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Alvarado scoring system in prediction of acute appendicitis. J Coll Physicians Surg Pak. 2011 Dec;21(12):753-5. doi: 12.2011/JCPSP.753755. [PubMed] PMID:22166697

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Objective: To evaluate the diagnostic accuracy of Alvarado score for the prediction of acute appendicitis.Study Design: Analytical study.Place and Duration of Study: This study was carried out in the Department of Surgery, Pakistan Institute of
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  Journal of the College of Physicians and Surgeons Pakistan 2011,Vol. 21 (12): 753-755  753 INTRODUCTION Acute appendicitis is one of the commonest abdominalemergencies and appendicectomy is in fact the mostcommon abdominal emergency operation performedworld over. The clinical presentation of acute appen-dicitis may vary from non-specific vague abdominal painto the classic presentation of right iliac fossa pain,tenderness and rebound tenderness. Left untreated,appendicitis has the potential for severe complications,including perforation, sepsis, and even death. 1-3 The diagnosis of appendicitis is clinical and essentiallyis based on history, clinical examination and routinelaboratory tests. The classic form of appendicitis may bepromptly diagnosed and treated, however, when itpresents with atypical features, it poses a diagnosticchallenge. In such cases, laboratory and imaginginvestigation may be useful in establishing a correctdiagnosis. Early and accurate diagnosis is essential toprevent morbidity and mortality related to appendicitis.According to available statistics, 1 out of 5 cases ofappendicitis is misdiagnosed whereas a normalappendix is found in 15-40% of patients who undergo anemergency appendectomy. 1-3 In attempts to increasethe diagnostic accuracy and reduce the high negativeappendectomy rate, various scoring systems, imagingmodalities and novel techniques have been devised,however, most of these are complex, expensive anddifficult to implement in emergency situation. 1,4-7 The present study was undertaken to evaluate theusefulness of Alvarado score in patients with provisionaldiagnosis of acute appendicitis and hence evolveevidence base that would guide clinical decision makingin patients presenting with clinical features suggestive ofacute appendicitis. METHODOLOGY The study included all adult patients of either genderwho presented with clinical findings suggestive of acuteappendicitis, who were assigned Alvarado scorepre-operatively and who subsequently underwentemergency appendicectomy with histological exami-nation of the resected specimens. Patients who eitherdid not consent to participate in the study, those whoreceived initial management at other hospitals or thosewith Alvarado score of 1-4 were excluded. Based onAlvarado score (Table I), the patients were stratifiedinto two groups. i.e. Group I (with a score of > 7) andGroup II (with a score of 5-7) All the patients receivedstandard emergency pre-operative management with nilby mouth status, intravenous fluids and Metronidazole,and systemic analgesics. All patients were subsequentlytreated with appendicectomy via Grid iron incision.Operative findings were recorded and the resectedspecimens were sent for histopathological examination. A BSTRACT Objective: To evaluate the diagnostic accuracy of Alvarado score for the prediction of acute appendicitis. Study Design: Analytical study. Place and Duration of Study: This study was carried out in the Department of Surgery, Pakistan Institute of MedicalSciences (PIMS), Islamabad, during the period from January 15, 2009 to July 15, 2010. Methodology: The study included all adult patients of either gender who presented with clinical findings suggestive ofacute appendicitis, who were assigned Alvarado score of < 4 pre-operatively and subsequently underwent emergencyappendicectomy with histological examination of the resected specimens. Based on the Alvarado score, the patients