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A study of Alvarado score and its correlation


with acute appendicitis

Article · January 2016


DOI: 10.18203/2349-2902.isj20163392

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International Surgery Journal
Mahesh SV et al. Int Surg J. 2016 Nov;3(4):1950-1953
http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20163392
Original Research Article

A study of Alvarado score and its correlation with acute appendicitis


Mahesh S.V.1*, Hota P.K.2, Sneha P.3

1
Associate Professor, Department of General Surgery, Malla Reddy Medical College for Women, Suraram,
Hyderabad, Telangana, India
2
Professor and HOD, Department of General Surgery, Mamata Medical College, Khammam, Telangana, India
3
Senior Resident, Department of General Surgery, Mamata Medical College, Khammam, Telangana, India

Received: 12 September 2016


Accepted: 16 September 2016

*Correspondence:
Dr. Mahesh S.V.,
E-mail: sonty_mahesh09@yahoo.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Scoring systems are valuable and valid for discriminating between acute appendicitis and nonspecific
abdominal pain. Alvarado scoring system is one of the many scoring systems available for the diagnosis of acute
appendicitis and is purely based on history, clinical examination and few laboratory tests and is very easy to apply.
The objectives of the study were to evaluate efficacy of Alvarado scoring system in preoperative diagnosis of acute
appendicitis and correlating it with postoperative findings.
Methods: The present study was a prospective study of 50 patients presenting with symptoms and signs of acute
appendicitis to the emergency department during a period of 2 years. Patients who met the inclusion criteria were
evaluated using Alvarado scoring system. All the patients were operated by conventional method of open
appendicectomy. The efficacy of Alvarado scoring system was assessed by calculating sensitivity, specificity, positive
predictive value, negative predictive value and negative appendicectomy rate.
Results: Pain was the most common presenting symptom (100%). Time of presentation ranged from 1-7 days with a
mean of 1.98 days. Out of 50 patients, 35 (70%) are in the score range of 7-10, 12 (24%) in the score range of 5-6 and
3 (6%) in the 1-4 group. Appendix was inflamed in 86% cases. In the present study, negative appendicectomy rate
was 14%.
Conclusions: Alvarado scoring system is an easy, simple, cheap, reliable and safe tool in pre operative diagnosis of
acute appendicitis and can work effectively in routine practice.

Keywords: Alvarado scoring system, Appendicitis, Practice

INTRODUCTION It is essentially a clinical diagnosis.5 Routine history and


physical examination still remains the most practical
The appendix was first described in 1521 and diagnostic modalities. Absolute diagnosis is only possible
inflammation of the appendix has been known to be a at operation and histopathological examination of the
clinical problem since 1759.1,2 The term ‘appendicitis’, specimen.6 Therefore; it is impractical to have a gold
however, was not used until Reginald Fitz described this standard for definitive preoperative diagnosis, which
condition in 1886.3 Acute appendicitis is one of the leads to an appreciable rate of negative appendicectomy
commonest surgical emergencies.4 About 6% of the as reported in the world literature varying from 20-40%
population is expected to have appendicitis in their with its associated morbidities of around 10%.7,8
lifetime. Misdiagnosis and delay in surgery can lead to
complications like perforation and finally peritonitis.9

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Mahesh SV et al. Int Surg J. 2016 Nov;3(4):1950-1953

Scoring systems are valuable and valid for discriminating Decision for appendicectomy was taken by the qualified
between acute appendicitis and nonspecific abdominal surgeon. All the patients were operated by conventional
pain.9 Alvarado scoring system is one of the many method of open appendicectomy. Details of intra-
scoring systems available for the diagnosis of acute operative findings were recorded and definitive diagnosis
appendicitis and is purely based on history, clinical was based on histopathological assessment of the
examination and few laboratory tests and is very easy to specimen.
apply.10 The use of an objective scoring system such as
the Alvarado system can reduce the negative The efficacy of Alvarado scoring system was assessed by
appendicectomy rate to 0-5%. However, this system is calculating sensitivity, specificity, positive predictive
not a substitute for clinical judgment. It is an aid in value, negative predictive value and negative
diagnosing acute appendicitis and arriving at a conclusion appendicectomy rate.
whether a particular case should be operated or not,
thereby reducing the number of negative laparotomies. RESULTS

