PEDIATRICS/EDITORIAL
Appendicitis: Do Clinical Scores Matter?
Anupam B. Kharbanda, MD, MSc*
*Corresponding Author. E-mail: anupam.kharbanda@childrensmn.org, Twitter: @A_Kharbanda.
0196-0644/$-see front matter
Copyright 2014 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2014.05.002
SEE RELATED ARTICLE, P. --- .
[Ann Emerg Med. 2014;-:1-3.]
Acute abdominal pain represents one of the most common
reasons for children and adults to seek care in the emergency
department (ED).1 The diagnosis can be difcult, with
signicant variability in the presentation and differential
diagnosis according to patient age and sex.2 Computed
tomography (CT) has improved our diagnostic ability, but
concerns related to ionizing radiation3 and overuse4 have
prompted clinicians to consider clinical scores and algorithms
to aid in the diagnosis.
Two well-studied appendicitis scores were developed by
Alfredo Alvarado for adults and Madan Samuel for children, with
the explicit purpose of diagnosing appendicitis. The Alvarado
score was developed in Philadelphia in the mid-1980s. The score
was derived from retrospectively collected data from 305 adult
patients admitted to a single hospital and had a sensitivity of 81%
and specicity of 74% (95% condence interval [CI] not
provided).5 Samuel derived a separate clinical decision rule
(Pediatric Appendicitis Score) to identify children at high risk for
appendicitis by prospectively evaluating 1,170 patients at a single
institution.6 The Pediatric Appendicitis Score had a reported
sensitivity of 100% (95% CI 99.2% to 100%) and specicity of
92% (95% CI 89.0% to 94.2%). When developed, given the
favorable test characteristics, both rules were thought to hold
considerable clinical utility. However, across multiple external
validation studies, their performance has varied.7 Furthermore,
many have questioned the actual utility of either score, given that
clinical judgment alone may provide similar test performance.2,8
In this months Annals, Ebell and Shinholser9 present a
meta-analysis of adult and pediatric studies evaluating the
performance of the Alvarado and Pediatric Appendicitis Score
appendicitis scoring systems. The authors aimed to use the
extensive published literature to identify optimal Pediatric
Appendicitis Score and Alvarado scores that can be used to
risk-stratify patients with acute abdominal pain as low, moderate,
or high risk for appendicitis. The authors focused their
meta-analysis on 24 prospective cohort studies (13 adult and
11 pediatric) in which the nal diagnosis was veried. These
validation studies were conducted in 16 countries and on
5 continents during a 20-year period. The authors aimed for
a low-risk population to have a less than or equal to 3% rate
of appendicitis and for a high-risk population to have an
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appendicitis rate of greater than or equal to 85%. In their model,
low-risk patients would be discharged home, whereas high-risk
patients would proceed to appendectomy.
With this approach, Ebell and Shinholser9 found that among
adult patients, using a pretest probability of greater than or equal
to 60%, an Alvarado score of greater than 8 would rule in
appendicitis. Furthermore, if the pretest probability were greater
than or equal to 40%, a score greater than or equal to 9 would
rule in the diagnosis. In children with a pretest probability of
appendicitis of less than or equal to 40%, an Alvarado score of
less than 5 would rule out appendicitis, whereas no high-risk
score would provide acceptable performance. The Pediatric
Appendicitis Score did not perform well enough to be useful to
identify children at high or low risk for appendicitis, given the
authors criteria.
The authors should be commended for performing a rigorous
analysis of existing studies on these 2 well-established scoring
systems. The main criticism of this meta-analysis relates to the
appropriateness of aggregating such a diverse group of studies.
First, the 24 studies came from vastly different geographic
regions, including both developing and industrialized nations. It
is likely that across these settings, factors affecting patients ability
to seek care in an ED and differential diagnoses for acute
abdominal pain differed. In addition, the enrollment criteria for
the included studies most certainly varied, as exemplied by the
rate of appendicitis ranging from 51.5% to 94% for adult studies
and the proportion of male patients varying from 46.2% to
62.6% among pediatric studies. This variability is conrmed by
the high heterogeneity (I2) reported by the authors, as well as the
wide CIs noted around the reported likelihood ratios.
Second, the historical and physical examination parameters
that compose the Alvarado and Pediatric Appendicitis Score are
known to have variable reproducibility.2 Of the included score
elements, only vomiting and coughing/hopping/percussion
cause pain in RLQ [right lower quadrant] have been shown
to have at least moderate reproducibility.10 Thus, for each
validation study, it is likely that that there was signicant noise or
uncertainty in the assessment of score performance.
Third, duration of abdominal pain before ED evaluation is
not reported in the present meta-analysis but, if not consistent
across included studies, would certainly impact patients clinical
presentation as well as their WBC count and differential, key
elements of both scores.11,12 Taken together, variability in study
setting and inclusion criteria, along with uncertain reproducibility
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Appendicitis: Do Clinical Scores Matter?
of clinical scores assigned, make it difcult to discern whether the
reported optimal score cutoffs offer clinical utility.
