kraus SJ, Fischer AC, Fleisher GR, Lund DP, Taylor GA (1999) Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 282:1041–1046CrossRefPubMedGoogle Scholar
  14. 14.
    Hoecker CC, Billman GF (2005) The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med 28:415–421.  https://doi.org/10.1016/j.jemermed.2004.12.010 CrossRefPubMedGoogle Scholar
  15. 15.
    Kaiser S, Frenckner B, Jorulf HK (2002) Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology 223:633–638.  https://doi.org/10.1148/radiol.2233011076 CrossRefPubMedGoogle Scholar
  16. 16.
    Karakas SP, Guelfguat M, Leonidas JC, Springer S, Singh SP (2000) Acute appendicitis in children: comparison of clinical diagnosis with ultrasound and CT imaging. Pediatr Radiol 30:94–98.  https://doi.org/10.1007/s002470050023 CrossRefPubMedGoogle Scholar
  17. 17.
    Kharbanda AB, Taylor GA, Bachur RG (2007) Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology 243:520–526.  https://doi.org/10.1148/radiol.2432060181 CrossRefPubMedGoogle Scholar
  18. 18.
    Kim DY, Shim DH, Cho KY (2016) Use of the pediatric appendicitis score in a community hospital. Indian Pediatr 53:217–220CrossRefPubMedGoogle Scholar
  19. 19.
    Kinner S, Pickhardt PJ, Riedesel EL, Gill KG, Robbins JB, Kitchin DR, Ziemlewicz TJ, Harringa JB, Reeder SB, Repplinger MD (2017) Diagnostic accuracy of MRI versus CT for the evaluation of acute appendicitis in children and young adults. AJR Am J Roentgenol 209:911–919.  https://doi.org/10.2214/ajr.16.17413 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA (2011) Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 259:231–239.  https://doi.org/10.1148/radiol.10100984 CrossRefPubMedGoogle Scholar
  21. 21.
    Lowe LH, Draud KS, Hernanz-Schulman M, Newton MR, Heller RM, Stein SM, Speroff T (2001) Nonenhanced limited CT in children suspected of having appendicitis: prospective comparison of attending and resident interpretations. Radiology 221:755–759.  https://doi.org/10.1148/radiol.2213010379 CrossRefPubMedGoogle Scholar
  22. 22.
    Lowe LH, Penney MW, Stein SM, Heller RM, Neblett WW, Shyr Y, Hernanz-Schulman M (2001) Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. AJR Am J Roentgenol 176:31–35.  https://doi.org/10.2214/ajr.176.1.1760031 CrossRefPubMedGoogle Scholar
  23. 23.
    Mullins ME, Kircher MF, Ryan DP, Doody D, Mullins TC, Rhea JT, Novelline RA (2001) Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. AJR Am J Roentgenol 176:37–41.  https://doi.org/10.2214/ajr.176.1.1760037 CrossRefPubMedGoogle Scholar
  24. 24.
    Sivit CJ, Applegate KE, Berlin SC, Myers MT, Stallion A, Dudgeon DL, Borisa VJ, Morrison SC, Weinert DM, Grisoni ER (2000) Evaluation of suspected appendicitis in children and young adults: helical CT. Radiology 216:430–433.  https://doi.org/10.1148/radiology.216.2.r00au38430 CrossRefPubMedGoogle Scholar
  25. 25.
    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 22:31–42.  https://doi.org/10.1007/s10140-014-1241-1 CrossRefPubMedGoogle Scholar
  26. 26.
    Yi DY, Lee KH, Park SB, Kim JT, Lee NM, Kim H, Yun SW, Chae SA, Lim IS (2017) Accuracy of low dose CT in the diagnosis of appendicitis in childhood and comparison with USG and standard dose CT. J Pediatr 93:625–631.  https://doi.org/10.1016/j.jped.2017.01.004 CrossRefGoogle Scholar
  27. 27.
    Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT (2006) US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241:83–94.  https://doi.org/10.1148/radiol.2411050913 CrossRefPubMedGoogle Scholar
  28. 28.
    Zhang H, Liao M, Chen J, Zhu D, Byanju S (2017) Ultrasound, computed tomography or magnetic resonance imaging—which is preferred for acute appendicitis in children? A meta-analysis. Pediatr Radiol 47:186–196.  https://doi.org/10.1007/s00247-016-3727-3 CrossRefPubMedGoogle Scholar
  29. 29.
    Daly CP, Cohan RH, Francis IR, Caoili EM, Ellis JH, Nan B (2005) Incidence of acute appendicitis in patients with equivocal CT findings. AJR Am J Roentgenol 184:1813–1820.  https://doi.org/10.2214/ajr.184.6.01841813 CrossRefPubMedGoogle Scholar
  30. 30.
    Kim HC, Yang DM, Kim SW, Park SJ (2012) Reassessment of CT images to improve diagnostic accuracy in patients with suspected acute appendicitis and an equivocal preoperative CT interpretation. Eur Radiol 22:1178–1185.  https://doi.org/10.1007/s00330-011-2362-5 CrossRefPubMedGoogle Scholar
