Acute Appendicitis: Diagnostic Accuracy of Alvarado Scoring System
Acute Appendicitis: Diagnostic Accuracy of Alvarado Scoring System
Acute Appendicitis: Diagnostic Accuracy of Alvarado Scoring System
journalhomepage:www.e-asianjournalsurgery.com
ORIGINAL ARTICLE
Received 25 July 2012; received in revised form 22 October 2012; accepted 3 April 2013
Available online 28 May 2013
KEYWORDS Summary Objective: To evaluate the usefulness of the Alvarado scoring system in reducing
Alvarado scoring; the percentage of negative appendectomy in our unit.
appendectomy; Materials and methods: A cross-sectional study was conducted, comprising 110 patients,
appendicitis admitted to Surgical Unit I, Civil Hospital, Karachi, in 2011 with a preliminary diagnosis of
acute appendicitis. Patients of both sexes and all age groups except younger than 10 years
were included in the study and their Alvarado scores calculated, on the basis of which patients
were divided into two groups: Group A (Alvarado score <6) and Group B (Alvarado score 6).
The signs, symptoms, laboratory values, surgical interventions, and pathology reports of each
patient were evaluated. Diagnosis was confirmed by histopathological examination. Sensi-
tivity, specificity, and positive and negative predictive values were calculated.
Results: Out of 110 cases (79 males, 31 females), 31 belonged to Group A (28.2%) and 79 belonged
to Group B (71.8%). Surgical procedures were performed in 98.2% of cases, along with conserva-
tive treatment. Final diagnosis by histopathology was confirmed in 77 cases (71.3%). The overall
negative appendectomy rate was 28.7% (males: 28.2%, females: 30%). Sensitivity and specificity
of the Alvarado scoring system were found to be 93.5% and 80.6% respectively. Positive and nega-
tive predictive values were 92.3% and 83.3%, respectively, and accuracy was 89.8%.
Conclusion: Alvarado score can be used effectively in our setup to reduce the incidence of nega-
tive appendectomies. However, its role in females was not satisfactory and needs to be supple-
mented by other means.
Copyright ª 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights
reserved.
* Corresponding author. Flat Number 5, Block 33, Defence Phase 1, Karachi, Pakistan.
E-mail address: [email protected] (Z.A. Memon).
1015-9584/$36 Copyright ª 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.asjsur.2013.04.004
Diagnostic accuracy of Alvarado scoring system 145
Table 2 Findings at exploration. Acute appendicitis remains the most common abdominal
condition requiring surgical intervention worldwide.8
Findings No. of patients (n) % Epidemiological studies have shown that appendicitis is
Inflamed appendix more common in the age 10e20 years group.4 Our study
Acute appendicitis 62 57.4 also reveals high incidence in the age <20 years group, in
Perforated appendix 10 9.2 concordance with Limpawattanisiri et al.4 Males were more
Gangrenous appendix 1 0.9 frequently affected than females in our study, a finding in
Pus in appendix 4 3.7 contrast with some studies.3,5
Normal appendix 31 28.7 The diagnosis of acute appendicitis still represents one
Right ovarian cyst 4 12.9 of the most controversial tasks in general surgery, and can
Pelvic inflammatory disease 3 9.6
Right ureteric colic 3 9.6
Mesenteric lymphadenitis 3 9.6 Table 4 Score-wise distribution of sensitivity.
Worm infestation 2 6.4
Matted gut loops 2 6.4 Score No. of cases (n) Sensitivity (%)
Acute cholecystitis 1 3.2 9 or 10 22 100
Meckel’s diverticulum 1 3.2 7 or 8 34 94.1
No diagnosis 12 38.7 5 or 6 38 60
Diagnostic accuracy of Alvarado scoring system 147
humble even the most experienced medical practitioner.4 pain, and a shorter duration of hospital stay, but higher
This may be due to variable presentations of the disease rates of readmission, intra-abdominal abscess formation,
and lack of a reliable diagnostic test.13 Surgical interven- and higher hospital costs.30 Outcome data on 235,473 pa-
tion early in the course of the disease to limit complica- tients with suspected acute appendicitis undergoing a
tions, leads to too many negative appendectomies being laparoscopic or open appendectomy between 2000 and
performed, with an associated mortality rate of 10%.14 The 2005 were obtained from the US Nationwide Inpatient
removal of a healthy appendix is associated with a greater Sample.31 The frequency of laparoscopic appendectomies
risk of abdominal adhesions as compared to acute appen- increased from 32% to 58% over the period studied. The
dicitis.15 This contrasts with an increasing rate of appen- proportion of patients with uncomplicated appendicitis was
diceal perforations associated with delayed surgical significantly higher in the laparoscopic group (76% vs.
