One of the most common causes of abdominal pain in children is appendicitis, which typically necessitates prompt surgical intervention Given the danger of perforation in 12.5–30% of cases, prompt identification of appendicitis in children is crucial. There is a significant risk of misdiagnosis; estimates place the number of misdiagnosed school-age children between 28 to 57%. Diagnosis of Acute Appendicitis in children is considered challenging.

 

The use of the Paediatric Appendicitis Score, based on patient history, physical examination and lab investigations is one way to arrive at the diagnosis of appendicitis. Today, a variety of investigations are done to determine the exact cause of an acutely inflamed appendix, including ultrasonography, CT scan, diagnostic laparoscopy, and MRI.

 

The Paediatric Appendicitis Score (PAS) [ is the most often used scoring systems. This system establishes cut-offs to predict the existence of appendicitis by allocating point values to information gathered from the patient’s medical history, physical examination, and laboratory tests.

 

The results could be especially helpful for underdeveloped nations because many health centres have limited access to diagnostic modalities. The PAS offers several advantages. It is simple, inexpensive, reproducible, and feasible in both advanced and resource-limited settings. Unlike imaging modalities, PAS does not expose children to radiation and can be applied at the bedside, allowing for rapid decision-making in emergency departments.

 

Furthermore, studies have shown that the use of PAS significantly reduces the rate of negative appendectomy, historically ranging from 10% to 30% in children.^9,10 By applying PAS, the rate of unnecessary surgery can be reduced by nearly half, minimizing operative morbidity, psychological distress for families, and healthcare costs.^11,12 The present study was therefore undertaken to assess the diagnostic efficacy of the Paediatric Appendicitis Score in children presenting with acute abdominal pain.

 

AIMS AND OBJECTIVES

·         To study the efficacy of Paediatric appendicitis score in children with Acute Abdominal Pain.

 

Objectives

·         To assess the efficacy of Paediatric Appendicitis Score in diagnosis of Acute Appendicitis in children presenting with acute abdominal pain.

·         To correlate Paediatric Appendicitis score with Imaging.

·         Study Design: The study was designed as a Prospective study.

·         Study Place: The study was carried out the Department of Pediatric at Kempegowda Institute of Medical Science& Research Centre, Bengaluru.

·         Study Period: The study was conducted over 18 a period of months.

·         Study Participants: The study included 70 children aged 5–18 years presenting with acute abdominal pain.

·         Sample Size: A total sample size were 70.

 

Statistical Analysis

The data were analyzed using the Statistical Package for Social Sciences (SPSS) for Windows, Version 22.0 (Released 2013, Armonk, NY: IBM Corp.). Descriptive analysis of explanatory and outcome parameters was performed using mean and standard deviation for quantitative variables, and frequency and proportions for categorical variables. For inferential statistics, the Chi-square test was used to compare age, gender, study characteristics, surgery performed, ultrasound findings, and biopsy performed based on different PAS scores among the study participants. The level of significance was set at p < 0.05. Any other relevant statistical test, if found appropriate during analysis, was also applied.

 

Inclusion Criteria

The study included children between 5 and 18 years of age presenting with right lower abdominal pain of less than three days’ duration.

 

Exclusion Criteria

Children with chronic abdominal pain, previous appendicectomy, or abdominal trauma were excluded from the study.

 

Sample Size Calculation

The sample size was calculated using the formula:

N=Z²×p(1−p)/d²

where Z=1.96Z = 1.96Z=1.96 for 95% confidence interval, p=0.75p = 0.75p=0.75 (based on a previous study by Kambalabettu Zohara Parveen et al., 2017, which reported that 75% of study patients with a PAS score > 8 taken up for surgery and biopsy showed appendicitis), and margin of error d=0.10d = 0.10d=0.10. The estimated sample size was 70.07, which was rounded off to 70. Thus, the present study comprised 70 children in whom appendicitis was suspected.

This figure demonstrates that the majority of patients fall within the 11–16 year age group, with a male predominance. Most patients belong to the PAS ≥7 category, indicating that a large proportion present with high-risk disease. This suggests delayed presentation or selection bias toward more severe cases in hospital settings. Clinically, it highlights that appendicitis is more common in older children and that PAS effectively stratifies patients into risk categories.

 

Figure 1: Demographic Characteristics and PAS Distribution

 

70 children aged 4–17 years presenting with acute abdominal pain were enrolled prospectively. PAS was calculated for each patient and stratified into three risk groups.

 

Table 1: Patient Distribution by PAS Risk Category

 

Nearly half the cohort (48.6%) fell into the high-risk category, all of whom had histologically confirmed appendicitis (PPV 100% at PAS ≥ 7).

 

Table 2: Demographic Characteristics

The majority of patients belonged to the 11–16 years age group (50%), followed by 6–10 years, indicating higher prevalence in older children. A male predominance (61%) was observed. Higher PAS scores were more common in older children, suggesting increasing disease severity with age. This aligns with known epidemiological patterns of appendicitis.

