title: Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children.
abstract: BACKGROUND
  Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies.
  
  
  METHODS
  Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated.
  
  
  RESULTS
  530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy.
  
  
  CONCLUSIONS
  Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions.
authors.affiliation: Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Partain
authors.affiliation: Emory College, Emory University, Atlanta, GA, USA.
authors.forename: Adarsh
authors.initials: A
authors.lastname: Patel
authors.affiliation: Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Curtis
authors.initials: C
authors.lastname: Travers
authors.affiliation: Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Courtney E
authors.initials: CE
authors.lastname: McCracken
authors.affiliation: Division of Pediatric Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Loewen
authors.affiliation: Division of Pediatric Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Kiery
authors.initials: K
authors.lastname: Braithwaite
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Kurt F
authors.initials: KF
authors.lastname: Heiss
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA. Electronic address: mehulvraval@emory.edu.
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
mesh_terms: D000293:Adolescent; D001064:Appendicitis / Q000000981:diagnostic imaging*; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D058996:Quality Improvement; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography
keywords: Appendicitis; Pediatric surgery; Quality improvement; Secondary signs; Ultrasound