You will undoubtedly see a patient with right lower quadrant abdominal pain in the near future. One of the most challenging patient populations to evaluate are adolescent females with RLQ pain. Why? Because of the ovaries of course! Their presence adds to the differential diagnosis and thus, female patients often require more testing to make the diagnosis.
The Pediatric Appendicitis Score (seen in the separate panel) is a prospectively validated tool for use in the assessment of patients with suspected appendicitis.
In a recent edition of Academic Emergency Medicine Scheller et al. attempted to answer the above question. This was a retrospective observational cohort of the female adolescents (13-21 years) present within the data of a prior prospective evaluation of 1,228 Pediatric Emergency Department patients with suspected appendicitis. The aim was to calculate the sensitivity, specificity, PPV and NPV of the PAS for acute appendicitis in the subset of female teens.
Overall the original cohort had a high rate of appendicitis for patients who had all elements of the PAS present – 73% (n=901/1,228) of the cohort had all elements of the PAS with 26.7% (n=249) of the 901 ultimately diagnosed with appendicitis. 272 of the 901 were adolescent females, making up the population for this secondary analysis. Salient take home points from the results are presented in the following table.
PAS ≤2 Low risk – Minimize unnecessary testing
PAS 3-6 Equivocal – Efficient use of diagnostic tests while minimizing unnecessary CT scans
PAS ≥7 High suspicion – Prompt surgical consult and minimize imaging via a consistent team based approach
Take Home Points
- If the PAS is ≥8, which is really high, it is very specific for appendicitis in female adolescents. That is a very high PAS generally picks up on teenage females with appendicitis.
- The PPV is really quite poor no matter the score cutoff
- This population of teens was derived from another previous study. Thus a dedicated study of teens – ideally a large population from multiple centers is warranted.
- I will push for the diagnosis of appy (over other pathology) in female teens with a PAS of 8 or higher however. This may not result in decreased use of imaging studies, but I do think, and many agree, that even teenage girls can have a “clinical” diagnosis of appendicitis. So, yes, it is OK to diagnose appendicitis in a teenage girl without doing an ultrasound or CT.