Factors affecting utilization of CT scan following ultrasound evaluation of suspected appendicitis

Context: When evaluating a pediatric patient in the emergency department for suspected appendicitis, a provider is often faced with the dilemma of deciding if a computed tomography (CT) scan is warranted when-as is most often the case-ultrasound results do not yield a definitive diagnosis. The potential risks of radiation must be weighed against numerous aspects of a patient's background, physical exam, and already-obtained workup. Objectives: This study aims to aid in future decision making of providers in their evaluation of patients with suspected appendicitis, to help facilitate a more comprehensive answer to the "next-steps" in the question of equivocal ultrasound, and to create a pathway utilizing lab results, physical exam findings, and pertinent positives and negatives in patient history to facilitate a more objective decision-making process for ordering a CT scan. Methods: A retrospective chart review was performed for patients who were evaluated for possible appendicitis at our institution between October 2016 and October 2017 and whose ultrasound results were equivocal. We determined what factors led to increased frequency of obtaining CT scans. Results: Statistical analysis showed that several factors were independently associated with the increased likelihood of having a CT scan performed. When considered in combination with the other parameters, it was found that older children, males, report of right lower quadrant (RLQ) pain, and presence of RLQ tenderness on physical exam were all associated with a significantly higher likelihood of having a CT scan performed. Conclusions: When combined with present algorithms and protocols already in use, this information can assist the provider in making prudent decisions for their patients with the potential for reduced provider bias.