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J Med Allied Sci 2013; 3 (2): 63-66

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Print ISSN: 2231 1696 Online ISSN: 2231 170X

Journal of

Medical

& Allied

Sciences

Original article
Alvarado score: A valuable clinical tool for diagnosis of acute appendicitis a retrospective study
Swagata Brahmachari1 and Ashwini B. Jajee2
1

Department of Surgery, LN Medical College and Research Centre, Kolar Road, Bhopal-462042,
Madhya Pradesh, India.
2
Department of Pathology, Surat Municipal Institute of Medical Education & Research, Surat, Gujrat, India.

Article history:
Received 01 May 2013
Accepted 12 July 2013
Early online 25 July 2013
Print 31 August 2013

Corresponding author
Swagata Brahmachari
Assistant Professor,
Department of Surgery,
LN Medical College and Research Centre,
Kolar Road, Bhopal-462042,
Madhya Pradesh, India.
Email: swagatabrahmachari@yahoo.in

Abstract
Appendicitis is a common surgical emergency and diagnosis is still
a great challenge. Accurate diagnosis and timely intervention reduces morbidity and mortality. The present study was conducted
to evaluate Alvarado scoring system for diagnosis of acute appendicitis in Indian set up. The study was carried out on 200 patients
admitted in Surgery ward between January 2009 and December
2010 with right lower quadrant abdominal pain. Alvarado score
was calculated and all patients were divided in three groups. Mean
age of presentation was 29.12 years and male to female ratio was
1.27:1. Higher the Alvarado score, more is the sensitivity. So patients having score 7 or above had sensitivity of 66%. We conclude that Alvarado score is unique since it incorporates signs,
symptoms and laboratory findings of suspicious patients. Alvarado
score can be utilized safely for diagnosis of acute appendicitis.
Key words: Alvarado score, appendicitis, inflammation, sensitivity, specificity
2013 Deccan College of Medical Sciences. All rights reserved.

ermiform appendix though described anatomically to be vestigial, is one of the most


important surgically concerned organs in the
human body. There are many pathological conditions involving appendix among which acute appendicitis is the commonest one. Approximately
200,000 appendectomies for acute appendicitis
1
are performed annually in the USA . The overall
lifetime risk of developing appendicitis is estimated
to be of 7% with the highest frequency occurring at
2
ages from 10 to 30 years . The risk gradually decreases until age 50, when it stabilizes.
In 1886 Reginald Heber Fits described the classical signs and symptoms of acute appendicitis as a
2
disease entity . Typical cases present classically
with para-umbilical pain migrating to the right lower
quadrant of the abdomen. Pain usually is asso-

ciated with nausea, vomiting and low-grade fever.


Variation in the position of the appendix, age of the
patient and degree of inflammation make the clinical presentation of appendicitis inconsistent. Unfortunately 20-33% of the patients suspected of having acute appendicitis present with atypical find2
ings .
Early diagnosis is a primary goal to prevent morbidity and mortality in acute appendicitis. In acute
appendicitis it is not possible to have definitive diagnosis by gold standard test (histopathology) preoperatively. Delay in diagnosis definitely increases
the morbidity, mortality and cost of treatment. The
perforation rate is as high as 35% when surgery is
3
delayed . In the subsequent 100 years, the mortali1
ty rate has fallen to less than 1% .

63

Brahmachari S and Jajee AB

Alvarado score: Diagnosis of acute appendicitis

In spite of advancements in medical diagnostics,


after elapse of more than a century since its first
description, it continues to be a diagnostic problem
and diagnostic inaccuracy in acute appendicitis
has remained unchanged. The most important diagnostic tool is still physical examination. The accuracy of a clinical examination ranges from 71%
to 97%, depending on the experience of the
3
surgeon .
Over the last two decades different protocols have
been introduced and tested by different researchers which include Lidverg, Fenyo, Christian, Ohman and Alvarado scoring system to make an early diagnosis of this sometimes very elusive disease. Alvarado in 1986 introduced a criterion for
4
the diagnosis of acute appendicitis .
The aim and objective of this study was to evaluate
the sensitivity of Alvarado scoring system in the
diagnosis of acute appendicitis, to reduce the rate
of negative appendectomy and to reduce the dire
complications of acute appendicitis due to misdiagnosis and delay in surgery.
Table 1: Alvarado scoring system
Characteristic features

Symptoms

Signs

Laboratory
findings

Score

Migratory right iliac fossa


pain

Anorexia

Nausea and vomiting

Tenderness in right iliac


fossa
Rebound tenderness in
right iliac fossa

2
1

Elevated temperature

Leucocytosis

Shift to left of Neutrophils

Total

10

Materials and methods


This retrospective study was conducted in a tertiary care teaching hospital in Central India. The
present investigation included patients who presented to surgery department between January
2009 and December 2010 with right lower quadrant abdominal pain who were suspected to be
having acute appendicitis. A total of 200 patients
qualified based on inclusion criteria. The proforma
containing demographics, presenting symptoms

