Podcast Episode 25: Pediatric Appendicitis

by Bob Stuntz in , ,


In what two age groups is perforated appendicitis most common?  If you said the very young and the very old, you would be correct.  As we all know, the workup and diagnosis of appendicitis in kids can be extremely difficult.  There are communication barriers, distractors, and mimickers.  So how do we tease out the right history and get to the correct conclusion?

In this episode, we discuss many of the more difficult and important aspects of the workup for a child with possible appendicitis.  Can physical exam change your pretest probability?  Can you do labs without imaging, or is it an all or nothing workup?  what about documentation and follow up?  How do you handle the indeterminate ultrasound?  Do you use oral contrast if CT is needed, or IV only?  

In this conference, we have a panel of five of our best and brightest attendings discussing these issues and more.  You'll hear from:

  • Dan Kaminstein, MD: You've heard him before, international medicine and ultrasound expert
  • Tom Kehrl, MD: From the Airway tips and tricks episode, and our EUS fellowship director
  • Andy Kepner, MD: Emergency Physician with a surgical background and director of our sim center
  • Erik Kochert, MD: Also a frequenter of the EM Res podcast, APD and Research director
  • Jess Riley, MD: Emergency physician with both academic and community experience
  • Bob Stuntz, MD: You know me

This episode does run longer than the typical episode, but it is chock full of good pearls.  Let us know what you think in the comments below, or head over to the Google Community to discuss this episode.

References:  

  1. Bundy DG1, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.  Does this child have appendicitis?  JAMA. 2007 Jul 25;298(4):438-51.
  2. Ebell MH1, Shinholser J2.  What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review.  Ann Emerg Med. 2014 Apr 11.
  3. Ohle R1, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD.  The Alvarado score for predicting acute appendicitis: a systematic review.  BMC Med. 2011 Dec 28;9:139.
  4. Meltzer AC1, Baumann BM, Chen EH, Shofer FS, Mills AM.  Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis.  Ann Emerg Med. 2013 Aug;62(2):126-31.
  5. Ross MJ1, Liu H, Netherton SJ, Eccles R, Chen PW, Boag G, Morrison E, Thompson GC.  Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound.  Acad Emerg Med. 2014 May;21(5):538-42.
  6. Estey A1, Poonai N, Lim R.  Appendix not seen: the predictive value of secondary inflammatory sonographic signs.  Pediatr Emerg Care. 2013 Apr;29(4):435-9.
  7. Bachur RG1, Dayan PS, Bajaj L, Macias CG, Mittal MK, Stevenson MD, Dudley NC, Sinclair K, Bennett J, Monuteaux MC, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.  The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.  Ann Emerg Med. 2012 Nov;60(5):582-590.
  8. Leeuwenburgh MM1, Stockmann HB, Bouma WH, Houdijk AP, Verhagen MF, Vrouenraets B, Cobben LP, Bossuyt PM, Stoker J, Boermeester MA; OPTIMAP Study Group.  A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med. 2014 May;21(5):488-96.
  9. Elikashvili I1, Tay ET, Tsung JW.  The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis.  Acad Emerg Med. 2014 Feb;21(2):163-70.
  10. Yu CW1, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC.  Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis.  Br J Surg. 2013 Feb;100(3):322-9.
  11. Kwan KY1, Nager AL.  Diagnosing pediatric appendicitis: usefulness of laboratory markers.  Am J Emerg Med. 2010 Nov;28(9):1009-15.

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