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Lancet Child Adolesc Health. 2020 Apr;4(4):271-280. doi: 10.1016/S2352-4642(20)30006-7. Epub 2020 Feb 13.

Appendicitis risk prediction models in children presenting with right iliac fossa pain (RIFT study): a prospective, multicentre validation study.

Collaborators (920)

Nepogodiev D, Wilkin RJ, Bradshaw CJ, Skerritt C, Ball A, Moni-Nwinia W, Blanco-Colino R, Chauhan P, Drake TM, Frasson M, Gee O, Glasbey JC, Matthews JH, Morley GL, Naumann DN, Pata F, Soares AS, Bhangu A, Abbas SH, Abdelgadir AM, Abdelrahman A, Abdelrahman M, Abdelwahed A, Abou El Ella Y, Abulafi M, Acharya A, Adam ME, Adams RE, Adegbola SO, Adimonye A, Adnan M, Afshar S, Ahad A, Ahel J, Ahern DP, Ahmad Asmadi A, Ahmed B, Ahmed G, Ahmed OS, Ahmed S, Akbari K, Akinsola O, Al-Khyatt W, Al-Sarireh B, Al-Sheikh M, Alani M, Alexander R, Alhammali T, Ali M, Aljorfi A, Allen M, Allington J, Alshafei A, Amarasinghe R, Amayo A, Amin V, Amuthalingam T, Anandan L, Anderson O, Andreani SM, Andrews B, Ang A, Aravind B, Archer JE, Aremu MA, Arunachalam S, Aruparayil N, Ashmore DL, Ashour O, Ashraf N, Assaf N, Avalapati H, Awokoya OO, Ayube-Brown J, Badenoch T, Bagga R, Baginski A, Bailey S, Bailey S, Baird C, Baker B, Balai EJ, Balasubramaniam A, Bandyopadhyay SK, Banks A, Bansal H, Barnieh W, Barrie A, Barter CA, Bastianpillai J, Beasley WD, Bell CR, Bell J, Beral D, Berry B, Bevan KE, Bevan V, Bhanderi S, Bhargava A, Bilku D, Birindelli A, Blackford OD, Blackwell J, Blake L, Blencowe NS, Boam TD, Boereboom C, Bogdan M, Bohra P, Bolger JC, Bolton W, Bond S, Borg CM, Borghol K, Boshier PR, Bouhadiba N, Bowen J, Bowerman H, Bowman CR, Boyd-Carson H, Bradshaw CJ, Branagan G, Brennan P, Brett M, Brewer HK, Brewer H, Bronder C, Brown A, Brown AG, Brown CE, Brown M, Brown R, Buckley-Jones S, Budzanowski A, Bukhari W, Bull C, Bullivant JK, Burns KM, Burnside D, Busuttil A, Byrne BE, Byrnes CK, Caldwell M, Callan R, Cameron FC, Campbell U, Campbell UM, Campbell W, Carden CA, Carder C, Carney K, Cartwright H, Cay P, Chalk A, Chambers B, Champsi A, Chan D, Chan T, Chandler SB, Chapman J, Charalabopoulos A, Chasty B, Chatzikonstantinou M, Cheah WL, Chean CS, Cheng S, Cheng SA, Cheruvu M, Chin MY, Chishti IA, Choi S, Chok SM, Chong B, Choong JH, Chowdhary M, Chowdhury F, Choy CH, Christian L, Christopoulos P, Chui K, Cipparrone M, Clark GL, Clarke SA, Cleeve SJ, Clement KD, Clements B, Clements C, Clements JD, Clements JM, Clements JS, Clements JA, Clingan R, Cloney L, Clough E, Coe PO, Collier-Wakefield O, Colliver DW, Colvin DA, Connelly TM, Connor MJ, Cook V, Cooke F, Cooper F, Cotton AE, Couch DG, Cousins L, Coyle D, Creasy W, Cresner RL, Crone A, Cross K, Crozier J, Cunha P, Curtis NJ, D'Souza N, Dagash H, Dalmia S, Daniels I, Danquah-Boateng D, Dar FA, Dart K, Das A, Daureeawoo R, Davidson S, Davidson JR, Davies PL, Davis S, Daya Shetty V, De-Manzoni-Garberini A, De-Marchi JA, Dean EA, Dean S, Delimpalta C, Denley S, Dennison G, Devine AA, Dharamavaram S, Dhari AA, Di Franco F, Di Saverio S, Dobson C, Docherty JA, Doherty C, Donaldson G, Donohoe NO, Donohoe O, Douka E, Doulias T, Downey M, Doyle C, Drye N, Du DT, Dudek JG, Dunning PG, Dyal A, Eardley NJ, Earnshaw L, Easdon S, Edwards SE, Egan RJ, Egan RJ, El-Masry S, El-Tayar O, Elbourne CR, Elgaddal S, Elseedawy M, Elshaer M, Elsharnoby OH, Elzeneini W, Emslie KM, Engall N, Ertansel B, Esmail HD, Ettles C, Evans J, Evans JD, Everden A, Fadel M, Fahmy SE, Fairfield