Pediatric Appendicitis Score (PAS)
Use for patients 3-18 years of age.
Children or adolescents with acute abdominal pain, especially localized to the right lower quadrant (RLQ), where appendicitis is suspected.
- The Pediatric Appendicitis Score (PAS) predicts likelihood of appendicitis in pediatric patients (3-18 years old) with abdominal pain of ≤4 days duration.
- Stratifies patients into low risk, high risk, or equivocal for appendicitis.
- Includes findings from history, physical, and lab data.
- Should NOT be used in patients with known GI disease, pregnancy, or previous abdominal surgeries.
- The Pediatric Appendicitis Score has been validated in multicenter studies.
- The PAS may be as good as clinician gestalt at identifying patients at low risk for appendicitis versus those with appendicitis.
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For patients who are not low risk, next steps include NPO status, IV fluids, analgesia, and imaging or surgical consultation.
Low Risk PAS (<4)
- Low likelihood of acute appendicitis, and likely do not warrant imaging.
- The score has a higher negative predictive value (95%) in the absence of RLQ pain, pain with walking/jumping or coughing, and an ANC <6,750.
- Consider other causes of acute abdominal pain.
Equivocal PAS (4-6)
- Imaging can be helpful for this subgroup of patients, preferably ultrasound or MRI for pediatric patients.
- Surgical consults are warranted for patients with equivocal scores and imaging where the appendix cannot be visualized.
High Risk PAS (>6)
- Surgical consult is warranted for these patients.
- Imaging may still be pursued, but patients should only undergo ultrasound prior to a surgical consult.
Patients in the low risk group according to the PAS do not have a zero risk. Use clinical discretion if imaging or surgical consult may aid in diagnosis.
Addition of the selected points.
Facts & Figures
|Right lower quadrant (RLQ) tenderness to cough, percussion, or hopping||2|
|Fever (temp ≥38.0ºC/100.4ºF)||1|
|Nausea or vomiting||1|
|Tenderness over right iliac fossa||2|
|Leukocytosis (WBC ≥10,000)||1|
|Left shift (ANC > 7,500)||1|
|Migration of pain to RLQ||1|
The Pediatric Appendicitis Score was developed by Madan Samuel in 2002 in a prospective cohort study of 1,170 patients ages 4 to 15 years with abdominal pain.
Clinical history, physical exam, and laboratory data were analyzed to find 8 variables that showed statistical significance for acute appendicitis, and the 10 point scoring system was created.
It has since been validated in numerous multicenter studies.
Shah and colleagues developed a diagnostic algorithm in 2016 which they used prospectively in 840 patients, 267 of which were ultimately diagnosed with appendicitis.
The algorithm was found to be 98.6% sensitive and 94.4% specific, with a decrease in utilization of CT from 75.4% to 24.2%.
Original/Primary ReferenceSamuel M. Pediatric Appendicitis Score. Journal of Pediatric Surgery, Vol 37,No 6 (June),2002: pp 877-881.
ValidationGoldman RD. The Paediatric Appendicitis Score (PAS) was useful in children with acute abdominal pain. Evid Based Med 2009;14:26 doi:10.1136/ebm.14.1.26Kharbanda, AB. Validation and Refinement of a Prediction Rule to Identify Children at Low Risk for Acute Appendicitis. Arch Pediatr Adolesc Med 2012;166(8):738-744. doi:10.1001/archpediatrics.2012.490Shah SR, Sinclair KA, Theut SB, Johnson KM, Holcomb GW 3rd, St Peter SD. Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm. Ann Surg. 2016 Sep;264(3):474-81.
About the Creator
Madan Samuel, MD, is a pediatric surgeon and urologist, currently at the Al Zahra Hospital in Dubai. He has been awarded by the Prime Minister of India and the United Kingdom for his accomplishments in his field. Dr. Samuel is an active researcher, having published over 66 articles in peer reviewed journals and book chapters in ten pediatric surgical textbooks.
To view Dr. Madan Samuel's publications, visit PubMed
- Jamie Lovell, MD