Podcast Episode 25: Pediatric Appendicitis

by Bob Stuntz


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 DG1Byerley JSLiles EAPerrin EMKatznelson JRice HE.  Does this child have appendicitis?  JAMA. 2007 Jul 25;298(4):438-51.
  2. Ebell MH1Shinholser 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 R1O'Reilly FO'Brien KKFahey TDimitrov BD.  The Alvarado score for predicting acute appendicitis: a systematic review.  BMC Med. 2011 Dec 28;9:139.
  4. Meltzer AC1Baumann BMChen EHShofer FSMills AM.  Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis.  Ann Emerg Med. 2013 Aug;62(2):126-31.
  5. Ross MJ1Liu HNetherton SJEccles RChen PWBoag GMorrison EThompson GC.  Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound.  Acad Emerg Med. 2014 May;21(5):538-42.
  6. Estey A1Poonai NLim R.  Appendix not seen: the predictive value of secondary inflammatory sonographic signs.  Pediatr Emerg Care. 2013 Apr;29(4):435-9.
  7. Bachur RG1Dayan PSBajaj LMacias CGMittal MKStevenson MDDudley NCSinclair KBennett JMonuteaux MCKharbanda ABPediatric 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 MM1Stockmann HBBouma WHHoudijk APVerhagen MFVrouenraets BCobben LPBossuyt PMStoker JBoermeester MAOPTIMAP 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 I1Tay ETTsung 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 CW1Juan LIWu MHShen CJWu JYLee 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 KY1Nager AL.  Diagnosing pediatric appendicitis: usefulness of laboratory markers.  Am J Emerg Med. 2010 Nov;28(9):1009-15.

Either click here to listen to the podcast, or check out the episode embedded below: