Clinical Practice Guidelines: Appendicitis

CLINICAL PRACTICE GUIDELINES (FULL LIST)

APPENDICITIS (CPG)

Appendicitis is a common pediatric surgical emergency. Despite its frequency, there is significant practice variability for diagnosing appendicitis in both general and pediatric-specific hospitals. Multiple clinical prediction tools have been validated to help standardize the diagnostic evaluation of appendicitis in children. While many children are diagnosed by ultrasound or by history and physical examination, the use of computed tomography has persisted. Given the increased lifetime risk of cancer due to the exposure of radiation from this imaging modality, standardizing the evaluation of appendicitis is needed. 
The Pediatric Surgery Quality Collaborative in partnership with the American College of Surgeons National Surgery Quality Improvement Program Pediatric Hospitals initiated a nationwide effort starting in 2020 to reduce the use of CT imaging in children in the diagnosis of appendicitis. Monroe Carell Jr. Children’s Hospital at Vanderbilt, in an effort to provide the best care for children with appendicitis, has agreed to participate in this collaborative. 
The goal of this clinical practice guideline is to encourage the use of the Pediatric Appendicitis Score, a clinical prediction tool, to help stratify the risk of appendicitis and to standardize the use of diagnostic tools and involvement of pediatric surgery with the ultimate goal of reducing CT imaging. Additional measures that will be monitored is emergency department time to diagnosis, the rate of negative pathology appendicitis, and emergency department return visits within 72 hours. 

 

Authors:

  • Monica Lopez, MD – Pediatric Surgery
  • Martin Blakely, MD – Pediatric Surgery
  • Barron Frazier, MD – Pediatric Emergency Medicine
  • Marta Hernanz-Schulman – Pediatric Radiology 
  • Melissa Danko, MD – Pediatric Surgery 
  • Jacob Olson, MD, Pediatric Surgery
  • Caroline Godfrey, MD, General Surgery
  • Anuradha Patel, MD, Pediatric Surgery
  • Jenny Overfield, MD – Pediatrics
  • Jessica Hayes, MD – Pediatrics
  • Clark Thornton, MD – Pediatrics 

Resources:

  • Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002 Jun;37(6):877-81. doi: 10.1053/jpsu.2002.32893. PMID: 12037754.
  • Fallon SC, Orth RC, Guillerman RP, Munden MM, Zhang W, Elder SC, Cruz AT, Brandt ML, Lopez ME, Bisset GS. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol. 2015 Dec;45(13):1945-52. doi: 10.1007/s00247-015-3443-4. Epub 2015 Aug 18. PMID: 26280638.
  • Carpenter JL, Orth RC, Zhang W, Lopez ME, Mangona KL, Guillerman RP. Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study. Radiology. 2017 Mar;282(3):835-841. doi: 10.1148/radiol.2016160175. Epub 2016 Oct 31. PMID: 27797677.
  • Telesmanich ME, Orth RC, Zhang W, Lopez ME, Carpenter JL, Mahmood N, Jadhav SP, Guillerman RP. Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams. Pediatr Radiol. 2016 Oct;46(11):1539-45. doi: 10.1007/s00247-016-3645-4. Epub 2016 Jun 9. PMID: 27282824.
  • Mangona KLM, Guillerman RP, Mangona VS, Carpenter J, Zhang W, Lopez M, Orth RC. Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference? Acad Radiol. 2017 Dec;24(12):1616-1620. doi: 10.1016/j.acra.2017.06.007. Epub 2017 Aug 18. PMID: 28826614.
  • Children’s Health Insurance Program Reauthorization Act (CHIPRA). Overuse of Imaging: Policy for ALARA Specific to Imaging Children Measure 0243.
  • Children’s Health Insurance Program Reauthorization Act (CHIPRA). Overuse of Imaging: Policy for ALARA Specific to Imaging Children Measure 0243 Measure Fact Sheet.
  • Lee KH, Lee S, Park JH, et al. Risk of Hematologic Malignant Neoplasms From Abdominopelvic Computed Tomographic Radiation in Patients Who Underwent Appendectomy. JAMA Surg. Published online January 20, 2021. doi:10.1001/jamasurg.2020.6357
  • Meulepas JM, Ronckers CM, Smets ANJB, et al. Radiation Exposure From Pediatric CT Scans and Subsequent Cancer Risk in the Netherlands, JNCI: Journal of the National Cancer Institute, Volume 111, Issue 3, March 2019, Pages 256–263, https://doi.org/10.1093/jnci/djy104