Ultrasound vs CT in diagnosing appendicitis in pediatric age group

Children are the most affected by acute appendicitis, which is the most prevalent surgical emergency in the children's population and is a frequent cause of acute abdominal pain that needs a quick diagnosis and treatment [1]. Delayed diagnosis can result in severe complications like perforation, peritonitis, and the formation of an intra-abdominal abscess, which are major complications that contribute greatly to the morbidity in children [2]. Nevertheless, clinical diagnosis among the pediatric patients may be tricky since they have symptoms that are not typical and could be similar to other ailments in the abdomen such as gastroenteritis, mesenteric adenitis, or urinary tract infections [3]. Imaging is therefore an important aspect in enhancing diagnostic accuracy and management. Ultrasonography (US) is widely recommended as the initial imaging modality of choice in children due to its non-invasiveness, widespread availability, and lack of ionizing radiation exposure [4]. Non-compressible enlarged appendix and inflammatory changes of the periappendiceal tissue can be detected with the help of grated compression ultrasound [5]. Although these exist, the sensitivity of ultrasound to diagnostics can be affected by the dependency of the operator and incapability to visualize the appendix in obese patients or when the bowel gas is observed [6].

 Computed tomography (CT) has greater anatomical detail and has been reported to have better sensitivity and specificity in the detection of appendicitis and its complications [7]. CT is sensitive enough to identify enlargement of the appendage, inflammation around, abscess, and other causes of abdominal pain [8]. Nevertheless, the issue of radiation exposure in children has made clinicians to restrict the use of CT and apply it in situations that have ultrasound results that are not conclusive [9]. The recent diagnostic approaches focus on the staged-imaging technique, in which ultrasound is performed and CT is performed occasionally when necessary [10]. Earlier studies have revealed that such a method has great diagnostic accuracy and has limited radiation exposure in children [11]. Imaging has also enhanced the accuracy of ultrasound in the diagnosis of appendicitis [12]. However, the comparative diagnostics of ultrasound and CT remain to be tested in other clinical environments [13]. Adequate imaging is required to ensure proper diagnosis of appendicitis as well as minimizing the negative appendectomy rates and enhancing patient outcomes [14]. The knowledge of the relative diagnostic value of ultrasound and CT can hence be used to optimise diagnostic pathways in pediatric appendicitis [15].

 Objective: To compare the diagnostic performance of ultrasound and computed tomography in detecting appendicitis in the pediatric age group.

A total of 285 pediatric patients were included with a mean age of 10.6 ± 2.9 years. The most common age group was 9–12 years (119, 41.8%), followed by 13–15 years (88, 30.9%) and 5–8 years (78, 27.4%). Males accounted for 164 patients (57.5%) and females for 121 (42.5%). The mean symptom duration was 28.4 ± 10.7 hours. Right lower quadrant pain was present in 251 patients (88.1%), nausea or vomiting in 182 (63.9%), fever in 167 (58.6%), and leukocytosis in 196 patients (68.8%)

Table 1. Demographic and Clinical Characteristics of Pediatric Patients (N = 285)

An appendiceal diameter >6 mm was observed in 164 appendicitis cases (82.8%) compared with 18 non-appendicitis cases (20.7%) (p <0.001). A non-compressible appendix was detected in 171 appendicitis patients (86.4%) and 21 non-appendicitis patients (24.1%). Periappendiceal fluid was present in 92 cases (46.5%) versus 11 cases (12.6%), while echogenic periappendiceal fat was observed in 118 (59.6%) versus 16 (18.4%).

Table 2. Ultrasound Findings in Pediatric Patients with Suspected Appendicitis

Appendiceal enlargement >6 mm was detected in 182 appendicitis patients (91.9%) compared with 9 non-appendicitis patients (10.3%). Appendiceal wall thickening was present in 168 cases (84.8%) versus 12 cases (13.8%). Periappendiceal fat stranding occurred in 156 patients (78.8%) versus 10 patients (11.5%), and periappendiceal fluid collection in 88 patients (44.4%) versus 7 patients (8.0%). Abscess formation was identified in 29 appendicitis cases (14.6%) and 2 non-appendicitis cases (2.3%).

