World J Surg (2008) 32:18431849

DOI 10.1007/s00268-008-9649-y

The Appendicitis Inflammatory Response Score: A Tool for the

Diagnosis of Acute Appendicitis that Outperforms the Alvarado
Score
Manne Andersson Roland E. Andersson

Published online: 14 June 2008

Societe Internationale de Chirurgie 2008

Abstract
Background The clinical diagnosis of appendicitis is a
subjective synthesis of information from variables with illdefined diagnostic value. This process could be improved
by using a scoring system that includes objective variables
that reflect the inflammatory response. This study describes
the construction and evaluation of a new clinical appendicitis score.
Methods Data were collected prospectively from 545
patients admitted for suspected appendicitis at four hospitals. The score was constructed from eight variables with
independent diagnostic value (right-lower-quadrant pain,
rebound tenderness, muscular defense, WBC count, proportion neutrophils, CRP, body temperature, and vomiting)
in 316 randomly selected patients and evaluated on the
remaining 229 patients. Ordered logistic regression was
used to obtain a high discriminating power with focus on
advanced appendicitis. Diagnostic performance was compared with the Alvarado score.
Results The ROC area of the new score was 0.97 for
advanced appendicitis and 0.93 for all appendicitis compared with 0.92 (p = 0.0027) and 0.88 (p = 0.0007),
respectively, for the Alvarado score. Sixty-three percent of
the patients were classified into the low- or high-probability group with an accuracy of 97.2%, leaving 37% for
further investigation. Seventy-three percent of the nonappendicitis patients, 67% of the advanced appendicitis, and
M. Andersson (&)
R. E. Andersson
Department of Surgery, County Hospital Ryhov,
551 85 Jonkoping, Sweden
e-mail: manne.andersson@lj.se
R. E. Andersson
Department of Surgery, University Hospital,
581 85 Linkoping, Sweden

37% of all appendicitis patients were correctly classified

into the low- and high-probability zone, respectively.
Conclusion This simple clinical score can correctly
classify the majority of patients with suspected appendicitis, leaving the need for diagnostic imaging or diagnostic
laparoscopy to the smaller group of patients with an
indeterminate scoring result.

Introduction
Acute appendicitis (AA) is a common condition and a frequently suspected differential diagnosis in patients presenting
with acute abdominal pain. The diagnosis is often elusive and
the management of patients with an equivocal diagnosis is
controversial. Some advocate early surgical exploration on
wide indications hoping to prevent perforation, with an
associated high frequency of negative explorations as an
acceptable tradeoff [1]. Others propose early exploration in
patients with obvious disease and active observation of
patients with an equivocal diagnosis, which gives fewer
negative explorations without increasing the number of perforations [25]. In this latter approach it is important to detect
patients with advanced appendicitis early [6].
Imaging techniques such as ultrasound (US) and computerized tomography (CT) and diagnostic laparoscopy
have been used with the hope of yielding a rapid and
accurate diagnosis. The main problems with routine use of
diagnostic imaging are potentially harmful ionizing radiation (CT), examiner-dependent efficacy (US), and
technique-associated morbidity (diagnostic laparoscopy)
[7]. Diagnostic imaging performs less well in groups of
patients with low or high prevalence of disease in spite of
high sensitivity and specificity [8].

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The initial management of patients with suspected

appendicitis therefore still needs to be based on the disease
history, physical signs, and basic laboratory tests reflecting
the inflammatory response. This involves a subjective
synthesis of a large amount of complex information, which
relies on the surgeons knowledge and previous experience
with similar patients. This process could be improved by
using a clinical scoring system that can objectively determine the prognosis for the current patient from those of
similar patients from which the score was constructed. A
clinical scoring system can be used as a basis for a structured algorithm for the management of the patients,
including selective use of diagnostic imaging depending on
the probability of appendicitis.
A large number of scoring systems have been proposed.
The Alvarado score is the most well known and best performing in validation studies [9, 10]. The Alvarado score
can be improved because it has some weaknesses. Its
construction was based on a retrospective review of
patients who had all been operated on for suspicion of
appendicitis, whereas the score is supposed to be used on
patients with suspicion of appendicitis. Because of the
difference in the spectrum of disease between these groups
of patients, the scoring weights may be biased [11]. The
variables were chosen without using an appropriate mathematical model to identify the variables with an
independent diagnostic value and to determine their scoring weights. Finally, discriminating capacity was lost
because of the dichotomization of the variables.
The aim of this study was to construct and validate a
user-friendly clinical scoring system based on prospectively collected data from patients admitted for suspected
appendicitis using an appropriate mathematic model
focused on detecting advanced appendicitis. It includes
inflammatory markers which have been shown to have high
discriminating power [12, 13]. Instead of dichotomous
variables, the clinical variables are graded according to the
severity of the symptoms and signs and the laboratory
variables are divided into intervals. Three diagnostic test
zones are defined: one with a high sensitivity for appendicitis to identify the patients who can be safely discharged
with an outpatient followup, another with a high specificity
for appendicitis to identify patients who can be operated on
without further examination, and an indeterminate group of
patients who need additional diagnostic workup [14].

