In the majority of cases, emergency department pediatric surgeons deal with classic and frequent surgical pediatric diseases. Before the development of radiology, throughout time, pain semiology with some specific signs was described like the “Blumberg’s sign” in peritonitis [1], “Rovsing’s sign” in appendicitis [2], “Murphy’s sign” in cholecystitis [3], or other signs or association of signs for intestinal obstruction or lesions with vascular damage. Progressively, imaging techniques first helped the clinicians to understand the clinical symptoms and degrees of severity before becoming for some diseases, the only way to obtain an exact diagnosis. Therefore, today, a good pediatric surgeon in the emergency suite is someone with good experience (in as much as many fields of pediatrics), for sure a physician examining himself his patients before asking for complementary imaging; a physician calling the radiologist himself to discuss the case; choosing together the best exam to perform, being present with the radiologist during complex examinations and finally discussing the optimal treatment with all specialists involved.

In the pediatric population, there is a clear split between two categories defined as before and after acquired language where physical exam is completed by children expressing precisely their pain and their history. Often, pediatric diseases are age-related. Therefore, in order to obtain the correct diagnosis, a strong knowledge of the potential diseases both by the clinician and by the radiologist is mandatory. This would also optimize the subsequent management and care. Furthermore, in infants particularly, symptoms are delayed or misinterpreted and a wandering diagnosis is frequent. Imaging techniques should be used rapidly but adequately.

In appendicitis, the statement reported in Rowe saying, “The PHYSICAL EXAMINATION is the most important single diagnostic determinant in children with acute abdominal conditions” should be maintained as a primary objective in teaching pediatric surgery [4]. For instance, one important predictor in the clinical diagnosis of acute appendicitis is the classic migration of pain described by Murphy in 1905 [5]. According to the medical literature, this specific sign has a diagnostic accuracy of up to 95% [6, 7]. Yet, this sign is not found constantly and depends on age, level of experience of the physician, previous treatments, or medical conditions, the diagnosis may be difficult to ascertain. In daily practice, clinical findings are missed or insufficiently searched by doctors with lack of sufficient experience in about 40% of cases; this could potentially lead to a higher perforation rate due to a delayed diagnosis [8]. Laboratory findings are not discriminatory and the aim of imaging should be to reduce the rate of missed diagnoses. Imaging techniques are also very helpful in infants where appendicitis is frequently seen in a more advanced stage with signs of septic and intestinal obstruction. In these patients, the contribution of physical examination is very limited and many of them have a history of recent antibiotherapy. In these young patients, imaging will frequently find abscesses due to perforation. To be noted, abscesses may also be post-operative findings and imaging is needed to find them and eventually to allow drainage under CT or US guidance. Not to forget, appendicitis in neonates or infants with a long history of constipation or abdominal distention could be a symptom of Hirschsprung disease.