title: Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?
abstract: OBJECTIVE
  The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure.
  
  
  METHODS
  We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports.
  
  
  RESULTS
  Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%.
  
  
  CONCLUSIONS
  Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.
authors.affiliation: 1 Department of Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY 10461.
authors.forename: Netta M
authors.initials: NM
authors.lastname: Blitman
authors.forename: Muhammad
authors.initials: M
authors.lastname: Anwar
authors.forename: KeriAnne B
authors.initials: KB
authors.lastname: Brady
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Taragin
authors.forename: Katherine
authors.initials: K
authors.lastname: Freeman
mesh_terms: D001064:Appendicitis / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009518:New York / Q000453:epidemiology; D061214:Patient Safety / Q000706:statistics & numerical data; D015995:Prevalence; D011379:Prognosis; D011835:Radiation Protection; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014463:Ultrasonography / Q000706:statistics & numerical data*; D064232:Visual Analog Scale; D055815:Young Adult
keywords: Alvarado score; appendicitis; body mass index; radiation reduction; ultrasound