Objectives: Acute appendicitis is on the list of differential diagnoses for any pediatric patient with abdominal pain. In the past, the diagnosis was largely clinical; however, with the advent of widespread imaging, patients typically undergo one or more imaging studies prior to diagnosis. As a tertiary pediatric hospital, a significant number of patients are transferred from adult emergency departments. Unnecessary or excessive imaging delays transfer of the patient to the treating institution and also exposes the patient to unnecessary radiation. We hypothesize that by using the Alvarado score to clinically stage patients, patient groups can be identified that could be transferred without imaging.
Methods: A retrospective review was performed for pediatric patients (age < 18) transferred from adult centers to our pediatric emergency department for abdominal pain with the differential diagnosis including appendicitis between 11/15/2020 – 3/31/2022. Variables collected included the Alvarado score components, imaging results, operative reports, and pathology. Alvarado score was calculated for each patient and patients were grouped into low (0-3), intermediate (4-6), and high (7-10) scores. Results were used to calculate positive predictive values (PPV) for patients who underwent CT.
Results: There were 196 patients (age 2-17, 58% male) transferred to our tertiary care center with suspected appendicitis. The Alvarado score was low in 18% (n=35), intermediate in 38% (n=74), and high in 44% (n=87). Appendicitis was diagnosed in 67% (n=131) of patients. In the low score group, the rate of appendicitis was 14% and the PPV of CT was 50%. In the intermediate group, the rate of appendicitis was 62% and the PPV of CT was 88%. In the high score group, the rate of appendicitis was 92% and PPV of CT was 98%. One patient from the low score group underwent a negative appendectomy.
Conclusion: There is a low rate of appendicitis in patients who have a low Alvarado score. The PPV of CT in this population is also low. While our study is small, the data suggests that patients who are unable to be discharged from the ED could be transferred to a pediatric hospital without a CT. Conversely, the rate of appendicitis is over 90% in the high score group, and patients may not need a reflexive CT. We propose that CT in the low and high scoring groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.
