Perforated Appendicitis Diagnosed by Timely Point-of-care Ultrasound Quality Assurance Review at a Children’s Hospital Tertiary Care Center

Introduction: Appendicitis with perforation can be challenging to diagnose. As point-of-care ultrasound (POCUS) becomes more widespread in pediatric emergency departments (PED), robust quality assurance (QA) mechanisms are necessary. We present two cases where perforated appendicitis was detected by POCUS director image review.

Case Description: Case 1: A 16-year-old male with profund diarrhea, fever, and abdominal pain for 4 days is transferred after computed tomography (CT) scan diagnosed enterocolitis versus inflammatory bowel disease. On exam he has tachycardia with exquisite tenderness to palpation and guarding. The inflammatory markers are all elevated. Surgical consultation does not recommend immediate intervention, and he is admitted to the pediatric hospitalist service. Prior to admission, bladder POCUS is performed for inability to urinate.

Review of the bladder POCUS at 7:30 am the next morning is concerning for signs of perforated appendicitis (Figure 1). The inpatient services are notified, and the patient is taken to the operating room where a definitive diagnosis of acute perforated appendicitis with diffuse purulent peritonitis is made.

Case 2: An 11-year-old male with five days of diarrhea, vomiting, intermittent abdominal pain and fever is admitted to the pediatric hospitalist service with presumed gastroenteritis for rehydration. Vital signs are normal in the PED and serial exams reveal a soft abdomen without any guarding or rebound pain. His white blood cell count is 9,500 per microliter of blood. An abdominal POCUS is performed on an educational scanning shift.

Review of the abdominal POCUS at 4:00 am during an overnight shift is concerning for signs of perforated appendicitis (Figure 2). Images are reviewed with the on-call house staff. Follow-up radiology ultrasound confirms the abnormality seen by POCUS. After surgical consultation, a CT scan further delineates a perforated appendix with a 6.4 cm x 4.1 cm x 4.3 cm pelvic abscess behind the bladder. Interventional radiology drainage of 50 milliliters of purulent fluid is performed with interval appendectomy weeks later.

Discussion: In 2015, the American Academy of Pediatrics published a policy statement and technical report on POCUS use in the PED. The report highlights the responsibility of pediatric emergency physicians to evolve with this technology to provide safer, better, and more efficient care delivery to pediatric patients. The QA process with designated regular image review and 100% accountability for all POCUS studies performed is essential to build successful partnerships across subspecialties and to mitigate misinterpretation errors that could adversely impact patient outcomes. In the cases presented, POCUS was performed without the purposeful intent to evaluate a pediatric appendix, but abnormal findings were nevertheless present.

Conclusion: A robust POCUS QA system is imperative for effective program development and patient safety. To optimize the synergistic benefits of POCUS integration with patient care, leadership support of POCUS faculty involved with QA review is required.