Abstract
PurposeTo identify available clinical prediction rules (CPRs) and investigate their ability to rule out appendicitis in children presenting with abdominal pain at the emergency department, and accordingly select CPRs that could be useful in a future prospective cohort study. MethodsA literature search was conducted to identify available CPRs. These were subsequently tested in a historical cohort from a general teaching hospital, comprising all children (< 18 years) that visited the emergency department between 2012 and 2015 with abdominal pain. Data were extracted from the electronic patient files and scores of the identified CPRs were calculated for each patient. The negative likelihood ratios were only calculated for those CPRs that could be calculated for at least 50% of patients. ResultsTwelve CPRs were tested in a cohort of 291 patients, of whom 87 (29.9%) suffered from acute appendicitis. The Ohmann score, Alvarado score, modified Alvarado score, Pediatric Appendicitis score, Low-Risk Appendicitis Rule Refinement, Christian score, and Low Risk Appendicitis Rule had a negative likelihood ratio < 0.1. The Modified Alvarado Scoring System and Lintula score had a negative likelihood ratio > 0.1. Three CPRs were excluded because the score could not be calculated for at least 50% of patients. ConclusionThis study identified seven CPRs that could be used in a prospective cohort study to compare their ability to rule out appendicitis in children and investigate if clinical monitoring and re-evaluation instead of performing additional investigations (i.e., ultrasound) is a safe treatment strategy in case there is low suspicion of appendicitis.
Highlights
The diagnosis of acute appendicitis in children remains challenging as symptoms can vary from mild abdominal pain to generalized peritonitis and septicemia
311 patients were identified in the defined time period of which 20 were excluded for the following reasons: abdominal pain caused by trauma (13 patients), presentation of another main complaint other than abdominal pain, transfer to an academic hospital, and no cooperation with physical examination
The negative likelihood ratio, sensitivity, and negative predictive value for the clinical prediction rules (CPRs) are presented in Table 3, which divides the CPRs into those that are developed for the pediatric population and those for the adult population
Summary
The diagnosis of acute appendicitis in children remains challenging as symptoms can vary from mild abdominal pain to generalized peritonitis and septicemia. The diagnosis of appendicitis is mainly based upon clinical examination in combination with biochemical variables indicative for inflammation. A disadvantage of this diagnostic strategy was the relatively high negative appendectomy rate of 12.3–19%.1, 2. An evidence-based guideline was proposed in 2010 by the Association of Surgeons of the Netherlands, which makes preoperative imaging mandatory in patients with suspected appendicitis.[3] Ultrasound is the preferred initial diagnostic imaging modality in both the adult and pediatric. J Gastrointest Surg (2019) 23:2027–2048 population.[3] Implementation of this guideline resulted in a significant decrease of negative appendectomies to 2.2%–5%.2,4. In the Netherlands, in 99.7% of the adult patients’ preoperative imaging studies are performed.[4] Implementation of this guideline resulted in a significant decrease of negative appendectomies to 2.2%–5%.2,4 Currently in the Netherlands, in 99.7% of the adult patients’ preoperative imaging studies are performed.[4]
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