interventions for the purpose of increasing diagnostic ac- 69%).
curacy at the opposite end of spectrum.4 Patients undergoing a laparoscopic appendectomy for
An appropriate approach towards the diagnosis of acute uncomplicated (e.g., imperforated, no abscess) acute
appendicitis is reached mainly by good history and proper appendicitis were significantly more likely to have a shorter
clinical examination.2,3 However, it is reliable mainly for mean hospital stay (1.5 days vs. 1.8 days), higher rates of
cases with classical presentation. Atypical cases present a intraoperative complications (odds ratio 2.61, 95% confi-
diagnostic dilemma. Therefore, clinical diagnosis should be dence interval 2.23e3.05), and higher costs (22%)
complemented with other diagnostic modalities such as compared with patients treated by an open appendectomy.
ultrasound, computed tomography (CT), laparoscopy, and For patients with complicated appendicitis, defined as an
C-reactive protein levels to reduce negative appendectomy appendiceal perforation or abscess, the laparoscopic
rate in equivocal cases.7,16e18 Some studies found no help approach was significantly associated with a shorter mean
from CT in diagnosis of acute appendicitis presenting with hospital stay (3.5 days vs. 4.2 days), higher rates of intra-
equivocal examination.19e21 CT had changed the treatment operative complications (odds ratio 1.61, 95% confidence
plan in 58% patients according to one study4 and sensitivity interval 1.33e1.94), and higher hospital costs (9%)
and specificity with intravenous and oral contrast ranging compared to patients undergoing an open appendectomy
from 91% to 98% and from 75% to 93%, for complicated appendicitis.
respectively.19,20,22e26 An advantage is that it permits In our study, the overall sensitivity was 93.5%, similar to that
visualization of entire abdomen as an alternative diagnosis; reported by Limpawattanisiri et al4 and Shah et al.15 This high
this changes the treatment plan in 15% patients according level of sensitivity (93.5%) suggests Alvarado score to be an
to one study.22 CT has drawbacks, especially in resource- effective diagnostic aid in acute appendi-citis. Moreover,
poor settings such as ours, as far as cost and availability application of Alvarado score can provide high degree of
are concerned, and it requires 2 hours to visualize oral positive predictive value (PPV) and high diagnostic accuracy.
contrast and during this time the appendix has a high PPV of Alvarado score in our study was 92.3%, comparable
chance to perforate. with reported PPV of 83.5%,3 83.7%,4,6
To discriminate between acute appendicitis and 95.2%,7 and 85.4%.32 Diagnostic accuracy was 89.8%,
nonspecific abdominal pain, various diagnostic scores have which is consistent with 83.2% in Thailand.9
been advocated to reduce the frequency of negative sur- The gender-wise analysis of the Alvarado scoring system
geries,5,13,27 one of which is the Alvarado scoring system. application revealed that this score falls disappointingly
Alvarado devised this in 1986, and it has been validated in short of expectations in females, especially of child-bearing
adult surgical practice,12 by giving relative weight to spe- age, reporting a negative appendectomy rate of 30% in
cific clinical manifestations often found in such pa- females as compared with males (28.2%). This finding is in
tients.4,13,15 It is simple, easy, extremely affordable, and concordance with other studies.4,33,34 Poor results in fe-
relatively accurate in aiding clinical diagnosis especially in male patients were probably due to the fact that it is a
interpreting the extremes of score range. 28 Various studies clinically based diagnostic system and female patients with
have shown promising results by incorporating this system right iliac fossa pain have a wide range of differential di-
in the diagnostic process with significant reduction in false agnoses such as ectopic gestation, ovarian cyst torsion,
negative cases.1,2,4,6 In our study, 71.3% of cases (n Z 77) salpingitis, and pelvic inflammatory disease.7,13,32 Simi-
were confirmed positive on histopathology, giving the larly, diagnosis during pregnancy is made difficult by
overall negative appendectomy rate of 28.7%, in concor- changes in position of appendix due to gravid uterus,
dance with reports of 33.1%7 and 33%,29 but in contrast nausea/vomiting, and raised leukocyte count during preg-
with 14.7%4 and 11.49%,27 reported in other studies. The nancy.13 This implies the need for additional investigations
reason for the high rate of negative appendectomy in our such as pelvic examination, ultrasound, and other modal-
setup may be that appendectomies were performed on ities to reduce negative appendectomy rate in this gender.35
almost all patients presented with conditions mimicking
acute appendicitis. However appendiceal perforations were Our study revealed significant differences in outcome for
also seen in our study due to delayed diagnosis and referral both the group of patients made on the basis of their
in some cases. Perforation rate was 9.2% comparable to calculated Alvarado scores. We noticed that in Group A,
7.8% and 9.4% in other studies.3,7 where Alvarado scores were less, the rate of negative ap-
When considering the approaches to appendectomy, pendectomy rate is high (i.e., 83.3%) in comparison with
both open and laparoscopic procedures are appropriate for Group B where high Alvarado scores were associated with
all patients. Patients treated with a laparoscopic appen- low frequency of negative appendectomies (7.7%). This is
dectomy have significantly fewer wound infections, less in concordance with Shah et al,15 who reported 71.4%
