APPENDICITIS (SUSPECTED)

MANOJ K. MITTAL, MD, MRCP(UK), DOLORES H. ALBERT, BSN, RN, CPEN, KATELYN N. YOUNG, RN, MSN, CPEN, JOY L. COLLINS, MD, FAAP, AND JANE LAVELLE, MD

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

Appendicitis is the most common surgical emergency in children leading to more than 70,000 pediatric appendectomies annually in the United States. The diagnosis can be challenging, with a substantial proportion misdiagnosed if based on clinical features and laboratory tests alone. Negative appendectomy and perforation rates remain high, indicating a need to reevaluate the diagnostic assessment for this condition. Over the last decade, computed tomography (CT) has been heavily relied on in the evaluation of children with possible appendicitis to improve diagnostic accuracy. However, because of increasing concern over the long-term malignancy risk related to CT-associated ionizing radiation in children, its routine use is being reappraised. Standardizing the approach to patients with suspected appendicitis has been shown to reduce variability, thus promoting the delivery of efficient, safe, and cost effective health care. Clinical prediction rules are used to stratify patients based on their risk for having appendicitis, thus allowing for tailored management. There is increasing use of ultrasound (US) as the primary imaging modality. The US has been shown to accurately confirm or exclude appendicitis in cases where the appendix is clearly identified. When appendix is not identified, however, other clinical approaches should be considered; these include repeat clinical assessment; laboratory testing including a potential future role for biomarkers; admission for repeat clinical examinations and repeat US; and/or focused right lower quadrant CT or magnetic resonance imaging, or discharge home with close follow-up.

Appendicitis may also serve as a model disease for examining healthcare disparities in children given its acute nature, high prevalence, and known adverse outcomes associated with appendiceal perforation. Higher rates of appendiceal perforation have been found in patients with decreased healthcare access such as in minorities, patients on Medicaid, and in Hispanics with limited English proficiency.

PATHWAY GOALS AND MEASUREMENT

Goals

The goals for this pathway include the following:

Use of US as first-line imaging modality for all patients to avoid unnecessary radiation exposure

Standardized US radiology reports to facilitate clinician decision making

Standardized order sets for laboratory studies to assist frontline clinicians in initiating timely workups

Expectation for timely communication with the surgical team guided by the clinical certainty of diagnosis at different stages of the evaluation process