Clinical Prediction Rules for Diagnosing Appendicitis

Appendicitis is the leading cause of abdominal surgery in children. However, its diagnosis poses a challenge due to the initial nonspecific symptoms that lead to delays in diagnosis.

A case-controlled study across five pediatric emergency departments discovered that 63% of children with appendicitis had delayed diagnoses due to initial misdiagnosis. These delays increase the propensity to poorer outcomes.

Various clinical scoring systems have been proposed to enhance diagnostic accuracy since Alvarado's introduction of the MANTRELS score in 1986. These systems consider patient symptoms, clinical examination findings, and laboratory results. However, there exists significant diversity among the variables and cut-off points utilized, with none thoroughly validated for appendicitis diagnosis.

Recently, Nandan et al. assessed the efficacy of the Pediatric Appendicitis Score (PAS) in diagnosing acute appendicitis. Among 205 children evaluated, 161 underwent surgery, with 159 confirmed cases of appendicitis. The study revealed a high sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for PAS, suggesting its utility in confirming the diagnosis, as well as in ruling out appendicitis. These findings surpassed previous reports. 

Regarding imaging, a meta-analysis highlighted the insufficiency of PAS alone to obviate the need for imaging. Ultrasound emerges as a valuable initial non-invasive tool. Particularly when performed by skilled operators, it aids in reducing misdiagnoses and expedites patient management.

As the search for the optimal diagnostic approach continues, clinicians must rely on tailored, individualized strategies based on patient clinical presentations.

Source: Bolia R. Indian J Pediatr. 2023;90:1173–1174.