Alvarado Score for Acute Appendicitis

Incomplete

Alfredo Alvarado. "A Practical Score for the Early Diagnosis of Appendicitis". Annals of Emergency Medicine. 1986. 15(5):557-564.
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Clinical Question

Among patients with suspected diagnosis of acute appendicitis, can a scoring system improve diagnostic accuracy of appendicitis?

Bottom Line

The Alvarado score is a simple scoring system requiring only history, physical exam, and basic laboratory work that can be utilized to diagnose appendicitis, with a score 7+ consistent with probable appendicitis, and score 5-6 consistent with possible appendicitis.

Major Points

Appendicitis is a clinical diagnosis with consideration of signs, symptoms, laboratory value, and imaging. The Alvarado score is a scoring system designed to assist in diagnosis. 10 total points are assigned for 8 factors with two points assigned to the most impactful (Right lower quadrant tenderness, leukocytosis, see below).

• Right Lower Quadrant Tenderness (+2)
• Leukocytosis (>10k) (+2)
• Migration
• Left Shift
• Temperature (>37.3)
• Anorexia-acetone
• Nauea-vomiting
• Rebound Pain
• Rectal tenderness

Retrospective studies have evaluated the Alvarado score's role in including imaging in diagnostic workup. These studies have demonstrated that while the excellent sensitivity (77%) and specificity (100%) in Alvarado scores > 7 render imaging unnecessary, the sensitivity drops to 35% (specificity 94%) for scores 4-6. However, these scores improve dramatically when combined with CT scan in marginal scores (sensitivity 90.4% and specificity 95%). ,

Guidelines

WSES Jerusalem guidelines,

• Alvarado score < 5 sufficient to exclude appendicitis
• Alvarado score is insufficient for diagnosing appendicitis

Design

• Design: Retrospective, single center
• Setting: Nazareth Hospital, Philadelphia, Pennsylvania
• Enrollment: 305 patients, January 1975-December 1976
• Mean follow-up:
• Analysis: Diagnostic weights, which are calculated via (patients/(true positive + true negative tests)
• Primary outcome:

Population

Inclusion Criteria

• abdominal pain (epigastric, diffuse, periumbilical, right lower quadrant)

Exclusion Criteria

*incomplete clinical information 9.1% (28/305)

Baseline Characteristics

• age = 25.3 years (range 4-80)
• Appendicitis Pathology of patients who underwent operation (22&)
  • Simple appendicitis 47% (108/227)
  • Suppurative appendicitis 30% (67/227)
  • Gangrenous, Perforated Abscessed 23% (52/227)

Interventions

-83% operated (254/305), 17% observed, (51/305) -Of those operated on, 89% (227/254) had pathologically confirmed acute appendicitis, 11% (27/254) did not have appendicitis

Outcomes

Primary Outcomes

Evaluation of Clinical and Laboratory Findings In Acute Appendicitis, diagnostic weight

• Right Lower Quadrant Tenderness 0.84
• Leukocytosis (>10k) 0.83
• Migration, 0.72
• Left Shift (neutrophils >75%) 0.7
• Fever (>37.3) 0.69
• Anorexia-acetone, 0.63
• Nauea-vomiting, 0.66
• Rebound Pain 0.55
• Rectal tenderness 0.49

Subgroup Analysis

• 95 patients underwent rectal examination documented, and diagnostic weight was considered too low to ultimately be included.
• Diagnostic weights are calculated for the 29 patients with mesenteric adenitis

Criticisms

• Small, retrospective cohort
• temperature used generally does not meet modern criteria for fever (100.4F)
• No immediate validation cohort
• Inclusion criteria not defined in the nonacute appendicitis cohort

Funding

• not disclosed