 

Younger children (5–10 years) showed lower sensitivity and specificity than adolescents (11–18 years), consistent with the well-recognised diagnostic challenge of appendicitis in the younger age group, where symptom localisation is often non-specific.

 

Table 3: Age- Stratified Diagnostic Performance

In children aged < 10 years, a higher index of clinical suspicion and lower threshold for imaging is warranted, even at borderline PAS scores.

 

Figure 2: Clinical and Laboratory Factors

 

This graph evaluates the association between individual PAS components and appendicitis. Leukocytosis, neutrophilia, and right lower quadrant tenderness show strong statistical significance, indicating they are the most reliable predictors. Fever and anorexia are moderately significant, while migration of pain, nausea/vomiting, and cough tenderness are not statistically significant. This suggests that objective findings are more dependable than subjective symptoms in diagnosing appendicitis.

 

Table 4: Clinical Factors vs PAS

Anorexia, leukocytosis, and neutrophilia increase with higher PAS scores, indicating strong association with appendicitis. Fever also shows a rising trend with increasing PAS. These findings highlight that objective laboratory parameters are more reliable predictors than subjective symptoms.

 

The table below ranks the eight PAS components by their adjusted odds ratio for histologically confirmed appendicitis, providing insight into the relative diagnostic weight of each parameter.

 

Table 5: Predictor Strength — Adjusted Odds Ratios of PAS Components

 

RLQ tenderness (OR 12.4) and leukocytosis (OR 8.1) are the strongest independent predictors of appendicitis in this cohort. Migration of pain and anorexia, while included in the PAS, contribute lesser independent diagnostic weight.

 

The following table summarises sensitivity, specificity, PPV, NPV, and positive likelihood ratio (LR+) for each diagnostic modality at the optimal threshold.

 

Table 6: Diagnostic Performance — PAS vs Ultrasonography (USG)

PAS ≥ 7 achieved 100% specificity — every patient with this score had confirmed appendicitis on HPE. The infinite LR+ at this threshold is a near-perfect rule-in test. USG alone demonstrated poor specificity (5.6%) and a negligible LR+ (1.06), indicating minimal independent diagnostic value in this cohort.

 

A LR+ > 10 is considered diagnostically conclusive. PAS ≥ 6 (LR+ 17.31) and PAS ≥ 7 (LR+ ∞) far exceed this threshold, whereas USG alone barely alters post-test probability.

 

Table 7: Positive Likelihood Ratio (LR+) — Comparison

This table summarizes diagnostic performance across PAS thresholds. PAS ≥6 shows the highest overall accuracy, while PAS ≥7 demonstrates 100% specificity and PPV. Ultrasound, although highly sensitive, shows very low specificity, limiting its usefulness as a confirmatory test.

The present study was undertaken to assess the efficacy of the Pediatric Appendicitis Score in children presenting with acute abdominal pain and to determine its usefulness as a structured clinical tool for early diagnosis, risk stratification, and decision-making in suspected acute appendicitis. Appendicitis was more common in older children, with the majority of patients belonging to the 11–16 years age group (43/70, 61.4%), followed by 6–10 years (13/70, 18.6%), 5 years (10/70, 14.3%), and 17 years (4/70, 5.7%). These findings indicate that the burden of acute appendicitis was concentrated predominantly in school-aged children and adolescents. The present study showed a mild male predominance, with 39 males (55.7%) and 31 females (44.3%) among the 70 children evaluated for acute abdominal pain.

 

The study aimed to evaluate how accurately PAS identifies children with true appendicitis, how effectively it distinguishes low-risk from high-risk cases, and how well it correlates with histopathological diagnosis and ultrasonographic findings. Another important aim was to identify the most appropriate PAS threshold for clinical application, particularly in relation to sensitivity, specificity, predictive values, and overall diagnostic accuracy. The significance of the study lies in the fact that acute appendicitis remains one of the most common surgical emergencies in children, yet its diagnosis is often challenging because symptoms may overlap with other causes of abdominal pain and younger children may present atypically. Delayed diagnosis may lead to perforation and complications, whereas overdiagnosis may result in unnecessary surgery and increased healthcare burden.

The present study demonstrates that the Pediatric Appendicitis Score (PAS) is a simple, reliable, and highly accurate tool for evaluating children with acute abdominal pain. Among 70 children aged 5–18 years, appendicitis was more common in older age groups, with a mild male predominance, and was confirmed in 74.3% cases. PAS showed a clear risk stratification, with no appendicitis in the low-risk group and universal confirmation in the high-risk group. At a cutoff of PAS 4-6, the score provided optimal diagnostic balance (sensitivity 96.2%, specificity 94.4%), making it suitable for screening, while PAS ≥7 was highly specific (100%) and effectively diagnostic of appendicitis, supporting its role as a rule-in criterion for surgical referral. The AUC of 0.991 indicates near-perfect diagnostic accuracy.

 

PAS performed well across all pediatric age groups and correlated strongly with objective clinical and laboratory findings. Although ultrasonography showed good diagnostic performance, PAS remains superior as a rapid, cost-effective, bedside tool that aids early decision-making.

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