What is the best course of action for a pediatric patient with suspected appendicitis, presenting with right lower quadrant pain, normal white blood cell (WBC) count, and no signs of fever, anorexia, or rebound tenderness?

Management of Low-Risk Suspected Appendicitis in a 9-Year-Old

Discharge this patient with clear return precautions and mandatory 24-hour follow-up (Option C), as she presents with a low-risk clinical picture that does not warrant immediate imaging or admission. 1, 2, 3

Risk Stratification

This patient has multiple features indicating low probability of appendicitis:

• Normal WBC count (9,000/μL): In pediatric patients aged 4-11 years, normal WBC has a negative predictive value of 89.5% for excluding appendicitis 4
• Absence of fever: Fever is a key component of classic appendicitis presentation, and its absence significantly decreases likelihood 3
• No rebound tenderness: Absence of peritoneal signs argues against acute appendicitis 1
• No anorexia: Preserved appetite further reduces the probability of appendicitis 3

Evidence-Based Diagnostic Approach

Clinical scoring systems should guide imaging decisions, not reflexive CT ordering 1:

• The Pediatric Appendicitis Score (PAS) and Appendicitis-Pediatric Score (APPE) are validated tools for risk stratification in children 1
• Low-risk patients (APPE score ≤8) can be safely discharged with appropriate safety netting, avoiding unnecessary imaging and radiation exposure 1
• Intermediate-risk patients benefit from systematic diagnostic imaging, but this patient's presentation does not meet intermediate-risk criteria 1

Why Not CT Imaging (Option B)?

CT should be reserved for intermediate or high-risk patients, not reflexively ordered for all suspected appendicitis 1, 2:

• The ACR Appropriateness Criteria recommend a step-up approach tailored to clinical risk stratification 1
• In children with low clinical suspicion, CT exposes patients to unnecessary radiation without changing management 1
• Only 50% of appendicitis cases present with "classic" features, but this patient lacks even the atypical high-risk features that would warrant imaging 2

Why Not Admission (Option A)?

Admission with 24-hour observation is not indicated for low-risk patients 1:

• This approach is resource-intensive and exposes the patient to unnecessary hospitalization costs and risks 1
• The WSES Jerusalem Guidelines specifically recommend against admission for low-risk patients who can be safely discharged with return precautions 1
• Serial clinical examinations can be performed in the outpatient setting with mandatory follow-up 3

Critical Discharge Instructions

Provide explicit return precautions for the following red flags 3:

• Development of fever (temperature >38°C/100.4°F)
• Worsening or migrating pain to the right lower quadrant
• Persistent vomiting or inability to tolerate oral intake
• Development of rebound tenderness or guarding
• Any clinical deterioration

Mandatory 24-hour follow-up is essential due to measurable false-negative rates in low-risk presentations 5, 3:

• Schedule definitive reassessment within 24 hours, either in clinic or by phone
• If symptoms persist or worsen at follow-up, proceed to imaging (ultrasound first-line in pediatrics, followed by CT if inconclusive) 1

Laboratory Markers in Context

While this patient has normal WBC, the absence of left shift is equally important 4:

• In children aged 4-11 years, the combination of normal WBC and absence of left shift has a negative predictive value of 90.5% 4
• CRP would add diagnostic value if obtained (CRP <10 mg/L further reduces appendicitis likelihood), but is not mandatory for discharge decision in this low-risk patient 1, 6

Common Pitfalls to Avoid

• Do not reflexively order CT for all RLQ pain: Risk-stratify first using clinical assessment and validated scoring systems 1, 2
• Do not assume normal WBC rules out appendicitis completely: While reassuring, it does not eliminate the diagnosis—hence the need for close follow-up 2, 4
• Do not discharge without explicit return precautions and scheduled follow-up: This is where diagnostic errors occur 5, 3