The present study aims at evaluating the efficacy of Table 1: Individual features of Alvarado score.
Alvarado scoring system in preoperative diagnosis of
acute appendicitis and correlating it with postoperative Number of patients
Clinical features
findings. (%) (n=50)
Migratory RIF pain 20 (40%)
METHODS Anorexia 34(68%)
Nausea and vomiting 42(84%)
The present study was a prospective study of 50 patients Tenderness over RIF 50(100%)
presenting with symptoms and signs of acute appendicitis Rebound tenderness RIF 37(74%)
to the emergency department during a period of 2 years
Elevated temperature 31 (62%)
from October 2012 to September 2014.
Leucocytosis 31(62%)
Inclusion criteria Shift to left 24(48%)

 Patients with symptoms and sings of acute Pain was the most common presenting symptom (100%)
appendicitis in whom emergency appendicectomy with migratory RIF pain in 40% cases. Nausea/Vomiting
was done. was seen in 84% and anorexia in 68%.
 Both the genders and all age groups were included
in the study. Table 2: Time of presentation in different Alvarado
 Patients who were willing to participate in study. score groups.

Exclusion criteria Time of


7-10 5-6 1-4 Total
presentation
 Patients with appendicular mass. <1 day 15 8 0 23 (46%)
 Patients who underwent elective/ interval 1-2 days 10 1 1 12 (24%)
appendicectomy. >2 days 10 3 2 15 (30%)
 Patients who were not willing to participate in the
study. Time of presentation ranged from 1-7 days with a mean
of 1.98 days and median of 2 days. 46% of patients
Patients with symptoms and signs suggestive of acute presented within 24 hrs of onset of symptoms whereas
appendicitis who met the inclusion criteria were admitted 24% presented after 2 days of start of symptoms.
and after taking informed consent and initial assessment
were subjected for detailed history taking, physical Table 3: Results of Alvarado score.
examination, routine laboratory investigations and
imaging. No. of No. of
Total no patients with patients
Alvarado
Then they were evaluated using Alvarado scoring system. of pts Acute with Normal
score
Each patient was given a score and based on the score (n) Appendicitis appendix
were divided into three groups. (%) (%)
7-10 35 35 (91.4%) 3 (8.6%)
Group 1: Score 7- 10: most likely acute appendicitis. 5-6 12 10 (83.3%) 2 (16.7%)
1-4 3 1 (33.3%) 2 (66.7%)
Group 2: Score 5- 6: probably acute appendicitis.
Out of 50 patients, 35 (70%) are in the score range of 7-
Group 3: Score 1- 4: unlikely acute appendicitis. 10, 12 (24%) in the score range of 5-6 and 3 (6%) in the

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Mahesh SV et al. Int Surg J. 2016 Nov;3(4):1950-1953

1-4 group. Out of patients in score range of 7-10, 32 68%. Migratory right iliac fossa pain was least common
(91.4%) had acute appendicitis whereas, 66.7% (2) out of seen in 40% cases. Tenderness over right iliac fossa had
3 patients in score range of 1-4 have normal appendix. leukocytosis and 48% had shift to left. These findings
were comparable to those of Lameris et al.18 Subedi et al
Table 4: Post-operative diagnosis (Per-operative and reported that 98% of patients with acute appendicitis
Histopathology). presented with pain in peri-umbilical region migrating to
right iliac fossa but leukocytosis was seen in only 65% of
No. of patients n cases which was comparable to present study.14 Abou-
Post-operative diagnosis
(%) (n=50) Merhi B et al concluded that anorexia, neutrophils left
Simple 19 (38%) shift and rebound tenderness are significantly correlated
Suppurative 8 (16%) with a correct diagnosis of appendicitis.19
Acute Gangrenous 4 (8%)
appendicitis Perforated 5 (10%) In the present study, maximum number of patients 19
Eosinophilic 2 (4%) (38%) had a score of 7, only 1 patients with a score of 10
and none with scores of 1, 2 and 4. Seventy percent (35)
Recurrent 5 (10% )
of the patients were in score range of 7-10, 24% (12) in
No pathology 5-6 range and 6% (3) were in 1-4 score range which was
4 (8%)
detected comparable to Kailashsingh et al.20 Memon ZA et al
Normal Ruptured ovarian reported that 31 belonged to Group A (28.2%) with
2 (4%)
appendix cyst Alvarado score <6 and 79 belonged to Group B (71.8%)
Meckel’s Alvarado score ≥6.17
1 (2%)
diverticulitis
In the present study, simple acute appendicitis was
Appendix was inflamed in 86% cases where as it normal confirmed intra-operatively in 34 (68%) patients. 4 (8%)
in 14%. Out of 7 cases of normal appendix, no pathology had acute gangrenous appendicitis (AGA) and 5 (10%)
was found in 4, Ruptured ovarian cyst in 2 cases and had perforated appendix. These findings were
Gangrenous Meckels diverticulitis was seen in 1 case. comparable to those reported by Subhajeet Deyet al.21

