Diagnostic Decision-Making in Intermediate-Risk Pediatric Appendicitis: A Prospective Cohort Study

Area of Science:

• Pediatric emergency medicine
• Diagnostic imaging in pediatrics
• Surgical decision support

Background:

• Diagnosing acute appendicitis in children with intermediate Pediatric Appendicitis Score (PAS) values presents a significant clinical challenge.
• Conflicting information from clinical findings, labs, and imaging creates diagnostic uncertainty in this gray zone.
• Identifying predictive factors for true appendicitis in this pediatric subgroup is crucial for effective management.

Purpose of the Study:

• To identify predictive factors for true appendicitis in children with intermediate PAS scores (4-6).
• To evaluate the diagnostic performance of ultrasound in this specific pediatric population.
• To improve diagnostic accuracy and guide management strategies for suspected appendicitis in children.

Main Methods:

• Prospective observational study of children aged 2-14 years with suspected appendicitis and PAS of 4-6.
• Inclusion criteria: suspected appendicitis, PAS 4-6, tertiary referral center.
• Data collection from January 2022 to October 2025.

Main Results:

• 559 children included; 51.7% had true appendicitis.
• Strongest predictors: positive ultrasound (OR 55.1), localized RLQ tenderness (OR 2.98), WBC > 15x10^9/L (OR 2.53), male sex (OR 1.99).
• Ultrasound showed 94% sensitivity, 93% NPV, 88% accuracy.

Conclusions:

• Ultrasound is central to diagnosing appendicitis in children with intermediate PAS scores.
• Ultrasound's high negative predictive value supports safe observation for negative cases.
• Positive ultrasound findings guide timely surgical intervention, improving pediatric appendicitis management.