Patients and methods

Patients
Information on the disease history, clinical findings, and
results of laboratory tests was recorded for 502 consecutive

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World J Surg (2008) 32:18431849

patients who were admitted for suspicion of appendicitis to

the hospitals in the towns of Jonkoping and Eksjo between
October 1992 and December 1993. Details about these
patients have been presented elsewhere [12]. Another 249
consecutive patients admitted to the hospitals Lanssjukhuset
Ryhov in Jonkoping, Hoglandssjukhuset in Eksjo, Lasarettet
in Motala, and Lanssjukhuset in Kalmar during a 3-month
period in 1997 were also included. Of these 751 patients a
complete data set was available for 545 patients. The
remaining 206 patients were excluded because of missing
values of neutrophils (n = 154), pain migration (n = 37),
defense (n = 7), vomiting (n = 3), CRP (n = 2), anorexia
(n = 2), and body temperature (n = 1). The patients who
were excluded because of missing values had the same distribution of appendicitis diagnoses as the study patients but
were more often women (62 vs. 51%, p \ 0.009), had a
significantly higher proportion of negative appendectomies
(18 vs. 11%, p \ 0.009), and were older (median
age = 24.4 vs. 21.0 years, p \ 0.004). Although surgeons
with all levels of experience were involved, the majority of
patients admitted for suspicion of appendicitis were initially
evaluated by surgeons in training with limited experience.
All excised appendices were examined by microscopy.
The criterion for phlegmonous appendicitis was histopathologic evidence of transmural inflammation and the
criterion for advanced appendicitis was histopathologic
evidence of transmural gangrene or perforation.
The nonoperated patients were followed up by a review
of their files, which is an accurate method of follow-up
according to the Swedish health care structure. None had
developed appendicitis at follow-up after 1 month. The
study was approved by the Human Ethical Committee at
Linkoping University Hospital.
Construction of the scores
Ordered logistic regression score
All included patients (n = 545) were randomly assigned a
value between 0 to 9. Patients with a value of 05
(n = 316) were used for the construction of the scoring
system and patients with a value of 69 (n = 229) were
used for validation of the scoring system. The variables in
the Alvarado score and a set of variables that were found to
have independent diagnostic importance for appendicitis in
a previous study [12] (right-lower-quadrant pain, pain
migration, muscular defense, rebound tenderness, WBC
count, proportion neutrophils, CRP, body temperature,
vomiting, anorexia, and gender) were included in an
ordered logistic regression analysis model, with the outcome coded as 0 for no appendicitis, 1 for phlegmonous,
and 2 for advanced (i.e., gangrenous or perforated)
appendicitis. To optimize the discrimination of advanced

World J Surg (2008) 32:18431849

1845

appendicitis, we used weighted ordered logistic regression

models with the weight of 1 for no appendicitis, 2 for
phlegmonous appendicitis, and 5 for advanced appendicitis. Dummy variables were constructed for a large range of
intervals for the continuous variables. Adjacent intervals
with similar regression coefficients were successively
combined until a set of intervals with distinct and significant regression coefficients was obtained. Variables and
intervals with a p \ 0.10 were kept in the final model [15].
The regression coefficients of the final, most parsimonious
model were used as scoring points.

discriminating capacity of the scores. Students t test, the v2

test, and Fishers exact test were used for analyzing differences in continuous variables and proportions. The
sensitivity and specificity of the new score were compared
with the Alvarado score using McNemars test. A p value of
less than 0.05 was regarded as significant. Patients with
phlegmonous appendicitis were excluded from the analyses
of the diagnostic value for advanced appendicitis.

Simplified score
A simplified score was constructed based on the regression
coefficients which were rounded up to the nearest integer,
except for pain in the right iliac fossa which had a
regression coefficient close to 1 and light rebound pain/
muscular defense, which were rounded down to obtain a
trend of increasing risk of appendicitis with increasing
intensity in this variable.

