Advertisement

Emergency Radiology

, Volume 25, Issue 2, pp 161–168 | Cite as

Secondary imaging for suspected appendicitis after equivocal ultrasound: time to disposition of MRI compared to CT

  • James F. Martin
  • David J. Mathison
  • Paul C. Mullan
  • Hansel J. Otero
Original Article

Abstract

Purpose

The purpose of this study was to compare MRI to CT as a secondary imaging modality for children age 5 years and older with suspected appendicitis after an equivocal abdominal ultrasound in terms of (1) the time to ED disposition decision, (2) surgery consultation rate, and (3) imaging test accuracy.

Methods

We retrospectively studied children with suspected appendicitis and equivocal ultrasound results who underwent MR or CT as secondary imaging in a pediatric emergency department over two-consecutive 9-month periods. No oral or intravenous contrast was utilized for MRI. No sedation was utilized for any modality. Time of disposition is the time to admission or discharge order.

Results

Twenty-five patients underwent CT and 30 underwent MRI, with no significant difference in the median time from ultrasound to disposition between the CT (5.9 h, IQR 4.5, 8.4) and the MRI (5.9 h, IQR 4.6, 6.9) groups (p = 0.65). Fifteen patients had appendicitis. Of the 40 negative or equivocal studies, surgery was consulted for 79% in the CT and 48% in the MRI group (odds ratio 4.12, 95% CI 1.02–16.67). Diagnostic accuracy was as follows: MRI: sensitivity of 90%, specificity of 97.1%, positive predictive value of 90%, and negative predictive value of 97.1%. Abdominal CT: sensitivity of 88%, specificity of 98.6%, positive predictive value of 95.7%, and negative predictive value of 95.8%.

Conclusion

MRI is a feasible alternative to CT for secondary imaging in acute appendicitis for showing comparable ED throughput metrics and diagnostic accuracy, with added benefits of reduced radiation and avoidance of intravenous contrast.

