Alvarado Scoring in Acute Appendicitis Dr.Damodhar, Drdamodhar, Appendicitis, Acute Appendicitis, Surgery

1. Appendicitis-
Alvarado score
Presented by,
Dr. Damodhar. M.V

2. Objectives
• Alvarado Score:
• Interpretation,
• Review
• Consider what you would do next
• Imaging choices
• US
• CT
• Non-contrast vs oral contrast vs rectal
– MRI

3. Statistics
• Incidence Rate: approximately 1 in 400 or 0.25% or
680,000 people in USA*
• Lifetime risk for Acute Appendicitis:
• Males- 8.6%
• Female- 6.7%.
• Negative Appendectomy Rate (NAR)-15.3%.*
*Rothrock et al, 2000
*Schwartz's Principles of Surgery Part II. 9th edition

4. Statistical Analysis
• Recently with the improvement in diagnostic
modalities the rate of negative appendectomy
reduced to 8.4%.*
• NAR in Females- 71.6%
• NAR in Male- 28.4%
• Removing a normal appendix is associated with a 4%
risk of fetal loss and 10% risk of early delivery
*Howard Hospital for Outcome research, Dept of Surgery AMJ-Surgery 2011

5. Qualities of effective scoring scale
• It should be simple
• It should be capable of being administered by all
strata of medical personnel
• It should be possible to assess quickly
• There should be no ambiguity

6. Scoring system for Appendicitis
• The Alvarado scoring,
• Modified Alvarado scoring,
• Tzanakis scoring,2005
• Simplified Appendicitis score
• Pediatric Appendicitis score
Right lower abdominal tenderness = 4 points
Rebound tenderness = 3
Presence of white blood cells greater than 12,000 in the blood = 2,
Presence of positive ultrasound scan findings of appendicitis = 6,
The maximum score is a total score of 15; where a patient scores 8 or more points, there is greater than 96% chance that appendicitis exists.

7. Alfredo Alvarado, MD
Plantation General Hospital, Florida.
Accepted for publication November 11,1985.
This scoring uses Bayesian analysis
The Alvarado score:
• Three symptoms
• Three signs
• Two laboratory finding
*Alvarado A:A practical score for the early diagnosis of acute appendicitis. Ann Emerg-Med
May 1986;15:557-564.]

8. The Alvarado Score
• Symptoms Score
 Migratory right iliac fossa pain 1
 Nausea/vomiting 1
 Anorexia 1
• Signs
 RIF tenderness 2
 Fever >37.30C 1
 Rebound pain in RIF 1
Laboratory test
 Leucocytosis (>10 X 109/L) 2
 Neutrophilic shift to the left >75% 1
• Total score 10
*Alvarado A:A practical score for the early diagnosis of acute appendicitis. Ann Emerg-Med May
1986;15:557-564.]

9. The Alvarado Score
• Those with a score of 5 or 6 require observation and further
investigation
• Score of 7 or above needed to proceed to surgery as it is likely
to be appendicitis.
*Clinical Presentation of Acute Appendicitis: Clinical Alvarado Score and Derivate Scores by David J.
Humes and John Simpson Springer-Verlag Berlin Heidelberg 2011

10. Analysis of Alvarado score
• Al-Hashemy A M, Seleem M I, (2004). Appraisal of the modified Alvarado Score for acute appendicits in adults.
Saudi Med J., 25: 1229-31
• Antevil J, Rivera L, Langenberg B, Brown C V, (2004). The influence of age and gender on the utility of
computed tomography to diagnose acute appendicitis.Am Surg., 70:850-3
• Bolandparvaz S, Vasei M, Owji AA, Ata-Ee N, Amin A, Daneshbod Y, Hosseini S V, (2004). Urinary 5-hydroxy
indole acetic acid as a test for early diagnosis of acute appendicitis. Clin Biochem., 37:985-9
• Esmer-Sanchez D D, Martinez-Ordaz J L, Roman-Zepeda P, Sanchez-Fernandez P, Medina-GonzalezE. Cir,
(2004). Appendiceal tumors. ClinicopathologicRreview of 5,307 appendectomies. 72:375-8
• Garfield J L, Birkhahn R H, Gaeta T J, Briggs W M, (2004), Diagnostic pathways and delays on route to
operative intervention in acute appendicitis. Am Surg., 70(11):1010-3
• Hong J J, Cohn S M, Ekeh A P, Newman M, Salama M, Leblang S D, (2003). Miami Appendicitis Group. Surg
Infect (Larchmt). A prospective randomized study of clinical assessment versus computed tomography for the
diagnosis of acute appendicitis. Fall.,4:231-9
• Iwahashi N, Kitagawa Y, Mayumi T, Kohno H. World, (2004) Intravenous Cont

11. Analysis of Alvarado score
• Analysis indicates that the Alvarado score has moderate
to high sensitivity (all studies 82%, men 88%, women
86% and children 87%) and
• Moderate specificity (all studies 81%, men 57%, women
73% and children 76%)
• *A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed
up to April 2011. This study was funded by the Health Research Board of Ireland (HRB) under grant reference
HRC/2007/1.

12. Analysis of Alvarado score
• The Alvarado score is a useful diagnostic 'rule out' score
at a cut off point of 5 for all patient groups.
• The score is well calibrated in men, inconsistent in
children and over-predicts the probability of appendicitis
in women.
• As a decision rule in relation to surgery the Alvarado
score cannot be used to 'rule in' a diagnosis of
appendicitis without surgical assessment and further
diagnostic testing.
*A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to
April 2011. This study was funded by the Health Research Board of Ireland (HRB) under grant reference
HRC/2007/1.