Table 3. CT Scan Findings in Pediatric Patients with Suspected Appendicitis

Ultrasound showed sensitivity of 84.8%, specificity of 79.3%, PPV of 90.6%, NPV of 69.8%, and accuracy of 83.2%. CT showed higher sensitivity (92.9%), specificity (89.7%), PPV (95.3%), NPV (84.9%), and accuracy (91.6%). CT also performed better in early appendicitis (sensitivity 91.3%) and complicated appendicitis (94.1%), while the combined imaging approach achieved the highest sensitivity (96.5%) and diagnostic accuracy (94.7%).

Table 4. Diagnostic Performance of Ultrasound and CT in Pediatric Appendicitis (N = 285)

This paper compared the diagnostics abilities of ultrasound and computed tomography in the diagnosis of appendicitis in children. The findings demonstrated that 198 out of 285 children (69.5%), had appendicitis, and the average age of patients was 10.6 and 2.9 respectively. Most of the patients were exhibiting right lower quadrant pain (88.1%), then nausea or vomiting (63.9%), and then fever (58.6%). A case of leukocytosis was found in 68.8%. The same clinical patterns have been documented in the past studies wherein abdominal pain, vomiting and leukocytosis were reported to be the most prevalent clinical manifestations of pediatric appendicitis [16]. This study on ultrasound showed that the ultrasound evidence is strongly related to appendicitis. In 86.4% of cases that were confirmed, a non-compressible appendix was seen and in 82.8% patients, an appendiceal diameter more than 6 mm was observed. Also prevalent among the appendicitis patients were periappendiceal fluid and echogenic periappendiceal fat. Similar findings have been found in the previous studies, which indicated the presence of such ultrasound indicators of appendicitis in childhood as the enlargement of the appendix, non-compressibility, and periappendiceal inflammation [17][18]. The CT imaging was shown to be more reliable in diagnosis than the ultrasound. Appendicitis cases exhibiting the enlargement of the appendix were found in 91.9 percent of appendicitis cases whilst peri appendiceal fat stranding and wall thickening were found in 78.8 percent and 84.8 percent of patients respectively. Complications like abscess development were also detected using CT in 14.6% cases. Other studies have reported similar findings the CT imaging has been shown to possess better visualization of the anatomy and better detection of the presence of appendiceal inflammation and complications [19].

 The diagnostic accuracy analysis indicated that CT was more sensitive (92.9% and specificity at 89.7%), and specific (89.7) than ultrasound (84.8% and specificity at 79.3%). The cumulative diagnostic adherence of CT was 91.6 and ultrasound demonstrated an adherence of 83.2. The same trends have been reported in earlier studies that have shown that CT tends to be more sensitive and specific in the diagnosis of appendicitis especially in instances where ultrasound findings are inconclusive [20]. Also, the staged imaging modality with the ultrasound then the CT had the highest diagnostic performance with a sensitivity of 96.5 and the accuracy of 94.7. Past studies have also indicated that such a successive strategy of imaging can greatly enhance accuracy of diagnosis besides minimizing irrelevant radiations exposure in children patients [21]. Thus, ultrasound as the primary modality and selective CT scanning as the second option might offer an effective and less harmful route in the diagnosis of a pediatric appendicitis.

 Limitations

There were a number of limitations of this research. First, it was carried out in a small sample of hospitals, thus the limiting the generalizability of the results. Second, ultrasound is operator dependent and radiologist experience differences could have affected the diagnostic accuracy. Third, the two imaging modalities were not used on all patients at the same time, which might have caused selection bias. Lastly, the study failed to determine the clinical outcome and radiation exposure effects in pediatric patients who are undergoing CT imaging in the long run.

This case reports a rare and complex presentation of a neonate with a giant congenital melanocytic nevus in bathing-trunk distribution coexisting with a large pedunculated low-flow vascular malformation. Despite normal antenatal scans, the postnatal emergence and progressive enlargement of the mass required timely diagnostic evaluation and multidisciplinary care. Imaging with Doppler ultrasound and MRI played a pivotal role by confirming the superficial nature of the lesion and excluding deeper structural involvement, thereby enabling safe surgical excision. Early surgery prevented potential complications such as ulceration, infection, or haemorrhage and resulted in an excellent short-term outcome. Given the lifelong risk of melanoma and the psychosocial impact associated with GCMN, long-term dermatological and neurological follow-up is essential. This case underscores the need for vigilance in examining newborns, even after normal antenatal imaging, and highlights the importance of coordinated management in rare congenital presentations.