Background: Acute appendicitis is the leading pediatric surgical emergency. Identifying drivers of disease severity and laparoscopic-to-open conversion remains critical for surgical planning. We evaluated the discriminative performance of clinical scores and inflammatory biomarkers for both peritonitis and surgical conversion, and explored combined clinical–laboratory models among children with acute appendicitis undergoing an initially attempted laparoscopic appendectomy. Methods: A retrospective study was conducted, including pediatric patients with acute appendicitis who underwent surgical treatment. Clinical scores (Alvarado score and Pediatric Appendicitis Score) and laboratory parameters (C-reactive protein, neutrophil count, and neutrophil-to-lymphocyte ratio) were analyzed. Receiver operating characteristic (ROC) curve analysis was used to assess discriminative ability, with calculation of the area under the curve (AUC). Combined models based on standardized variables were constructed and evaluated. Comparisons between AUCs were performed using DeLong’s test. Results: For prediction of peritonitis, clinical scores suggested good discriminative ability within the sample, with AUC values of 0.805 for the Alvarado score and 0.812 for the Pediatric Appendicitis Score, whereas C-reactive protein showed moderate performance (AUC = 0.735). Combined models achieved AUC values of 0.823 for both zPAS + zCRP and zAlvarado + zCRP, and 0.773 for zCRP + zNLR. For surgical conversion, higher within-sample AUC values were observed, reaching 0.879 for the Alvarado score and up to 0.932 for the combined models (zAlvarado + zCRP), followed by 0.926 for zPAS + zCRP and 0.874 for zCRP + zNLR. However, these results should be interpreted with caution due to the limited number of conversion events. Conclusions: Clinical scoring systems and inflammatory biomarkers suggested good ability to predict peritonitis in pediatric acute appendicitis, while their performance for predicting surgical conversion appeared higher but remains exploratory. Combined clinical–laboratory models showed promising within-sample discriminative ability; however, given the very small number of conversion events, these findings should be regarded as exploratory and hypothesis-generating only.

Background and Clinical Significance: Torsion of the vermiform appendix is a rare condition with a clinical presentation closely resembling acute appendicitis, while preoperative investigations are of limited value in distinguishing between the two entities. In most cases, the definitive diagnosis is made incidentally during surgery. Case Presentation: The authors present the case of an 18-day-old female neonate who presented with marked abdominal distension, diffuse spontaneous and palpation-induced abdominal pain, guarding, and signs of peritoneal irritation. The clinical manifestations and paraclinical findings mimicked a neonatal intestinal obstruction; however, intraoperative exploration revealed a gangrenous vermiform appendix twisted 240° anticlockwise, associated with a fibrinous pseudomembrane and multiple enlarged mesenteric lymph nodes. Although the initial therapeutic strategy was to perform a laparoscopy, severe abdominal distension caused by marked aerocolia necessitated conversion to a supra- and infraumbilical midline laparotomy. We thus describe, to the best of our knowledge, one of the youngest neonatal cases of appendiceal torsion reported in the literature. Conclusions: Although rare, appendiceal torsion should be considered in the differential diagnosis of neonatal acute abdomen, and timely surgical exploration is key to achieving a favorable outcome.

Background/Objectives: Distinguishing perforated from non-perforated appendicitis preoperatively is difficult, and routine scores diagnose appendicitis rather than grade severity. We examined whether two inflammatory markers and one sonographic sign, combined in a model, discriminate between perforated and non-perforated appendicitis, and how this compares with a bedside score. Methods: Retrospective single-center cohort of 142 children aged 3–17 years undergoing initially attempted laparoscopic appendectomy (October 2022–December 2023). Log-transformed neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) were prespecified; sonographic free peritoneal fluid was selected from four signs using the outcome, and reported in-sample performance is an upper bound. Predictors were fitted by Firth penalized logistic regression with bootstrap validation. Results: Perforation occurred in 27 patients (19.0%). All three were independent predictors (odds ratios: CRP 2.583, NLR 3.045, free peritoneal fluid 3.638). The area under the curve was 0.900 (0.890 optimism-corrected). At the Youden-optimal threshold, sensitivity was 96.3% and negative predictive value 98.9%. The Pediatric Appendicitis Score reached 0.855 (difference not significant, p = 0.375); at matched sensitivity its specificity was 38.9% versus 74.8%. Conclusions: The model’s potential value lies in excluding perforation rather than establishing it, and applies after the decision to operate has been taken, informing antibiotic selection, operative urgency and family counselling rather than the indication for surgery. Overall discrimination did not differ significantly from the Pediatric Appendicitis Score, the advantage lying in the operating point rather than in the area under the curve. These findings are hypothesis-generating and require external validation.

Background: Acute appendicitis is a leading pediatric surgical emergency. Timely diagnosis remains challenging, particularly in young children with atypical presentations. Clinical evaluation alone yields variable diagnostic performance, prompting the use of risk stratification tools. Objective: To evaluate and compare the Alvarado score against alternative clinical scoring systems, laboratory biomarkers, and imaging modalities in pediatric acute appendicitis. Methods: A narrative literature review with structured selection elements was conducted across PubMed, Scopus, and Web of Science for studies published between 2016 and 2026. Results: The Alvarado score demonstrates moderate diagnostic accuracy in children, with good sensitivity but limited specificity (57–76%) at standard cut-offs (≥7). Pediatric-specific scores like the Pediatric Appendicitis Score (PAS) offer higher sensitivity, while the Appendicitis Inflammatory Response (AIR) score provides superior specificity and better identifies complicated appendicitis (including gangrene, phlegmon, and perforation). Continuous risk models, notably the Pediatric Appendicitis Risk Calculator (pARC), outperform fixed additive scores in pediatric cohorts. Combining clinical scores with C-reactive protein, neutrophil-to-lymphocyte ratio, and selective ultrasonography enhances diagnostic precision. Computed tomography reserved for equivocal cases further optimizes diagnostic yield. Conclusion: The Alvarado score should not be used as a standalone tool. A structured, stepwise multimodal approach integrating clinical scores (such as pARC or PAS), inflammatory biomarkers, and selective imaging optimizes diagnostic accuracy and supports timely surgical decision-making in children.