13. Clearly Imaging Reduces NAR
Guss et al., “Impact of
Abdominal Helical CT on the
Rate of Negative
Appendicitis” JEM 2008; 34(1)
- Retrospective review of
before and after frequent CT
- Decrease in NAR from 15.5%
to 7.6%
- 12% CT rate before readily
available, 81% after
Kim, K. et al, “The Impact of Helical CT on
Negative Appendectomy Rate: A Multi-
Center Comparison; JEM 2008; 34(1)
- CT Rate and NAR inversely related
- NAR decreased 20% to 6%
- Limited by no follow up on negative scans
Wagner et al., Surgery. 2008; 144(2)
- Retrospective review of four-year time
periods before and after frequent CT
- NAR decreased 16% to 6%
- NAR decreased mostly due to adult women
- No change in NAR with kids (8%)
- Adult male decreased from 9% to 5% (NSS)
- Adult women decreased 20% to 7%

14. Ultrasound
• Very safe! No radiation, no contrast required
• Sensitivity and Specificity:
– Sensitivity – 74-83%,
– Specificity – 93-97%
• If can’t visualize – need to move on to the next
step
Findings on US for
appendicitis
- Non-compressible
appendix
- Appendix >6mm
diameter
- Signs of perforation
-Free fluid
-Abscess

15. Ultrasound
• All studies should be performed in both the transverse
and longitudinal planes with a technique referred to as
"graded compression,"
• Examiner exerts gentle pressure using the ultrasound
probe and either one or two hands to palpate the RLQ in
the same way as when performing an abdominal
examination.
• Utilizing varying pressure, this method is used to
decrease the distance between the ultrasound probe and
the pathology and eliminate overlying bowel gas, which
can cause overlying bowel gas artifact.

16. Ultrasound- Graded Compression method
*Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado
score BMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7266.919 (Published 14 October 2000)Cite this
as: BMJ 2000;321:919

17. Computed Tomography
• Advantages:
• Sensitivity 94-98% / specificity 95-99%
• Alternative diagnoses
• May see extravasation
• Better if little intra-abdominal fat
• Fluid collections

18. Computed Tomography
• Disadvantages:
• Large volume contrast
• What if vomiting?
• If not, probably will
• Risk of aspiration
• Aren’t they NPO?
• Increased lifetime cancer risk
• Increases difficulty of assessing bowel wall
• 2 hour delay:
• Delays surgical decision
• Risk of perforation

19. CT with or without contrast
• For diagnosis of appendicitis
• No need to drink contrast – no delay
• No change in diagnostic accuracy with IV Contrast
• Sensitivity 94-98% Specificity – 95-99%
• No difference in making the diagnosis with IV or no
contrast
• Some even thought IV obscured the intra-abdominal
structures
*Keyzer, C., et al, Am J Roent. August 2008
*Basak S, et al., J Clin Imag. 2002; 26.
*Hoecker CC, et al, JEM. May 2005
*Lowe LH, et al., Am J Roent. Jan 2001
*Ege G, et al., Br J Radiology. 2002; 75

20. Females of Child bearing age
• US first
• MRI vs CT
• Serial exams
Dose of radiation thought to be teratogenic and increase risk of
cancer in fetuses is 50 mGy
ACOG gives CT a level 2 recommendation
-

21. Modified Alvarado Score
• Medical facilities that are unable to perform a differential white
blood cell count use Modified Alvarado Score with a total of 9.
• Modified Alvarado score and the Alvarado score are useful
complementary methods in the diagnosis of patients suspected to
have acute appendicitis. The diagnostic value of the modified
Alvarado score is higher than the Alvarado score in this study.*
*The Modified Alvarado Score Versus the Alvarado Score for the Diagnosis of Acute Appendicitis
The THAI Journal of SURGERY 2005; 26:69-72. The Royal College of Surgeons of Thailand

22. Modifications to Alvarado score
• Diagnosing appendicitis can be very challenging.
Neutrophilic leucocytosis and a raised Alvarado score of
>5 were the only two findings that were significantly
associated with appendicitis
*Utility of Alvarado score in diagnosing appendicitis and its modification to make it more useful Gastroenterology
Today 2005 Issue 3

23. Conclusion

24. Conclusion
• The diagnosis of acute appendicitis depends on experience and
clinical judgment. The diagnosis of acute appendicitis remains a
challenging task for surgeons.
• Alvarado scoring system is a non-invasive, safe diagnostic
procedure that is simple, fast, cheap and reliable.
• The application of this scoring system improves diagnostic
accuracy and can be used as an objective criterion in screening
patients with suspected appendicitis for admission.
*International Journal of Basic and Applied Medical Sciences ISSN: 2277-2103 2012 Vol. 2
*Alvarado score as an admission criterion for suspected appendicitis in adults . Gastroenterol 2004;10:86-91

25. Conclusion
• Classic presentation of Anorexia, Pain and Nausea should always
be kept in mind.*
• Thorough clinical examination cannot be replaced to any diagnostic
modalities or scoring.
• No imaging – take to the OR*
*Schwartz's Principles of Surgery Part II. 9th edition
*Kalliakmans V, et al., Scan J Surg. 2005; 94(3Guss DA, et al., JEM. 2008; 34(1)
*Wagner PL, et al., Surgery. 2008 Aug; 144(2)

26. Conclusion
• Classic presentations do not require imaging
• Reserve imaging for equivocal cases
• Abdominal CT estimated increase cancer risk 1 in 2000
• Keep in mind CT not shown to decrease NAR in men and children.
• Oral or IV contrast provides no added value.
• Consider US first for kids, women, and pregnant
• MRI is a reasonable alternative if available
• Cut it, ligate it but never burry it!!!

27. Appendicitis is a pocket
size time bomb!!!
Thank you