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tubo-ovarian abscess, ovarian torsion, or ectopic pregnancy are suspected.
Significant pain should be treated with intravenous (IV) narcotics prior to US, as
US requires graded compression of the bowel and can be quite painful in a patient
with appendicitis. Administration of narcotics has not been shown to mask
symptoms in a clinically significant way. US has a reported sensitivity of 80% to
92% with a specificity of 86% to 98%. In general, US has less utility in patients
with a high body mass index and patients earlier in the course of disease.
Secondary signs of appendicitis on US (focal edema of fat, free fluid, local ileus)
are helpful if the appendix is not visualized. Technically, a noncompressible
enlarged appendix is diagnostic of appendicitis, although the study must be
considered equivocal if the appendix is not identified. The management of
children with nondiagnostic US should be guided by the level of clinical
suspicion; children with low suspicion who are improving may be candidates for
observation, whereas children with persistent concern for appendicitis may
warrant advanced imaging or admission for serial examinations. When available,
a pediatric surgeon should be consulted for management decisions about children
with high suspicion of appendicitis but equivocal US results. CT and magnetic
resonance imaging (MRI) have both been used for diagnosis. Focal CT has a
diagnostic sensitivity of 95% with a specificity of 96%. CT can identify an
enlarged appendix, focal thickening of the cecum, periappendiceal inflammation,
mesenteric nodes, and fluid collections associated with perforation. CT should be
performed using IV contrast; oral and rectal contrast are not generally necessary.
CT is most interpretable in patients with adequate periappendiceal fat. MRI has
been shown to have equivalent test characteristics to CT, and can be performed
rapidly in children without the need for sedation or contrast.