|Year : 2015 | Volume
| Issue : 1 | Page : 17-20
Evaluation of modified Alvarado score in the diagnosis of suspected acute appendicitis
Samir M Kohla, Moharram Abdel-Samie Mohamed, Fawzy Abu-Bakr Bakr, Hesham M Emam MBChB
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||01-Sep-2013|
|Date of Acceptance||19-Jan-2014|
|Date of Web Publication||29-Apr-2015|
Hesham M Emam
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the efficacy of modified Alvarado score in the diagnosis of acute appendicitis.
Diagnosis of acute appendicitis is sometimes difficult. Prompt and accurate diagnosis of appendicitis is crucial in lowering the incidence of complications caused by appendiceal rupture. A number of scoring systems have been advocated to minimize the number of negative appendectomies; the most prominent and most commonly used of those scores is that developed by Alvarado and modified by Kalan.
Patients and methods
A total of 100 patients with acute lower abdominal pain suspecting acute appendicitis were included, examined clinically, and their modified Alvarado score was calculated and listed. All specimens of appendectomies were sent to histopathological examination and then their results were compared with the results of modified Alvarado score.
The results of this study showed that modified Alvarado score at the cutoff value of at least 7 has a sensitivity of 93.33%, specificity of 52.94%, accuracy of 84.42%, and negative appendectomy rate of 12.5%.
The Alvarado score is a cheap, reliable, and reproducible diagnostic tool. When the score is high (≥7), there are strong indications for urgent surgery. When the score is low (<4), the diagnosis of appendicitis is very unlikely.
Keywords: Alvarado, appendicitis, score
|How to cite this article:|
Kohla SM, Mohamed MA, Bakr FA, Emam HM. Evaluation of modified Alvarado score in the diagnosis of suspected acute appendicitis. Menoufia Med J 2015;28:17-20
|How to cite this URL:|
Kohla SM, Mohamed MA, Bakr FA, Emam HM. Evaluation of modified Alvarado score in the diagnosis of suspected acute appendicitis. Menoufia Med J [serial online] 2015 [cited 2019 Nov 20];28:17-20. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/17/155906
| Introduction|| |
Fitz  described the syndrome of acute appendicitis as a diagnostic and clinical entity, which required urgent surgical treatment. Acute appendicitis is relatively rare in infants and becomes increasingly common in childhood and early adult life, reaching a peak incidence in the teens and early 20s. After middle age, the risk of developing appendicitis is quite small .
The lifetime rate of appendectomy is 12% for men and 25% for women, with ~7% of all people undergoing appendectomy for acute appendicitis during their lifetime .
Diagnosis of acute appendicitis is sometimes difficult. Decision making in case of acute appendicitis may be difficult especially for junior doctors who can get confused by a long list of conditions mimicking this clinical scenario. Equivocal cases usually require in-patient observation and multiple laboratory and imaging investigations. This delay in diagnosis may increase the morbidity and cost.
Prompt and accurate diagnosis of appendicitis is crucial in lowering the incidence of complications caused by appendiceal rupture.
Immediate appendectomy is the recommended treatment for acute appendicitis because of the presumed risk of progression to rupture.
The overall rate of perforated appendicitis is 25.8% of all cases of acute appendicitis. Children below 5 years of age and patients above 65 years of age have the highest rates of perforation (45 and 51%, respectively) .
There is no accurate way of determining when an appendix will rupture before resolution of the inflammatory process.
To avoid complications related to delayed diagnosis or treatment, for example, appendicular rupture, appendicular abscess, or portal pyemia, there is a tendency of over diagnosis of the condition, and different studies found a high negative appendectomy rate (11-30%) ; these rates are even higher in women of child-bearing age .
However, with all operations, postoperative complications can exist, including wound infections, intra-abdominal abscesses, ileus, and in the longer term, adhesions.
With this in mind, it is worth considering that the mainstay of treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics.
A number of scoring systems have been advocated to minimize the number of negative appendectomies; they combine clinical, laboratory, and ultrasound parameters to increase the security of diagnosis.
In daily clinical practice, the use of a scoring system has been found to be associated with a reduced rate of nonindicated appendectomies .
In 1986, Alvarado  described a scoring system, which has been validated in adult surgical practice. This scoring system includes eight variables: three symptoms (migrating pain from the umbilicus to the right iliac fossa, anorexia, and vomiting), three signs (tenderness, rebound tenderness, and pyrexia) and two laboratory data (leukocytosis and shifting to the left of neutrophil maturation) yielding a total score of 10 .
