Use of CT for Pediatric Abdominal Pain Growing Rapidly

James Brice

April 26, 2012

April 26, 2012 — That anxious hospital emergency department (ED) visit to learn whether a child's belly ache is a sign of appendicitis increasingly involves computed tomography (CT) to render a diagnosis, according to a new study involving 16.9 million pediatric ED visits.

The study, published online April 24 in Radiology, indicates that diagnostic ultrasonography lost its position as the imaging modality of choice for ED evaluations of pediatric abdominal pain as CT's popularity grew between 1999 and 2007.

Findings by Anastasia L. Hryhorczuk, MD, and colleagues at Children's Hospital of Boston in Massachusetts were based on the National Hospital Ambulatory Medical Care Survey, a federally administered annual survey that estimates ED use in the United States.

The researchers found physician reliance on CT increased steadily from 2% of all pediatric ED visits for abdominal pain in 1999 to 16% in 2007 (P < .001 for trend).

Changes in the use of ultrasonography for the same indications did not follow any statistically predictable pattern (P = .27 for trend). Use of ultrasonography ranged from 7% to 11% for all pediatric ED visits for abdominal pain.

Only 3% of patients with an ultimate diagnosis of appendicitis were imaged with both ultrasonography and CT, despite published guidelines that supported the initial use of ultrasonography for diagnosing pediatric appendicitis, explain the researchers.

Pediatric EDs did not perform CT for children with abdominal pain as frequently as EDs in general hospitals, however. Their young patients were more than 25% less likely to undergo CT than pediatric patients who were examined for suspected appendicitis in general hospital EDs (P = .004).

Use of ultrasonography for pediatric abdominal pain did not vary significantly among general hospitals, teaching hospitals, and pediatric hospitals.

The odds of CT use increased for teens, whites, evaluations performed at midwestern facilities, urban settings, privately insured patients, and patients who were admitted or transferred.

Risks of CT-Related Radiation Controversial

Alfred Sacchetti, MD, a spokesperson for the American College of Emergency Physicians, told Medscape Medical News that CT's high speed, accuracy, and easy access in light of the severe medicolegal risks associated with misdiagnosed appendicitis made it a logical choice.

"Imagine how difficult it would be explaining why you did not perform a CAT scan and let the child go home, let the appendix perforate, and let the child develop peritonitis because you wanted to avoid radiation," he said. "It is not as black and white as it seems," he said.

The risks of CT-related radiation are controversial. The small possibility of an induced cancer lies many years in the future, whereas the clinical benefits of CT are immediate, he said.

Unlike radiation-free ultrasonography, abdominal CT can expose a child to more than 10 mSv of ionizing radiation (the equivalent of 500 chest radiographs), according to some sources.

Physicians are now generally better informed about ionizing radiation and appear to be more cautious about ordering CT for children than in 2007, Dr. Hryhorczuk said. She credited the Society of Pediatric Radiology's Image Gently and Image Wisely programs for raising public awareness.

"It will be interesting to look at the upcoming release years of this [National Hospital] dataset to see if the trends continue or if they change over time as these educational programs were put forth in the medical literature," she said.

The study authors, including Dr. Hryhorczuk, and Dr. Sacchetti have disclosed no relevant financial relationships.

Radiology. Published online April 24, 2012. Abstract

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