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Barbara M. Garcia Peña, MD; Kenneth D. Mandl, MD, MPH; Steven J. Kraus, MD; Anne C. Fischer, MD, PhD; Gary R. Fleisher, MD; Dennis P. Lund, MD; George A. Taylor, MD

JAMA. 1999;282:1041-1046.

Context  Limited computed tomography with rectal contrast (CTRC) has been shown to be 98% accurate in the diagnosis of appendicitis in the adult population, but data are lacking regarding the accuracy and effectiveness of this technique in diagnosing pediatric appendicitis.

Objective  To determine the diagnostic value of a protocol involving ultrasonography and CTRC in the diagnosis and management of appendicitis in children and adolescents.

Design, Setting, and Participants  Prospective cohort study of 139 children and adolescents aged 3 to 21 years (2 patients were older than 18 years) who had equivocal clinical findings for acute appendicitis and who presented to the emergency department of a large, urban, pediatric teaching hospital between July and December 1998.

Interventions  Children were first evaluated with pelvic ultrasonography. If the result was definitive for appendicitis, laparotomy was performed; if ultrasonography was negative or inconclusive, CTRC was obtained. Patients who did not undergo laparotomy had telephone follow-up at 2 weeks and medical records of all patients were reviewed 4 to 6 months after study completion.

Main Outcome Measures  Specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of tests based on final diagnoses; surgeons' estimated likelihood of appendicitis on a scale of 1 to 10 for each case and their case management plans before imaging, after ultrasonography, and after CTRC.

Results  A total of 108 patients underwent both ultrasonography and CTRC examinations. The protocol had a sensitivity of 94%, specificity of 94%, positive predictive value of 90%, negative predictive value of 97%, and accuracy of 94%. A normal appendix was identified by ultrasonography in 2 (2.4%) of 83 patients without appendicitis and by CTRC in 62 (84%) of 74 patients. A negative ultrasonography result did not change the surgeons' clinical confidence level in excluding appendicitis (P=.06), while a negative CTRC result did have a significant effect (P<.001). Positive results obtained for either ultrasonography or CTRC significantly affected surgeons' estimated likelihood of appendicitis (P=.001 and P<.001, respectively). Ultrasonography resulted in a beneficial change in patient management in 26 (18.7%) of 139 children while CTRC correctly changed management in 79 (73.1%) of 108.

Conclusions  These data show that CTRC following a negative or indeterminate ultrasonography result is highly accurate in the diagnosis of appendicitis in children.

Author Affiliations: Department of Medicine, Division of Emergency Medicine (Drs Peña, Mandl, and Fleisher), and Departments of Radiology (Drs Kraus and Taylor), and Surgery (Drs Fischer and Lund), Children's Hospital, Harvard Medical School, Boston, Mass.

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