148 Z.A. Memon et al.
versus 11.1% negative appendectomy rates in Groups A 3. Khan I, Rehman AU. Application of Alvarado scoring system in
and B. This signifies that for high Alvarado scores the diagnosis of acute appendicitis. J Ayub Med Coll Abbotabad.
chances of having false positive cases are reduced, 2005;17:41e44.
implying the need for further evaluation and observation in 4. Limpawattanasiri C. Alvarado score for the acute appendicitis
in a provincial hospital. J Med Assoc Thai. 2011;94:441e448.
the <6 score group.14
5. Chan MYP, Tan C, Chiu MT, Ng YY. Alvarado score: an
It was noticed that although a high Alvarado score ( 6) admission criterion in patients with right iliac fossa pain.
provides an easy and satisfactory aid for the early diagnosis Surgeon. 2003; 1:39e41.
of acute appendicitis in the adult male population, the 6. Singh K, Gupta S, Parga P. Application of Alvarado scoring
results are discouraging in the female population even in system in the diagnosis of acute appendicitis. JK Sci. 2008;10:
the group with scores 6, where the negative appendec-tomy 84e86.
rate was 10% as compared with males from the same 7. Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified
group (6.8%). The reason may be the greater number of Alvarado scoring system as a diagnostic tool for acute appen-
differential diagnosis in females even with high scores, dicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC
resulting in over diagnosis of acute appendicitis. Surgery. 2011;11:1e5.
8. Hanif MS, Tahir TH, Sheikh IA, Ranjha MZ. Acute appendicitis:
We also noticed that even with high scores, clinical
gaining time in mass casualty scenario. Pak Armed Forces
decision making for management of such patients varies Med J. 2010;3:1e6.
according to the degree of clinical suspicion. In our study, 9. Mardan MA, Mufti TS, Khattak IU, et al. Role of ultrasound in
patients with a score of 9 or 10 reported sensitivity of 100%, acute appendicitis. J Ayub Med Coll Abottabad. 2007;19:
those with a score of 7 or 8 reported 94.1%, and with a 72e78.
score of 5 or 6 reported 60%, emphasizing the need for 10. Yegane R, Peyvandi H, Hajinasrollah, Salehei N, Ahmadei M.
different management options in different groups of Evaluation of modified Alvarado score in acute appendicitis
patients. among Iranian patients. Acta Medica Iranica. 2008;46:
Therefore, the Alvarado scoring system should be used 501e506.
in clinical practice for determining the most probable 11. Munir K, Iqbal J, Mushtaq U, Ishaque I, Mudassar J, Khalid A.
Modified Alvarado scoring system in the diagnosis of acute
management option in patients with different scores and appendicitis. APMC. 2008;2:91e94.
clinical suspicion. However, the scoring system is not 100%
12. Alvarado A. A practical score for the early diagnosis of acute
reliable and diagnostically accurate, but it can be used as a appendicitis. Ann Emerg Med. 1986;15:557e564.
complimentary aid to decide which manage-ment option is 13. Phophrom J, Trivej T. The modified Alvarado score versus the
particularly suitable for the patient’s benefit. Alvarado score for the diagnosis acute appendicitis. Thai J
Surg. 2005;26:69e72.
In conclusion, the Alvarado score can be used effec- 14. Baidya N, Rodrigues G, Rao A, Khan SA. Evaluation of
tively in our setup to reduce the incidence of negative Alvarado score in acute appendicitis: a prospective study.
appendectomies. The patients are not unduly exposed to Internet J Surg. 2007;9:1e6.
risks of delay in intervention or significant increase in 15. Shah SWA, Khan CA, Malik SA, Waqas A, Tarrar AM, Bhutta
IA. Modified Alvarado score: accuracy in diagnosis of acute
number of false negative cases. Its use is economical and appendicitis in adults. Prof Med J. 2010;17:546e550.
can be applied easily even by junior surgeons with limited 16. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis
diagnostic facilities available to them. However its role in scoring system using a prospective pediatric cohort. Ann
females was not satisfactory and needs to be supple- Emerg Med. 2007;49:778e784.
