Association of Alvarado Score and The Severity of Acute Appendicitis
Association of Alvarado Score and The Severity of Acute Appendicitis
Association of Alvarado Score and The Severity of Acute Appendicitis
003
ABSTRACT
Objective: To determine the association between Alvarado score and the severity of acute appendicitis in an
East Coast Hospital, Malaysia. Methods: The cross-sectional study involved reviewing the record of all 177
Patients operated for suspected acute appendicitis in the hospital. Data were collected using a proforma. The
severity of appendicitis was divided into perforated or non-perforated from the histo-pathological examination
reports. Alvarado score recorded during the presentation to hospital was recorded. Simple and multiple logistic
regression analysis were used to determine the association between Alvarado score and the severity of acute
appendicitis. Results: Prevalence of perforated appendicitis was 25.1%. The mean of Alvarado score was 7.5
(SD: 1.35). Multiple logistic regression analysis showed a significant association between Alvarado score and
severity of acute appendicitis after adjusting for age, gender and duration of pain before presentation.
Conclusion: Higher Alvarado score is associated with higher odds of perforation. Therefore, Alvarado score
could be used not just for diagnostic purpose, but also for predicting the severity of appendicitis.
Keywords: Appendicitis, Alvarado score, Perforation, Surgical Emergencies
score of ten points. A score of <5 considered less likely to before presentation. Ethics: Ethical approval was
be appendicitis, a score of >5 were more likely (Douglas obtained from National Medical Research Register. The
et al., 2000). An Alvarado score of 7 or more increased main ethical issue in this study involved confidentiality
the probability of acute appendicitis with a likelihood of the secondary data. The confidentiality of the subjects
ratio of 3.1 (Ebell and Shinholser, 2014). Although was maintained throughout the process of data
Alvarado score is used for diagnosis of appendicitis, collection, analysis and interpretation. No identifiable
currently there is no study done on the association of information was collected and data presented as
Alvarado score and the perforation of appendicitis. The collective and not by individual information.
objectives of this study were (Humes & Simpson, 2006) RESULTS
to determine the prevalence of perforated appendicitis
and (Addiss, et al.,1990) the association between From the medical record, a total of 228 patients
Alvarado score and perforation of appendicitis among underwent appendicectomy in the hospital between
patients undergoing appendicectomy in an East Coast January 2013 and September 2014. After excluding
hospital, Malaysia. incomplete and missing data, 177 patients were included
in the study. Figure 1 shows the flow diagram of the
METHODOLOGY search strategy.
Data Collection: We conducted a cross-sectional study
in a hospital in East Coast of Malaysia between
September 2016 to October 2017. We identified and
traced the medical record of all patients that underwent
appendicectomy between January 2013 and September
2014. Designated proforma was used to record
information from the medical records. Information
collected from the medical record were age, gender,
duration of pain in days prior to presentation, Alvarado
score on presentation, the time between diagnosis and
operation and duration of the operation. We then traced
the histopathological examination findings of the
appendix samples send intraoperatively. Any medical
record with more than 30% missing, incomplete required
data or histopathological examination (HPE) result was
not available were excluded from the study.
Data Analysis: Data analysis was carried out using
SPSS version 24.0. Prevalence of perforated appendicitis
and 95% confidence interval was calculated. Perforated
appendicitis was coded with binary coding '1' and non-
perforated appendicitis was coded '0'. Non-perforated
appendicitis included HPE reported as white appendix.
Diagnosis other than white appendix and appendicitis
were excluded from the analysis. The association Figure 1: Subject recruitment flowchart
between Alvarado score with the severity of appendicitis
was done using simple logistic regression analysis Table 1 shows the characteristics of the patients. Mean
followed by multiple logistic regression analysis age of the patients were 22.0 (SD: 9.20) years old. The
adjusting for age, sex and duration of pain before mean Alvarado score was 7.3 (SD: 1.67). About 75%
presentation. We then rerun another multiple logistic of the subject had non-perforated appendicitis on HPE
regression analysis by dividing the subjects into two result (white appendix = 5 subjects and acute
groups, Alvarado score ≥ 7 and ≤ 6, to determine the appendicitis = 127 subjects). HPE result with perforated
association of between-subject that scored for a high appendicitis was reported for 45 subjects and 2 subjects
probability of appendicitis and the severity of HPE result reported other diagnoses (ovarian cyst and
appendicitis adjusting for age, sex and duration of pain reactive lymphoid hyperplasia).
