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Journal of Pediatric Surgery (2011) 46, 11151120

www.elseier.co!"locate"#$edsurg
Surgeon%$erfor!ed ultrasound as a diagnostic tool
in a$$endicitis
Je&rey '. (urford a,) , 'elin S. *assinger a,+, Sa!uel *. S!it, a
a
)
Pediatric Surgery, -r.ansas /,ildren0s 1os$ital 1 /,ildren0s 2ay 3ittle 4oc., -4 52202%6571, 8S-
Surgery, 8niersity of -r.ansas for 'edical Sciences, 3ittle 4oc., -4, 8S-
4eceied 9 'arc, 2011: acce$ted 26 'arc, 2011
;ey words<
-$$endicitis:
8ltrasound
-)stract
Pur$ose< *iagnosing a$$endicitis !ay re=uire ad#unct studies suc, as co!$uted to!ogra$,y or
ultrasound (8S). /o!)ining a clinical e>a!ination wit, surgeon%$erfor!ed 8S (SP8S) !ay increase
diagnostic accuracy and decrease radiation e>$osure and costs.
'et,ods< - $ros$ectie study was conducted including c,ildren wit, a $otential diagnosis of
a$$endicitis. - surgery resident $erfor!ed a clinical e>a!ination and 8S to !a.e a diagnosis. ?inal
diagnosis of a$$endicitis was con@r!ed )y o$eratie @ndings and $at,ology. 4esults were co!$ared
wit, radiology de$art!ent 8S (4*8S) and a large rando!iAed trial. -nalysis was $erfor!ed using
?is,er e>act test.
4esults< ?ifty%four $atients were ealuated and underwent SP8S. Bwenty%nine $atients (54C) ,ad
a$$endicitis. Derall accuracy was 97C, wit, accuracy increasing fro! 95C to 76C )etween t,e 2
,ales of t,e study. 4adiology de$art!ent 8S was $erfor!ed on 21 $atients )efore surgical
ealuation,
yielding an accuracy of 91C. Surgeon%$erfor!ed 8S on t,ose 21 $atients yielded an accuracy of
70C.
Eo statistical di&erences were found )etween any grou$s (P E .05).
/onclusion< -ccuracy of SP8S was si!ilar to 4*8S and t,at of a large $ros$ectie rando!iAed trial
$erfor!ed )y radiologists. ?urt,er!ore, w,en t,e sa!e clinician $erfor!s t,e clinical e>a!ination
and
8S, a ,ig, leel of accuracy can )e ac,ieed. 2it, t,is degree of accuracy, SP8S !ay )e used as a
$ri!ary diagnostic tool and co!$uted to!ogra$,y resered for c,allenging cases, li!iting costs,
and
radiation e>$osure.
F 2011 Glseier Hnc. -ll rig,ts resered.
-$$endicitis is one of t,e !ost co!!on surgical diseases
treated in c,ildren. *iagnosis of t,e disease was
traditionally
!ade )ased solely on ,istory and clinical e>a!ination,
leading to a negatie a$$endecto!y rate of u$ to 20C I1,2J.
B,is co!$lication rate ,ad )een considered acce$ta)le
)ecause of t,e $reference of a negatie la$aroto!y or
+ /orres$onding aut,or. Bel.< K1 501 664 1446: fa>< K1 501 664 1516.
G%!ail address< dassinger!elinsLua!s.edu ('.S. *assinger).
0022%6469"M see front !atter F 2011 Glseier Hnc. -ll rig,ts resered.
doi<10.1016"#.#$edsurg.2011.06.040
la$arosco$y oer t,e !or)idity of a $erforated a$$endi>
I2%4J. 1oweer, t,e i!$roed =uality of co!$uted to!og%
ra$,y (/B) ,as led to t,e li)eral use of t,is i!aging !odality
to i!$roe t,e accuracy of diagnosis in )ot, adult and
$ediatric $o$ulations I4,5J.
'ore recently, t,e routine use of /B for a$$endicitis ,as
)een =uestioned )ecause of concerns oer ineNciency, ,ig,
costs, and t,e long%ter! e&ects of ioniAing radiation
e>$osure
I2,6%7J. -s a result, grou$s ,ae i!$le!ented clinical
1116
$at,ways using ultrasound (8S) as t,e $ri!ary i!aging
!odality I10J. 1oweer, 8S studies are o$erator de$endent
and are ty$ically $erfor!ed in t,e radiology de$art!ent,
w,ere access !ay )e li!ited after O)usinessP ,ours.
