Ultrasonographic features can predict outcome of conservative management of acute appendicitis in children

Shiran Levy; Nurith Hiller; Naama Lev-Cohain; S Nahum Goldberg; Ido Mizrahi; Natalia Simanovsky

doi:10.1007/s10140-021-01984-5

Ultrasonographic features can predict outcome of conservative management of acute appendicitis in children

Emerg Radiol. 2022 Feb;29(1):59-65. doi: 10.1007/s10140-021-01984-5. Epub 2021 Sep 17.

Authors

Shiran Levy¹, Nurith Hiller², Naama Lev-Cohain², S Nahum Goldberg², Ido Mizrahi³, Natalia Simanovsky²

Affiliations

¹ Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel. Shiran.h2@gmail.com.
² Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
³ Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.

PMID: 34533666
DOI: 10.1007/s10140-021-01984-5

Abstract

Purpose: To determine whether specific ultrasonographic features can predict failure of conservative treatment of acute appendicitis.

Methods: A 2-year retrospective study was conducted on children admitted with acute appendicitis. Those with uncomplicated appendicitis diagnosed solely by ultrasound, and treated conservatively, were followed 18-24 m to assess treatment outcome. Management was considered successful if recurrent acute appendicitis was not observed during follow-up. Appendix diameter, wall thickness, presence of mucosal ulceration, hyperechogenic fat, free fluid, and lymph nodes were evaluated as potential discriminatory ultrasonographic predictors. T-tests, chi-square, sensitivity, specificity, and odds ratios were calculated.

Results: Out of 556 consecutive patients that were admitted with acute appendicitis, 180 (32%) managed conservatively. One hundred eleven (62%) imaged by US only. Ninety-two out of 111 (83%) were followed 18-24 m to assess treatment outcome, and 19/111 (17%) were lost to follow-up. Conservative management was successful in 72/92 (78.2%), with treatment failure in 20/92 (21.8%) (5/92 (5.4%) with recurrent acute appendicitis and 15/92 (16.3%) underwent appendectomy). Of the ultrasonographic features studied, mucosal ulceration demonstrated statistically significant predictive value. Fifteen out of 20 (75%) treatment failures had mucosal ulceration, compared to 21/72 (29.2%) of the patients with successful treatment (p < 0.001). This yielded a positive odds ratio of 7.3 (2.3-22.6, 95% CI), 70.8% (58.9-80.9, 95% CI) specificity, and 75% (50.9-91.3, 95% CI) sensitivity. Positive predictive value was 41.6% (31.5-52.5, 95% CI) while intact mucosa had negative predictive value of 91% (82.4-95.6, 95% CI) for conservative management success.

Conclusion: The presence or absence of appendiceal mucosal ulceration at ultrasound can predict conservative management outcome in the setting of acute appendicitis, potentially improving pediatric patient selection for conservative management.

Keywords: Acute appendicitis; Conservative treatment; Mucosal ulceration; Pediatrics; Ultrasound.

MeSH terms

Acute Disease
Appendectomy
Appendicitis* / diagnostic imaging
Appendicitis* / therapy
Appendix*
Child
Conservative Treatment
Humans
Retrospective Studies