American College of Surgeons

View all recommendations from this society

Released September 4, 2013

Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent in experienced hands. Recognizing that expertise may vary, strategies including improving diagnostic expertise in community based ultrasound and the development of evidence-based clinical decision rules are realistic goals in improving diagnosis without the use of CT scan.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American College of Surgeons (ACS) solicited recommendations for the ABIM Foundation’s Choosing Wisely® campaign from the Commission on Cancer, Committee on Trauma, and the Advisory Councils for Colon and Rectal Surgery, General Surgery, and Pediatric Surgery. The committees were provided with a description of the campaign’s initiative, a link to the Choosing Wiselywebsite, and published recommendations from organizations already participating in the campaign were referenced and reviewed during discussions. All of the recommendations collected from the ACS committees were reviewed, and five items were identified. The ACS’ disclosure and conflict of interest policy can be found at www.facs.org.

Participating ACS Committees:

Advisory Council for Colon and Rectal Surgery

  • Chair: Thomas E. Read, MD, FACS, Burlington, MA

Advisory Council for General Surgery

  • Chair: E. Christopher Ellison, MD, FACS, Columbus, OH

Advisory Council for Pediatric Surgery

  • Chair: Mary E. Fallat, MD, FACS, Louisville, KY
  • Immediate Past Chair: Thomas F. Tracy Jr., MD, FACS, Providence, RI

Commission on Cancer

  • Chair: Daniel P. McKellar, MD, FACS, Greenville, OH

Committee on Trauma

  • Chair: Michael F. Rotondo, MD, FACS, Greenville, NC

Sources

Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, Doria AS. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis-a Markov decision analytic model. Radiology. 2009;250:378-86.

Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for diagnosis of appendicitis in children? A meta-analysis. Radiology. 2006;241:83-94.

Garcia K, Hernanz-Schulman M, Bennett DL, Morrow SE, Yu C, Kan JH. Suspected appendicitis in children: diagnostic importance of normal abdominopelvic CT findings with nonvisualized appendix. Radiology. 2009;250:531-7.

Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011;259:231-9.

Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL, Grant TH, Greene FL, Jones B, Katz DS, Lalani T, Miller FH, Small WC, Spottswood S, Sudakoff GS, Tulchinsky M, Warshauer DM, Yee J, Coley BD, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® right lower quadrant pain — suspected appendicitis. [Internet]. Reston (VA): American College of Radiology (ACR); 2010. 7 p.

Frush DP, Frush KS, Oldham KT. Imaging of acute appendicitis in children: EU versus US or US versus CT? A North American perspective. Pediatr Radiolol. 2009;39(5):500-5.

Saito JM, Yan Y, Evashwick TW, Warner BW, Tarr PI. Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis. Pediatrics. 2013;131(1):e37-44.

Kharbanda AB, Stevenson MD, Macias CG, Sinclair K, Dudley NC, Bennett J, Bajaj L, Mittal MK, Huang C, Bachur RG, Dayan PS, and for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Interrater reliability of clinical findings in children with possible appendicitis. Pediatrics. 2012;129(4):695-700.