werestratified into two groups. i.e. Group I (with a score of > 7) and Group II (with a score of 5-7). Alvarado score was comparedwith the histopathology. The data was subjected to statistical analysis to measure the objective. Results: The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score foracute appendicitis were 66%, 81%, 96%, 29% respectively. The sensitivity was higher though not significant, for maleswith a score over 7 than females with similar scores (97% vs. 92%). However, for scores less than 7, sensitivity amongmales was significantly higher than females with similar scores (79% vs. 61%; p < 0.05). Conclusion: The presence of a high Alvarado score in adult males is highly predictive of acute appendicitis, however,in women of child bearing age other causes of similar clinical presentation lead to a low diagnostic accuracy of the score. Key words: Acute appendicitis. Alvarado score. Appendicectomy. Appendectomy.  Department of General Surgery 1  / Burn Care Centre 2  , Pakistan Institute of Medical Sciences (PIMS), Islamabad. Correspondence:  Dr. Ana Jalil, House No. 163, Street No. 20,Sector G-10/2, Islamabad. E-mail: drana24@yahoo.com Received January 24, 2011; accepted October 20, 2011. Alvarado Scoring System in Prediction of Acute Appendicitis Ana Jalil 1 , Syed Aslam Shah 1 , Muhammad Saaiq 2 , Muhammad Zubair 1 , Umbreen Riaz 1 and Yasir Habib 1 CLINICAL PRACTICE ARTICLE  Alvarado score was correlated with the histopathology.The data were recorded on proforma and subjected tostatistical analysis to measure the objective.The data was analysed through Statistical Packagefor Social Sciences (SPSS) version 10 and variousdescriptive statistics were used to calculate frequencies,percentages, means and standard deviation. Thenumerical data such as age were expressed as mean ±standard deviation while the categorical data suchas histopathology of the resected specimens wereexpressed as frequency and percentages. Two-by-twotable was employed to determine sensitivity, specificity,positive predictive value and negative predictive value.Percentages were compared by employing chi-squaretest and a p-value of less than 0.05 was regardedstatistically significant. RESULTS Out of a total of 262 patients, 58 % (n=152) were maleswhile 42% (n=110) were females. The age range was13-61 years, with a mean of 22.27 ±7.67 years. Majorityof the patients (90.45%) were in their 2nd and 3rddecades of life.There were 157 patients in Group I (with a score of > 7)while 105 patients in Group II (with a score of 5-7). InGroup I, out of 157 patients, 150 (96%) had acuteappendicitis on histopathology while 7 patients (4%)showed negative results. In Group II, out 105 patients,75 (71%) patients were confirmed as acute appendicitison histopathology while 30 (29%) showed negativeresults. Overall rate of negative appendectomy for thetwo groups was 14%. The rate of negative appendec-tomy was significantly higher in group II than group I(29% vs. 4%; p < 0.05). Gender-wise, the rate ofnegative appendectomy was significantly higher infemales than males (21% vs. 9%; p < 0.05).The overall sensitivity, specificity, positive predictivevalue and negative predictive value of Alvarado scorefor acute appendicitis were 66%, 81%, 96%, 29%respectively. The sensitivity was higher though notsignificant, for males with a score over 7 than femaleswith similar scores (97% vs. 92%). However, for scoresless than 7, sensitivity among males was significantlyhigher than females with similar scores (79% vs. 61%;p < 0.05, Table II).Out of 262 patients, 21 patients (13%) had perforatedappendix and all had Alvarado score over 7 (Table III). DISCUSSION Although acute appendicitis is a common surgicalemergency presentation, it still poses significantdiagnostic challenge to the clinical judgment of youngtrainee surgeons who are often the first ones todiagnose it. It is highly desirable not to miss a diagnosisas the condition has a potential for significantcomplications. Also it is equally important to avoid un-necessary surgery for an otherwise normal appendix. In1986 Alvarado introduced a scoring system in order toaid clinical diagnosis of acute appendicitis and alsoreduce the rate of negative appendectomies. 