Integration of radiological findings and a clinical score in the diagnostic evaluation of pediatric appendicitis

Integration of Radiological Findings and a Clinical Score in the Diagnostic Evaluation of Pediatric Appendicitis Objective: To determine the value of ultrasonography (US) and abdominal radiography for appendicitis in children when combined with clinical assessment based on the Pediatric Appendicitis Score (PAS). We also aimed to establish a practical pathway for acute appendicitis in childhood. Materials and Methods: Prospective, observational cohort study conducted at an urban, academic pediatric emergency department. After initial evaluation, patients were determined to be at low (PAS 1–4), intermediate (PAS 5–7), or high (PAS 8–10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up within 10 days, patients at intermediate risk for appendicitis underwent plain radiography and US. High-risk patients received immediate surgical consultation. Patients were histopathologically grouped as proven acute appendicitis and other medical reasons. Results: A total of 288 children with a mean age 11.1 (SD ±3,63 ) years were enrolled; 56.5% of were male. Surgery was performed in 134 (46.5%) patients, and 128 (95.5%) had positive histopathology. An initial PAS of 1–4 was noted in 66 (22.8%), 4–7 in 139 (48.3%), and 8–10 in 83 (28.8%) patients. The mean PAS of patients with and without appendicitis was 7.09±1,42 and 4.97±2,29 respectively (p:0.00). Based on this pathway the rate of missed cases was 6 of 288 (2%), and negative appendectomy rate was 6 of 134 (4.4%). When the score cut-off value was set at 5, the sensitivity and the specificity of PAS was respectively 99.2% and 40.6%. The diagnostic performance of day time US included a sensitivity of 91.1%, specificity 71.1%. Sensitivity and specificity of radiography was 57.5% and 90.4%. Integrating the results of US with clinical assessment showed a sensitivity and specificity respectively 95.8% and 43.0%, and radiography with clinical assessment 99.2% and 29.4%. Conclusion: PAS was significantly higher in appendicitis group. PAS safely used to rule out acute appendicitis in low risk group, but had low value in the diagnosis in moderate and high-risk group. Integrating the results of US and radiography with clinical assessment didn't increase diagnostic value for acute appendicitis.