July 2017 Bulletin

Tips for Diagnosing Appendicitis: A Q&A With Drs. Daniel Ledbetter and Mark Ferguson

Diagnosing appendicitis in children can be difficult. Symptoms range dramatically and the disease progresses much faster than in adults. In some cases, kids don't complain of pain until after their appendix has ruptured.

Additionally, the imaging modality used to diagnose this disease varies by care center. Despite safety concerns and national recommendations to use ultrasound when possible, over 40% of children in Washington state still had computed tomography (CT) scans between 2008 and 2013. Nationally, researchers have determined children initially evaluated for suspected appendicitis at referring hospitals are much more likely to receive a CT.

At Seattle Children’s, care teams have collaborated to diagnose patients quickly and reduce the use of CT scans. While cases vary, the majority of patients are treated before their appendix ruptures and spend less than 24 hours in the hospital.

Seattle Children’s general surgeon Dr. Daniel Ledbetter and Ultrasound Division Chief Dr. Mark Ferguson offer the following advice to referring providers who are often the first to identify potential appendicitis.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek; a member of Seattle Children’s medical staff; chief of digital innovation for Seattle Children’s; and author of the Seattle Mama Doc blog, for submitting these questions.

What information would you like outside clinicians to provide when referring a patient with potential appendicitis to Seattle Children’s emergency department or surgical clinic?

Ledbetter: We always ask for complete blood count, a urinalysis and any imaging that’s been done. I also like to know the patient’s history and details of their physical exam. I want to know how long the child’s been ill, what their symptoms are and anything else the provider thinks might be going on.

I understand Seattle Children’s ultrasound technologists, radiologists and surgeons are increasingly using ultrasound for diagnosis rather than CT scans. How often can sonographers find the appendix with ultrasound and avoid a CT?

Ferguson: Ultrasound is the modality of choice at Seattle Children’s for diagnosing appendicitis. CT is very rarely necessary in the evaluation of these patients. This is of great benefit to our patients by avoiding exposure to ionizing radiation and sedation. We can offer same-day evaluations by the surgical team and the radiology team using mobile ultrasound machines and sonographers who are available 24 hours a day. Ultrasound has been shown to be a very accurate diagnostic tool in experienced hands. Our goal as radiologists is to provide timely and accurate sonographic evaluations to assist in our patient’s care and further reduce the negative appendectomy rate – the number of times a patient is taken in to surgery but actually has a healthy appendix.

When a community clinician performs an ultrasound that is inconclusive for a diagnosis of appendicitis, should they do a CT scan or have an ultrasound repeated at Seattle Children’s on evaluation?

Ferguson: They should come to Seattle Children’s to have the ultrasound repeated. These are not simple exams but we are fortunate at Seattle Children’s to have sonographers who are quite experienced with these evaluations. We don’t see the appendix every time, but I would say we find it at least 75% of the time. Furthermore, even when we don’t see it, ultrasound can often provide valuable diagnostic information.

What advice would you suggest to community clinicians regarding physical exams in cases of suspected appendicitis?

Ledbetter: Young kids can be difficult to examine, especially if they’re in pain. Often, they won’t let you determine tenderness because they don’t want you to push on a painful area. It can be hard to know if they’re just unhappy or in physical pain, but I recommend erring on the side of caution. If a child appears to have persistent right lower quadrant tenderness, then providers should be suspicious of appendicitis and pursue more advanced testing with ultrasound, CBC and a urinalysis.

What can community clinicians do to improve our partnership in caring for children with suspected appendicitis?

Ledbetter: The best thing providers can do is always keep the diagnosis of appendicitis in mind when they’re dealing with children of any age who have fever or abdominal pain or any abdominal tenderness. When providers consider appendicitis, diagnoses are rarely missed.

Screening for Abuse in Seattle Children’s Emergency Department

Seattle Children’s has increased efforts to identify children and infants at risk of physical abuse and to educate our health care providers on signs of physical abuse. We know that the first signs of physical abuse can be as subtle as a fading bruise on the face of an infant. Research shows that between 27% and 44% of children who have been abused had a previous sentinel injury that was missed by medical providers.1,2

These cases can be challenging to diagnose and require both awareness and quick decision-making.

Two mnemonics we use as the basis for our screening at Seattle Children’s are “those who don’t cruise, rarely bruise” and the TEN-4 rule:3,4

  • Any child under the age of 4 months with a bruise anywhere on their body without a clear and plausible explanation is more likely abuse
  • Any bruise in the TEN region (torso – including genitourinary area, ear and neck) on a child between the ages of 4 months to 4 years without a clear and plausible explanation is more likely abuse.

Despite our shared vigilance, cases of abuse may still be missed. We appreciate your continued efforts to help keep children safe. If you have any questions, concerns or specific cases you would like to discuss, please call the Suspected Child Abuse or Neglect (SCAN) team at Seattle Children’s. You can also find more information about screening for bruising in Seattle Children’s Emergency Department in the ED Bruising Pathway (PDF).


  1. Jenny, C., et al. (1999). “Analysis of missed cases of abusive head trauma.” JAMA 281(7): 621-626.
  2. Sheets, L. K., et al. (2013). “Sentinel injuries in infants evaluated for child physical abuse.” Pediatrics 131(4): 701-707.
  3. Pierce, M. C., et al. (2010). “Bruising characteristics discriminating physical child abuse from accidental trauma.” Pediatrics 125(1): 67-74.
  4. Sugar, N. F., et al. (1999). “Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network.” Arch Pediatr Adolesc Med 153(4): 399-403.

Upcoming Grand Rounds for July 2017 (CME Credit Available)

Upcoming Grand Rounds

  • July 6: Pediatric and Adolescent Sports Concussions: A New Guideline and Update for Pediatric and Primary Care
  • July 13: Antimicrobial Stewardship
  • July 20: Cerebral Palsy Management
  • July 27: Prenatal Diagnosis of CHD

For Provider Grand Rounds information, visit our Grand Rounds page.

Watch Past Grand Rounds online

  • Beginning With The End in Mind: Cardiotoxicity After Childhood Cancer
  • Congenital Disorders of Glycosylation, a Sweet Branch of Biochemical Genetics
  • Disaster Management

View a list of all online videos in our video library.

New Medical Staff and Allied Health Professionals for July 2017

Medical staff

  • Boldt, Adam, DO, Olympia Pediatrics, PLLC, Pediatrics
  • Koo, Kevin, MD, Seattle Children's, Radiology

Allied health professionals

  • Buendia, Finese, ARNP, Seattle Children's, Neurology
  • Foster, Carrie, ARNP, Seattle Children's, Surgical Specialties
  • Gayraud, Lena, ARNP, Seattle Children's, Critical Care
  • Skelley, Kathryn, DNP, ARNP, Providence Regional Medical Center Everett – Pavilion for Women & Children, Neonatology
  • Wein, Amy, ARNP, Seattle Children's, Cancer and Blood Disorders