CJ, Fanibi BF, Farina V, Farrell SM, Farrow EZ, Fasuyi JA, Faulkner G, Fawkner-Corbett D, Fawzi F, Fehervari M, Ferguson N, Finch JG, Finlayson H, Flack T, Foers W, Foley NM, Ford K, Forgie A, Foster A, Foster JD, Fox A, Francis N, Franklin D, Froud H, Fuller HL, Gaines E, Galea J, Gammeri E, Garnham J, Garvin J, Gates Z, Gentry R, Ghaffari I, Ghatorae S, Gidwani AL, Gilbert TG, Gilbert TM, Gill S, Gillespie M, Gillick J, Giorga A, Gopalakrishnan K, Gopalswamy S, Gopinath S, Gormely R, Govind G, Grant C, Graveston J, Gray J, Gray RT, Griffith D, Griffith JP, Griffiths EA, Griffiths SN, Griggs EJ, Grosvenor S, Grove T, Gulamhussein M, Guliani J, Gummaraju A, Gunning S, Gurjar SV, Guru-Naidu S, Gurung S, Habib H, Hackney L, Haddow JB, Hajibandeh S, Halkias C, Hall NJ, Hamelmann RN, Haneef M, Haneef MS, Hanif Z, Hanley C, Hann AJ, Hanna T, Hardy E, Harlinska A, Harper F, Harries RL, Harris A, Harris G, Harris MP, Hasan R, Hassane A, Hatt JR, Haveliwala Z, Hawkins W, Hayat Z, Hayes C, Hebbar K, Henderson L, Henderson LT, Herrod P, Hever P, Hickey LM, Hicks G, Hodgson JM, Hoff M, Hollingsworth A, Hook A, Hornby ST, Horsfield E, Howie EE, Huang L, Hudson-Peacock NJ, Hughes DL, Hureibi KA, Hussain A, Hussain N, Hussaini SA, Hussein A, Hutchinson B, Ibrahim Y, Ikram S, Ilozue T, Iosif E, Iqbal MR, Irukulla S, Irwin R, Islam N, Ivey P, Jackson CR, Jackson A, Jah S, Jain A, Jain S, Jain S, Jama GM, Jamieson NB, Janardanan S, Jasinski B, Jenner D, Jerome E, Johnson B, Johnstone A, Jokhan S, Jones A, Jones CE, Jones CS, Jones E, Jones L, Kabir U, Kabwama S, Kamal M, Kamande IW, Kanakala V, Kannegieser-Bailey M, Kaptanis S, Karim MJ, Karwal RS, Kaur G, Keegan R, Kelay A, Kennedy ND, Kent DA, Khair A, Khan K, Khan S, Khasria A, Kho H, Kilkenny J, King R, Kinross J, Kirkham EN, Knight B, Kochupapy R, Koh C, Kouli O, Krishnamoorthy A, Krivan S, Kumar K, Kumar S, Kung V, Kuo R, Lafaurie G, Lai CW, Lal N, Lawday S, Layman S, Layton GR, Lazzaro A, Lecky-Thompson L, Lee KA, Lee KJ, Lee M, Lee SL, Leighton PA, Leitch RP, Lennox-Warburton HC, Leung EL, Li CH, Lim JM, Limb C, Ljungqvist G, Lloyd G, Lodhia S, Logan PC, Long M, Long P, Long RH, Longshaw A, Louw C, Lund JN, Ly C, Lynch Wong MJ, Ma J, Macdonald A, Macinnes E, Magro T, Mahapatra R, Mahendran B, Mahmood F, Mahmoud A, Mahon D, Mai D, Maina A, Major CP, Makhija R, Malam Y, Malik A, Malik K, Malik SN, Manda VM, Manektella KM, Mann C, Manoharan P, Manson R, Mansoor S, Mansour MM, Mansour S, Maqboul F, Maragouthakis D, Marangoni G, Mardhiah S, Maripi H, Marriott P, Marsh L, Marshall G, Martin A, Martin LM, Martinou E, Mashar R, Mason J, Masood M, Mathew G, Maude K, Mazumdar E, Mc-Dermott A, Mcarthur D, Mccain RS, McCain S, Mccann C, Mccaughey P, Mccluney SJ, Mccullough J, Mcdonnell D, Mcdowall NA, McEntee JE, McGlynn K, Mcgrath D, Mcgucken O, Mcilwaine S, Mcilwrath AC, Mckay SC, McKelvie MA, Mckenna M, Mckeon J, Mckevitt KL, Mckinley NC, McLaughlin D, McMahon SV, Mcmorran D, McNally L, Mcquaid M, Mcwhirter DM, Mealy K, Mears A, Menzies D, Merai H, Mersh RJ, Miguras M, Milgrom D, Miller K, Milward J, Mirza S, Misky AT, Mistry D, Mitchard MJ, Mitru RM, Mohamed IM, Mohamed I, Mohamed TM, Mohamed WO, Mohd N, Moore C, Moradzadeh J, Morrison T, Morrison-Jones V, Morton DG, Mothe BS, Mothe BS, Motiwala F, Motter D, Mowbray NG, Mughal Z, Mulsow J, Mundkur N, Muntean A, Murphy C, Murphy R, Murray MP, Muzaffar M, Myatt A, Nadeem A, Nagarajan D, Nagendram S, Nair A, Nair MK, Nair MS, Naismith KN, Nambiar