doi: 10.31674/mjmr.2020.v04i04.

003

ASSOCIATION OF ALVARADO SCORE AND THE SEVERITY OF

ACUTE APPENDICITIS
Asraf Ahmad Qamruddin¹*, Azizul Hadi Ahmad², Abdul Malek Mohamad², Hamzah Sukiman²

Department of Community Medicine, UniversitiSains Kubang Kerian, Kelantan, Malaysia

Department of General Surgery, Hospital Kemaman, Terengganu
*Corresponding author: [email protected]

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

INTRODUCTION colicky central abdominal followed by vomiting and

migration of the pain to right iliac fossa may only
Appendicitis is the most common abdominal present in 50% of patients (Yamini, D., et al., 1998).The
emergency with appendicectomies the most common benefit of modalities such as computed tomography
emergency surgery (Humes & Simpson, 2006). It is screening and ultrasonography despite having been
most common between the ages of 10 to 20 years but shown in clinical trials has not been utilised fully in
could occur at any age (Addiss, et al., 1990). The general practice due to lack of widespread availability
chances of undergoing appendectomy during a lifetime (Flum & Koepsell, 2002).
are about 20% in females and 12% in males (Addiss, et
al., 1990). The spectrum of appendicitis can range from Over the years, various scoring systems have been
early appendicitis to appendiceal perforation and developed to aid surgeons in the diagnosis of acute
abscess (Willemsen, et al., 2002). The mortality and appendicitis. Alvarado score was introduced in 1986 and
morbidity are influenced by the stages of the disease. In has been extensively used in the diagnosing of acute
the case of perforation, the mortality is 5.1 per 1000 appendicitis (Alvarado, 1986). It is a scoring system
(Blomqvist, P.G., et al., 2001). Urgent appendicectomy based on symptoms, clinical examinations and
is a relatively safe procedure and the accepted treatment laboratory findings (Alvarado, 1986 and Kalan, M., et
al., 1994) The score has 6 clinical items (abdominal pain
to prevent perforation with mortality rate of less than
which migrates to the right iliac fossa, ketones in the
1% (Humes & Simpson, 2006).
urine or anorexia, nausea or vomiting, rebound
The primary presenting complaint of patients with tenderness, right iliac fossa tenderness and fever of 37.3
acute appendicitis is abdominal pain. Despite the ºC or more) and 2 laboratory measurements
increased use of ultrasonography and computed (leucocytosis> 10,000 per mm3 and Neutrophilia> 70%)
tomography, the diagnosis of acute appendicitis in (Chan, Teo, and Ng, 2001). Tenderness in right iliac fossa
countries such as Malaysia relies on the surgeon and leucocytosis are considered the two most important
thorough history and examination. However, this could factor. Therefore, assigned two points while the six other
be difficult, as the classical diagnostic sequence of factors are assigned one point each giving a possible total

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 ASSOCIATION OF ALVARADO AND ACUTE APPENDICITIS

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).

