Validation of the Pediatric Appendicitis Score

Abstract

Emergency Medicine| November 01 2009 Validation of the Pediatric Appendicitis Score AAP Grand Rounds (2009) 22 (5): 50. https://doi.org/10.1542/gr.22-5-50 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Validation of the Pediatric Appendicitis Score. AAP Grand Rounds November 2009; 22 (5): 50. https://doi.org/10.1542/gr.22-5-50 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: appendicitis Source: Bhatt M, Joseph L, Ducharme FM, et al. Prospective validation of the Pediatric Appendicitis Score in a Canadian pediatric emergency department. Acad Emerg Med. 2009;16(7):591–596; doi:10.1111/j.1553-2712.2009.00445.x To evaluate the diagnostic utility of the Pediatric Appendicitis Score (PAS),1 Canadian investigators prospectively studied a convenience sample of children aged 4 to 18 years with possible appendicitis. Children with acute abdominal pain for less than three days who presented to Montreal Children’s Hospital Emergency Department (ED) between 2003 and 2005 were eligible for the study if the ED physician considered appendicitis as a diagnosis. Nonverbal children, those with a history of chronic abdominal pathology (eg, inflammatory bowel disease) or prior appendectomy, and those who did not have a complete blood count (CBC) performed were excluded. The PAS score ranges from 0 to 10 and includes eight diagnostic indicators. One point each is scored for the presence of anorexia, pyrexia, nausea/emesis, migration of pain, leukocytosis >10,000, and polymorphonuclear neutrophilia. The presence of right lower quadrant tenderness generates two points, and tenderness with cough, percussion, or hopping generates another two points. Physicians with at least two years of post-graduate education completed a standardized data collection form during the child’s ED visit. Imaging, consultation, and disposition occurred at the discretion of the treating physician. One month later, telephone interviews were conducted with parents of children discharged home to detect missed appendicitis cases. Of 246 enrolled patients, 95 children underwent appendectomy, and 83 children had histological confirmation of appendicitis, including 14 with perforation. Approximately 12% of study children who underwent appendectomy had specimens that were histologically negative. No missed cases of appendicitis occurred. A receiver operator characteristic (ROC) curve was constructed to evaluate performance of the PAS and yielded an area under the curve of 0.895 (see AAP Grand Rounds, July 2001;6:8 for explanation of ROC curves). The optimal cut-point for the PAS score in terms of sensitivity and specificity was ≥ 6 for surgical intervention, similar to that from the original description of the PAS.1 Using a score of ≥ 6, sensitivity and specificity were 92.8% and 69.3%, respectively, which would result in 50 (37.6%) negative appendectomies and 6 (7.2%) missed cases. Due to these findings, the authors proposed that children with a PAS of ≤ 4 may be discharged without further intervention, children with a score of ≥ 8 should undergo appendectomy, and children with scores from 5 to 7 require further imaging. This strategy would have resulted in two cases of missed appendicitis (2.4%) with a sensitivity of 97.6% and NPV of 97.7%, and eight negative appendectomies (8.8%) with a specificity of 95.1% and PPV of 85.2%. The authors conclude that the PAS may be a useful clinical tool in the evaluation of children with suspected appendicitis, and argue that categorization of risk via the PAS may be more valuable for directing patient care than using a single cut-point. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not... You do not currently have access to this content.