Patient presents with suspected appendicitis Calculate the Pediatric Appendicitis Score (PAS) Is the PAS< 4? Consult Surgery Is the AUS positive for appendicitis? Work-up alternative diagnosis or discharge home Is appendicitis diagnosed? No Admit for OR Is pt. going to OR? Yes Order an Appendicitis Ultrasound (AUS) and a CBC with Differential Admit for antibiotics and non-operative management No No Yes Is the PAS ?7? Indeterminate Is a CT scan necessary for a diagnosis? Obtain CT Abdomen and Pelvis with IV contrast (order as CT Appendicitis) No Yes No Pediatric Appendicitis Score (PAS) Sign/Symptom Points Cough/percussion/heel tapping tenderness at RLQ 2 Anorexia 1 Low-grade fever ? 38.0° C 1 Nausea/emesis 1 RLQ tenderness on light palpation 2 Leukocytosis (>9.000/mm³) 1 Left shift (>75% neutrophilia) 1 Migration of pain to RLQ 1 Use the PAS order to enter score into chart Labs and AUS may be ordered concurrently Contact Information: Surgery Fellow ? (816) 458-5767 Jason Fraser, MD Pager: (816) 458-5934 jdfraser@cmh.edu Kelly Sinclair, MD ksinclair@cmh.edu Algorithm finalized/revised: 02.2017; 06.2020 No Yes Yes Yes
Appendicitis diagnosis guidelines (Children's Mercy Kansas City)
Guideline · Jan 2021 · 1 min read
In brief
In brief
Standardized diagnostic algorithm for pediatric appendicitis developed by Children's Mercy Hospital Kansas City. Provides systematic approach to clinical evaluation and decision-making for suspected acute appendicitis in children.
- Use Pediatric Appendicitis Score (PAS) as initial triage: PAS <4 suggests low risk, PAS ≥7 warrants surgical consult.
- Appendicitis ultrasound (AUS) with CBC is first-line imaging for intermediate-risk patients (PAS 4-6).
- Reserve CT abdomen/pelvis for cases where ultrasound is indeterminate and diagnosis remains unclear.
- Non-operative management with antibiotics is an option for select diagnosed appendicitis cases not proceeding to OR.
- PAS incorporates 8 clinical/lab findings (max 10 points): RLQ tenderness, fever, leukocytosis, anorexia, and pain migration.
Written by the GCMD Library team from the guideline.
Initial Assessment Using Pediatric Appendicitis Score
The algorithm begins with calculation of the Pediatric Appendicitis Score (PAS), an 8-point clinical scoring system incorporating physical exam findings (RLQ tenderness, cough/percussion tenderness), symptoms (anorexia, nausea/vomiting, pain migration, fever), and laboratory values (leukocytosis, neutrophilia). Patients are stratified into three risk categories based on their PAS: low risk (PAS <4), intermediate risk (PAS 4-6), and high risk (PAS ≥7). This initial stratification guides subsequent diagnostic workup and management decisions.
Low-Risk Pathway (PAS <4)
Patients with PAS <4 are considered low probability for appendicitis and do not require imaging. These patients should be worked up for alternative diagnoses or discharged home with appropriate return precautions. Surgical consultation is not routinely required for this low-risk group.
Intermediate-Risk Diagnostic Workup (PAS 4-6)
Patients with intermediate PAS scores undergo appendicitis ultrasound (AUS) and complete blood count with differential. If ultrasound is positive for appendicitis, the patient proceeds to surgical consultation. If ultrasound is indeterminate or negative but clinical suspicion remains, CT abdomen/pelvis with IV contrast may be obtained to establish definitive diagnosis.
High-Risk Pathway (PAS ≥7)
Patients with PAS ≥7 have high probability of appendicitis and warrant immediate surgical consultation. These patients may proceed directly to operative management or may undergo confirmatory imaging if diagnosis remains uncertain. The high clinical suspicion in this group justifies expedited surgical evaluation.
Surgical Management Decision
Once appendicitis is diagnosed through clinical assessment and/or imaging, the surgical team determines whether operative or non-operative management is appropriate. Patients selected for surgery are admitted for appendectomy. Selected patients may be candidates for non-operative management with intravenous antibiotics and hospital admission.
Statements in this guideline
The Pediatric Appendicitis Score should be calculated for patients presenting with suspected appendicitis.
Cough, percussion, or heel tapping tenderness at the right lower quadrant scores 2 points on the Pediatric Appendicitis Score.
Anorexia scores 1 point on the Pediatric Appendicitis Score.
Low-grade fever of 38.0°C or higher scores 1 point on the Pediatric Appendicitis Score.
Nausea or vomiting scores 1 point on the Pediatric Appendicitis Score.
Right lower quadrant tenderness on light palpation scores 2 points on the Pediatric Appendicitis Score.
Leukocytosis greater than 9,000/mm³ scores 1 point on the Pediatric Appendicitis Score.
Left shift with greater than 75% neutrophilia scores 1 point on the Pediatric Appendicitis Score.
Migration of pain to the right lower quadrant scores 1 point on the Pediatric Appendicitis Score.
Patients with a Pediatric Appendicitis Score less than 4 should be worked up for alternative diagnosis or discharged home.
Patients with a Pediatric Appendicitis Score of 7 or higher should have surgery consulted.
Patients with an indeterminate Pediatric Appendicitis Score should have an appendicitis ultrasound and a CBC with differential ordered.
Labs and appendicitis ultrasound may be ordered concurrently.
If the appendicitis ultrasound is positive for appendicitis, surgery should be consulted.
CT scan of the abdomen and pelvis with IV contrast should be obtained if necessary for diagnosis when ultrasound is indeterminate.
Patients diagnosed with appendicitis who are going to the operating room should be admitted for OR.
Patients diagnosed with appendicitis who are not going to the operating room should be admitted for antibiotics and non-operative management.