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Gestalt for Pediatric Appendicitis?

May 20, 2020

Written by Aaron Lacy

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ED physicians were found to be accurate, based on clinical gestalt alone, in predicting pediatric appendicitis, especially in patients they considered low risk.

Why this matters
Appendicitis is a life-threatening diagnosis that warrants rule out, and often imaging is ordered. If physician gestalt is accurate and can be incorporated into decision making tools, the possibility for reducing CT and ultrasound utilization can be explored.

“I got a slam dunk appendicitis for you…”
This subanalysis of patients from 11 community EDs prospectively enrolled patients aged 5-20 years with a chief complaint of abdominal pain with duration ≤5 days. After identifying eligible patients (3,426), board eligible or board certified emergency physicians (n=436) entered a sliding scale (1%-10%, 11%-49%, 50%-89%, 90%-100%) based on their predicted risk (gestalt) of appendicitis. Patients were excluded if imaging was ordered or resulted before enrolling the patient. Of enrolled patients, 9.8% had appendicitis, and physician gestalt had strong ROC characteristics (c-statistic = 0.83, 95% CI 0.81-0.85), with highest performance in the ‘low-risk strata’ of 1-10% (NPV = 98.9%). There was a trend toward overestimation of risk at the higher end of the spectrum. Physicians with ≥5 years since medical school graduation demonstrated improved gestalt (p = 0.007). Elevated WBC count is incorporated into several appendicitis risk calculators, but in this study there was no significant difference in gestalt performance if WBC resulted before or after enrolling the patient.

Ultimately, I will use this study to help guide my imaging decisions. In this study, 23% of patients in the 1%-10% gestalt category underwent imaging, and only 1% had appendicitis. 86% of patients in the 50-89% gestalt category received some form of imaging, with 27% having appendicitis. If my gestalt is low, this study makes me feel more comfortable not obtaining imaging to rule-out appendicitis in children with abdominal pain.

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years. Acad Emerg Med. 2020 Apr 2. doi: 10.1111/acem.13931. [Epub ahead of print]

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