[size=20px]A 10-year-old girl presents with nausea, vomiting, and vague abdominal pain. She has mild RLQ tenderness and all labs (including WBC count) are normal. Ultrasound is unable to visualize the appendix and is otherwise normal. What is the best next step in management?

 

A IV antibiotics and laparoscopic appendectomy

 

B Non-operative management with IV antibiotics only

 

C CT scan with PO and IV contrast

 

D MRI without contrast

 

E Observation[/size]

E

E

correct

 

Ultrasound (US) is often the first imaging study obtained in the work-up for appendicitis.The accuracy of US is still operator dependent and influenced by patient factors (obesity, bowel gas, movement).Unfortunately, only 10-50% of children with normal appendices are visualized.When a normal appendix is not visualized, there is still a risk of appendicitis despite an otherwise normal ultrasound study.Since appendicitis cannot be equivocally ruled out, additional imaging or observation is warranted.Recent studies have shown that the risk of appendicitis in children when the appendix is not visualized on US ranges between 2-10%.The risk is even lower when there are no secondary signs of appendicitis noted on US and/or in the presence of a normal WBC count.This patient does not have a diagnosis of appendicitis and treatment with appendectomy or antibiotics is not indicated.Since the history and physical exam are not classic with appendicitis and there are no secondary signs of appendicitis on US and no leukocytosis, the risk of appendicitis is extremely low, and no additional studies are needed.Observation in the emergency department or in the hospital are reasonable options.If the family is reliable, this patient may also be safely discharged with return precautions.