B,e use of surgeon%$erfor!ed 8S (SP8S) in trau!a,
endocrine, )reast, and ascular surgery ,as )een well
docu!ented I11J. ?urt,er!ore, we ,ae $u)lis,ed our
institution0s e>$erience wit, SP8S for $yloric stenosis I12J.
B,is increasing fa!iliarity wit, 8S tec,ni=ues cou$led wit,
t,e lac. of access to Oafter ,oursP 8S led us to design a
study to
assess t,e role of SP8S in t,e diagnosis of a$$endicitis.
2e ,y$ot,esiAed t,at a surgeon a$$ro$riately trained in
a)do!inal sonogra$,y s,ould )e a)le to $erfor! an
a)do!inal 8S for a$$endicitis at t,e ti!e of initial
ealuation wit, accuracy co!$ara)le wit, a study
$erfor!ed
in t,e radiology de$art!ent 8S (4*8S).
J.'. (urford et al.
)ased on t,e co!$lete clinical ealuation, w,ic, included
,istory ta.ing, $,ysical e>a!ination, and 8S. B,e decision
to $erfor! an a$$endecto!y was ulti!ately t,e attending
$ediatric surgeon0s and too. into account all releant clinical
data including any and all i!aging studies. B,e @nal
diagnosis of a$$endicitis, )ot, unco!$licated and
$erforated,
was con@r!ed )y o$eratie @ndings and $at,ology.
1.1. Statistical analysis
B,e resident0s diagnoses were t,en co!$ared wit, eit,er
t,e o$eratie @ndings or t,e condition at disc,arge, for
t,ose
$atients w,o were o)sered. Sensitiity, s$eci@city, $ositie
$redictie alue, negatie $redictie alue, and accuracy
were calculated w,en 8S alone was used to !a.e t,e
diagnosis as well as w,en it was used in con#unction wit,
,istory and $,ysical e>a!ination. - second analysis was
$erfor!ed focusing on t,e co,ort of $atients w,o underwent
8S studies )ot, )y t,e surgery resident and )y t,e radiology
de$art!ent. Eo!inal aria)les were co!$ared using ?is,er
e>act test, wit, P ) .05 considered statistically signi@cant.
1. 'et,ods
-fter institutional reiew )oard a$$roal, de!ogra$,ic
and clinical data were $ros$ectiely collected during a
5%!ont, $eriod fro! $atients ealuated in a tertiary referral
c,ildren0s ,os$ital e!ergency de$art!ent for $ossi)le
a$$endicitis. -ll $atients were initially ealuated )y
e!ergency de$art!ent $,ysicians w,o su)se=uently
o)tained a $ediatric surgical consult.
- $ostgraduate year 6 surgical resident w,o ,ad
$artici$ated in a 6%day introductory a)do!inal ultrasonog%
ra$,y course was designated to ealuate all $atients. Hf ,e
was on call, ,e $erfor!ed t,e initial ealuation: if ,e was
not
i!!ediately aaila)le, t,e $atient was seen )y a $ediatric
surgery resident, and t,e $ostgraduate year 6 surgical
resident ealuated t,e $atient at t,e earliest o$$ortunity. Hn
all cases, t,is resident was )linded to t,e surgical tea!
!e!)ers0 o$inions as well as any i!aging o)tained )efore
surgical consultation.
/onsent was o)tained fro! t,e guardian, and assent was
o)tained fro! c,ildren older t,an 5 years: ,istory ta.ing,
$,ysical e>a!ination, and a)do!inal 8S were t,en $er%
for!ed. B,e SP8S was conducted using a Sonosite 'icro%
!a>> (Seattle, 2-,) 8S wit, a 6% to 16%'1A ,ig,%fre=uency
linear transducer. B,e 8S study was $erfor!ed using a
graded
co!$ression tec,ni=ue wit, initial e!$,asis on t,e area of
!a>i!al tenderness. Hf eidence of a$$endicitis was not
found
at t,e site of !a>i!al tenderness, t,e rig,t lower =uadrant
was
scanned in )ot, transerse and longitudinal a>es. B,e rig,t
lower =uadrant was ealuated for signs of a$$endicitis
including
a nonco!$ressi)le )lind%ending tu)ular structure wit, a
dia!eter greater t,an 6 !!. 1y$ere!ia, $eria$$endiceal
Quid, a$$endicolit,s, and Quid collections were considered
secondary signs of a$$endicitis I1,16,14J.
