Background.

A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children.

Objective.

To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children.

Design, Setting, and Subjects.

Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998.

Protocol.

Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC.

Main Outcome Measures.

Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital's cost database and by ratios of costs to charges.

Results.

Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient.

Conclusion.

A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.

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