Regardless of the above limitations, the current study
highlights key concepts that should be considered when
managing patients with suspected appendicitis. Paramount are
the ideas of risk stratication and thresholds to treat as actual effect of these scores on clinical practice is unclear but likely
together these can help to tailor clinical decisionmaking. The
Alvarado score and Pediatric Appendicitis Score may be useful in
some settings, but their use must be considered alongside the
risk the clinician is willing to accept for a particular patient.
RISK THRESHOLDS
For a high-risk score to gain clinical acceptance, its test
performance must be similar to that of current management. For
patients at high risk of appendicitis, one clinical outcome to
consider is an appendectomy in which the appendix is
histologically normal, a negative appendectomy. In a recent
analysis of data from 40 US childrens hospitals, the reported
proportion of negative appendectomies was 3.6%.13 Similarly, in a
recent meta-analysis of adult studies, the widespread use of CT for
acute abdominal pain has resulted in a negative appendectomy
proportion between 5% and 9%.14 Unfortunately, under the
assumptions of the current study, an Alvarado score greater than or
equal to 9 would result in 9% of operations having negative
appendectomy results for adults and 19% for children. Thus, an
elevated score would indicate a patient who is at increased risk for
appendicitis rather than a patient with denite appendicitis.
Ultimately, surgical consultation would determine the need for
diagnostic imaging versus immediate operation.
The concept of low risk for appendicitis is more complicated,
given the medical and legal implications of missed appendicitis and
possible perforation. Recent prospective studies that have enrolled
patients with acute abdominal pain have described 2% to 3% of
subjects as having missed appendicitis.15,16 Furthermore, the
proportion of false-negative CTs is reported to be 6% to 8%.17
Thus, the 3% criteria used by the authors to demarcate a low-risk
group (3%) would seem to be appropriate.
The above risk thresholds must be considered alongside the
prevalence of appendicitis in the population of interest as the
prevalence will affect any scores utility. This can be a difcult
concept to apply to a particular patient in the ED but points to the
need for clinicians to understand the prevalence of disease in their
clinical settings. Virtually all studies on appendicitis scores have
enrolled enriched populations, for whom there is a higher suspicion
for appendicitis. In the studies included in the current meta-
analysis, the approximate prevalence appendicitis was 35% in
children and 60% in adults. However, the prevalence of
appendicitis among all patients with undifferentiated abdominal
pain who present for an ED evaluation is undoubtedly much lower,
thus further decreasing the expected utility of the current scores.
BOTTOM LINE
Given these concepts, how can we use the results of the current
meta-analysis to help manage patients? Neither the Pediatric
2 Annals of Emergency Medicine
Kharbanda
Appendicitis Score nor the Alvarado score is adequate to identify a
high-risk group that can proceed directly to the operating room
without increasing the rate of negative appendectomies. Both scores
appear to be better at identifying a select population that can be safely
discharged, as long as close outpatient follow-up can be ensured. The
inuenced by clinician experience, availability of surgical
consultation, and risk tolerance among both physicians and patients.
Perhaps the best evidence in regard to the potential utility of
appendicitis scoring systems comes from several recent pediatric
implementation studies. These studies are instructive as they
provide real-world test performance and demonstrate how
clinical scores can affect patient safety and CT use through
standardization of care. 15,16,18 The clinical pathway in these
studies called for patients with abdominal pain identied as low
risk to be discharged home with close outpatient follow-up,
medium-risk patients to undergo a staged ultrasonographic CT
protocol (CT only if the ultrasonography result was equivocal),
and high-risk patients to receive immediate surgical consultation.
Similar to that in the meta-analysis by Ebell and Shinholser,9 the
prevalence of appendicitis in the 3 studies ranged between 33%
and 41%. The proportion of patients with perforation, missed
appendicitis, and negative appendectomy result was similar after
implementation. CT use decreased in all studies.
Although the goals of the current meta-analysis were to
identify optimal cutoffs for pediatric and adult populations, the
scores alone are still not likely to alter practice. However, if
incorporated into an overarching clinical pathway, use of clinical
scores for risk stratication is a safe and feasible option for
standardizing care. Although an experienced clinician likely
would come to the same conclusion as a score or pathway, these
pathways may be most benecial when used by clinicians with
differing levels of training to standardize assessment and guide
decisionmaking. Ultimately, this reduction in variability provides
a more cost-effective approach.19 As institutions adopt clinical
pathways for patients with suspected appendicitis, they will need
to monitor safety and performance outcomes to ensure that
individual ED practice is consistent with national benchmarks.
Supervising editor: Kathy N. Shaw, MD, MSCE
Author afliations: From Department of Pediatric Emergency
Medicine, Childrens Hospitals and Clinics of Minnesota,
Minneapolis, MN.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, nancial, and other relationships
in any way related to the subject of this article as per ICMJE conict
of interest guidelines (see www.icmje.org). The author has stated
that no such relationships exist.
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