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CT Technique Spots Appendicitis in Children.

WASHINGTON - Focal appendiceal helical CT using colon contrast material establishes the diagnosis of appendicitis in 96% of pediatric cases, Dr. Mark Mullins reported at the annual meeting of the American Roentgen Ray Society.

The technique has the potential to halve the rate of unnecessary exploratory surgery in children suspected of having appendicitis, said Dr. Mullins, a resident in radiology at Massachusetts General Hospital in Boston.

Focal appendiceal helical CT with colon contrast (FACT-CC) has been reported to be 98% accurate in diagnosing appendicitis in adults but had not yet been extensively studied in children.

Assessing suspected appendicitis is more challenging in the pediatric population because children's lower levels of intraabdominal fat make imaging the area more difficult, Dr. Mullins noted in his presentation.

To determine the accuracy and feasibility of the procedure in children, he and his associates conducted a retrospective study of 199 subjects aged 1-18 years who had been evaluated at his hospital for suspected appendicitis between 1997 and 1999. The mean age of the 90 boys and 109 girls was 12 years.

All of the subjects underwent FACT-CC and abdominal radiography; 32 also underwent ultrasound evaluation of the abdomen.

For FACT-CC, 40 cc of Gastrografin was diluted in a liter bag of saline, and 500-1,000 cc of the solution was instilled in the rectum. Imaging was performed from the level of L3 to the acetabulum, with the patient lying in the right lateral decubitus position.

All patients were accompanied by their parent or guardian, which greatly facilitated compliance, he said.

FACT-CC yielded true positive results in 64 cases, true negative in 128, false positive in 1, false negative in 2, and indeterminate results in 4. The overall accuracy of the procedure was 96%, just slightly lower than that reported in adults.

The sensitivity of FACT-CC was 97%, the specificity was 99%, and both the negative and positive predictive values were 98%.

In contrast, abdominal radiography was judged "not helpful" in making the diagnosis in 94% of these cases. Similarly, 26 of the 32 ultrasound assessments (81%) yielded indeterminate results, Dr. Mullins said.

In addition to ruling out appendicitis in patients who were mistakenly thought to have the disorder, FACT-CC established alternative diagnoses in nearly half of them (62 patients). Among these diagnoses were inflammatory bowel disease, mesenteric adenitis, ovarian cysts, pelvic inflammatory disease, and ureteral calculi, he said.

By facilitating diagnosis, FACT-CC halved the rate of unnecessary exploratory surgery among children at this hospital and substantially reduced delays in appropriate treatment.

It also markedly cut treatment costs. Even after taking into account the added costs of doing the procedure, FACT-CC saved approximately $100 per patient, or $20,000 overall, in the cost of unnecessary surgery alone. "That doesn't even include the savings in costs for treating complications and for extra hospital days," Dr. Mullins said.

In the question-and-answer session following his presentation, a member of the audience asked how a procedure using colon contrast material was so well tolerated in children, "who usually won't even comply with an enema."

Dr. Mullins answered that instilling the contrast material very slowly was the key to success.

Trying to quickly get the procedure over with actually causes more anxiety and discomfort in the child. By moving slowly--even taking as long as 45 minutes to instill the contrast material--and by making sure that the parents are present, excellent compliance can be achieved, he said.
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Publication:Family Practice News
Geographic Code:1USA
Date:Jul 15, 2000
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