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Three Part Question

In [children with suspected appendicitis] how [useful is abdominal pain when asked to hop] at [confirming or refuting the diagnosis]

Clinical Scenario

A 9 year old presents to the ED with acute abdominal pain; is pain on hopping/jumping indicative of appendicitis?

Search Strategy

Medline 1946-February week 3 2012 using the OVID interface
{(appendicitis/ OR acute appendicitis/ OR appendicitis.mp) AND (hop.mp OR hopping.mp OR jump$.mp)} NO LIMITS applied

Search Outcome

Altogether 6 papers were found, 4 of which were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Colvin JM et al 2007 USA	379 children 3-12 years of age	Retrospective case note analysis	Appendicitis	Pain on hopping/jumping/coughing present in 67% confirmed cases appendicitis	Study split into 3 separate age groups (3-5.99 years, 6-8.99 years and 9-11.99 years). Only 15 confirmed cases in youngest age group. Criteria offered at hopping/coughing/jumping - no individual breakdown offered
			Appendicitis	Pain on hopping/coughing/jumping - 89% Sensitivity 66% specificity in 6-8.99 year age group
			Appendicitis	Pain on hopping/coughing/jumping - 80% Sensitivity 70% specificity in 3-5.99 year age group
			Appendicitis	Pain on hopping/coughing/jumping - 73% Sensitivity 51% specificity in 9-11.99 year age group
Samuel M 2002 UK	1170 children aged 4-15	Prospective study of common signs/symptoms looking to create a clinical scoring system for assessing possible appendicitis in children	Pain present on hopping/percussion/coughing	Sens 93%, Spec 100%, Positive Predictive Value 1, Negative Predictive Value 0.88	Variables in score overlap with other pathology (eg urinary tract infection, gastroenteritis) Narrow proposed score cut-off Applied across wide range of ages High disease prevalence (63% not replicated in subsequent validation studies)
Goldman D et al 2008 Canada	849 children 1-17	Prospective study, validation of proposals of Samuel	Appendicitis	Cough/percussion/hopping pain present in 72% of confirmed appendicitis 9% of non-appendicitis. Significant p value of<0.01 3rd most common finding in confirmed group after RIF pain (80%) and nausea/vomiting (75%)	Validation study of scoring system proposed by Samuel. Only 2 negative appendectomies Little statistical analysis of individual variables prevalence No analysis of cut-points proposed previously Disease prevalence 14%
Bhatt et al, 2009, Canada	246 children 4-18	Prospective study, validation of proposals of Samuel	Appendicitis	Score <4 has 97.6% sensitivity and negative predictive value 97.7% and can be discharged Score of 8 has 95.1 specificity and positive predictive value 85.2% and should go to theatre Scores 5 to 7 diagnosis uncertain and require further imaging for diagnosis.	No analysis of prevalence of components of scoring system. Study looking at sens/spec of total scores Disease prevalence 34%

Comment(s)

Further validation of a scoring system to aid clinical judgment is required

Clinical Bottom Line

The presence of abdominal pain when asked to hop seems to be both reasonably sensitive and specific to a diagnosis of appendicitis in children.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Colvin JM. Bachur R. Kharbanda A. The presentation of appendicitis in preadolescent children. Pediatric Emergency Care 23(12):849-55, 2007 Dec
2. Samuel M. Pediatric Appendicitis Score. Journal of Pediatric Surgery 37(6):877-81, 2002 Jun
3. Goldman RD, Carter S, Stephens D, et al. Prospective validation of the pediatric appendicitis score. Journal of Pediatrics 153(2):278-82, 2008 Aug
4. Bhatt M, Joseph L, Ducharme FM et al. Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Academic Emergency Medicine 16(7):591-6, 2009 Jul.