  31. 31.
    Peck J, Peck A, Peck C, Peck J (2000) The clinical role of noncontrast helical computed tomography in the diagnosis of acute appendicitis. Am J Surg 180:133–136CrossRefPubMedGoogle Scholar
  32. 32.
    Weyant MJ, Eachempati SR, Maluccio MA, Rivadeneira DE, Grobmyer SR, Hydo LJ, Barie PS (2000) Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis. Surgery 128:145–152.  https://doi.org/10.1067/msy.2000.107422 CrossRefPubMedGoogle Scholar
  33. 33.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 151:W65–W94CrossRefPubMedGoogle Scholar
  34. 34.
    Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536.  https://doi.org/10.7326/0003-4819-155-8-201110180-00009 CrossRefPubMedGoogle Scholar
  35. 35.
    Suh CH, Park SH (2016) Successful publication of systematic review and meta-analysis of studies evaluating diagnostic test accuracy. Korean J Radiol 17:5–6.  https://doi.org/10.3348/kjr.2016.17.1.5 CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration website. handbook. http://handbook-5-1.cochrane.org/. Accessed 8 September 2017
  37. 37.
    Deville WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, Bezemer PD (2002) Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol 2:9CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58:882–893.  https://doi.org/10.1016/j.jclinepi.2005.01.016 CrossRefPubMedGoogle Scholar
  39. 39.
    Borenstein M, Hedges LV, Higgins JP, Rothstein HR (2010) A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods 1:97–111.  https://doi.org/10.1002/jrsm.12 CrossRefPubMedGoogle Scholar
  40. 40.
    DerSimonian R, Kacker R (2007) Random-effects model for meta-analysis of clinical trials: an update. Contemp Clin Trials 28:105–114.  https://doi.org/10.1016/j.cct.2006.04.004 CrossRefPubMedGoogle Scholar
  41. 41.
    Sivit CJ (1993) Diagnosis of acute appendicitis in children: spectrum of sonographic findings. AJR Am J Roentgenol 161:147–152.  https://doi.org/10.2214/ajr.161.1.8517294 CrossRefPubMedGoogle Scholar
  42. 42.
    Yoon HM, Suh CH, Cho YA, Kim JR, Lee JS, Jung AY, Kim JH, Lee JY, Kim SY (2018) The diagnostic performance of reduced-dose CT for suspected appendicitis in paediatric and adult patients: a systematic review and diagnostic meta-analysis. Eur Radiol 28:2537–2548.  https://doi.org/10.1007/s00330-017-5231-z CrossRefPubMedGoogle Scholar
  43. 43.
    Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW (2010) Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med 55:71–116.  https://doi.org/10.1016/j.annemergmed.2009.10.004 CrossRefPubMedGoogle Scholar
  44. 44.
    Jang KM, Lee K, Kim MJ, Yoon HS, Jeon EY, Koh SH, Min K, Choi D (2010) What is the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after CT? Eur J Radiol 74:71–76.  https://doi.org/10.1016/j.ejrad.2008.11.017 CrossRefPubMedGoogle Scholar
  45. 45.
    Poletti PA, Platon A, De Perrot T, Sarasin F, Andereggen E, Rutschmann O, Dupuis-Lozeron E, Perneger T, Gervaz P, Becker CD (2011) Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT. Eur Radiol 21:2558–2566.  https://doi.org/10.1007/s00330-011-2212-5 CrossRefPubMedGoogle Scholar
  46. 46.
    Sim JY, Kim HJ, Yeon JW, Suh BS, Kim KH, Ha YR, Paik SY (2013) Added value of ultrasound re-evaluation for patients with equivocal CT findings of acute appendicitis: a preliminary study. Eur Radiol 23:1882–1890.  https://doi.org/10.1007/s00330-013-2769-2 CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2018

Authors and Affiliations

  • Dong Wook Kim
    • 1
  • Hee Mang Yoon
    • 2
  • Jeong-Yong Lee
    • 3
  • Jung Heon Kim
    • 4
  • Ah Young Jung
    • 2
  • Jin Seong Lee
    • 2
  • Young Ah Cho
    • 2
  1. 1.Department of RadiologyTaean-gun Health Center and County HospitalTaean-gunRepublic of Korea
  2. 2.Department of Radiology and Research Institute of Radiology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  3. 3.Department of Pediatrics, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  4. 4.Department of Emergency Medicine, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea

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