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

Mohamed Zouari1,2, Manel Belhajmansour1,2, Manar Hbaieb1,2

  • 1Research Laboratory "Developmental and Induced Diseases" (LR19ES12), Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia.

World Journal of Surgery
|March 26, 2026
PubMed

Insights

Diagnosing appendicitis in children with intermediate scores is challenging. Ultrasound is key, accurately ruling out appendicitis and guiding treatment decisions for pediatric patients.

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.
Abstract

Keywords:
childrendiagnostic gray zonepediatric appendicitisultrasound

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