However, in 1994, Kalan omitted the parameter of left shift of neutrophil maturation and produced a modified score .
There are mixed results regarding the efficacy of modified Alvarado score ,,,,.
| Patients and methods|| |
A prospective study was conducted during the period from April 2012 to April 2013. This study was carried out on 100 patients with abdominal pain suspecting acute appendicitis. In all, 100 patients were selected from the admitted patients at the Department of Surgery at the Menoufia University Hospital at Shebin El-Koum and Talaba Hospital (Alexandria).
All patients underwent the following:
- Clinical assessment: Complete history taking and thorough clinical examination.
- Laboratory investigations: White blood cell count and other investigations according to the patient's condition.
- Classification according to the modified Alvarado score: According to their Alvarado score, patients were graded into three groups based on six clinical manifestations and one laboratory test (migrating abdominal pain, tenderness at the right iliac fossa, rebound tenderness at the right iliac fossa, fever, nausea/vomiting, anorexia, and leukocytosis), each weighted by a coefficient on a score pad.
- Intraoperative assessment: To determine the cause of abdominal pain if possible.
- Postoperative pathological examination: Histopathological examination of collected specimens of patient who underwent surgical intervention, and hence the patients were classified into four groups: negative (not appendicitis), catarrhal appendicitis, suppurative appendicitis, and complicated appendicitis.
The decision to operate was made independently of the modified Alvarado score and was based purely on clinical judgment. The diagnosis of those who underwent surgery was confirmed by both operative findings and histopathological examination of the appendectomy specimen.
These results were compared with the postoperative histopathological finding, and hence we could evaluate the performance of the score.
Data were fed to the computer using IBM SPSS software package version 20.0. Qualitative data were described using number and percentage. Comparison between different groups regarding categorical variables was tested using the c2 -test.
| Results|| |
The present study was conducted on 100 patients complaining of lower abdominal pain with provisional diagnosis of acute appendicitis.
They were admitted to the General Surgical Department of Menoufia University Hospital at Shebin El-Koum and Department of General Surgery at Talaba Hospital at Alexandria, from April 2012 to April 2013.
Distribution of the parameters of modified Alvarado score among the studied patients
Tenderness was present in most of the cases (99%), followed by leukocytosis (84%). The least frequent symptom was the migrating pain, which was present only in 49% of cases.
Evaluation of patients using modified Alvarado score
The most frequent score of the patient was 8, followed by 7 then 6. None of the patient had a score of 1, and only four patients had a score of 2 and other four patients had a score of 3.
Evaluation according to the management
Of the entire group of 100 patients, 77 (77%) underwent surgery, whereas 23 (23%) did not.
Evaluation according to the histopathological examination of the removed specimens
Number of patients with proven acute appendicitis was 64 (81.3%) and number of patients with normal appendicitis was 13 (16.9%). In all, 36 cases were catarrhal appendicitis, 17 were suppurative appendicitis, and 11 were complicated appendicitis.
Evaluation of the modified Alvarado score according to the postoperative results
The highest percentage of patients with proven acute appendicitis had a modified Alvarado score of 8, and the highest percentage for those with no proven acute appendicitis had a score of 6.
Estimation of the performance of the modified Alvarado score
The overall sensitivity for modified Alvarado score at the cutoff value of at least 7 was 93.33 (94.59 for male individuals and 91.30 for female individuals), overall specificity was 52.94 (62.5 for male individuals and 44.44 for female individuals), positive predictive value (PPV) was 87.5, negative predictive value was 69.23, and accuracy was 84.42.
| Discussion|| |
In this study, we set a cutoff value of modified Alvarado score of at least 7, which is recommended by several studies ,,.
In a study conducted by Ahmed et al. , 98% of patients with Alvarado score of at least 7 had evidence of acute appendicitis on histopathology with PPV of 98.1.
The study of Horzic et al.  documented 100% PPV with a score of at least 7 in the diagnosis of acute appendicitis in female individuals.
The study of Hizbullah et al.  documented PPV of 85% at a score of at least 7. However, in another study conducted by Ikramullah et al. , PPV was found to be 83.5% in adults. In the current study, the PPV was 87.5% at a score of at least 7, which is comparable with the previous results.
In the current study, at the cutoff point modified Alvarado score of at least 7, the sensitivity was 93.33%, which is comparable with the results of Muzaffaruddin  and Amer  in their respective studies. Another study conducted by Pruekprasert et al.  reported sensitivity of 79% at a score of at least 7.