K, Nana GR, Nash Z, Nastro P, Nazarian S, Neagle G, Neale A, Neary PM, Newton RC, Ng M, Ng S, Niaz O, Nickson S, Nicol D, Nimako E, Noor Mohamed MS, Nyeko-Lacek M, O'Connor BR, O'Neill E, O'Neill N, O'Sullivan D, O'Brien J, Oakey M, Obeid N, Odeh A, Ogboru S, Ogbuokiri C, Okekunle B, Okorocha E, Olagbaiye O, Olivier JB, Ooi R, Orawiec P, Orizu M, Orme N, Ormiston R, Paget C, Pal A, Palani-Velu LK, Pan Y, Panda N, Pandey V, Pandya R, Pandya D, Paramasevon KR, Pardy C, Parkola MJ, Pasquali S, Patel AS, Patel BY, Patel C, Patel H, Patel N, Patel RT, Patel S, Patel Y, Patel MM, Patil SD, Payne CJ, Payne RE, Pearce J, Pearce L, Pedder A, Peirce CB, Peiris GB, Peleki A, Pellino G, Pento V, Peprah D, Perera HS, Perera MI, Phelan L, Photiou D, Pierre R, Pilkington JP, Pinkney TD, Pisavadia B, Poacher A, Podda M, Pollard H, Popova D, Poudevigne M, Prideaux A, Pullabatla Venkata UP, Quddus A, Quill S, Rabie M, Rabie MR, Radwan RW, Rae JF, Rahim A, Rahmani LS, Rajagopal S, Rajaram R, Rajaretnam N, Rajjoub Y, Rallage H, Ramcharan S, Ranathunga S, Rao M, Rao V, Raofi A, Rashid M, Rate A, Ravindran R, Raymond M, Raza SS, Reddy A, Redman EP, Redmond AE, Rekhraj S, Renshaw S, Rex D, Rezacova M, Rezvani S, Ribeiro B, Rich JE, Richardson TD, Rigby S, Rigney B, Rinkoff S, Robb HD, Robertson C, Robinson D, Robinson A, Rodger V, Rolph R, Roomi S, Roth N, Rothnie K, Roy C, Rupani S, Rutherford DG, Sacks R, Saghir N, Saha A, Sahay SJ, Sahnan K, Salama Y, Salim S, Samuel M, Sana S, Sandu L, Sarmah P, Sarveswaran J, Saunders S, Savill A, Savioli F, Schuster Bruce JR, Sebastian JF, Seddon TC, Seneviratne N, Seth M, Setshwaelo T, Sezen E, Sgardelis P, Sgrò A, Shah C, Shah J, Shah K, Shah SM, Shakoor Z, Shalaby MS, Shanmuganathan V, Shanmugarajah K, Sharma A, Sharma P, Sharma A, Sharp OL, Shepherd JA, Sherif MA, Shet S, Shingler G, Shiwani MH, Shreshta D, Sian T, Siddiqui MN, Siddiqui ZA, Siggens KL, Sihra N, Silva I, Simioni A, Simmonds L, Simpson DJ, Singh A, Singh S, Singhal T, Sivaloganathan P, Sloan K, Smallcombe N, Smart CJ, Smart NJ, Smith R, Smoker H, Solinas L, Souter J, Springate EL, Stephens GF, Stevenson R, Stewart DJ, Stoica I, Strachan E, Stubbs BM, Stupalkowska W, Suliman A, Sultana A, Sunter H, Suriyakumar S, Symons N, Szentpali K, Szucs A, Tabain V, Tague LE, Tailor K, Tan CY, Tan S, Tang AM, Tarazi M, Tay YH, Tayeh S, Taylor M, Taylor NS, Taze D, Teasdale E, Thakral N, Thava B, Thavanesan N, Thaventhiran AJ, Theodoropoulou K, Thomas AT, Thomas L, Thompson DB, Thompson R, Thoukididou SN, Tiboni SG, Tiedt LA, Ting N, Tinsley BJ, Tognarelli JM, Torkington J, Torrance A, Townsend DC, Tozer PJ, Trail M, Trew F, Tudyka V, Tullie L, Turnbull A, Turner EJ, Twum-Barima CS, Tyler R, Vakis S, Valle A, Van Boxel GI, Vance-Daniel J, Varcada M, Varma N, Vaughan EM, Velchuru VR, Velho R, Venkatasubramaniam AK, Venn ML, Vijay V, Vinnicombe Z, Vitish-Sharma P, Wagener S, Waite K, Walters KJ, Walters U, Wardle BG, Wardle SD, Warusavitarne J, Watfah J, Watson N, Wauchope J, Weatherburn LW, Weegenaar CR, Welsh S, Wheatstone S, Whewell HE, Whitehouse P, Whiteman E, Whittaker L, Wijesundera K, Wilkinson D, Williams GL, Williams M, Williams R, Williams S, Wilson EJ, Wilson M, Winter DC, Winter G, Wolff J, Wong A, Wong C, Wong SY, Wood CS, Woodrow C, Woodward A, Woodward B, Wright E, Wright HL, Wu F, Yalamarthi S, Yang P, Yardimci E, Yasin T, Yen SK, Yoganathan S, Yoong S, Youssef H, Yow L, Zaborowski A, Zadi AZ, Zarka ZA, Zarog MA, Zhang AY, Bhangu A.

