A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process

Abstract

Background: The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history.

Methods: Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses.

Results: 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4.

Conclusions: There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration.

Trial registration: Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021).

Clinical trials registration number: ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

Keywords: Acute appendicitis; Children; Emergency; PAS score; Primary care.

Fig. 1

Study flowchart. AA = acute appendicitis; ED = emergency department; NA = non-addressed; NPC = with no prior consultation; PC = with prior consultation

Fig. 2

A. Distribution of patients depending on the severity of appendicitis. B. PAS scores and CRP levels in acute appendicitis (AA), mesenteric lymphadenitis (LM), and gastroenteritis (GE) according to pain duration

Fig. 3

Proposal for the management of pediatric abdominal pain in primary care. Legend: We believe that diagnosing AA should primarily rely on clinical scoring. A: For cPAS < 4 with a duration of pain > 48 h, the risk is very low, and patients can be observed at home. If the pain onset is < 48 h, revaluation at 24 h is recommended. B: For intermediate cPAS scores from 4 to 5, inflammatory markers should be assessed. If the pain duration is < 48 h with normal inflammatory marker levels, scheduling imaging such as a ultrasound examination is recommended within 12 h. If one of the inflammatory markers is increased, however, ED admission is recommended. If the pain duration is > 48 h with normal inflammatory marker levels, home observation with a blood test at 48 h can be undertaken. Yet, if the inflammatory markers are increased, especially if the CRP level is above the 50 mg/L cutoff, timely admission to the ED is required. C: Thus, a cPAS score ≥ 6 would correspond to a high risk of AA and a very high risk if there is associated abdominal guarding. Referral to the ED is appropriate from the outset