A new clinical score to identify children at low risk for appendicitis

Abstract

BackgroundBesides clinical signs and imaging, in recent years, biomarkers have proven to be a viable diagnostic resource for acute appendicitis (AA). ObjectiveThe objective of this study was to develop a clinical score including clinical signs and a combination of biomarkers to identify children with abdominal pain at low risk of AA. Design/methodsWe prospectively included children 2 to 14 years of age with abdominal pain suggestive of AA who presented to the emergency department between July 2016 and September 2017. A new score, the Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte (WBC) and neutrophil (ANC) counts and plasma C-reactive protein (CRP) and calprotectin (CP) levels was developed and validated through secondary analyses of two distinct cohorts The validation sample included visits to a single pediatric emergency department from 2012 to 2013 and 2016 to 2017. ResultsThe derivation sample included 278 children, 35.9% of whom had AA and the validation sample included 255 children, 49% of whom had AA. Using logistic regression, we created a 6-part score that consisted of nausea (3 points), history of focal right lower quadrant pain (4 points), ANC of ≥7500/μL (7 points), WBC of ≥10,000/μL (4 points), CRP ≥ 10.0 mg/L (2 points) and CP ≥ 0.50 ≥ ng/mL (3 points). This score exhibited a high discriminatory power (area under the curve: 0.88; 95% confidence interval: 0.84 to 0.92) and outperformed the PAS and Kharbanda scores (area under the curve: 0.76; 95% confidence interval: 0.71 to 0.82 and 0.82; 95% confidence interval: 0.77 to 0.87, respectively). A PALabS ≤6 had a sensitivity of 99.2% (95% confidence interval [CI]: 95.6–99.9), negative predictive value of 97.6% (95% CI: 87.7–99.6), and negative likelihood ratio of 0.03 (95% CI: 0.00–0.18) in the validation set. ConclusionIn our validation cohort of patients with acute abdominal pain, the new score can accurately predict which children are at low risk of appendicitis and could be safely managed with close observation.