Integration of radiology and clinical score in pediatric appendicitis
Eylem Ulas Saz
Department of Pediatrics, Division of Pediatric Emergency,
Department of Radiology, Division of Pediatric Radiology,
and Departments of
Pediatric Surgery and
Pathology, Ege University School of Medicine, Izmir, Turkey
Abstract Background: The efﬁcacy of ultrasonography (US) and abdominal X-ray in combination with Pediatric Appendicitis
Score (PAS) is complicated in the diagnosis of acute appendicitis. Abdominal X-ray is as useful as US with clinical
assessment when evaluated by experienced pediatric radiologist in acute appendicitis. The aim of this study was to
determine the value of US and abdominal X-ray for appendicitis in children when combined with clinical assessment
based on PAS, and to establish a practical pathway for acute appendicitis in childhood.
Methods: A prospective, observational cohort study was conducted at an urban, academic pediatric emergency
department. Patients were classiﬁed at low (PAS 1–4), intermediate (PAS 5–7), or high (PAS 8–10) risk for appen-
dicitis. Low-risk patients were discharged with telephone follow-up in ≤10 days; those at intermediate risk under-
went X-ray and US. High-risk patients received immediate surgical consultation. Patients were grouped on
histopathology as having either proven acute appendicitis or no appendicitis.
Results: A total of 288 children were analyzed. Surgery was performed in 134 patients (46.5%), and 128 (95.5%)
had positive histopathology. Mean PAS in the patients with and without appendicitis was 7.09 Æ 1.42 and
4.97 Æ 2.29, respectively (P = 0.00). The rate of missed cases was 6/288 (2%), and the negative appendectomy rate
was 6/134 (4.4%). When the score cut-off was set at 6, the sensitivity and speciﬁcity of PAS was 86.7% and
63.1%, respectively. The diagnostic performance of daytime US had a sensitivity of 91.1% and speciﬁcity of
71.1%. Also, positive US or PAS >6 or both, had sensitivity and speciﬁcity 96.7% and 59.9%, respectively.
Conclusion: US or abdominal X-ray in children with possible appendicitis should be integrated with PAS to deter-
mine the next steps in management. In the case of discordance between the clinical ﬁndings and radiology,
prolonged observation or further imaging are recommended.
Key words appendicitis, children, clinical score, radiology.
Acute appendicitis is the most common acute abdominal
emergency requiring surgical intervention in the pediatric
age group. The lifelong risk of acute appendicitis is 7%. It
is most prevalent between the ages of 6 and 12 years.
Although it has been well-deﬁned for more than a century,
some challenges in its diagnosis still prevail. Adolescents
and older children develop appendicitis more often than
younger children, and are symptomatically similar to adults.
Non-speciﬁc signs and symptoms, inability to exactly
describe the symptoms, and challenges during physical
examination make diagnosis more difﬁcult in younger chil-
dren. Several clinical scoring systems have been introduced
to increase diagnostic accuracy. The ﬁrst scoring system
was deﬁned by Alvarado in 1986.
The second most
commonly used system, constructed by Samuel in 2002, is
the Pediatric Appendicitis Score (PAS) which was the ﬁrst
system speciﬁc to pediatric patients.
PAS consists of six
clinical and two laboratory parameters (Table 1).
The key to a successful outcome is early diagnosis and
surgical management to prevent perforation and gangrene. The
ratio of negative appendectomy is still around 5–17%, and
28–57% of school children diagnosed with acute appendicitis
have been previously followed up with different clinical diag-
Despite the wide range of ratios reported in the litera-
ture, the sensitivity and speciﬁcity of PAS in acute
appendicitis varies at 88.1–97.6% and 50–98.2%, respec-
Therefore, a clinical scoring system is crucial in the
management of suspected acute appendicitis. There have been
few studies, however, on the combined use of clinical scoring
The aim of this study was therefore to investigate the effect
of combined radiology and clinical scoring on the speciﬁcity
and sensitivity of the diagnosis of appendicitis.
Correspondence: Caner Turan, MD, Department of Pediatrics,
Division of Emergency Medicine, Ege University School of Medi-
cine, Izmir, Turkey. Email: email@example.com
This study was presented at the Second European Pediatric Resus-
citation and Emergency Medicine Conference, Gent, Belgium,
18–19 May 2017.
Received 2 August 2017; revised 29 September 2017; accepted
29 November 2017.
© 2017 Japan Pediatric Society
Pediatrics International (2018) 60, 173–178 doi: 10.1111/ped.13471