Appendicitis demands prompt treatment because of the risk of perforation, which occurs in approximately one-third of cases. Appendicitis is the most common surgical emergency in children, yet its diagnosis continues to challenge clinicians. Between 5 and 25 percent of children with suspected appendicitis are found to have a normal appendix during surgery. These unnecessary surgeries were reduced by nearly half at one hospital with use of a clinical guideline and selective use of computerized tomography (CT) and ultrasound (US), according to a study that was supported in part by the Agency for Healthcare Research and Quality (T32 HS00063).
A multidisciplinary team of surgeons, emergency department physicians, radiologists, and nurses at Children's Hospital Boston developed a clinical practice guideline (CPG) for the diagnosis and management of acute appendicitis. Douglas S. Smink, M.D., M.P.H., and his colleagues retrospectively analyzed the medical records of patients evaluated under the CPG at their hospital during 2001.
Depending on a child's clinical presentation, the CPG recommends immediate surgery or further evaluation with CT or US. The researchers compared negative appendectomy (surgery on a normal appendix) and perforation rates, as well as admissions for inpatient observation in CPG patients evaluated for acute appendicitis in 2001 compared with similar patients who were evaluated in 1997, before the existence of the CPG and more frequent use of imaging studies.
Although 90 percent of the 571 patients evaluated for acute appendicitis in 2001 received a CT or US, only 6 percent were admitted to the surgical service for serial examinations. The percent of surgical patients with a histologically normal appendix decreased from 10.6 percent in 1997 to 5.5 percent in 2001. Also, 22.2 percent of patients in 2001 had a perforated appendix compared with 28.5 percent in 1997. The CPG, which incorporates clinical judgment and selected imaging, had a sensitivity of 98.8 percent and a specificity of 95.2 percent.
See "Diagnosis of acute appendicitis in children using a clinical practice guideline," by Dr. Smink, Jonathan A. Finkelstein, M.D., M.P.H., Barbara M. Garcia Pena, M.D., M.P.H., and others, in the March 2004 Journal of Pediatric Surgery 39(3), pp. 458-463.
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