8/15/2012 1 Endowed lectureship fitting memorial to Lee Prewitt, MD “In his work in radiology, Lee loved the children,” said Cindy Prewitt, wife of Lee H. Prewitt, MD. “He treated each one of them as if they were his own.” Dr. Prewitt died in December 2007 after 31 years as a physician in the Radiology Department at Children’s Hospitals and Clinics of Minnesota. An early member of the hospital’s radiology program, Dr. Prewitt was committed to Children’s and to life-long learning. Cindy, and children, Jenna and Bryce, established a fitting memorial to him focused on health care education at the hospital. The inaugural Lee H. Prewitt Memorial Lecture was held in April 2009 on “Pediatric Uroradiology - A Reminiscence” presented by Dr. Prewitt’s mentor, Robert L. Lebowitz, MD, Professor Emeritus of Radiology, Children’s Hospital Boston and Harvard Medical Center. Each year the Lee H. Prewitt Memorial Lecture will be part of Grand Rounds. “There have been many changes over the years in how physicians are trained, as well as how they keep up with new advances in pediatric health care. Lee was always striving to be the best he could be, and I think he would appreciate how this lectureship continues that spirit by bringing people together to enhance the care of children,” said Cindy. Working with Children’s Foundation, Cindy has ensured that the lectures will continue every year through her annual gift, and in her estate planning she has created an endowed fund named after Lee that will support the lecture series permanently. Viewing Time This presentation will take approximately one hour to complete. 4 Target Audience This program is designed for primary care physicians. Other health care professionals working with patients and their families may also find this program of interest. Faculty Disclosure It is the policy of Children’s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity, and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentations. They have also been requested to let you know when any products mentioned in their presentations are not labeled for the use under discussion or are still under investigation. 6 Speaker Faculty Disclosure Peter J. Strouse, MD has disclosed no actual or apparent conflict of interest in relation to this educational activity. During this educational activity Dr. Strouse will not be discussing the off-label use of any commercial or investigational product not approved for any purpose by the FDA.
24
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8/15/2012
1
Endowed lectureship fitting
memorial to Lee Prewitt, MD “In his work in radiology, Lee loved the children,” said
Cindy Prewitt, wife of Lee H. Prewitt, MD. “He treated
each one of them as if they were his own.” Dr. Prewitt
died in December 2007 after 31 years as a physician
in the Radiology Department at Children’s Hospitals
and Clinics of Minnesota.
An early member of the hospital’s radiology program,
Dr. Prewitt was committed to Children’s and to life-long
learning. Cindy, and children, Jenna and Bryce,
established a fitting memorial to him focused on health
care education at the hospital.
The inaugural Lee H. Prewitt Memorial Lecture was
held in April 2009 on “Pediatric Uroradiology - A
Reminiscence” presented by Dr. Prewitt’s mentor,
Robert L. Lebowitz, MD, Professor Emeritus of
Radiology, Children’s Hospital Boston and Harvard
Medical Center. Each year the Lee H. Prewitt Memorial
Lecture will be part of Grand Rounds.
“There have been many changes over the years in
how physicians are trained, as well as how they keep
up with new advances in pediatric health care. Lee
was always striving to be the best he could be, and I
think he would appreciate how this lectureship
continues that spirit by bringing people together to
enhance the care of children,” said Cindy.
Working with Children’s Foundation, Cindy has
ensured that the lectures will continue every year
through her annual gift, and in her estate planning she
has created an endowed fund named after Lee that will
support the lecture series permanently.
Viewing Time
This presentation will take
approximately one hour to complete.
4
Target Audience
This program is designed for primary care physicians.
Other health care professionals working with patients and their families may also find this program of interest.
Faculty Disclosure It is the policy of Children’s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity, and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentations.
They have also been requested to let you know when any products mentioned in their presentations are not labeled for the use under discussion or are still under investigation.
6
Speaker Faculty Disclosure
Peter J. Strouse, MD has disclosed no actual or apparent conflict of interest in relation to this educational activity.
During this educational activity Dr. Strouse will not be discussing the off-label use of any commercial or investigational product not approved for any purpose by the FDA.
8/15/2012
2
Imaging of Appendicitis:
What can We Do for You?
Pediatric Grand Rounds: August 16, 2012
Peter J. Strouse, M.D., F.A.C.R.
Director, Section of Pediatric Radiology
Director, Pediatric Radiology Fellowship Program
C.S. Mott Children’s Hospital
Professor, Department of Radiology
University of Michigan Health System
Ann Arbor, Michigan,
Imaging of Appendicitis:
What can We Do for You?
A lecture about the imaging of appendicitis along
with a suggested algorithm for the proper use of
physical exam, US, and CT
Program Objectives
Upon completion of this program, participants should be able to:
Discuss the imaging findings of appendicitis.
Present the goals of imaging for appendicitis.