The construction and validation samples were similar with

regard to gender, prevalence of appendicitis, and Alvarado
score (Table 1). However, the patients in the construction
sample were older (mean age = 25.9 vs. 23.4 years for the
validation sample, p = 0.022). In total, 250 of the 545
patients underwent surgery. The prevalence of appendicitis
was 36 and 33% in the construction and validation samples,
and the prevalence of negative appendectomy was 11 and
10%, respectively.

Validation of the scores

Construction of the score

The scores were validated on the validation sample of 229

patients. The discriminating capacity of the scores was
compared with that of the Alvarado score from the ROC
areas. Separate analyses were done for the discrimination of
all appendicitis and for advanced appendicitis. Two cutoff
points were defined: one to obtain a high sensitivity for
advanced appendicitis and another with high specificity for
appendicitis. The sensitivity and specificity for all and for
advanced appendicitis were calculated for both cutoff points.

The regression coefficients of the weighted ordered logistic

regression analysis of the random sample of 316 patients
for the construction of the score are presented in Table 2.
Migration of pain, anorexia, and male gender were found to
have p [ 0.10 and were excluded from further analysis.
Eight variables reflecting the gastric upset, peritoneal irritation and the inflammatory response (right-lower-quadrant
pain, vomiting, muscular defense, rebound tenderness,
WBC count, proportion neutrophils, CRP and body temperature) remained in the final model. The simplified
integer-based score ranged from 0 to 12 points.

Statistical methods
Weighted ordered logistic regression analysis was used in the
construction of the scores to identify the variables with an
independent predicting capacity and to obtain the variables
scoring weights. The ROC area was used for comparing the
Table 1 Characteristics of the
patients in the construction and
validation samples

Results

Validation of the score

The regression-based and the simplified scores were evaluated and compared with the Alvarado score on the

Characteristic
Number of patients

Construction sample

Validation sample

p value

316

229

Men

145 (46%)

105 (46%)

Women

171 (54%)

124 (54%)

0.994

25.9

23.4

0.022

Mean age (years)

Number with appendicitis
Phlegmonous appendicitis
Advanced appendicitis
Number with negative appendectomy
Mean Alvarado score

115 (36%)

76 (33%)

71 (22%)

46 (20%)

44 (14%)

30 (13%)

0.731

36 (11%)
5.1

23 (10%)
5.2

0.735

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World J Surg (2008) 32:18431849

Table 2 The new scores and the Alvarado score for comparison
Score

Proposed score

Table 3 Discriminating capacity of the new scores compared with

the Alvarado score, according to the ROC areas
ROC area

Regression

Simplified

Alvarado

Relocation of pain

ns

+1

Vomiting

0.45

+1

+1

Patients

Pain in RIF

1.12

+1

+2

All appendicitis

Anorexia

ns

+1

Male gender

ns

Regression

Alvarado Score p value Score p value

Construction sample 0.868

Validation sample
0.879

0.913 0.003
0.922 0.024

0.913 0.0007
0.927 0.0007

Advanced appendicitis

Rebound tenderness or muscular defense

None
Light

0
1.54

0
+1

0
+1

Medium

1.90

+2

+1

Strong

2.32

+3

+1

37.537.9C

+1

38.038.4C

+1

0.85

+1

+1

Body temperature

C38.5C

Simplified

Proportion polymorphonuclear leukocytes

Construction sample 0.912

0.965 0.0004

0.961 0.0004

Validation sample

0.962 0.037

0.972 0.0027

0.924

Table 4 Discriminating capacity of the simplified score compared to

the Alvarado score in subsets of the validation sample according to
the patients gender and age
ROC area
Patients

Numbers Alvarado
score

Simplified
score

p
value

Men

105

0.850

0.917

0.0021

Women

124

0.914

0.935

0.27

0.16

0.59

7074%

0.92

+1

7584%

0.92

+1

+1

Gender

C85%

1.41

+2

+1

WBC count
10.014.9 9 109/L

0.96

+1

+2

C15.0 9 109/L

p value, men vs. women

1.46

+2

+2

Age

CRP concentration
1049 g/L

012 years

49

0.925

0.977

1.04

+1

1329 years

124

0.892

0.925

0.053

2.35

+2

30+ years

56

0.814

0.889

0.02

0.25

0.058

C50 g/L

p value, between age

groups

validation sample of 229 patients. The discriminating

capacity of the scores is presented in Table 3. In all analyses the simplified score performed at least as good as the
regression-based score. Therefore, the remaining results are
presented for the simplified score only. The score that was
constructed from the ordered logistic regression model
performed better in discriminating for advanced appendicitis compared with a score based on a logistic regression
model (data not shown).
The simplified score had a better discriminating capacity
for all appendicitis compared with the Alvarado score, with
ROC area of 0.93 vs. 0.88 (p = 0.0007). The same was
true for advanced appendicitis with ROC area of 0.97 vs.
0.92 for the Alvarado score (p = 0.0027). The performance of the scores was similar in males and females
(Table 4). There was a nonsignificant trend toward a poorer
performance with increasing patient age (p = 0.058).
Two cutoff points were defined to obtain three diagnostic test zones: one with a high sensitivity for
appendicitis that could be used to rule out appendicitis, and
one with a high specificity for appendicitis that could be
used to rule in appendicitis. The results were compared

