Case #1: A 5-year-old boy with abdominal pain was brought to the ED by his parents. The pain had been present for 12 hours, and the child had vomited once. There was no fever or diarrhea. Tenderness in the right lower quadrant was noted on examination. Laboratory data reveal 10-25 white cells per high-powered field in the urine and a WBC count of 7,600/μL. What should be done next?
Options include: (1) treat for a UTI and send home; (2) culture the urine but do not treat and send home; (3) order a CT scan of the abdomen; and (4) order an ultrasound of the right lower quadrant.
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While all of the options except #1 could be correct depending on the circumstances, ultrasound of the right lower quadrant is the most appropriate choice. A UTI should not cause unilateral pain or tenderness, and appendicitis may cause a sympathetic pyuria with up to 25 white cells per field (up to 100 white cells per field is possible). If there is minimal tenderness on exam and the rest of the exam is normal, home observation with recheck in eight hours is a perfectly viable option for possible early appendicitis. While CT scan is very sensitive for appendicitis, the radiation exposure should be considered as a disadvantage in a patient this young.
Diagnostic ultrasound is almost as sensitive as CT, with overall sensitivities in the 80%-90% range or better (compared with 92%-97% for CT).1 Ultrasound is also faster than CT and has the advantage of being contrast- and radiation-free. In general, ultrasound should be the initial imaging test of choice in the pediatric patient with suspicion for appendicitis. If negative, CT scanning or home observation with eight-hour recheck should be considered, depending on clinical suspicion and other factors.
In this case, ultrasound was positive for a dilated appendix (Figure 1). The patient was taken to the operating room (OR) and underwent a successful appendectomy.
A final option to consider in classic appendicitis is surgery without imaging. This minimizes delay and radiation exposure. Malpractice suits involving ruptured appendixes have been won on the basis of an avoidable delay attributable to imaging deemed unnecessary due to a classical presentation.
Case #2: A woman aged 40 years presented to the ED after two hours of severe abdominal pain. On exam, the patient was found to be in severe distress with rebound tenderness. Her husband was yelling at the staff, “Why don’t you people do something?” What would be the initial diagnostic test of choice?
An ectopic pregnancy should be the first consideration with a woman in her childbearing years with sudden severe abdominal pain. Rapid ultrasound at the bedside is the imaging test of choice for conditions in which the usual delays associated with more formal imaging could prove fatal (e.g., ectopic pregnancy or leaking abdominal aortic aneurysm). If the provider is proficient in emergency bedside ultrasonography, a rapid transabdominal ultrasound can detect hemoperitoneum (Figure 2) in 60 seconds. This patient was diagnosed with a ruptured ectopic pregnancy and taken to the OR before her pregnancy test results were even available. She became quite hypotensive after arrival, but recovered well thanks to a speedy disposition to the OR. If there had been further delay, the outcome might have been worse.