B,e resident t,en docu!ented 2 O@nalP diagnoses< t,e
@rst )ased solely on 8S @ndings, si!ulating diagnostic
decisions !ade in t,e radiology de$art!ent, and t,e second
2. 4esults
?ifty%four of 55 consecutie $atients ealuated )y t,e
surgical resident for $ossi)le a$$endicitis were enrolled in
t,e study. B,e !ean age of t,e $atients ealuated was 9.9
years (range, 6%16 years). Bwenty%eig,t $atients (52C) were
!ale, and t,e !ean )ody !ass inde> of all $atients was
17.6 .g"!2 (range, 16.7%29.7 .g"!2). ?orty%nine (71C) of 54
$atients underwent i!agingR/B, 8S, or )ot,R)efore
surgical ealuation. Bwenty%nine $atients (54C) were
found to ,ae a$$endicitis at t,e ti!e of o$eration, wit, 7
(15C) $atients ,aing $erforated a$$endicitis.
4esults are su!!ariAed in Ba)le 1. Surgeon%$erfor!ed
8S alone yielded signs of a$$endicitis in 26 of 27 $atients
deter!ined to ,ae a$$endicitis. B,e single $atient wit, a
false%$ositie 8S e>a!ination ,ad an enlarged nonco!$res%
si)le )lind%ending tu)ular structure wit, a dia!eter greater
t,an 6 !! )ut was ulti!ately deter!ined not to ,ae
a$$endicitis )ased on clinical o)seration. Df t,e 6 false%
negatie e>a!inations, 2 $atients ,ad secondary signs of
a$$endicitis, )ut a de@nitie nonco!$ressi)le structure was
not identi@ed: 1 ,ad a retrocecal a$$endi>: and t,e
re!aining
6 were si!$ly not seen. 'ean )ody !ass inde> for $atients
wit, t,e a$$endi> isualiAed on 8S was 19.1 .g"!2
co!$ared wit, 17.4 .g"!2 for t,ose $atients in w,o! t,e
a$$endi> was not seen (P S .6107). B,e oerall accuracy of
SP8S alone in ealuating a$$endicitis was 95C.
2,en SP8S was co!)ined wit, ,istory and $,ysical
e>a!ination, 25 of 27 $atients were correctly diagnosed
wit, a$$endicitis, increasing t,e diagnostic accuracy to
97C: ,oweer, t,e rate of false%$ositie e>a!inations
increased slig,tly.
8ltrasound as a diagnostic tool in a$endicitis
Ba)le 1 /o!$arison of results
SP8S
Eo. of $atients
Brue $ositie (sensitiity)
?alse negatie
?alse $ositie
Brue negatie (s$eci@city)
Positie $redictie alue
Eegatie $redictie alue
-ccuracy
54
26"27 (57C)
6"27 (21C)
1"25 (4C)
24"25 (76C)
26"24 (76C)
24"60 (90C)
45"54 (95C)
SP8S wit, clinical
e>a!ination
54
25"27 (76C)
2"27 (5C)
4"25 (16C)
21"25 (94C)
25"61 (95C)
21"26 (71C)
49"54 (97C)
4adiology%$erfor!ed
8S
21
6"6 (50C)
6"6 (50C)
1"15 (5C)
14"15 (76C)
6"4 (55C)
14"15 (92C)
15"21 (91C)
1115
SP8S on $atients
wit, radiology 8S
21
5"6
1"6
1"15
14"15
5"6
14"15
17"21
(96C)
(15C)
(5C)
(76C)
(96C)
(76C)
(70C)
Bwenty%one of 54 $atients enrolled also underwent
4*8S. Si> (27C) of t,ose 21 $atients ,ad a$$endicitis.
4adiology de$art!ent 8S yielded an accuracy of 91C
co!$ared wit, SP8S, w,ic, $roduced an accuracy of 70C.
Df t,e 6 $atients w,o ,ad a$$endicitis, 4*8S was a)le to
identify a$$endicitis in 6 $atients co!$ared wit, SP8S,
w,ic, identi@ed 5 $atients wit, t,e disease.
