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Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT
  1. Sean K Golden1,
  2. John B Harringa1,
  3. Perry J Pickhardt2,
  4. Alexander Ebinger3,
  5. James E Svenson1,
  6. Ying-Qi Zhao4,
  7. Zhanhai Li4,
  8. Ryan P Westergaard5,
  9. William J Ehlenbach5,
  10. Michael D Repplinger1,2
    1. 1BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
    2. 2Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
    3. 3Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
    4. 4Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
    5. 5Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
    1. Correspondence to Dr Michael D Repplinger, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine & Public Health, 800 University Bay Drive, Suite 310 Mail Code 9123, Madison, WI 53705, USA; mdreppli{at}


    Objective To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis.

    Methods Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn.

    Results Of the 287 patients (mean age (range), 31 (12–88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(−)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(−) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(−) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(−) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(−) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7).

    Conclusions Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.

    • abdomen- non trauma, gastro-intestinal
    • clinical assessment, effectiveness
    • imaging, CT/MRI
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