Table 1: Characteristics of the subjects underwent Table 3: Multiple logistic regression analysis of
appendicectomy in the hospital between January 2013 Alvarado score and the severity of acute appendicitis
and September 2014 (n= 177) adjusting for age and gender (n = 177)
Variable Mean (SD) Frequency (%) Crude OR p- Adjusted OR p-
Variable (95% CI)a value (95% CI)a value
Age (years) 22.0 (9.20)
Alvarado score 1.61 (1.22,2.13) 0.001 1.69 (1.24, 2.30) 0.001
Gender
Controlled variable
Male 83 (46.9)
Female 94 (53.1) Age 0.99 (0.97, 1.02) 0.676 0.99 (0.96, 1.03) 0.650
Gender
Ethnicity Male
0.66 (0.33,1.32) 0.237 0.60 (0.27, 1.32) 0.206
Malay 173(97.7) Female
1
Other(s) 4 (2.3)
Duration of pain
Duration of pain before 2.1 (1.00)a before presentation
1.06 (0.89, 1.26) 0.513 1.06 (0.87, 1.28) 0.584
presentation (days) (days)
a
Alvarado score 7.3 (1.67) CI=Confidence interval
Constant -5.011
Type of appendicitis No multicollinearity and no interaction detected
Non-perforated 132 (74.6) Hosmer-Lemeshow test, p-value=0.850
Classification table 81.9% correctly classified
Perforated 45 (25.4) Area under the receiver operating characteristic was 86.4%
Time between diagnosis 9.0 (10.00)a
and operation (hours) Table 4 shows both the simple and multiple logistic
regression analysis of Alvarado score ≥ 7 and the severity
Duration of operation 70.0 (25.77) of appendicitis after adjusting for the three confounding
(minutes)
factors. Alvarado score for subjects scoring ≥ 7 showed
a
Median (interquartile range) higher odds of having severe appendicitis compared to
Table 2 shows the frequency of the Alvarado score analysis using the entire study subjects. The model was fit
among the subjects. All the subjects had an Alvarado with p-value for Hosmer-Lemeshow test was 0.820,
score of 5 and above. Majority of the patient scored 7 and classification table of 76.7% correctly classified cases and
above (79.6%) which indicated a high probability of area under the receiver operating characteristic of 82.5%.
acute appendicitis on the Alvarado Score. Table 4: Multiple logistic regression analysis of
Table 2: Frequency distribution of the subjects Alvarado score ≥ 7 and the severity of acute appendicitis
according to Alvarado score (n=177) adjusting for age and gender (n = 177)
Crude OR p- Adjusted OR p-
Alvarado Score Frequency (%) Variable (95% CI)a value (95% CI)a value
5 10 (5.7) Alvarado score≥ 7 2.43 (1.08, 5.48) 0.032 2.65 (1.02, 6.92) 0.041
6 26 (14.7) Controlled variable
7 50 (28.2) Age 0.99 (0.97, 1.02) 0.676 0.99 (0.96, 1.03) 0.852
8 47 (26.6)
Gender
9 28 (15.8) Male
Female 0.66 (0.33,1.32) 0.237 0.64 (0.30, 1.36) 0.245
10 16 (9.0) 1
Duration of pain
before
Table 3 shows the simple and multiple logistic presentation 1.06 (0.89, 1.26) 0.513 1.06 (0.87, 1.28) 0.51
regression analysis of Alvarado score and the severity of (days)
appendicitis. After adjusting for age, sex and duration of a
CI=Confidence interval
pain before presentation, Alvarado score was Constant -5.011
No multicollinearity and no interaction detected
significantly associated with severity of appendicitis on Hosmer-Lemeshow test, p-value=0.820
HPE result. Classification table 76.7% correctly classified
advancement in imaging modalities and development Ebell, M.H. and J. Shinholser, What are the most clinically
of other scoring system. We have shown that for useful cutoffs for the Alvarado and pediatric
patients presenting and suspected of acute appendicitis appendicitis scores? A systematic review. Annals of
in hospital and scored high on Alvarado score, they not emergency medicine, 2014. 64(4): p. 365-372. e2.
only have higher odds of having appendicitis but the
odds of having more severe appendicitis are also Flum, D.R. and T. Koepsell, The Clinical and Economic
higher. Correlates of Misdiagnosed Appendicitis: Nationwide
Analysis. JAMA Surgery, 2002. 137(7): p. 799-804.
Conflict of Interest
Guss, D.A. and C. Richards, Comparison of men and
The authors declare that they have no conflict of interest. women presenting to an ED with acute appendicitis.
ACKNOWLEDGEMENTS Am J Emerg Med, 2000. 18(4): p. 372-5.
We would like to thank Hospital Kemaman, Terengganu Gwynn, L.K., The diagnosis of acute appendicitis:
for allowing our study to be conducted at their site. clinical assessment versus computed tomography
evaluation. The Journal of emergency medicine,
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