8 In this study, there was a slight male preponderance andmore frequent involvement of young individuals. Malepredominance and more frequent involvement ofyounger population is also reported in the publishedliterature. 1,9,10 In this series, the rate of negative appendectomy was14%. This is comparable with the published literaturewhere upto 40% rate of negative appendectomies isreported. 1,11,12 In this study, Alvarado scoring system was highlysensitive for the diagnosis of acute appendicitis in adultmales. This finding is in conformity with other publishedstudies. 12-15 754 Journal of the College of Physicians and Surgeons Pakistan 2011,Vol. 21 (12): 753-755 Ana Jalil, Syed Aslam Shah, Muhammad Saaiq, Muhammad Zubair, Umbreen Riaz and Yasir Habib Table I: The Alvarado score. VariablesClinical featuresScoreSymptomsMigratory right iliac fossa pain 1Anorexia1Nausea/ Vomiting1SignsTenderness right iliac fossa2Rebound tenderness1Elevated temperature >37.3 o C1Laboratory findingsLeukocytosis >10.0x10 9  / L2Neutrophils >75% or left shift1Total score10 Table II: Correlation of Alvarado score with histopathological findings(n=262). Alvarado score> 75-7TotalHistopathologyAppendicitis15075225[92/58]*[46/29]*Normal appendix73037[2/5]*[12/18]*Total157105[94/63]*[58/47]* * Figures in parentheses indicate males versus females respectively. Table III: Histopathology and operative findings among the two groups. Histopathology/ Group IGroup IIp-valueoperative findings(n=157)(n=105)(%)Acute appendicitis129 (82.16%)75 (71.42%)0.02*Acute appendicitis with perforation 21 (13.37%)0 (%)0.01*Normal appendix with no per-operative diagnosis1 (0.63%)12 (11.42%)0.02*Meckel's diverticulitis2 (1.27%)1 (0.95% )0.5**Pelvic inflammatory disease1 (0.63%)3 (2.85%)0.5**Acute salpingitis0 (%)1 (0.95%)0.5**Ruptured right ovarian cyst2 (1.27%)7 (6.66%)0.5**Torsion of ovarian cyst0 (%)3 (2.85%)0.5**Ruptured ectopic pregnancy1 (0.63%)3 (2.85%)0.5** * Significant; ** Insignificant.  Alvarado scoring system was not found to be of highsensitivity in women of child bearing age. In this subsetof patients, negative appendectomy rate was 21%. Infact women of child bearing age pose a diagnosticdilemma as various gynaecological conditions maypresent with signs and symptoms similar to those ofacute appendicitis. One concern in this subset ofpatients is to avert unnecessary appendicectomies,however, it is also imperative not to miss or delay aneeded appendicectomy as there is otherwise risk ofperforation with greater morbidity in the short-termpotentially leading to late complications such asadhesive obstruction or infertility. Lamparelli et al  .employed a combination of Alvarado score and laparo-scopy in adult females to increase the diagnosticaccuracy. 16 Diagnostic laparoscopy is now increasinglybeing advocated in this group of patients. 17-19 In this study, none of the patients with perforatedappendix had an Alvarado score of less than 7. Thismeans that patient with score between 5-7 may safelybe kept under observation followed by serial re-evaluation with Alvarado scoring and the decision tooperate or not may be changed accordingly.Alvarado score was found to be simple and easy toapply, since it relies only on history, clinical examinationand routine laboratory investigations. Alvarado scoreprovides an economical alternative to the other availablecostly diagnostic modalities such as CT scan, MRIscans etc. Such economic implications are particularlyimportant in the context of our poor patients. The studyillustrates that this simple scoring system in adult malessuspected of having acute appendicitis works reliablywell. However, in women, particularly those of childbearing age, its predictive value falls disappointinglyshort of expectations. Unnecessary surgery in this lattergroup can be