Propose a paradigm for imaging of appendicitis.
Disclaimer
Children’s Hospitals and Clinics of Minnesota accepts no responsibility for the materials presented through these Grand Rounds seminars. Each professional presenter assumes all responsibility for maintaining confidentiality or obtaining authorization, in accordance with all applicable laws.
Accreditation
Children’s Hospitals and Clinics of Minnesota is accredited by the Minnesota Medical Association to provide continuing medical education for physicians.
Children’s Hospitals and Clinics of Minnesota designates this educational activity for a maximum of 1 AMA Category 1 Credit
TM toward the AMA Physician’s Recognition Award.
Each Physician should only claim credit for the actual time he/she spent in the activity.
Retention of CME Records
It is the policy of Children’s Medical Education program that we cannot offer to retain CME records for physicians attending or viewing the online CME activity.
The Minnesota Medical Association designates that physicians are responsible for maintaining their own CME records.
8/15/2012
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Receiving CME Credit
To receive CME credit, you must view the entire program. When the program is completed, click the Post Test button on the interface to access the Post Test.
You must successfully pass the Post Test to receive CME credit.
Imaging of Appendicitis:
What can We Do for You?
Peter J. Strouse, M.D., F.A.C.R.
Professor
Director, Section of Pediatric Radiology
Director, Pediatric Radiology Fellowship Program
C.S. Mott Children’s Hospital
Department of Radiology
University of Michigan Health System
Ann Arbor, Michigan, U.S.A.
Disclosures
None
Objectives
1) Discuss the imaging findings of
appendicitis
2) Present the goals of imaging for
appendicitis
3) Propose a paradigm for imaging of
appendicitis
The Appendix
• Midgut derivative
• Outpouching of cecum by 8th
week of gestation
• No known function
• With normal rotation and
fixation of cecum in right
lower quadrant
• Location varies
• Length varies
(adult: 9 cm average length)
Obstruction (lymphoid hyperplasia,
Inspissated feces,
appendicolith, etc.)
Bacterial Overgrowth
Mucous Production
Inflammation, Distention
Increased Pressure
Venous Obstruction
Necrosis
Bacterial Translocation
Bacteremia
Sepsis
Gangrene
Perforation
Peritonitis Phlegmon
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Who gets Appendicitis?
Lifetime risk:
7-8%
Addiss DG, et al. The epidemiology of appendicitis and
appendectomy in the United States. Am J Epidemiol
1990;132: 910-925
Capacity: 109,901
Aaron
Friedkin, MD
USA: 250,000 - 680,000 cases of
appendicitis per year (all ages)
Prompt Diagnosis Decreases
Morbidity (& Mortality) In hospital delay in diagnosis
• Higher complication rate (58.6% vs. 28.9%)
• Higher perforation rate (23.1% vs. 18.9%)
• Higher abscess formation rate (35.8% vs. 10.1%)
• Needed more drain procedures (5.7% vs. 0.4%)
• More hemicolectomies, SB laceration repairs, small bowel
resections
• Longer length of stay (10.4 days vs. 2.9 days)
• Higher cost ($53,500 vs. $17,900)
• Higher mortality (0.68% vs. 0.03%)
National database – 683,016 hospitalizations for appendicitis
Lee J, et al. Missed opportunities in the treatment
of appendicitis. Pediatr Surg Int 2012;28:697-701
Why Image?
• ~ 1/3 Atypical Presentation
Goal: hasten diagnosis, reduce complications
from delayed diagnosis, reduce negative
laparotomy (laparoscopy) rate
Goal: make alternative diagnoses
• Identify complications
Goal: identify perforation and/or abscess,
which may alter therapy
Is imaging required?
“The diagnosis of appendicitis . . .
is established by repeated clinical
examination by a skilled clinician.”
“Appendicitis is a diagnosis you make
with your hands”
Anthony Lander, FRCS.
Pediatr Radiol 2007;37:5-9
Michael D. Klein, MD.
Pediatr Radiol 2007;37:1114
8/15/2012
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• In general, literature supports that
imaging (US, CT) has decreased the
negative appendectomy rate
• Hastens diagnosis
• Boys > 5 years old - ? omit imaging
Bachur RG, et al. Diagnostic imaging and
negative appendectomy rates in children:
effects of age and gender. Pediatrics, 2012
Is imaging required? Problems with the Appendicitis
Imaging Literature
• Few direct prospective comparisons
• Studied populations vary and are poorly defined
• Results are technique dependent
• Evolving technology
• Role of clinical evaluation is usually overlooked
• Equivocal cases variably handled
• Acceptance of gold standard (path/surgery/f/u)
• Whatever your point, there is a paper to prove it
Three Questions asked of
the Radiologist:
1) Does the patient have appendicitis?
2) If not, is there another diagnosis?
3) If yes, is it perforated?
= Appendix
= Appendicolith
= Something else
1) Does the patient have
appendicitis?
