Alvarado Score for Acute Appendicitis

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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%). [1], [2]

Guidelines

WSES Jerusalem guidelines[3],

  • 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

Further Reading

  1. 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.
  2. 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.
  3. Di Saverio S et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016. 11:34.