-ll 54 $atients in t,e study were t,en strati@ed into 2
grou$s
)ased on t,e accu!ulated e>$erience of t,e surgery
resident
$erfor!ing t,e 8S e>a!inations. 4esults are su!!ariAed in
Ba)le 2. 2,en t,e @rst 25 $atients were co!$ared wit, t,e
second 25 $atients enrolled, s$eci@city increased fro! 50C
to
76C, and accuracy increased fro! 95C to 76C.
?urt,er!ore,
false%$ositie diagnoses decreased fro! 6 $atients in t,e
@rst
grou$ to 1 $atient in t,e second.
6. *iscussion
Dur study was designed to assess t,e feasi)ility of SP8S
in $ediatric a$$endicitis. D)taining an accurate diagnosis of
t,e disease can )e c,allenging at ti!es )ecause of
i!$recise
data or $oor ,istory e>a!inations in c,ildren, leading to t,e
use of ad#unctie i!aging I16J. /o!$uted to!ogra$,y
scans
are co!!only o)tained )ecause t,ey are readily aaila)le
to
e!ergency de$art!ent $,ysicians. 1oweer, t,ese studies
will li.ely )e used less fre=uently in t,e future )ecause data
concerning radiation%induced !alignancy is accu!ulated
and $u)lis,ed I15%15J. 'oreoer, a$$endiceal /B scans !ay
re=uire $atients to drin. oral contrast t,at !ay )e
un$alata)le
or ine&ectie, creating delays in t,e diagnosis of a $atient
e>$eriencing gastrointestinal sy!$to!s I19J.
8ltrasound e>a!inations, alt,oug, $otentially safer,
$resent t,eir own set of c,allenges. ?irst, 8S studies for
a$$endicitis ,ae lower sensitiities and s$eci@cities t,an
/B I9,16,17J. Second, t,e use of 8S also relies on $ersonnel
fro! an outside de$art!ent, w,o !ay not .ee$ t,e sa!e
)usiness ,ours as t,e surgeons ealuate t,e $atient.
?urt,er!ore, 8S is o$erator de$endent, and studies
o)tained
during Oo& ,oursP are li.ely to )e $erfor!ed )y unsu$er%
ised tec,nicians, w,ic, ,as )een associated wit,
decreased
sensitiity and s$eci@city I20J.
-s t,e $endulu! s,ifts toward 8S, surgeons ,ae a
uni=ue o$$ortunity. 4esidents are increasingly e>$osed to
8S tec,ni=ues during t,eir general surgery training: !ost
graduating residents are facile at focused a)do!inal sono%
gra!s for trau!a, and !any ,ae )een e>$osed to )ot,
)reast and t,yroid 8S e>a!inations. ?urt,er!ore, we ,ae
s,own t,at residents and fellows can accurately $erfor! 8S
for $ediatric%s$eci@c disease suc, as $yloric stenosis I12J.
B,us, as surgeons continue to gain e>$erience, it see!s
natural t,at surgeons will )egin to $erfor! 8S w,en initially
ealuating a $atient wit, $ossi)le a$$endicitis.
Surgeon%$erfor!ed 8S, w,ic, ta.es a$$ro>i!ately 10
!inutes to co!$lete, was $erfor!ed on all enrolled
$atients.
Hn t,is study, a single resident w,o ,ad attended an
Ba)le 2 Be!$oral analysis of SP8S co!)ined wit, clinical e>a!ination
Second 25 $atients
Eot -$$y
6
5
10
17
9
16"15 (74C)
5"10 (50C)
16"17 (94C)
5"9 (99C)
26"25 (95C)
*>K
*>T
-$$y
11
1
12
Eot -$$y
1
14
15
12
15
11"12 (72C)
14"15 (76C)
11"12 (72C)
14"15 (76C)
25"25 (76C)
?irst 25 $atients
-$$y
*>K
*>T
16
1
15
Sensitiity
S$eci@city
Positie $redictie alue
Eegatie $redictie alue
-ccuracy
Sensitiity
S$eci@city
Positie $redictie alue
Eegatie $redictie alue
-ccuracy
*> K indicates $reo$eratie diagnosis of a$$endicitis: -$$y indicates $ositie $at,ologic diagnosis of a$$endicitis.
