Does This Child Have Appendicitis? The Rational Clinical Examination: Bundy DG, Byerley JS, Liles EA, et al. JAMA 2007;298(4):438–51

Abstract

Appendicitis is the most frequent surgical etiology among children presenting to the Emergency Department or outpatient clinics with abdominal pain. The authors of this study conducted a literature review to assess the precision and accuracy of symptoms, signs, and laboratory results for evaluating children with a possible diagnosis of appendicitis. A literature search yielded 25 studies that provided primary data on children in whom the diagnosis of appendicitis was considered. There was only one study that included all children who presented with abdominal pain of less than 1 week duration, (assigned a quality level of 1); the prevalence of appendicitis was 10%. The 24 remaining studies included patients with a predetermined suspicion of appendicitis (all assigned a quality level of 3). Symptoms useful in the diagnosis of appendicitis included fever with a likelihood ratio (LR) of 3.4 and negative LR of 0.32 in the level 1 study (although less predictive in the level 3 studies with a LR of 1.2), vomiting (LR of 1.4), abdominal pain migrating to the right lower quadrant (LR range 1.9–3.1), and right lower quadrant pain (LR of 1.2 and negative LR of 0.56). Signs useful in the diagnosis of appendicitis include rebound tenderness (LR of 3.0 and negative LR of 0.28), Psoas sign (positive LR range 2.0–2.5 and negative LR range 0.75–0.86), and rectal tenderness (LR of 2.3 and negative LR of 0.70), whereas right lower quadrant tenderness was less useful (positive LR 1.3, negative LR 0.45). The laboratory data evaluated in the level 3 studies included white blood cell (WBC) count > 14,900 or 15,000 uL (LR of 1.7, negative LR 0.77), WBC count > 10,000 or 10,100 uL (LR of 2.0, negative LR of 0.22), and absolute neutrophil count > 6750 (LR 2.0, negative LR 0.06). C-reactive protein > 25 had a reported LR of 5.2 in one study, whereas erythrocyte sedimentation rate > 20 had an LR of 3.8 in one study. The authors noted that symptom and sign combinations (the Alvarado or MANTRELS score) demonstrated accuracy similar to the clinical gestalt of trained clinicians.