CT and appendicitis

Here’s an interesting article on appendicitis:

http://www.nytimes.com/2015/06/17/health/study-supports-antibiotic-use-to-treat-appendicitis.html?ref=health

Avoiding surgery would certainy be a positive development.  Appendicitis is another sometimes complicated diagnosis, fraught with many “side” issues.  I drive my friends and colleagues a little crazy sometimes going on about it.  And I will state up front that, as a pediatrician and not a surgeon, I should be careful in what I say and how I say it.  But that’s the point:  ultimately this diagnosis is best made by a qualified surgeon at the bedside–not be me, not by an emergency room doctor and, for heaven’s sake, not be a CT scan.

The use of CT scans in the evaluation of abdominal pain in the ER is a great concern of mine.  Now, CT is a great tool for us doctors in trying to diagnose many problems like the cause of abdominal pain.  LIke any tool, used properly it’s a great help; improperly it can just make a mess of things (like me using a hammer and screw driver to defrost the fridge–of course, I hit the freon line and destroyed it: wrong tool, bad outcome). The purpose of this tool(CT) when introduced into the abdominal pain evaluation algorithm was to assist the surgeon to avoid “false positives”–taking people to the OR who ended up not having appendicitis.  So, it’s purpose is not to allow me or the ER doctor to say “this guy has appendicitis and needs a surgeon and that guy just has a bellyache and doesn’t.”  Also note that CT’s power comes from the amount of radiation administered.  I have seen estimates of abdominal CT being equivalent to 650 chest xrays worth of radiation.  That’s a ot of rads for your kid to be carrying around in her guts for the rest of her life!

So please allow me to make several suggestions to keep in mind:

  • Ask about doing an ultrasound.  There are lots of studies showing that US is very accurate in diagnosing appendicitis without the radiation
  • Ask pointed questions about the radiologist’s report.  Did she clearly say she saw the appendix?  Did she say that she did/did not see inflammation? Or did she say something like “appendix not completely visualized?”
  • Ask for a surgical evaluation.  If your child has an abdominal CT and no surgeon is available to evaluate your child at that time then perhaps she should be admitted for observation and the surgeon can come in later/the following morning.  If your child is sick enough to have a CT then she is sick enough to wait for the surgeon and the opposite also holds–if she isn’t that sick then she probably doesn’t need the scan.
  • Have the ER call me.  As you can see, I am very passionate about this subject.  I want to help the ER make the best call for your kid.  Better yet, call me before you head to the ER.  Maybe I can help your child avoid the entire traumatic ER experience.

Please send questions or comments, and thanks for following.

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