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0.13

with the corresponding test zones for the Alvarado score

(Table 5).
The simplified score classified 144 of the 229 patients
(63%) to either the low- or the high-risk group with an
accuracy of 0.97 compared with 119 patients (52%) used
for the Alvarado score (p = 0.023) with an accuracy of
0.98. Eighty-five patients (37%) had an indeterminate
result with the simplified score compared with 110 patients
(48%) with the Alvarado score (p = 0.023).
Twenty-nine of the 229 patients (13%) were classified to
the high-risk group with more than 8 scoring points
(Table 5). This included 20 of the 30 patients with
advanced and 8 of the 46 patients with phlegmonous
appendicitis and 1 patient with nonoperatively treated
diverticulitis, giving a sensitivity of 0.37 and a specificity
of 0.99 for all appendicitis and a sensitivity of 0.67 and a
specificity of 0.99 for advanced appendicitis (Table 6). The
corresponding result for the Alvarado score was 23 patients
(10% of all patients, p = 0.42) of which 12 patients had
advanced and 9 patients had phlegmonous appendicitis, 1

World J Surg (2008) 32:18431849

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Table 5 Distribution of patients according to the diagnostic test zone

and diagnosis for the simplified score and the Alvarado score
Diagnostic test zones
and diagnoses
Score [ 8 = High probability

Simplified
score

Alvarado
score

Table 6 Diagnostic characteristics of the new simplified score

according to the cutoff points compared with the Alvarado score,
tested on the validation sample
Cutoff point

29

23

Advanced appendicitis

20

12

Diagnostic value

Phlegmonous
Negative appendectomy

8
1

9
2

All appendicitis

Nonoperated

85

110

Score = 58 = Indeterminate
result
Advanced appendicitis

10

18

Sensitivity

Simplified score

Alvarado score

[4 points

[8 points

[4 points

[8 points

0.96

0.37*

0.97

0.28*

Specificity

0.73

0.99

0.61

PV+

0.64

0.97

0.56

0.99
0.91

PV-

0.97

0.76

0.98

0.73

Advanced appendicitis

Phlegmonous

35

35

Negative appendectomy

13

12

Sensitivity

1.00

0.67

1.00

0.40

Nonoperated

27

45

Specificity

0.73

0.99

0.61

0.99

115

96

PV+

0.42

0.95

0.34

0.86

PV-

1.00

0.94

1.00

0.89

Score \ 5 = Low probability

Advanced appendicitis
Phlegmonous
Negative appendectomy
Nonoperated

0
3

9
103

9
85

patient with diverticulitis, and 1 with no pathology found,

giving a sensitivity of 0.28 (p = 0.07) and a specificity of
0.99 for all appendicitis and a sensitivity of 0.40
(p \ 0.005) and a specificity of 0.99 for advanced
appendicitis.
One hundred fifteen of the 229 patients (50%) were
classified to the low-risk group with less than 5 scoring
points (Table 5). There were three patients with phlegmonous appendicitis giving an accuracy of 0.97. The
corresponding result for the Alvarado score was 96 patients
(42%) (p = 0.091) of which two patients had phlegmonous
appendicitis, giving an accuracy of 0.98. Of the nine negative appendectomies, there was one patient each with
salpingitis, retrograde menstruation, and ruptured ovarian
cyst, respectively, and two patients with omental torsion.
Of the 153 nonappendicitis patients, the simplified score
correctly classified 112 (73%) to the low-probability group
compared to 94 (61%, p \ 0.039) for the Alvarado score.
A score of greater than 4 points gave a similar sensitivity
for the simplified score and the Alvarado score (0.96 for all
and 1.00 for advanced appendicitis vs. 0.97 and 1.00,
respectively) but a higher specificity (0.73 vs. 0.61 irrespective of stage of disease, p \ 0.0007) (Table 6). This
corresponds to a negative predictive value of 0.97 for all
and 1.00 for advanced appendicitis at a score of less than 5
for the simplified score compared to 0.98 and 1.00,
respectively, for the Alvarado score. The positive predictive value of a score greater than 8 was 0.97 for all
appendicitis and 0.95 for advanced appendicitis for the
simplified score and 0.91 and 0.86, respectively, for the
Alvarado score.

