Original ContributionUsing appendicitis scores in the pediatric ED☆
Introduction
Appendicitis is one of the most common causes of acute abdominal pain in pediatrics and is the most common indication for emergency abdominal surgery in childhood [1]. For the past decade, there has been greater use of abdominal computed tomographic (CT) scans in the ED attempting to improve the diagnostic accuracy of appendicitis and to decrease the negative laparotomy rate [2]. The can use, however, results in exposure to ionizing radiation, which in pediatric patients may lead to increased cancer risks [3], [4], [5]. Ultrasound imaging has become more popular and negates the risk of radiation. However, ultrasound use is operator dependent, and different institutions have varying expertise in its use and availability [6], [7]. More recently, different clinical scoring systems aiding in the diagnosis of appendicitis have been developed.
The 2 most used scores (Alvarado and the pediatric appendicitis score [PAS] by Samuel) are based on the presence or absence of symptoms with each feature being scored as a 1 or 2 depending on the feature and each given different levels of significance (Table 1). For each score, the author identified a cut point at which surgery was recommended vs observation. Most studies examining these scores have had varying results [8], [9], [10], [11], [12], [13], [14].
The Alvarado score has been studied more extensively than the PAS with several studies assessing the Alvarado score finding statistically significant improved performance in male vs female patients. To our knowledge, the PAS's performance has not previously been stratified by sex [14], [15], [16].
Both the PAS and Alvarado scores have the potential value of eliminating excessive use of abdominal CT scans and permitting more rapid surgical consultation in patients with suspected appendicitis. The primary objective of this study was to prospectively assess the performance of the Alvarado and PAS scoring systems in a pediatric ED. The secondary objective was to determine if these scoring systems performed better based on sex.
Section snippets
Methods
This study was a prospective observational study conducted at an urban, level 1, pediatric ED with approximately 60 000 visits per year. The study was approved by the hospital's institutional review board.
Verbal children between 4 and 17 years of age with suspected appendicitis were enrolled from June 2008 to May 2009. Written, informed consent was obtained from parents or legal guardians, and informed assent was obtained from children 7 years and older. Patients were excluded if they were
Data analysis
All data analyses were conducted with SPSS 17.0 for Windows (SPSS Inc, Chicago, Ill). Bivariate analyses was used to assess the differences in patients' demographic characteristics (such as age and sex), symptoms, and PAS and Alvarado scores between patients with appendicitis and patients without appendicitis. Computed scores were used to assess the accuracy of the Alvarado system with a score of 7 or greater, and a PAS score of 6 or greater, as originally intended by the scoring system
Results
During the study period, 962 patients presented to the ED with a complaint of abdominal pain, who had a history and/or physical examination concerning appendicitis. Of those, 487 patients were diagnosed with appendicitis, and 287 patients meeting the inclusion and exclusion criteria gave given consent and enrolled. All patients who gave consent had complete data for both the PAS and Alvarado scores.
The median age was 9.8 years with an SD of 3.1 (range, 4-16); 125 patients (43.7%) were less than
Discussion
The Alvarado scoring system was originally derived retrospectively and included both pediatric and adult patients. It was developed primarily to identify patients with suspected appendicitis that could be taken directly to the operating room. Several studies have assessed the Alvarado scoring system with mixed results [9], [10], [11], [12], [13], [14]. Schneider et al [13] observed 588 patients aged 3 to 21 years, and using the Alvarado recommended score of 7 as a cutoff value for having
Conclusion
Neither the PAS nor Alvarado scores have adequate predictive values in the diagnosis of appendicitis. Although the scores do perform better in males, the predictive values are not sufficient to be used solely for making the diagnosis of appendicitis.
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Cited by (63)
Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines
2021, Journal of Surgical ResearchCitation Excerpt :The Pediatric Appendicitis Score was cited in two of CPGs,21,33 and the Alvarado Risk Score in 3 of CPGs.12,17,34 Both are common risk assessment scores that have been validated for children with abdominal pain.35-39 The utility of the score is to stratify the likelihood of the patient having appendicitis and guiding use of imaging techniques (ultrasound or computed tomography imaging) versus clinical examination in making the diagnosis of appendicitis.37
A new clinical score to identify children at low risk for appendicitis
2020, American Journal of Emergency MedicineValidation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting
2019, Annals of Emergency MedicineAppendicitis versus non-specific acute abdominal pain: Paediatric Appendicitis Score evaluation
2018, Anales de PediatriaPediatric Appendicitis
2017, Surgical Clinics of North America
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Financial disclosure: Study received no funding support.