Appendicitis: Pre-Imaging Era
• 1980’s and prior
• Dx made based on history, physical
exam, labs, +/- radiographs
• Barium enema
• Negative appendectomy rate ≈ 15-20%
• Perforation rate ≈ 20-30%
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Radiography
Advantages
• Inexpensive
• Quick
Disadvantages
• Not sensitive
• Radiation
Radiography
• Usually normal in
w/o perforation
11-year-old girl
Radiography
• Appendicolith (5-10%) • Appendicolith (5-10%)
• Ileus
• Mass effect
Radiography
Are radiographs useful?
• May suggest alternative diagnosis
• May guide choice of US vs CT
• Not necessary if already
committed to doing a CT
Foreign
Body
Appendicitis
2 1/2-year-old boy
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7
Barium Enema - Historical
Image here
8-year-old girl
Ultrasound
Puylaert, JBCM
“Acute Appendicitis: Ultrasound Evaluation
Using Graded Compression”
Radiology 1986;158:355-360
a
v Psoas m. v
• Linear array transducer
• Graded compression
9-year-old girl
Appendicitis
9-year-old girl
Ultrasound Technique
• Start in area of pain/tenderness
• Then search systematically
From: Baldisserotto &
Marchiori, AJR 2000
Appendicitis
Cecum Cecum
8/15/2012
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Normal Appendix
• ≤ 6 mm diameter
• Compressible
• Non-tender
8-year-old boy
Normal Appendix
15-year-old boy
Abnormal Appendix
• Non-compressible
• Blind ending
• Tubular structure
• > 6 mm diameter
• Tender
• +/- Appendicolith
• +/- Secondary findings
12-year-old boy
Abnormal Appendix = “non-compressible”
Appendicitis
13-year-old boy
Appendicitis
8-year-old boy
Appendicitis
11-year-old boy
8/15/2012
9
Appendicitis
7-year-old boy
Cecum
Appendicitis
7-year-old boy
16-year-old boy
Appendicitis
Appendicitis
Ultrasound Advantages
• No sedation
• No prep
• No radiation
• Realtime
• Spatial resolution
• Pelvis/GB/Urinary
tract
• Low FP rate
Disadvantages
• Operator dependent
• Technique dependent
• Takes time
• May be painful • Normal appendix may
not be seen • High FN and/or
indeterminate rate
• Less accurate than CT for perforation
Limitations of US
• Large or obese patients
• Bowel gas, guarding
• Anomalous appendix position
• “Not as accurate as CT”
• Acceptance and understanding of referring clinician (and surgeon)
8/15/2012
10
Appendicitis
4-year-old boy
Is it necessary to see the
normal appendix?
10-year-old boy
Is it necessary to see the
normal appendix?
Stewart et al, Sonography for Appendicitis: Nonvisualization of
the Appendix Is an Indication for Active Clinical Observation
Rather Thank Direct Referral for Computed Tomography. J Clin
Ultrasound 2012
• 260/400 patients had non-visualization
of the appendix on ultrasound
• 16/260 (6.2%) had appendicitis
• Clinical observation; not CT in all
Pooled
Sensitivity
Pooled
Specificity
US 88% 94%
Ultrasound is a Good Test
Doria AS, et al. US or CT for Diagnosis of
Appendicitis in Children and Adults? A Meta-
Analysis. Radiology 2006;241:83-94
Sensitivity: 50-100%
Specificity: 88-99%
Maybe not ?
Taylor GA, Suspected appendicitis in children: in search of the
Single best diagnostic test. Radiology 2004;231:293-294
Two largest studies (>5000 children)
• Sensitivity – 90-92%
• Specificity – 97-98%
• PPV – 82-90%
• NPV – 98%
Hahn HB, et al. Pediatric Radiology 1998
Schulte B, et al. Eur J Radiol 1998
Ultrasound is a Good Test
8/15/2012
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Wiersma et al
• Normal appendix seen in 82% of asymptomatic children
• 15 min maximum time allowed
Hahn et al
• Normal appendix seen in 82% of patients w/o acute appendicitis
• 20 min maximum time searching
How good can Ultrasound be?
Hahn HB, et al. Pediatric Radiology 1998
Wiersma et al. Radiology 2005
• Prospective study
• 425 children – 199 proven appendicitis
• Used supplemental views
• 20 min average
• Sensitivity 98.5%
• Specificity 98.2%
• PPV 98.0%
• NPV 98.7%
Baldisserotto & Marchiori, AJR 2000
How good can Ultrasound be?
• United States
• Retrospective review of prospective Dx’s
• 81 pts to OR w/o CT or US
– 20% FP rate (16 = normal appx)
• 389 imaged (382 US, 3 CT, 4 US&CT)
– 137 to OR
– 3% FP rate (4 = normal appx)
Hernandez JA, et al. Imaging of acute appendicitis: US as the