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 ASSOCIATION OF ALVARADO AND ACUTE APPENDICITIS

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

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 ASSOCIATION OF ALVARADO AND ACUTE APPENDICITIS

DISCUSSION having perforated appendicitis was increased by 1.69

times. If we considered Alvarado score of ≥ 7 against
The mean age of patients undergoing appendicectomy
those scored lower than 7, the odds of having perforated
in our study was 22 years old. The peak incidence of
appendicitis was higher at 2.65 times after adjusting or
appendicitis has been reported occurring between the
age, gender and duration of pain before presentation,
ages of 10 and 30 years (Gwynn, 2001). This is further
This finding is supported by earlier study that reported
supported by a study of acute appendicitis done in a
Alvarado score above seven was associated with a
university hospital in Kuala Lumpur, Malaysia that
higher risk of perforation as compared to at 7 or lower
reported an average age of 27 years old among cases of
(Nshuti, Kruger, & Luvhengo, 2014). Therefore
appendicitis reported there (Lee, Jayalakshmi, &
subjects that score Alvarado score ≥ 7, which is
Noori, 1993). The cases of appendicectomy were
considered as having high probabilities of acute
slightly higher in female compared to male (53.1% vs
appendicitis were also more likely to have more severe
46.9%). This is on contrary to the commonly reported
appendicitis as compared to those who scored lower.
that the diagnosis of appendicitis is more common in
Therefore, despite Alvarado score has been commonly
men due to difficulty in diagnosis in female because of
used as a tool for surgeons in diagnosing appendicitis,
additional clinical considerations (Guss & Richards,
high score especially at or above 7 could also be
2000). However, our finding is in line with the previous
interpreted as having higher odds or more severe
study in the East Coast hospital which reported a higher
appendicitis (Nshuti, Kruger, & Luvhengo, 2014).
rate of appendicectomy in female than male (Abdullah,
2015). Although these findings suggest there is a possible
association between the Alvarado score and severity of
In view of the fact that the Malay race is the main ethnic
appendicitis, a causal relationship and temporality could
group in Terengganu,about 98% of the workers were
not be established due to the limitation of the study
Malay. In Kelantan, Malays comprise about 94% of the
design. The preferred study design to evaluate the
population (DSM, 2017). The median time of
outcome is a cohort study. However, conducting a
presentation to healthcare was 2.1 days after onset of
cohort study would have been more costly and time-
symptoms. This is supported by a study on acute
consuming.As this study was conducted among subjects
appendicitis presentation in a hospital in South Africa
that underwent appendicectomy in a hospital, the
which reported 63% of patients presented 2 days after
findings should be interpreted as such and could not be
the onset of their symptoms (17 Appendicitis are
generalised to subjects that did not undergo
typically initially described as peri-umbilical colicky
appendicectomy. The subjects in this study scored 5 or
pain. This later intensifies, becoming more constant and
above in Alvarado score and must be interpreted as such.
sharper in nature and migrates to the right iliac fossa in
The result of the multiple logistic regression analysis as
the first 24 hours. This could explain the delay in
shown in Table 3 cannot be applied to subjects that
presentation from the onset of pain (Nshuti, Kruger, &
scored less than 5 in Alvarado score. This study was
Luvhengo, 2014). The mean Alvarado score on
conducted in a hospital in East Coast of Malaysia.
presentation was 7.3 which is considered a high
Hence, the results cannot be generalised to subjects in
probability ofappendicitis.This is not surprising as our
other parts of Malaysia. Majority of the workers'
sample only consisted of subjects that underwent
population in this study were Malays (97.7%) which
appendicectomy and did not include subjects that were
might be different in other states. We also used
sent back home or treated conservatively, who would
secondary data in this study. Therefore, there is no
probably have scored lower Alvarado score. This
control over the type of data available and limited
finding is congruent with subjects that underwent
control over missing or incomplete data. However,
appendicectomy in a teaching hospital in Pakistan that
secondary data eliminated interviewer bias that could
reported mean Alvarado score of 8.4 (Nshuti, Kruger, &
have occurred in primary data collection.
Luvhengo, 2014).
CONCLUSION
After adjusting for confounding factors such as age,
gender and duration of pain before presentation, with Alvarado score is still the most well-known scoring
every one unit increased in Alvarado score the odds of system to aid the diagnosis of acute appendicitis despite

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 ASSOCIATION OF ALVARADO AND ACUTE APPENDICITIS

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,
REFERENCES 2001. 21(2): p. 119-123.
Abdullah, R., Delayed Versus Early Appendicectomy Humes, D.J., Simpson, J., (2006) Acute appendicitis.
in Adult Patients with Acute Appendicitis: A BMJ, 333(7567); pp: 530-534.
Retrospective Study in Hospital Sultanah Nur
Zahirah, Terengganu. 2015, Universiti Sains Kalan, M., et al., Evaluation of the modified Alvarado
Malaysia. score in the diagnosis of acute appendicitis: a
prospective study. Annals of the Royal College of
Addiss, D.G., Shaffer, N., Fowler, B.S., Tauxe R.V. Surgeons of England, 1994. 76(6): p. 418
(1990) The epidemiology of appendicitis and
appendectomy in the United States. American Khan, I. and A. ur Rehman, Application of Alvarado
journal of epidemiology, 132(5): pp: 910-925. scoring system in diagnosis of acute appendicitis.
Journal of Ayub Medical College Abbottabad, 2005.
Alvarado, A., A practical score for the early diagnosis 17(3).
of acute appendicitis. Annals of emergency
medicine, 1986. 15(5): p. 557-564. Lee, H.Y., P. Jayalakshmi, and S.H. Noori, Acute
appendicitis--the University Hospital experience.
Blomqvist, P.G., et al., Mortality after appendectomy in Med J Malaysia, 1993. 48(1): p. 17-27.
Sweden, 1987–1996. Annals of surgery, 2001.
233(4): p. 455. Nshuti, R., D. Kruger, and T.E. Luvhengo, Clinical
presentation of acute appendicitis in adults at the
Chan, M., B. Teo, and B. Ng, The Alvarado score and Chris Hani Baragwanath academic hospital.
acute appendicitis. Annals of the Academy of International Journal of Emergency Medicine, 2014.
Medicine, Singapore, 2001. 30(5): p. 510-512. 7(1): p. 12.
Department of Statistics Malaysia, Perangkaan Penting Willemsen, P.J., Hoorntje, L.E., Eddes, E.H., Ploeg, R.J.
J.P. Malaysia, Editor. 2017, Department of (2002) The need for interval appendectomy after
Statistics, Malaysia: Putrajaya. resolution of an appendiceal mass questioned.
Digestive surgery, 19(3): pp. 216-222.
Douglas, C.D., et al., Randomised controlled trial of
ultrasonography in diagnosis of acute appendicitis, Yamini, D., et al., Perforated appendicitis: is it truly a
incorporating the Alvarado score. BMJ (Clinical surgical urgency? The American Surgeon, 1998.
research ed.), 2000. 321(7266): p. 919-922. 64(10): p. 970.

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