1119
introductory a)do!inal 8S course $erfor!ed eery e>a!i%
nation. 1oweer, t,e course did not focus on s$eci@c organ
syste!s, and t,e resident ,ad no for!al training s$eci@cally
in sonogra$,y for a$$endicitis. *es$ite t,is fact, ,e
$erfor!ed t,e e>a!inations wit, a ,ig, degree of accuracy,
w,ic, increased in t,e second ,alf of t,e study as ,e gained
e>$erience and con@dence. B,is con@dence is i!$ortant
)ecause a nor!al a$$endi> is not always isualiAed, and
learning to a$$reciate t,e negatie $redictie alue of an
inconclusie e>a!ination co!)ined wit, t,e ,istory and
$,ysical e>a!ination see!s i!$ortant in t,e learning cure
for SP8S I21J. -lt,oug, t,ere is no acce$ted learning cure
for a$$endiceal 8S, our resident0s e>$erience !irrors t,e
learning cure seen for focused a)do!inal sonogra!s for
trau!a e>a!ination I22J.
B,e current study co!$ares t,e results of SP8S to t,at of
4*8S and found no statistical di&erences. Df t,e 6 $atients
wit, a$$endicitis w,o underwent )ot, 4*8S and SP8S,
SP8S was a)le to isualiAe t,e a$$endi> in 5 $atients
co!$ared wit, 6 $atients wit, isualiAation )y 4*8S. B,is
di&erence !ay )e e>$lained )y t,e fact t,at 4*8S at our
institution is $erfor!ed )y a 8S tec,nician and t,en
inter$reted )y a radiologist. B,e inter$retation of 8S is
de$endent on t,e tec,nician0s e>$erience and furt,er
a&ected )y a disconnect )etween t,e $atient0s clinical
condition and t,e radiologist reading t,e i!ages. Hf t,e
$,ysician inter$reting t,e i!ages is t,e $erson scanning t,e
$atient, t,e e>a!ination can )e tailored to t,e $atient0s
s$eci@c e>a!ination @ndings, and !ore ti!e can )e focused
on concerning areas or $oints of !a>i!al tenderness.
(ecause t,e nu!)er of $atients w,o underwent 4*8S
was relatiely s!all, we also co!$ared our results to a large
$ros$ectie Guro$ean trial ealuating i!aging in t,e
diagnosis of a$$endicitis. B,e Guro$ean trial included 8S
e>a!ination of 600 $atients and was $erfor!ed )y
$,ysicians e>$erienced in 8S. B,at study ,ad an
a$$endicitis
rate of 41C co!$ared wit, 54C in our study (P S .0960).
B,ere was no statistically signi@cant di&erence in any
!easured $ara!eter w,en t,e results of t,e study were
co!$ared wit, ours.
-ll $atients enrolled in our study underwent SP8S. 2e
are cogniAant of t,e fact t,at a$$endicitis is still a OclinicalP
diagnosis, and $atients $resenting wit, a classic ,istory and
$,ysical e>a!ination do not re=uire furt,er i!aging. Hn fact,
studies ,ae logically suggested t,at t,e greatest )ene@t of
8S for a$$endicitis is for cases wit, an e=uiocal clinical
diagnosis I26J. 1oweer, SP8S is noninasie and essen%
tially aug!ents t,e $,ysical e>a!ination. ?urt,er!ore,
$erfor!ing SP8S on all cases of sus$ected a$$endicitis
will li.ely lead to i!$roed accuracy in e=uiocal cases
)ecause $reious re$orts suggest t,at sonogra$,ers or
clinicians w,o e!)race t,e tec,ni=ue ,ae greater accuracy
and con@dence I7,21J.
B,is study ,as de!onstrated t,at a surgery resident can
$erfor! 8S for $ediatric a$$endicitis wit, a ,ig, degree of
accuracy. B,is @nding suggests t,at an algorit,! using
J.'. (urford et al.
SP8S on initial surgical ealuation is an acce$ta)le and
$ossi)ly $referred !et,od of ealuation. B,is a$$roac, !ay
i!$roe t,e eNciency of diagnosis and aoid unnecessary
/B scans. Hn addition, residents and fellows w,o )eco!e
facile wit, t,ese e>a!inations can train ot,er trainees and
clinicians, as we ,ae s,own in $yloric stenosis I24J.
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I20J Po,l *, Uolu) 4, Sc,wartA UG, et al. -$$endiceal ultrasonogra$,y
$erfor!ed )y nonradiologists< does it ,el$ in t,e diagnostic $rocessX
J 8ltrasound 'ed 1779:15<215%21.