Table 5: Negative appendicectomy rate. Subedi N et al found that the most common pre-operative
finding was acutely inflamed appendix (84%) followed
No. of negative Percentage by perforated appendix (7.5%), gangrenous appendix
appendicectomy (3.5%) and appendicular lump (1.5%).14 Shrestha R et al
Male 5 13.2% observed that appendicitis accounted for 88.8%.12
Female 2 16.7%
Total 7 14% In the present study, overall positive and negative
appendicectomy rates were 86% and 14% respectively
In the present study, negative appendicectomy rate was which was comparable to other studies.11,20,22
13.2% in males, 16.7% in females and overall was 14%. Bhattacharjee PK et al concluded that high score was
found to be a dependable aid both in the pre-operative
DISCUSSION diagnosis of acute appendicitis and in the reduction of
negative appendicectomies in men and children but the
In the present study, the age range was 7-80 with a mean same was not true for women who had a high false
age of 24.08 years. 33 (66%) patients were in the age positive rate for acute appendicitis.23 Shrivastava et al
group of 11-30 which is comparable to those found in stated that in women, additional investigations may be
Talukder BD et al., Shresha et al, Swagata et al, whereas required to confirm the diagnosis because of the high
Subedi et al reported mean age of 42 years.11-14 Gendel L negative appendicectomy rate.24
et al studied children with inflamed with mean age of
10.9±3.2 years as compared to those with normal Subhajeet Dey et al revealed that, out of 92 who
appendix with mean age of 12.1±2.3 years, which was underwent appendicectomy with the intention to treat
statistically significant, p=0.004.15 appendicitis, diagnosis was confirmed in 80 patients with
positive appendicectomy frequency of 86.9%.21
In the present study, there was male preponderance
(Males 38, 76%) as compared to females 12 (24%) with a In the present study, the sensitivity and specificity of the
male to female ratio of 3.2:1 which is comparable to Alvarado scoring system with a cut-off of 7 were 74.42%
Patra RK et al, Memon et al, Subedi et al, whereas male and 57.14% respectively which was comparable to other
to female ratio was 1.27:1 in Swagata et al.13,14,16,17 studies.13,17,24

In the present study, pain was the most common In the present study, positive predictive value was
presenting symptom (100%) followed by 91.43% which was comparable to other studies.17,21,22
Nausea/Vomiting in 84% of patients and anorexia in

International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1952


Mahesh SV et al. Int Surg J. 2016 Nov;3(4):1950-1953

In the present study, negative predictive value was 10. Fenyo G, Linberg G, Blind P, Enochsson L, Oberg
26.67% which was comparable to other studies.22 It was A. Diagnostic decision support in suspected acute
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52.4% and in memon et al at 83.3%.17,24 system, Eur J Surg. 1997;163:831-8.
11. Talukder DB, Siddiq AKMZ. Modified Alvarado
CONCLUSION scoring system in the diagnosis of acute
appendicitis. JAFMC Bangladesh. 2009;5(1):18-20.
Alvarado scoring system is an easy, simple, cheap, 12. Shrestha R, Ranabhat SR, Tiwari M.
reliable and safe tool in pre operative diagnosis of acute Histopathalogic analysis of appendectomy
appendicitis and can work effectively in routine practice. Specimens. Journal of pathology of Nepal.
Alvarado score is very effective in the diagnose of acute 2012;2:215-9.
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along with the clinical scoring system to rule out other appendicitis-a retrospective study. J Me d A l I e d S
pelvic pathology and thereby reducing the higher rates of c I. 2013;3(2):63-6.
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application of Alvarado scoring system definitely Baral R. Acute appendicitis: a 2 years review of
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15. Gendel l, Gutemacher M, Bukhlan G, Lazar L.
Funding: No funding sources Kidron D, Paran H, et al. relative value of clinical,
Conflict of interest: None declared laboratory and imaging tools in diagnosing pediatric
Ethical approval: The study was approved by the acute appendicitis Eur J Pediatr surg.
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16. Patra RK, Gupta DO, Paril RR. Clinicopathological
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Cite this article as: Mahesh SV, Hota PK, Sneha P.
A study of Alvarado score and its correlation with
acute appendicitis. Int Surg J 2016;3:1950-3.

International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1953

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