* p = 0.07,

p \ 0.0007,

p \ 0.005

Discussion
The scoring system presented in this study could correctly
classify 73% of the nonappendicitis patients to the lowprobability group and 67% of the patients with advanced
appendicitis to the high-probability group with high accuracy. Only 37% of the patients remained in the
indeterminate group. This compares favorably with the
Alvarado score which gave 61, 40, and 48% for the corresponding results. This shows the potential of our clinical
scoring system to improve the clinical diagnosis of
appendicitis and to decrease the number of patients that
need in-hospital observation or further examination with
diagnostic imaging or diagnostic laparoscopy.
A clinical scoring system estimates the probability of
appendicitis in a patient compared with a large number of
similar patients from which the score was designed. This
information can be used for decision support for the less
experienced surgeon and may facilitate communication
between emergency room physicians and surgeons. A
clinical scoring system can also be the basis for a structured
management of patients with suspected appendicitis as
described in Table 7. Today it is common practice to
perform CT or US in all patients suspected of having
appendicitis. However, imaging does not perform well in
patients with low and high prevalence of the disease, and
CT should be used selectively to minimize exposure to
ionizing radiation [8]. Recent reports also suggest that the
indiscriminate use of CT scans may lead to the detection of
low-grade appendicitis that would otherwise have resolved
spontaneously [1618].
A clinical score may therefore be a suitable instrument
for selecting patients for immediate surgery, observation at

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Table 7 Scoring sheet with proposed clinical algorithm

Vomiting

Pain in right inferior fossa

Rebound tenderness or muscular defense

Light

Medium

Strong
Body teperature C38.5
Polymorphonuclear leukocytes
WBC count
CRP concentration

3
1

7084%

C85%

10.014.9 9 109/L

C15.0 9 109/L

1049 g/L

C50 g/L

Sum (012)
Sum 04 = Low probability. Outpatient follow-up if unaltered general condition
Sum 58 = Indeterminate group. In-hospital active observation with
rescoring/imaging or diagnostic laparoscopy according to local
traditions
Sum 912 = High probability. Surgical exploration is proposed

home, or further examination with imaging techniques. The

score can be repeated in equivocal cases during active
observation which improves the diagnostic accuracy [19,
20]. It can be used to monitor the evolution of the disease
in cases that are treated conservatively or that show signs
of spontaneous resolution. A clinical score can also be used
to describe the patients that are included in clinical studies
to facilitate the comparison of results.
The Alvarado score is the most well known and best
performing compared with others and performed well in
this study [10]. However, it has not gained wide acceptance
in everyday clinical practice probably because of an
insufficient discriminating capacity, although it has been
used in a number of prospective studies. The present score
is similar to the Alvarado score in many respects, but there
are important differences that may explain the better performance. The Alvarado score was constructed using
retrospective material and univariate analysis, whereas our
score is based on prospectively collected data of variables
with independent prognostic value using a mathematically
more appropriate method for the construction. The unspecific and subjective variables anorexia, nausea, and
relocation of pain were exchanged for the more specific
and objective variables vomiting, CRP, and guarding. Less diagnostic information is lost by the use of
graded clinical findings and intervals of laboratory variables instead of dichotomization of variables. Many
surgeons of all levels of experience serving at four different
centers were involved in the collection of data. All these
features will probably increase the reproducibility and
generalizability of the score.

123

However, although the diagnostic data were collected

prospectively, a disturbingly high proportion of patients
had to be excluded because of missing data. One reason
was that at the time of the study the proportion of polymorphonuclear leukocytes had not been part of the routine
diagnostic workup, its diagnostic properties were not recognized, and the laboratory did not automatically deliver
this information. Today the neutrophil count is automatically performed in most laboratories together with the
WBC count. We do not think that the scoring points for the
proportion of polymorphs is biased because the distribution
of missing values was random over the diagnoses.
To conclude, management of patients with suspected
acute appendicitis is still challenging and the optimal
management algorithm is still being debated even after the
introduction of CT, US, and diagnostic laparoscopy. This
study described the construction and evaluation of a simple
clinical scoring system that has a high discriminating
power, especially for advanced appendicitis. The score
outperforms the Alvarado score, which is currently the
most well-known scoring system. It can correctly classify
the majority of patients into those who can be sent home
for outpatient follow up or to be operated on immediately,
leaving a smaller number of patients with an indeterminate
result who are suitable for further investigation. The score
needs further evaluation in a prospective interventional
study, including external centers.
Acknowledgment This study was supported by the Jonkoping
County Research Council.

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