Alvarado Score for Acute Appendicitis
Among patients with suspected diagnosis of acute appendicitis, can a scoring system improve diagnostic accuracy of appendicitis?
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.
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)
- Left Shift
- Temperature (>37.3)
- 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%). , 
WSES Jerusalem guidelines,
- Alvarado score < 5 sufficient to exclude appendicitis
- Alvarado score is insufficient for diagnosing appendicitis
- 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:
- abdominal pain (epigastric, diffuse, periumbilical, right lower quadrant)
*incomplete clinical information 9.1% (28/305)
- 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)
-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
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
- 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
- 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
- not disclosed
- Coleman JJ et al. The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain. J Trauma Acute Care Surg 2018. 84:946-950.
- McKay R & Shepherd J The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007. 25:489-93.
- Di Saverio S et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016. 11:34.