The overall specificity of the test at the score of at least 7 was 52.94% (62.5% for male individuals and 44.44% for female individuals), which is comparable with the results of a study conducted by Pouget-Baudry et al.  that showed overall specificity of 58.18%.
In the study of Ahmed et al. , negative appendectomy at the score of at least 7 was 13.3% with presence of other pathology for the symptoms, whereas in a study by Malik and Sheikh  negative appendectomy rate was 11%; however, in the current study, negative appendectomy rate was 12.5% at the cutoff value of modified Alvarado score of at least 7, which was comparable with the results of the other studies.
The overall accuracy of the modified Alvarado score in the current study was 84.42% (88.89% for male individuals and 78.13% for female individuals). This is comparable with the results obtained by Owen et al.  with overall diagnostic accuracy of 87.4% [Table 1] and [Table 2].
|Table 1: Distribution of the studied cases according to postoperative pathological assessment|
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|Table 2: Evaluation of the results of the modified Alvarado score among the studied patient|
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| Conclusion|| |
- Clinical judgment and heightened clinical suspicion are still the most important factors in the management of patients with suspected acute appendicitis.
- The Alvarado score is a cheap, reliable, and reproducible diagnostic tool that can be used by the primary care physician and the emergency room physician to evaluate a patient who presents with right lower quadrant abdominal pain.
- When the score is high (≥7), there are strong indications for urgent surgery. When the score is low (<4), the diagnosis of appendicitis is very unlikely and the patient needs no complementary diagnostic studies, and if the score is intermediate (4-6) the patient requires, at the least, serial examination and follow-up.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fitz RH. Perforating inflammation of the vermiform appendix. Am J Med Sci 1886; 92:341-346.
P Ronan O′Connell. In: NS Williams, Bulstrode CJK, P Ronan O′Connell. The vermiform appendix. Baily & Love′s short practice of surgery
. 25th ed. London: Arnold; 2008. 67:??-??.
Pittman-Waller VA, Myers JG, Stewart RM, et al.
Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 2000; 66:548-554.
Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002; 137
Ahmad N, Abid KJ, Khan AZ, Shah STA. Acute appendicitis. Incidence of negative appendicectomies. Ann KE Med Coll 2002; 8
Styrud J, Eriksson S, Segelman J, et al.
Diagnostic accuracy in 2351 patients undergoing appendicectomy for suspected acute appendicitis: a retrospective study 1986-1993. Dig Surg 1999; 16
Alvarado A. A practical score for early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15
Kalan M, Rich AJ, Talbot D, Cunliffe WJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994; 76
Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado score for acute appendicitis in adults. Saudi Med J 2004; 25
Sadiq M, Amir S. Efficacy of modified Alvarado scoring system in the diagnosis of acute appendicitis. JPMI 2002; 16
Amer S. Protocol based diagnosis of appendicitis. JPMI 2004; 18
Bhattacharjee PK, Chowdhury T, Roy D. Prospective evaluation of modified Alvarado score for diagnosis of acute appendicitis. J Indian Med Assoc 2002; 100
Khan I, Rehman A. Application of Alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005; 17
Bukhari SAH, Rana SH. Alvarado score: a new approach to acute appendicitis. Pak Armed Forces Med J 2002; 52
Shrivastava UK, Gupta A, Sharma D. Evaluation of the Alvarado score in the diagnosis of acute appendicitis. Trop Gastroenterol 2004; 25
Ahmed AM, Vohra LM, Khaliq T, Lehri AA. Diagnostic accuracy of Alvarado score in the diagnosis of acute appendicitis. Pak J Med Sci 2009; 25
Horzic M, Salamon A, Kopljar M, Skupnjak M, Cupurdija K, Vanjak D. Analysis of scores in diagnosis of acute appendicitis in women. Coll Antropol 2005; 29
Jan H, Khan J. Evaluation of modified Alvarado score in the diagnosis of acute appendicitis. Pak J Surg 2007; 23
Pruekprasert P, Maipang T, Geater A, Apakupakul N, Ksuntigij P. Accuracy in diagnosis of acute appendicitis by comparing serum C-reactive protein measurements, Alvarado score and clinical impression of surgeons. J Med Assoc Thai 2004; 87
Pouget-Baudry Y, Mucci S, Eyssartier E, Guesdon-Portes A, Lada P, Casa C, et al.
The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult. J Visc Surg 2010; 147
Malik KA, Sheikh MR. Role of modified Alvarado score in acute appendicitis. Pak J Surg 2007; 23
Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J R Soc Med 1992; 85
[Table 1], [Table 2]