Imaging strategies in children with suspected appendicitis

Appendicitis is the commonest acute surgical emergency of childhood, and occurs in approximately 2–4 per 1000 infants. It is usually seen in infants older than 5 years but can occur at any age. Atypical clinical findings are seen in 30–50% of children, especially the younger ones, and often leads to a delayed diagnosis. Preoperative clinical assessment alone has yielded an accuracy ranging between 70 and 90% but is associated with a normal appendectomy rate of 13–25%. Preoperative imaging using the graded compression US technique and/or different helical CT techniques has been able to reduce this rate to 3–7% without an increase in perforation rate. An extensive review of the literature revealed several papers examining the accuracy of different imaging modalities and strategies of acute appendicitis in children. The reported sensitivity of US varied between 87 and 95%, vs 95–97% for helical CT, while the specificity ranged between 85 and 98% for US and 94 and 97% for helical CT. Only one truly randomised study was found, showing that compared with US alone, a combination of US and helical CT increased the sensitivity from 86 to 99%, while the specificity decreased from 95 to 89%. We conclude that imaging should be performed in all children with suspected appendicitis and that US should be the initial procedure with CT as a complementary tool.