Identification of Children With a Positive Ultrasound and Appendicitis Using the Pediatric Appendicitis Risk Calculator: Retrospective Cohort Study.

Objectives: Up to 10% of positive ultrasounds (US) for suspected pediatric appendicitis are false positive. Minimizing the negative appendectomy rate is gaining importance as a quality indicator, with a proposed benchmark of < 2%. The validated Pediatric Appendicitis Risk Calculator (pARC) score [range 0%-100%] used alone identifies the entire appendicitis risk spectrum, whereas the optimal surgical candidates should be at a very high risk. Therefore, pARC risk stratification in conjunction with positive US may be useful to identify the best surgical candidates. The primary objective was to determine the proportion of children with positive US plus medium-high risk pARC ≥ 25% with appendicitis.

Hypothesis: We hypothesized this proportion would be 98%, with lower 95% CI ≥ 96%.

Methods: A retrospective cohort study of 327 previously healthy children 4-17 years old at a pediatric ED with suspected appendicitis and positive US interpretations. Four investigators abstracted demographic, clinical, and imaging data. pARC includes seven demographic, clinical, and laboratory variables and is quantified according to the published formula. The primary outcome was appendicitis, based on pathology. All non-operated patients underwent a follow-up to exclude missed appendicitis.

Results: A total of 294/327 (89.9%) patients with positive US had pathology-proven appendicitis, and 33 (10.1%) had no appendicitis; pARC ≥ 25% was assigned to 259/327 (79.2%) patients. In total, 255/259 (98.5%) children with pARC ≥ 25% had pathology-proven appendicitis (95% CI 96.1-99.6) versus 39/68 (57.3%) with pARC < 25%; p < 0.0001. Probability of no appendicitis increased with decreasing pARC cut-offs from 0/230 (0%) for pARC ≥ 40% to 13/284 [4.6% (2.5-7.7)] for pARC ≥ 15%. The pARC ≥ 25% plus positive US combination had sensitivity 86.7% (82.3-90.4), specificity 87.9% (71.8-96.6), positive predictive value 98.5% (96.1-99.6), and negative predictive value 42.6% (30.7-55.2).

Conclusions: In children with suspected appendicitis, a combination of positive US and pARC ≥ 25% carries a very high probability of appendicitis. Children with lower pARCs may be candidates for clinical re-evaluation or further imaging.