Keywords

Appendicitis MRI CT Ultrasound Children 

Notes

Acknowledgements

We would like to thank Dr. James Chamberlain and Dr. Kristen Breslin for their support and guidance during this project.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V (2012) Changing epidemiology of acute appendicitis in the United States: study period 1993–2008. J Surg Res 175(2):185–190.  https://doi.org/10.1016/j.jss.2011.07.017 CrossRefPubMedGoogle Scholar
  2. 2.
    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® right lower quadrant pain—suspected appendicitis. Ultrasound 31(2):85–91.  https://doi.org/10.1097/RUQ.0000000000000118 CrossRefGoogle Scholar
  3. 3.
    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(1):83–94.  https://doi.org/10.1148/radiol.2411050913 CrossRefPubMedGoogle Scholar
  4. 4.
    Poortman P, Oostvogel HJ, Bosma E, Lohle PN, Cuesta MA, de Lange-de Klerk ES et al (2009) Improving diagnosis of acute appendicitis: results of a diagnostic pathway with standard use of ultrasonography followed by selective use of CT. J Am Coll Surg 208(3):434–441.  https://doi.org/10.1016/j.jamcollsurg.2008.12.003 CrossRefPubMedGoogle Scholar
  5. 5.
    Toorenvliet BR, Wiersma F, Bakker RF, Merkus JW, Breslau PJ, Hamming JF (2010) Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg 34(10):2278–2285.  https://doi.org/10.1007/s00268-010-0694-y CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Binkovitz LA, Unsdorfer KM, Thapa P, Kolbe AB, Hull NC, Zingula SN et al (2015) Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Ped Radiology 45(13):1934–1944.  https://doi.org/10.1007/s00247-015-3432-7 CrossRefGoogle Scholar
  7. 7.
    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(1):231–239.  https://doi.org/10.1148/radiol.10100984 CrossRefPubMedGoogle Scholar
  8. 8.
    Lourenco P, Brown J, Leipsic J, Hague C (2016) The current utility of ultrasound in the diagnosis of acute appendicitis. Clin Imag 40(5):944–948.  https://doi.org/10.1016/j.clinimag.2016.03.012 CrossRefGoogle Scholar
  9. 9.
    Dillman JR, Gadepalli S, Sroufe NS, Davenport MS, Smith EA, Chong ST, Mazza MB, Strouse PJ (2015) Equivocal pediatric appendicitis: unenhanced MR imaging protocol for nonsedated children—a clinical effectiveness study. Radiology 279(1):216–225.  https://doi.org/10.1148/radiol.2015150941 CrossRefPubMedGoogle Scholar
  10. 10.
    Fullerton K, Depinet H, Iyer S, Hall M, Herr S, Morton I et al (2016) Association of hospital resources and imaging choice for appendicitis in pediatric emergency departments. Acad Emerg Med 24(4):400–409CrossRefGoogle Scholar
  11. 11.
    Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, Oh PS, Behr G, Chen S, Lampl B, Middlesworth W, Kandel J, Ruzal-Shapiro C (2014) Ultrasonography/MRI vs CT for diagnosing appendicitis. Pediatrics 133(4):586–593.  https://doi.org/10.1542/peds.2013-2128 CrossRefPubMedGoogle Scholar
  12. 12.
    Orth RC, Guillerman RP, Zhang W, Masand P, Bisset IIIGS (2014) Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis. Radiology 272(1):233–240.  https://doi.org/10.1148/radiol.14132206 CrossRefPubMedGoogle Scholar
  13. 13.
    Moore MM, Brian JM, Methratta ST, Hulse MA, Choudhary AK, Eggli KD et al (2014) MRI for clinically suspected pediatric appendicitis: case interpretation. Ped. Radiology 44(5):605–612Google Scholar
  14. 14.
    Kulaylat AN, Moore MM, Engbrecht BW, Brian JM, Khaku A, Hollenbeak CS, Rocourt DV, Hulse MA, Olympia RP, Santos MC, Methratta ST, Dillon PW, Cilley RE (2015) An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Ped Surg 50(8):1359–1363.  https://doi.org/10.1016/j.jpedsurg.2014.12.012 CrossRefGoogle Scholar
  15. 15.
    Thieme ME, Leeuwenburgh MM, Valdehueza ZD, Bouman DE, de Bruin IG, Schreurs WH et al (2014) Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis. Eur Rad 24(3):630–637.  https://doi.org/10.1007/s00330-013-3044-2 CrossRefGoogle Scholar
  16. 16.
    Moore MM, Gustas CN, Choudhary AK, Methratta ST, Hulse MA, Geeting G, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Ped Radiology 2012;42(9):1056–1063Google Scholar
  17. 17.
    Johnson AK, Filippi CG, Andrews T, Higgins T, Tam J, Keating D, Ashikaga T, Braff SP, Gallant J (2012) Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. Am J Roent 198(6):1424–1430.  https://doi.org/10.2214/AJR.11.7436 CrossRefGoogle Scholar