I21J 1olsc,er 1/, 1ei# 1-. H!aging of acute a$$endicitis in c,ildren< G8
ersus 8SZ or 8S ersus /BX - Guro$ean $ers$ectie. Pediatr 4adiol
2007:67<475%7.
I22J Uracias V1, ?ran.el 13, Uu$ta 4, et al. *e@ning t,e learning cure
for t,e focused a)do!inal sonogra! for trau!a (?-SB) e>a!ination<
i!$lications for credentialing. -! Surg 2001:65<664%9.
8ltrasound as a diagnostic tool in a$endicitis
I26J 3essin 'S, /,an ', /atalloAAi ', et al. Selectie use of
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155<176%6.
I24J 'cay '4, /o$eland *4, 'c'a,on 3G, et al. Surgeon%$erfor!ed
ultrasound for diagnosis of $yloric stenosis is accurate, re$roduci)le,
and clinically alua)le. J Pediatr Surg 2007:44<167%52.
1117
are $atients wit, an indeter!inate e>a! t,at ,ae )een
sent for t,at reason. Ht is $ro)a)ly not fair to co!$are
t,e! to t,e ones t,at !ig,t ,ae ot,erwise gone to t,e
o$erating roo! wit, no diagnostic study if your $rotocol
,ad not )een in $lace.
J. (urford< 2e didn0t e>actly loo. at t,e $reo$eratie
diagnosis of a$$endicitis ersus no a$$endicitis wit, or
wit,out ultrasound. 2e did @nd t,at so!e $atients
o)iously would )ene@t or would not )ene@t fro! an
ultrasound to !a.e t,e diagnosis. So we don0t ,ae t,at
data to loo. at. -s far as )linded results fro! t,e radiology
i!ages, we didn0t loo. at t,at e>actly )ut we do ,ae our
i!ages aaila)le for $ossi)le furt,er inestigation in t,e
future to loo. if an outside $arty could accurately identify
it and t,e slides are )ased on t,e i!ages t,at we
o)tained.
*ennis Vane (St 3ouis, 'D)< H assu!e it is you w,o did t,e
ultrasoundsX
J. (urford< Wes, sir.
*. Vane< 1ow long did it ta.e you to learn ,ow to do itX
B,ere is a lot of data to indicate t,at attending radiologists
do a fairly good #o) )asically e=uialent to w,at you
found w,en t,ey do t,e ultrasounds. 1oweer, if
residents, second and t,ird year radiology residents do
t,e ultrasounds, t,e accuracy is now,ere near w,at you
found, so ,ow long did it ta.e you to learn ,ow to )e
)etter t,an a second or t,ird year residentX
J. (urford< H ,ad attended a wee.end course in a)do!inal
ultrasound and t,en t,roug,out our study we noticed t,at
as ti!e $rogressed, our @rst ,alf of our $atients co!$ared
wit, t,e second ,alf, we noticed a stee$ decline in errors
and if we carried it out een furt,er to anot,er ten
$atients
included in our study, results were al!ost 100C correct.
So H t,in. t,ere0s a fairly stee$ learning cure and a future
study would include teac,ing new residents to $erfor!
t,e sa!e e>a!.
S,erif G!il ('ontreal, /anada)< H t,in. we0re way )e,ind
our Guro$ean counter$arts in ta.ing t,is on. *id you get
consent fro! t,e $atients, H !ean w,en you sit wit, a
c,ild w,o ,as a$$endicitis and is undergoing ultrasound,
it0s not a $articularly $leasant e>$erience for t,e c,ild, so
if you are to re$eat t,is ultrasound again, ,ow did you
e>$lain t,is to a $arent and ,ow did you get consent to )e
a)le to do t,atX
J. (urford< 2e #ust e>$lained it to t,e $arents. 2e did
o)tain consent fro! t,e $arents and we o)tained consent
fro! t,e $atients t,at were greater t,an seen years of
age
in our study. -ll $atients tolerated it ery well, wit, t,e
e>ce$tion of one or two t,at were e>tre!ely tender on
$,ysical e>a!.
