US Can Help Determine Course of Treatment in Pediatric Appendicitis

Saturday, Dec. 05, 2020

By Melissa Silverberg

Treating children with appendicitis with IV antibiotics is gaining acceptance as a safe and cost-effective measure for less complicated cases, but about 20% of cases will still require surgical removal.

Shiran Levy, MD, a radiology resident at Hadassah Hebrew University Medical Center in Jerusalem, presented a digital poster at RSNA 2020 describing how US technology can help physicians decide which pediatric patients will benefit from each treatment option.

Acute appendicitis in children can be painful for patients and stressful and expensive for their families, so quick diagnosis and efficient and effective treatment is important, Dr. Levy said.

Previous studies have examined clinical factors such as body temperature or white blood count as determinants for choosing a course of treatment, but less is known about using imaging criteria.

"Seeing these children come into the hospital in pain, we wondered if there was a better way to tell, by ultrasound, who would respond well to conservative treatment and which patients would ultimately need surgery," Dr. Levy said.

Conservative Treatment with US Proves Effective

Researchers conducted a retrospective medical chart review of 556 patients between the ages of 2 and 16 who were diagnosed with acute appendicitis. Within that group, 180 (32%) of patients were treated conservatively without surgery using US to determine the severity of the appendicitis. Of these, 111 were diagnosed with uncomplicated appendicitis based solely upon US examination. Ninety-two (82.8%) of these patients were followed for a minimum of 18 months to assess treatment outcome based upon chart review and supplemental phone calls.

Treatment was considered successful if a recurrent event of acute appendicitis was not observed. Recurrent hospitalization for acute appendicitis or indicated appendectomy was considered failure of conservative treatment.

Appendix diameter, wall thickness and the presence of mucosal ulceration, hyperechogenic fat, free fluid and lymph-nodes were evaluated as potential discriminatory ultrasonographic predictors of treatment failure.

The conservative treatment was successful in 72 (78.2%) patients, whereas in 20 patients (21.8%) conservative treatment failed. Of the US features studied, only mucosal ulceration demonstrated a statistically significant predictive value. Dr. Levy said the study found 75% of treatment failures had mucosal ulceration.

"We had a hunch this would be the result," Dr. Levy said. "It may be a sign the disease is more advanced or severe."

Although the sample size at Hadassah Hebrew University Medical Center was small, Dr. Levy said she hopes to see results elsewhere that confirm her findings.

"I hope it can help with selection of patients. In children, you want to avoid surgery if you can, but on the other hand you don't want to cause them more pain and more admissions because you didn't just choose surgery and get it taken care of sooner," Dr. Levy said. "I'm very excited for the future of this work."

For More Information:

View the RSNA 2020 session Ultrasonographic features can predict failure of conservative treatment of acute appendicitis in children — PD-1A-22 at