Hot Off the Press: Does This Adolescent Female Have Appendicitis? Can the Pediatric Appendicitis Score Help?

Appendicitis is diagnosed in 1% to 8% of children presenting to the emergency department (ED) for abdominal pain and is the most common condition requiring emergent abdominal surgery in childhood. The adolescent age group has the highest prevalence.1 The diagnosis of appendicitis can be missed in children over 50% of the time leading to higher complication rates including perforation. Yet, the negative appendectomy rate (NAR) is not negligible, particularly in children under 5 years of age (NAR up to 17%) and postmenarchal females (NAR up to 5%).1, 2 The diagnosis of appendicitis, particularly in the pediatric population, is a common yet difficult one. This diagnostic dilemma has led many in search of a clinical sign, symptom, or decision tool to assist in the correct diagnosis of appendicitis. Among the tools to evaluate children for appendicitis are the most commonly used Pediatric Appendicitis Score (PAS) and the Alvarado score. Both have been prospectively studied in pediatric populations, but neither has been shown to be consistently superior to another.3, 4 Clinical symptoms and signs, laboratory markers, and prediction scores have been effective in categorizing low- to high-risk groups, but they are not effective in improving diagnostic outcomes such as perforation rates and NARs as mentioned.3, 4 This retrospective, observational cohort study evaluated how well the PAS performs in adolescent female patients. This is a subgroup analysis of a previously studied database that included 901 patients with complete PASs aged 3 to 21 years who presented to a single, tertiary ED seeing 90,000 patients. This analysis compared PAS and pathologic confirmation of patients who were female aged 13 to 21 years to all other patients in the data set. A diagnosis of appendicitis was defined by histologic confirmation of appendicitis and a negative diagnosis of appendicitis was defined as a histologic confirmation negative for appendicitis or no known surgery within 1 month from presentation. The outcome data reviewed included the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of the PAS. Overall, this is a high-quality study that answers a well-defined clinical question that is relevant to the practice of emergency medicine. The study population is well representative of the target population that would normally be tested for appendicitis. Diagnostic criteria were comprehensive, explicit, valid, and reproducible. The reference standard of histologic confirmation of appendicitis was appropriate as the criterion standard. Limitations are inherent in the design of a retrospective cohort study and a single-site study.5 Furthermore, it is assumed that if a patient had no surgery in the 1 month after presentation at this one center, he or she did not have appendicitis. This does not account for patients who may have presented to another healthcare facility or patients who were treated with antibiotics and improved without surgery. The key results demonstrated no significant difference in the sensitivity or NPV for the cutoff value of 3 or the specificity for the cutoff value of 7. The specificity of the cutoff value of 8 was significantly better in the adolescent female group compared to the pediatric nonadolescent female group. In the end, the authors concluded the PAS score, as commonly used clinically (i.e., with cutoffs of ≥3 and ≥8), showed better specificity and equivalent sensitivity for female adolescent patients compared to all other patients, as well as a good NPV in both groups. These data suggest that the PAS is at least as good a tool in adolescent female patients as it is for the rest of the pediatric population. In children presenting to the ED with abdominal pain with clinician concern for appendicitis, the PAS can be used, even in an adolescent female. Care must be taken, as the PAS, as well as the Alvarado score, are imperfect decision tools. However, to use one of these as a risk stratification tool as part of a discussion of shared decision-making with the patient or part of an evidence-based clinical practice guideline may be advantageous. A systematic review in the Lancet (1993) examined 59 studies that evaluated clinical guidelines and met specific, rigorous scientific guidelines. The overwhelming majority (55 of 59 studies) illustrated an improvement in the process of care and the majority (nine of 11) reported significant improvements in outcomes of care.6 As an example, Warner et al.7 demonstrated that an evidence-based appendicitis pathway for pediatric patients suspected of appendicitis decreased the duration of hospitalization and cost without any adverse effects on the diagnosis or therapy. Despite this evidence, health services research consistently reports a substantial delay of evidence-based knowledge uptake into practice.8, 9 Appropriateness of care is often defined as adherence to professional standards. It is a useful way to measure the underuse and overuse of care. More focus is being placed upon “quality indicators” as a way of measurement of appropriate care in our current practices. Despite the difficulty in measuring the adherence to evidence-based knowledge or appropriateness of care, estimates of current practice in the United States are poor with a nonadherence rate of 30%–50%.10 A clinical decision aid like PAS for the purposes of risk stratification can be an effective tool toward improved quality care. The tool may be of utility in improved shared decision-making with patients and in clinical guideline application. Clinicians have the option of using the PAS or the Alvarado score to help risk stratify children with abdominal pain with regards to appendicitis risk. The PAS has similar utility in adolescent females patients compared to other pediatric patients. Both scores require laboratory investigations, specifically a CBC. Neither tool is perfect and both should be used with caution. For low-risk patients who are being sent home, adequate discharge planning is paramount. For intermediate-risk patients, clinicians should adopt a strategy of investigation that minimizes radiation exposure. The PAS along with other evidence-based clinical decision aids have great utility in discussing with patients the risk of having appendicitis and understanding the decisions made in their care as a result. Richard Hamilton: Would love to see the likelihood ratios from “Does This Patient Have Appendicitis?” http://ja.ma/1Y7TzcK integrated into PAS chart. I think it would explain why certain things have 2 points and other 1 point. Ideal world is when you “train” your gestalt to be like PAS or Alvarado. … then you have a calibrated gestalt! Not just basing it on your personal practice or experience. Anthony Crocco: Agree that gestalt is often used, but for folks in resource-limited settings (i.e., rural, low-income, etc.) or for folks with less peds ED experience, this could be very helpful … Sharon Humiston: … Seeing that the PAS score worked as well in adolescent females as the rest of the Pediatric ED population made me wonder—could this be generalized to adolescents females presenting in other settings (e.g., urgent care)? Also, could use of the PAS help with clear communication between outside facilities and the pediatric ED?

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