Pediatrics/original researchEvaluating Appendicitis Scoring Systems Using a Prospective Pediatric Cohort
Introduction
Appendicitis is one of the most common causes of acute abdominal pain in pediatrics and is the most common indication for emergency abdominal surgery in childhood.1 Despite substantial research, the diagnosis of pediatric appendicitis remains challenging. Recent studies have proposed different methods to treat children presenting to the emergency department (ED) with symptoms suggestive of appendicitis.2, 3, 4, 5 Clinical scores used in these studies have relied on historical, physical examination, and laboratory findings. Ideally, a clinical score could accurately distinguish those patients that need immediate operative care from those that may benefit from further investigation or observation. Two pediatric appendicitis scoring systems, published by Alvarado6 and Samuel,7 are the most widely referenced in the literature.3 Neither score has been validated.
A clinical scoring system should be validated in a different sample before widespread use. The original intent of both Alvarado6 and Samuel7 was to determine which patients required operative care. A pediatric appendicitis score that aided clinical diagnosis would be valuable to the emergency medicine clinician.
The objective of this study is to evaluate the performance of Alvarado’s6 and Samuel’s7 scoring systems in a prospectively identified cohort of pediatric patients with suspected appendicitis. As intended by the original authors, the test-performance characteristics of each score for determining operative care will be presented.
Section snippets
Study Design and Setting
This prospective observational study was conducted from July 2003 to December 2004 at a tertiary pediatric medical center, with an ED volume of 52,000 visits per year. A portion of this data set was previously published as a clinical decision rule identifying low risk for appendicitis.2
Selection of Participants
Children between 3 and 21 years of age, with suspected appendicitis, were enrolled; entry into the study required surgical consultation for possible appendicitis. Any patient who is treated by a pediatric
Results
During the period of enrollment, 6,120 patients were treated in the ED for abdominal pain. Of the patients with abdominal pain, 821 had a surgical consultation for possible appendicitis. We captured 92% of eligible patients, or 755 patients, who had suspected appendicitis. Of the 755 patients enrolled, 588 patients (78%) had complete data to compute a Samuel and Alvarado score. All 588 patients had operative care (37%) or follow-up (63%). The 167 patients with missing data were missing the
Limitations
Our study sample consisted of children undergoing evaluation for possible appendicitis, as determined by a pediatric emergency physician; this sample likely will vary from that of other pediatric centers. In addition, our study sample had a relatively high prevalence of appendicitis, and therefore the scoring systems’ performance should not be generalized to a population of nonspecific abdominal pain. Additionally, the symptomatology and signs of appendicitis are a function of timing of
Discussion
The original article by Alvarado6 retrospectively investigated 305 patients who were admitted to the hospital with abdominal pain suggestive of appendicitis. Although not explicitly written in the published article, the test performance of the score can be calculated according to available data: sensitivity 81%, specificity 74%, PPV 92%, and NPV 46%.
Additional validation of the Alvarado score has had mixed results. Hsiao et al8 performed a case-control retrospective study, applying the Alvarado
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My tummy! Appendicitis
2021, Pediatric Imaging for the Emergency ProviderRIPASA and air scoring systems are superior to alvarado scoring in acute appendicitis: Diagnostic accuracy study
2020, Annals of Medicine and SurgeryImproving the diagnostic accuracy of appendicitis using a multidisciplinary pathway
2020, Journal of Pediatric SurgeryCitation Excerpt :A requirement for institutional review board (IRB) approval was waived based on the QI nature of the initiative. The pathway utilized the Alvarado Score (AS), one of several validated pediatric appendicitis scoring tools which combines historical symptoms, clinical signs, and laboratory findings, to stratify patients into low, moderate, and high risk groups for any child who was considered to have possible appendicitis based on initial EM physician assessment [1–14]. The choice of the AS tool was made by the EM physicians, with cut-offs for the low- and high- risk categories based on a published optimization study [4].
A new clinical score to identify children at low risk for appendicitis
2020, American Journal of Emergency MedicinePediatric Appendicitis Score or Ultrasonography? In Search of a Better Diagnostic Tool in Indian Children with Lower Abdominal Pain
2023, Indian Journal of Pediatrics
Supervising editor: David M. Jaffe, MD
Author contributions: AK and RB conceived the study and designed the trial. AK and RB supervised the conduct of the trial and data collection. AK and RB undertook recruitment of patients and managed the data, including quality control. RB provided statistical advice on study design, RB takes responsibility for all statistical calculations in the manuscript, CS and RB analyzed the data, CD drafted the manuscript, and all authors contributed substantially to its revision. CD, AK and RB take responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Publication dates: Available online March 26, 2007.
Reprints not available from the authors.