Surgeons have been caring for children with appendicitis for over 100 years. Over time, we have gotten better at making this diagnosis. The old adage that you must have a 10% negative appendectomy rate in order not to miss any patients with appendicitis is no longer the current standard. Most contemporary quality collaboratives work hard to keep their negative appendectomy rates significantly below 5%. To better achieve these ends, we have devised methods to make this diagnosis faster, more accurately, and with less adverse exposure to the child. Methods such as scores to risk stratify patients based on clinical findings (Alvarado and Pediatric Appendicitis Score {PAS}), ultrasound (US) reporting templates to improve reporting accuracy, and computerized tomography (CT) scanning algorithms to minimize radiation exposure all have fueled improvements in diagnosing pediatric appendicitis. We thought we had reached the pinnacle of this task, with current accuracy rates of 90-95%, but we were wrong. Two recent publications have brought magnetic resonance imaging (MRI) use for diagnosing appendicitis to the discussion. Kulaylat et al. reported their 2.5-year experience utilizing specifically MRI for diagnosing appendicitis, showing a sensitivity of 97%, specificity of 97% and median scan time of 11 minutes. Aspelund et al. reported their experience using selective MRI after non-diagnostic US, reporting a sensitivity of 100%, specificity of 99% and approximate scan time of 30 minutes. These are pretty impressive results. They certainly made me take notice. High accuracy with no radiation exposure… what a great idea!
But, is this really realistic? Is it likely that we can reproduce these results at non-pediatric community hospitals? If we can, would this be cost-effective for the healthcare system? Our institution recently performed a cost-effective analysis study modeling costs associated with diagnosing and treating pediatric appendicitis, comparing use of PAS with US, US alone, CT, ED clinician judgment alone, and surgeon evaluation with overnight observation. Our results showed that using CT to diagnose appendicitis is significantly more expensive than using US alone or PAS with selective US. Using MRI would likely be just as expensive if not more expensive than using CT, adding significant burden to our already over-extended healthcare system. Alternatively, selective use of MRI may be a viable option in situations where the diagnosis is unclear, as that option may be cheaper than performing a diagnostic laparoscopy. Nevertheless, utilizing this new modality will require intentional training and education, both for technicians who need to learn how to maintain a child still and radiologists who need to recognize appendicitis-specific MRI characteristics. We also need to remind ourselves that combining cost-effective modalities such as PAS with US is likely to make an accurate diagnosis in most patients. Ultimately, starting with simple, inexpensive tests with escalation to high fidelity, expensive imaging for uncertain cases is likely to give us the best balance between accuracy and effective use of our healthcare dollars. Towards this end, we should continue to remind ourselves and our trainees that the beginnings of making a good diagnosis, as it has been for 100 years, is with a good history and physical exam.