*iscussion
2alter /,wals ((oston, '-)< Wour study ,ig,lig,ts t,e fact
t,at ultrasound is a ia)le way in w,ic, to deter!ine
w,et,er or not you ,ae acute a$$endicitis. *id you
co!$are your data wit, ot,er i!aging studies, i.e. /B
scan studies t,at ,ad )een o)tained in t,e sa!e $atients
to
deter!ine ,ow t,e ultrasound co!$ared wit, /B scansX
J. (urford< So!e $atients in t,e study did receie /B scans.
B,e resident was )linded to t,e results $rior to ,is
ealuation, )ut results were ery si!ilar )etween t,e /B
scan @ndings and t,e @ndings of t,e surgery resident.
B,ere were so!e $atients t,at ,ad $ositie /B scans
ulti!ately t,at led to surgery t,at t,ese surgery resident
did not $ic. u$.
2. /,wals< H o)sered t,at t,e data you $resent ,ere are
si!ilar to accuracy, sensitiity, s$eci@city, $ositie and
negatie $redictie alue in /B scan related studies. *id
you note t,at w,en you were oer t,e a$$endi> t,ere was
increased $ain on t,e $art of t,e $atientX
J. (urford< 2e did @nd H guess as e>$erience was gained
t,at t,e ultrasound did sere also as an e>tension of t,e
$,ysical e>a! and in so!e $atients w,ere @ndings were
so!ew,at in conclusie t,ere was H guess increased $ain
or @ndings on $,ysical e>a! t,at aided in t,e diagnosis.
*ouglas (arn,art (Salt 3a.e /ity, 8B)< H ,ae two
=uestions< ?irst, w,at is t,e added )ene@t of t,e
ultrasoundX Wou clearly de!onstrate t,at a surgery
resident wit, an ultrasound can ,ae a ,ig, degree of
accuracy. Bwo $resentations later, we are going to see
surgeons $resent t,e use of clinical e>a! and la)oratory
alues to !a.e si!ilarly accurate diagnoses. 'y =uestion
is w,at data do you ,ae t,at suggests t,at t,ere actually
was an added )ene@t to t,e ultrasound, for e>a!$le, do
you ,ae data t,at s,ow t,at if you go )ac. and
reinter$ret
t,ese ultrasounds )linded to t,e $atient infor!ation, t,at
you actually are !a.ing t,e diagnosis )ased on t,e
ultrasound and not on t,e total clinical co!$osite $icture.
Second, o)iously t,e $atients t,at go to radiology for
an ultrasound are di&erent t,an t,e 54 $atients t,at you
routinely $erfor!ed an ultrasound on for t,e study. So!e
of t,ese $atients could ,ae )een diagnosed clinically
wit,out an ultrasound. (ased on t,at H =uestion t,e
conclusion t,at your accuracy rate is as ,ig, as t,at of t,e
radiology $erfor!ed ultrasound )ecause H t,in. t,e latter
1120
*aniel an -ll!en (/incinnati, D1)< /orollary to *ennis0
=uestion< t,ere is increasing concern in our institution
a)out
clinicians w,o are not for!ally trained to do ultrasound for
clinical decision !a.ing $ur$oses. *id you )ill for t,e study
and was it docu!ented in t,e c,arts, saed in radiologyX
J. (urford< Ht was docu!ented in t,e c,art as an e>tension
of t,e surgeon0s $,ysical e>a!.
* an -ll!en< (ut t,e ultrasound itself was not recordedX
J. (urford< B,e ultrasound results were docu!ented in t,e
c,art as an e>tension of t,e surgeon0s $,ysical e>a!. -nd
t,ere was no )illing done for t,is.
J.'. (urford et al.
4onald 1irsc,l (-nn -r)or, 'H)< H @nd t,is study
fascinating. 8ltrasound is )eco!ing a tool not #ust for
radiologists )ut a clinical tool in t,e H/8, in t,e trau!a
)ay and so on, t,is is #ust anot,er e>tension. H want to
)ounce o& *oug (arn,art0s =uestion. B,e radiologist
#ust gets a re=uisition t,at says rule out a$$endicitis, and
t,e surgeon ,as all t,e clinical data aaila)le to ,el$ wit,
t,e ealuation. So, H t,in. your data con@r! t,at in fact,
t,is is t,e surgeon0s adantage using t,e ultrasound, and
H t,in. t,at0s fantastic.
J. (urford< Hndeed, it was our $re!ise t,at we could
i!$roe t,e eNciency and accuracy of t,e diagnosis
)ased on our .nowledge of t,e $atient.