Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis

Suzanne Schuh; Carina Man; Eman Marie; Ghufran Hassan A Alhashmi; Dan Halevy; Paul W Wales; Dana Singer-Harel; Aya Finkelstein; Judith Sweeney; Andrea S Doria

doi:10.1016/j.ajem.2023.06.026

Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis

Am J Emerg Med. 2023 Sep:71:217-224. doi: 10.1016/j.ajem.2023.06.026. Epub 2023 Jun 16.

Authors

Affiliations

¹ Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada. Electronic address: suzanne.schuh@sickkids.ca.
² Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada.
³ Radiology Department, King Abdulaziz University Hospital, College of Medicine, Jeddah, Saudi Arabia.
⁴ Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto Canada.
⁵ Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada.
⁶ The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
⁷ Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.

PMID: 37453161
DOI: 10.1016/j.ajem.2023.06.026

Abstract

Objective: to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED).

Study design: prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway.

Results: 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT.

Conclusion: this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.

Keywords: Appendicitis; Children; MRI; Ultrasound.

MeSH terms

Adolescent
Appendectomy
Appendicitis* / diagnostic imaging
Appendicitis* / surgery
Child
Child, Preschool
Humans
Magnetic Resonance Imaging / methods
Predictive Value of Tests
Prospective Studies
Retrospective Studies
Sensitivity and Specificity
Ultrasonography