1. Evaluation of Acute Appendicitis in Children using Bedside Ultrasound Amanda Bates

2. Appendicitis  Epidemiology  Most common cause of emergent abdominal surgery in children  Rare in very young children  More common in males than females  Most common in children age 10-20yrs  Classic presentation of anorexia, vomiting, & periumbilical pain migrating to RLQ occurs in only half of all patients  Perforation = surgical emergency

3. Diagnosing Appendicitis in the ED  Clinical diagnosis  HPI – anorexia, periumbilical pain migrating to RLQ, fever, nausea/vomiting  PE – Rovsing sign, Obturator sign, Iliopsoas sign, rebound/guarding, RLQ tenderness  Cannot reliably exclude appendicitis from ddx when classic symptoms are absent  Multiple pediatric clinical scoring systems  Alvarado Score  Pediatric appendicitis score  Refined Low-Risk Appendicitis Score

4. Diagnosing Appendicitis in the ED  Unique challenges with pediatric population  May not be able to communicate clearly/verbalize where pain is located  Symptoms may be nonspecific  Clinical presentation varies by age  Children <5yrs: abdominal pain (diffuse vs. RLQ), diarrhea, fever, N/V, lethargy, irritability  Children 5-12yrs: abdominal pain, N/V, limp/R hip pain, trouble walking, diarrhea, anorexia  Children >12yrs: may present similarly to adults

5. Diagnosing Appendicitis in the ED  Differential for abdominal complaints in children  Infants : necrotizing enterocolitis, volvulus, colic, gastroenteritis, constipation, testicular torsion  Toddlers : intussusception, volvulus, testicular torsion, gastroenteritis, constipation, UTI  Young children : torsion, gastroenteritis, constipation, UTI  Adolescents : torsion, ectopic/intrauterine pregnancy, DKA, IBD, PID, gastroenteritis

6. Diagnosing Appendicitis in the ED  Can dx with CT or ultrasound  Concern with exposing children to radiation limits use of CT  ACEP guidelines for pediatric population  Recommend ultrasound as initial imaging modality  Ultrasound can confirm but not exclude appendicitis  CT can definitively confirm or exclude appendicitis

7. Ultrasound Technique  Pain control  High frequency linear array probe  Place on point of maximal tenderness  Graded compression to displace bowel gas  Visualize in longitudinal and transverse planes

8. Identifying the Appendix  Find ascending colon – no peristalsis, contains gas and fluid – follow to the cecum & identify terminal ileum  Appendix should be at cecal tip ~1cm below ileum  Use psoas muscle and iliac vessels as landmarks

9. Identifying the Appendix  Normal anatomy Psoas Iliac Vessels Image: http://www.minnisjournals.com.au/ajum/article/Appendicitis-21

10. Diagnosing Appendicitis  Criteria include: tubular structure, blind ending, noncompressible, >6mm in diameter, nonperistalsing  Transverse view – “target sign”  Doppler can show increased flow to wall of appendix  +/- appendicolith – hyperechoic, cause shadowing  + sonographic McBurney’s  Limitations in visualizing the appendix: variations in anatomy, perforation, pain, habitus, bowel gas

11. Acute Appendicitis - Longitudinal Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874

12. Acute Appendicitis - Transverse Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874

13. Acute Appendicitis Image: http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874

14. Evaluation by EM Physicians

15.  Participating pediatric attendings/fellows trained with 30 min lecture & 30 min of hands on practice  150 scans, 50 cases of verified acute appendicitis  Verified by surgical pathology or phone follow up  1 false negative, 5 false positives  Limitations: single center study, convenience sample  EM sonographers demonstrated high specificity in identifying acute appendicitis  Study found reduction in CT use and decreased ED LOS  CT rate dec from 44.2% to 27.3%  LOS 154 min vs. 288 min for radiology US and 487 min for CT

16. Evaluation by EM Physicians

17.  13 peds EM sonographers  1 faculty physician trained 12 fellows (no prior experience scanning bowel) with 45 min lecture & 5 practice exams  264 scans, 85 cases of verified acute appendicitis  Verified by surgical pathology or phone follow up  13 false positive studies  Limitations: single center, lead sonographer performed 43% of study imaging  Ultimately POCUS performed by EM physicians had high specificity, especially in sonographers with more scanning experience

19. Conclusion  Ultrasound can be used to confirm acute appendicitis in children, a population in which it’s advisable to limit exposure to radiation with CT scans  CT definitive test if US equivocal/appendix not visualized  Bedside ultrasound performed by trained EM physicians can have high specificity comparable to CT or formal US studies

20. References  Clinical Policy: Evaluation and Management of Suspected Appendicitis. American College of Emergency Physicians. http://www.acep.org/Clinical---Practice- Management/Clinical-Policy--Evaluation-and-Management-of-Suspected- Appendicitis. Accessed October 17, 2015http://www.acep.org/Clinical---Practice- Management/Clinical-Policy--Evaluation-and-Management-of-Suspected- Appendicitis  Appendicitis. Medscape. http://emedicine.medscape.com/article/773895- overview. Accessed October 17, 2015http://emedicine.medscape.com/article/773895- overview  Wessen DE. Acute Appendicitis in Children. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2015  Focus On: Ultrasound for Appendicitis. American College of Emergency Physicians. http://www.acep.org/Continuing-Education-top-banner/Focus-On--Ultrasound-for- Appendicitis. Accessed October 17, 2015 http://www.acep.org/Continuing-Education-top-banner/Focus-On--Ultrasound-for- Appendicitis  Abdomen and Retroperitoneum. Ultrasound Cases. http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874. Accessed October 17, 2015 http://www.ultrasoundcases.info/Slide-View.aspx?cat=187&case=6874

21. References  Polites SF, Mohamed MI, et al. A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children. Surgery. 2014; 156:2  Elikashvili I, Tay ET, Tsung JW. The Effect of Point-of-care Ultrasonography of Emergency Department Length of Stay and Computed Tomography Utilization in Children with Suspected Appendicitis. Academic Emergency Medicine. 2014; 163-170  Sivitz AB, Cohen SG, Tejani C. Evaluation of Acute Appendicitis by Pediatric Emergency Physician Sonography. Annals of Emergency Medicine. 2014; 64:4  SonoTutorial: Appendicitis assessment by ultrasound. SonoSpot: Topics in Bedside Ultrasound. https://sonospot.wordpress.com/2014/04/10/sonotutorial-appendicitis- assessment-by-ultrasound-foamed-foamus/. https://sonospot.wordpress.com/2014/04/10/sonotutorial-appendicitis- assessment-by-ultrasound-foamed-foamus/