  18. 18.
    Herliczek TW, Swenson DW, Mayo-Smith WW (2013) Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. Am J Roent. 200(5):969–973.  https://doi.org/10.2214/AJR.12.10078 CrossRefGoogle Scholar
  19. 19.
    Koning JL, Naheedy JH, Kruk PG (2015) Does abdominal pain duration affect the accuracy of first-line MRI for pediatric appendicitis? Abd Imag 40(2):352–359.  https://doi.org/10.1007/s00261-014-0223-9 CrossRefGoogle Scholar
  20. 20.
    Petkovska I, Martin DR, Covington MF, Urbina S, Duke E, Daye ZJ, Stolz l, Keim SM, Costello JR, Chundru S, Arif-Tiwari H, Gilbertson-Dahdal D, Gries L, Kalb B (2016) Accuracy of unenhanced MR imaging in the detection of acute appendicitis: single-institution clinical performance review. Radiology 279(2):451–460.  https://doi.org/10.1148/radiol.2015150468 CrossRefPubMedGoogle Scholar
  21. 21.
    Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim SM, Martin DR (2016) A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis. Am J Roent. 206(3):508–517.  https://doi.org/10.2214/AJR.15.14544 CrossRefGoogle Scholar
  22. 22.
    Moore MM, Kulaylat AN, Hollenbeak CS, Engbrecht BW, Dillman JR, Methratta ST. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Ped Radiology 2016;46(6):928–939Google Scholar
  23. 23.
    Wiersma F, Toorenvliet BR, Bloem JL, Allema JH, Holscher HC. US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol 2009; 19(2):455–456, DOI:  https://doi.org/10.1007/s00330-008-1176-6
  24. 24.
    Estey A, Poonai N, Lim R (2014) Appendix not seen: the predictive value of secondary inflammatory sonographic signs. Acad Emerg Med 21(5):538–542CrossRefGoogle Scholar
  25. 25.
    Ross MJ, Liu H, Netherton SJ, Eccles R, Chen PW, Boag G et al (2013) Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Pediatr Emerg Care 29(4):435–439CrossRefGoogle Scholar
  26. 26.
    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. J Pediatr 182:164–169.  https://doi.org/10.1016/j.jpeds.2016.11.062 CrossRefPubMedGoogle Scholar
  27. 27.
    Leung RS (2015) Radiation protection of the child from diagnostic imaging. Curr Pediatr Rev 11(4):235–242.  https://doi.org/10.2174/1573396311666150729121930 CrossRefPubMedGoogle Scholar
  28. 28.
    Sodhi K, Krishna S, Saxena AK, Sinha A, Khandelwal N, Lee EY (2015) Clinical application of ‘Justification’ and ‘Optimization’ principle of ALARA in pediatric CT imaging: how many children can be protected from unnecessary radiation? Eur J Radiol 84(9):1752–1757.  https://doi.org/10.1016/j.ejrad.2015.05.030 CrossRefPubMedGoogle Scholar
  29. 29.
    Georgiou R, Eaton S, Stanton M, Pierro A, Hall N (2017) Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis. Pediatrics 193(3):e20163003CrossRefGoogle Scholar
  30. 30.
    Trout A, Sanchez R, Ladino-Torres M, Pai D, Strouse PA (2012) Critical evaluation of US for the diagnosis of pediatric acute appendicitis in a real-life setting: how can we improve the diagnostic value of sonography? Pediatr Radiol 42(7):813–823.  https://doi.org/10.1007/s00247-012-2358-6 CrossRefPubMedGoogle Scholar
  31. 31.
    Leeuwenburgh M, Wiarda B, Bipat S, Nio C, Bollen T, Kardux J et al (2012) Acute appendicitis on abdominal MR images: training readers to improve diagnostic accuracy. Radiology 264(2):455–463.  https://doi.org/10.1148/radiol.12111896 CrossRefPubMedGoogle Scholar
  32. 32.
    Leeuwenburgh M, Wiarda B, Jensch S, Van EH, Stockmann H, Gratama J et al (2014) Accuracy and interobserver agreement between MR-non-expert radiologists and MR-experts in reading MRI for suspected appendicitis. Eur J Radiol 83(1):103–110.  https://doi.org/10.1016/j.ejrad.2013.09.022 CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2017

Authors and Affiliations

  • James F. Martin
    • 1
  • David J. Mathison
    • 1
  • Paul C. Mullan
    • 2
  • Hansel J. Otero
    • 3
  1. 1.Division of Emergency MedicineChildren’s National Health SystemWashington, DCUSA
  2. 2.Division of Emergency MedicineChildren’s Hospital of the King’s DaughtersNorfolkUSA
  3. 3.Department of RadiologyChildren’s Hospital of PhiladelphiaPhiladelphiaUSA

Personalised recommendations