avoided by employing other diagnosticmodalities such as diagnostic laparoscopy.This is a single centre study which remains a limitation. CONCLUSION The presence of a high Alvarado score in adult males ishighly predictive of acute appendicitis, however inwomen of child bearing age other causes of similarclinical presentation lead to a low diagnostic accuracy ofthe score. Hence, Alvarado score when employed alonein the pre-operative assessment of adult males canconsiderably reduce the negative appendicectomy ratewithout increasing morbidity and mortality. In females ofchild bearing age other diagnostic modalities should beselectively employed to complement the Alvarado score. REFERENCES 1.Santacroce L. Appendectomy [Internet]. 2010. [cited 2011 Jan 1].Available from: http://emedicine.medscape.com/article/195778-overviews2.O'Connel PR. The vermiform appendix. In: Williams NS,Bulstrode CJ, O'Connel PR, editors. Bailey and Love's Shortpractice of surgery. 25th ed. London:  Edward Arnold  ; 2008. p.1204-18.3.van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J,Boermeester MA. Acute appendicitis: meta-analysis ofdiagnostic performance of CT and graded compression USrelated to prevalence of disease.  Radiology 2008; 249 :97-106.Epub 2008 Aug 5.4.Kwok My, Kim MK, Gorelick MH. Evidence based approach tothe diagnosis of appendicitis in children.  Pediatr Emerg Care 2004; 20 :690-8; quiz 699-701.5.Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J,Schuh S, et al  . US or CT for diagnosis of appendicitis in childrenand adults? A meta-analysis.  Radiology 2006; 241 :83-94. Epub2006 Aug 23.6.Pham VA, Pham HN, Ho TH. Laparoscopic appendectomy: anefficacious alternative for complicated appendicitis in children.  Eur J Pediatr Surg  2009; 19 :157-9. Epub 2009 Apr 3.7.Branicki FJ. Abdominal emergencies: diagnostic and therapeuticlaparoscopy.  Surg Infect (Larchmt) 2002; 3 :269-82.8.Alvarado A. A practical score for the early diagnosis of acuteappendicitis.  Ann Emerg Med  1986; 15 :557-64.9.Qureshi WI, Durrani KM. Surgical audit of acute appendicitis.  Proceeding Shaikh Zayed Postgrad Med Inst  2000; 14 :7-12.10.Amer S. Protocol based diagnosis of appendicitis.  J Postgrad Med  Inst  2004; 18 :280-3. 11.Osime OC. Incidence of negative appendectomy: experience froma company hospital in Nigeria. California J Emerg Med 2005; 6 :69-73.12.Khan I, Abdur Rehman. Application of Alvarado scoring systemin diagnosis of acute appendicitis.  J Ayub Med Coll Abbottabad 2005; 17 :41-4.13.Malik KA, Khan A, Waheed I. Evaluation of the Alvarado scorein the diagnosis of acute appendicitis.  J Coll Physicians Surg Pak 2000; 10 :392-4.14.Sanei B, Mahmoodieh M, Hosseinpour. Evaluation of validity ofAlvarado scoring system for diagnosis of acute appendicitis.  Pak J Med Sci 2009; 25 :298-301.15.Sung Ouk Jang, Byung Seok Kim, Duk Jin Moon. [Application ofAlvarado score in patients with suspected appendicitis].  Korean J Gastroenterol  2008; 52 :27-31. Korean.16.Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB. A prospectiveevaluation of the combined use of the modified Alvarado scorewith selective laparoscopy in adult females in the manage-ment of suspected appendicitis.  Ann R Coll Surg Engl  2000; 82 :192-5.17.Rennie ATM, Tytherleigh MG, Theodoroupolou K, Farouk R.A prospective audit of 300 consecutive young women with anacute presentation of right iliac fossa pain.  Ann R Coll Surg Engl  2006; 88 :140-3.18.Chandler B, Beegle M, Elfrink RJ, Smith WJ. To leave or not toleave? A retrospective review of appendectomy during diagnosticlaparoscopy for chronic pelvic pain.  Modern Med  2002; 99 :502-4.19.Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosisof appendicitis decreased over time? A population-basedanalysis.  J Am Med Assoc 2001; 286 :1748-53. Journal of the College of Physicians and Surgeons Pakistan 2011,Vol. 21 (12): 753-755  755 Alvarado scoring system in prediction of acute appendicitis l l l l l O l l l l l
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