J Med Allied Sci 2013;3(2)

and signs were documented. The patients symptoms, signs and laboratory indicators of appendicitis recorded according to Alvarado score for Appendicitis. The patients were further divided into 3
groups.
With a score 7 as diagnostic (high probability),
score 4-6 as doubtful (equivocal) but potential
candidates suffering from the disease and score 3
unlikely (low probability) to suffer from disease.
The appendectomy or surgical intervention was
performed; all appendices and other specimens
were submitted to pathology department. Appropriate statistical analysis was performed using statistical package for the social science software
(SPSS) version 17 (SPSS Inc, Chicago, IL, USA).
The sensitivity and specificity were calculated.
Results
Out of 200 patients included in the study, 112 were
males and 88 were females, male:female ratio being 1.27:1 (Table 2). Age of the patients ranged
from 13 to 68 years, with majority of patients in
third decade as shown in table 3. Mean age of
presentation was 29.12 years.
Table 2: Distribution of patients according to
gender
Gender

No. of
patients

Percentage
%

Male

112

56%

Female

88

44%

Total

200

100%

Male:
Female

1.27:1

Table 3: Distribution of patients as per age groups


Age group
(years)

No. of patients

Percentage (%)

11-20

43

21.5

21-30

81

40.5

31-40

32

16

41-50

29

14.5

51-60

12

61-70

1.5

Total

200

100%

Alvarado score was calculated. Seventy nine patients were found to have Alvarado score 7
(Highly probable), of which 52 (65.82%) were
64

Brahmachari S and Jajee AB

Alvarado score: Diagnosis of acute appendicitis

found to have acute appendicitis. Total 89 patients


had Alvarado score ranging between 4 and 6, out
of which 36 (40.44%) had acute appendicitis. Alvarado score 3 was found in 32 patients of whom
only 9 (28.12%) had acute appendicitis (Table 4).

Patients with Alvarado score 7 and above had


sensitivity of 74% in males and 55% in females
(Table 5). Patients with Alvarado score below 7;
sensitivity was 38% in males and 37% in females
and overall sensitivity of 37% (Table 6).

Table 4: Number of patients in different categories according to Alvarado score


Diagnosis
Sensitivity

Alvarado
score

Total

Acute appendicitis

Normal appendix

7(Highly probable)

79

52 (65.82%)

27 (34.17%)

66%

4-6 (Doubtful)

89

36 (40.44%)

53 (59.55%)

40%

3 (Low probable)

32

9 (28.12%)

23 (71.87%)

28%

200

97

103

Total

Table 5: Sensitivity of Alvarado score 7 and above


Gender

No. of patients with


score 7 or above

Acute appendicitis

Normal appendix

Sensitivity

Male

43

32

16

74%

Female

36

20

11

55%

Total

79

52

27

66%

Table 6: Sensitivity of Alvarado score below 7


Gender

No. of patients with


score below 7

Acute appendicitis

Normal appendix

Sensitivity

Male

69

26

42

38%

Female

52

19

34

37%

Total

121

45

76

37%

Discussion
Appendicitis is very common disease with life time
5
occurrence of 7% . The chief presentation is pain
in right lower quadrant of abdomen with vomiting.
The routine investigations done were complete
5
blood count and urine analysis . Clinical examination is very important but nowadays increasing use
of imaging techniques especially ultrasonography
(USG) is much informative and achieve less perfo6
ration rate and fewer complications . USG is a valued tool for clinically suspected appendicitis and
enhances diagnostic accuracy in cases with pain in
right iliac fossa and reduces the number of nega7
tive appendicectomies .
In 1986, Alfredo Alvarado published 8 predictive
factors, which he found to be useful in making the
J Med Allied Sci 2013;3(2)

diagnosis of acute appendicitis . Since then few


studies have been carried out to validate this scoring system.
In the present study we found that acute appendicitis is very much common in the age group of 2130 years with 40.5% patients. Next most susceptible group was between 11-20 years (21.5% patients). These findings were very similar to Talukd8
9
er DB . Some of the epidemiological studies show
that appendicitis is more common in age group 1029 years of age. We could not find relevant studies
on Indian population.
In our study, 56% of cases were males and 44%
were females. Male to female ratio was found to be
1.27:1. Thus males are more susceptible than fe8
males to develop appendicitis. Talukder DB et al
65

Brahmachari S and Jajee AB

Alvarado score: Diagnosis of acute appendicitis

found male to female ratio as 1.38: 1 (Males-58%,


Females-42%).

2.

The accurate diagnosis of appendicitis is great


challenge for surgeons. Negative appendicectomy
10
rate of 20-40% is common . The present study
show that higher the Alvarado scores more is its
sensitivity. Same observations were also made by
8
other authors . Patients having Alvarado score 710, 4-6 and 1-3 have sensitivity of 66%, 40% and
11
28% respectively. Lone et al showed that in the
same score range, sensitivity is more in males than
in females. Our study also confirms his findings.
Lower values in females are attributed to presence
of genital tract diseases i.e. ovarian diseases, salpingitis, etc.

3.

Conclusion
Diagnosis of acute appendicitis is real problem for
the surgeons. Alvarado score is unique since it
incorporates signs, symptoms and laboratory findings of suspicious patients. It is simple, reliable,
rapid, non-invasive, repeatable diagnostic modality
without any additional expenses and complications. The application of this scoring system improves diagnostic accuracy and further reduces
complication rate.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Acknowledgments: None
Conflict of interest: None

13.

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