American Academy of Pediatrics – Section on Surgery

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November 4, 2019

Avoid using computed tomography (CT scan) as the first-line imaging modality in the evaluation of suspected appendicitis in children. Ultrasound should be done first with a CT scan or magnetic resonance imaging (MRI) considered in equivocal cases.

Although CT is the most accurate radiologic modality for the evaluation of appendicitis, ultrasound should be the preferred initial evaluation in children. This modality is cost effective, avoids radiation exposure, and has excellent accuracy, with a reported sensitivity and specificity of 94 percent in experienced hands. When the ultrasound is equivocal, decision guidelines based on clinical findings as well as radiologic findings may assist in determining the need for cross-sectional imaging. Other options to consider prior to CT scan may include an evaluation by a surgeon, observation with serial exams, repeat ultrasound after a period of observation, and MRI, which has been shown to have similar diagnostic accuracy as CT.

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

Members of the American Academy of Pediatrics Section on Surgery Subcommittee on Education and Delivery of Surgical Care submitted the top 5 topics for Choosing Wisely items based on a review of the literature and expert opinion. The items were refined, ranked and approved by the Section on Surgery leadership. The list was then reviewed and approved by more than a dozen relevant AAP Committees, Councils and Sections. The AAP Executive Committee granted final approval of the list.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

Doria AS, Moineddin R, et al. US or CT for diagnosis of appendicitis in children? A meta-analysis. Radiology. 2006; 241:83-94.

Krishnamoorthi R, Ramarajan N, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011; 259:231-239.

Smith MP, Katz DS, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria Right Lower Quadrant Pain-Suspected Appendicitis. Ultrasound Q. 2015 June;31(2):85-91.

Samuel M. Pediatric Appendicitis Score. J Ped Surg. 2002;37(6):877-881.

Nielsen JW, Boomer L, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template. J Pediatr Surg. 2015; 50: 144–148.

Aspelund G, Fingeret A, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 2014 Apr;133(4):586-593.