mented by other means to improve the diagnostic accu- 17. Shafi SM, Malah MA, Malah HR, Reshi FA. Evaluation of
racy. Ultrasound is the most commonly used investigation modified Alvarado score incorporating the C-reactive protein in
for this purpose. It helps to make prompt decision in sus- the patients with suspected acute appendicitis. Ann Nigerian
pected cases especially in patients at extreme of ages and Med. 2011;5:6e11.
females but it cannot be relied upon to the exclusion of the 18. Stephens PL, Mazzucco JJ. Comparison of ultrasound and the
surgeon’s careful and repeated evaluation. Our rec- Alvarado score for the diagnosis of acute appendicitis. Conn
Med. 1999;63:137e140.
ommendations are: false results are unlikely in patients with
19. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultraso-
a high score (9 or 10) and no further investigation is
nography do not improve and may delay the diagnosis and
needed; those with scores of 7 or 8 may require further treatment of acute appendicitis. Arch Surg. 2001;136:
investigationsdespecially female patients or those at age 556e562.
extremes; and those with scores of 5e6 may have the 20. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized
disease and further observation or investigations are study of clinical assessment versus computed tomography for
needed. the diagnosis of acute appendicitis. Surg Infect (Larchmt).
2003;4:231e239.
21. Morris KT, Kavanagh M, Hansen P, Whiteford MH, Deveney K,
Standage B. The rational use of computed tomography scans
References in the diagnosis of appendicitis. Am J Surg. 2002;183:
547e550.
1. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. 22. Schuler JG, Shortsleeve MJ, Goldenson RS, Perez-Rossello
Evaluation of Alvarado scoring in acute appendicitis. J R Soc JM, Perlmutter RA, Thorsen A. Is there a role for abdominal
Med. 1992;85: 87e88. computed tomographic scans in appendicitis? Arch Surg.
2. Soomro AG, Siddiqui FG, Abro AH, Abro S, Shaikh NA, 1998; 133:373e376.
Memon AS. Diagnostic accuracy of Alvarado scoring system in 23. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order
acute appendicitis. J Liaquat Univ Med Health Sci. 2008;7: a CT scan and when should we rely on the results to diagnose
93e96. an acute appendicitis? Curr Surg. 2006;63:464e468.
Diagnostic accuracy of Alvarado scoring system 149
24. Perez J, Barone JE, Wilbanks TO, Jorgensson D, Corvo PR. 30. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic
Liberal use of computed tomography scanning does not versus open surgery for suspected appendicitis. Cochrane
improve diagnostic accuracy in appendicitis. Am J Surg. 2003; Database Syst Rev. 2010. CD001546.
185:194e197. 31. Sporn E, Petroski GF, Mancini GJ, Astudillo JA, Miedema BW,
25. Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute Thaler K. Laparoscopic appendectomydis it worth the cost?
appendicitis in adults: accuracy of color Doppler sonography Trend analysis in the US from 2000 to 2005. J Am Coll Surg.
and MDCT compared with surgery and clinical follow-up. AJR 2009;208:179e185.
Am J Roentgenol. 2008;190:1300e1306. 32. Nizamuddin S, Samo KA, Mangi MH, Rehamn SU. Protocol
26. Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic based management of acute right iliac fossa pain to improve
review: computed tomography and ultrasonography to detect the diagnostic accuracy. Medical Channel. 2009;15: 101e104.
acute appendicitis in adults and adolescents. Ann Intern Med.
2004;141:537e546. 33. Fenyo¨ G, Lindberg G, Blind P, Enochsson L, Oberg A.
27. Malik KA, Sheikh MR. Role of modified Alvarado score in acute Diagnostic decision support in suspected acute appendicitis:
appendicitis. Pak J Surg. 2007;23:251e253. validation of a simplified scoring system. Eur J Surg. 1997;163:
28. Ahmad KI, Shamsul AS, Ismail MS. The relationship between 831e838.
Alvarado score and pain score in managing adult acute 34. Kalan M, Talbot D, Cunliffe WJ, Rich A. Evaluation of the
appendicitis in emergency department. J Surg Academia. modified Alvarado score in the diagnosis of acute appendicitis:
2011;1:15e29. a prospective study. Ann R Coll Surg. 1994;76:418e419.
29. Izbicki JR, Knoefel WT, Wilker DK, et al. Accurate diagnosis of 35. Shrivastava UK, Gupta A, Sharma D. Evaluation of the
acute appendicitis: a retrospective and prospective analysis of Alvarado score in the diagnosis of acute appendicitis. Trop
686 patients. Eur J Surg. 1992;158:227e231. Gastro-enterol. 2004;25:184e186.