Abstract

BACKGROUND:

Acute appendicitis is the most common surgical emergency in children. Differentiation of acute appendicitis from conditions that do not require operative management can be challenging in children. This study aimed to identify the optimum risk prediction model to stratify acute appendicitis risk in children.

METHODS:

We did a rapid review to identify acute appendicitis risk prediction models. A prospective, multicentre cohort study was then done to evaluate performance of these models. Children (aged 5-15 years) presenting with acute right iliac fossa pain in the UK and Ireland were included. For each model, score cutoff thresholds were systematically varied to identify the best achievable specificity while maintaining a failure rate (ie, proportion of patients identified as low risk who had acute appendicitis) less than 5%. The normal appendicectomy rate was the proportion of resected appendixes found to be normal on histopathological examination.

FINDINGS:

15 risk prediction models were identified that could be assessed. The cohort study enrolled 1827 children from 139 centres, of whom 630 (34·5%) underwent appendicectomy. The normal appendicectomy rate was 15·9% (100 of 630 patients). The Shera score was the best performing model, with an area under the curve of 0·84 (95% CI 0·82-0·86). Applying score cutoffs of 3 points or lower for children aged 5-10 years and girls aged 11-15 years, and 2 points or lower for boys aged 11-15 years, the failure rate was 3·3% (95% CI 2·0-5·2; 18 of 539 patients), specificity was 44·3% (95% CI 41·4-47·2; 521 of 1176), and positive predictive value was 41·4% (38·5-44·4; 463 of 1118). Positive predictive value for the Shera score with a cutoff of 6 points or lower (72·6%, 67·4-77·4) was similar to that of ultrasound scan (75·0%, 65·3-83·1).

INTERPRETATION:

The Shera score has the potential to identify a large group of children at low risk of acute appendicitis who could be considered for early discharge. Risk scoring does not identify children who should proceed directly to surgery. Medium-risk and high-risk children should undergo routine preoperative ultrasound imaging by operators trained to assess for acute appendicitis, and MRI or low-dose CT if uncertainty remains.

FUNDING:

None.

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