Think about the children! Ruling in appendicitis
Acute appendicitis. Yellow arrows=appendix. Red arrow=appendicolith.
A few days ago I was shocked and surprised to have an 8 year old male taken to the O.R. by our surgeon with only a clinical exam and my bedside scan. The child was seen in the late evening when access to U/S and CT is very limited at our shop. While the pain and presentation were typical, there was no fever or elevated white count and I was fully expecting to be told to hold the patient for further imaging in the morning.
I did a scan over the area of maximum tenderness and was able to demonstrate a non-compressible blind ended tube with a large appendicolith lying against the psoas. Slam dunk!
One of the most challenging POCUS applications is imaging the appendix. However it can be extremely rewarding to make the diagnosis, or confirm your clinical suspicions with a positive scan. While not sensitive enough to use as a rule-out, at least in some studies the specificity is around 90% making it useful for helping to rule in appendicitis, particularly in children and thin adults.
Note that in most studies the physicians were using older machines with poorer resolution and artifact filters than the newest generation. In addition, the POCUS skills of physicians is improving significantly as it becomes a core ED skill. I suspect that we will see a gradual increase in specificity and sensitivity just like U/S-experienced European radiologists have demonstrated with many ultrasound applications compared to their North American CT-lovin’ brethren.
Pathology confirmed my patient had a very inflamed appendix, definitely in danger of rupture. The child was in the O.R. not long after my exam and avoided any radiation. I am going to chalk that one up as a big win for everyone.
Click on this link for a great podcast! Pediatric abdominal pain & appendicitis by Anna Jarvis and Stephen Freedman at EM Cases