Alvarado score: an admission criterion in patients with right iliac fossa pain

Diagnostic Performance of Surgical Criteria Incorporating MDCT for Suspected Acute Appendicitis

Objective

The objective of this study was to evaluate the effectiveness of a new set of criteria and multidetector computed tomography (MDCT) in determining whether surgical intervention is required in cases of appendicitis, with the aim of reducing unnecessary procedures and postoperative complications.

Methods

The patients were divided into 2 groups: group A, comprising patients who were admitted between 2008 and 2013 and treated based on the new criteria; and group B, comprising patients who were admitted between 2003 and 2007 and treated based on the standard criteria. Positive and negative predictive values were calculated.

Results

Of 1021 patients, 533 (274 males, 259 females) belonged to group A and 488 (263 males, 225 females) to group B. Surgical procedures were performed in 46.0% (245 cases) of patients in group A and 64.3% (314 cases) in group B (P > 0.001). The rate of conservative treatment was significantly higher in group A. The overall rate of catarrhal appendicitis based on histopathologic findings was 6.9% (17 cases) in group A and 15.0% (47 cases) in group B (P > 0.003). The overall rate of surgical complications was significantly higher in group B, being observed in 14.6% (46 cases) in this group, but only 8.2% (20 cases) in group A (P > 0.02). No statistically significant difference was observed in rate of conversion to surgery after conservative therapy or recurrence between the 2 groups.

Conclusion

Our new surgical criteria incorporating MDCT are effective in reducing the incidence of negative appendectomies and surgical complications.

[Role of the Alvarado score in the diagnosis of acute appendicitis]

INTRODUCTION

Acute appendicitis is the most frequent surgical emergency in the Emergency Department and diagnosis is mainly based on clinical examination. However, its clinical features are sometimes deceptive as well as the wide range of differential diagnoses are frequently sources of diagnostic errors and of a delayed management. In order to reduce these diagnostic difficulties, the number of complementary examinations and abusive surgical procedures, several clinical scores have been developed, including the Alvarado score. The objective of this study aimed to apply this score to a population of adult patients presenting with pain in the right iliac fossa in order to evaluate its performance as well as its limits.

METHODS

We conducted a prospective study of all patients over the age of 15 years presenting with pain of the right iliac fossa. In patients undergoing surgery, the final diagnosis of acute appendicitis was confirmed by the anatomo-pathological examination while it was negated when the symptoms regressed in the absence of any treatment.

RESULTS

Our study included 106 patients. In patients with Alvarado score less than 4, the diagnosis of acute appendicitis was never retained. The best sensitivities and specificities were found in patients with a threshold value of 8 (Alvarado score). Our study demonstrated that Alvarado score can provide immediate benefit in the diagnosis of acute appendicitis based on its good sensitivity (81.25%) and correct positive predictive value (74,28%). The group of patients with a score strictly less than 4 was considered to be low risk. The patients with Alvarado score strictly greater than 6 would require hospitalization either to undergo emergency surgery or to undergo imaging examinations and be monitored. In the group of patients with a score between 4 and 6 (extremes included) there was no diagnostic certainty, hence complementary imaging techniques were essential.

CONCLUSION

In our Emergency Department Alvarado score helps clinicians to streamline patient's management and to give an indication to the diagnosis by limiting the prescription of radiological examinations, the cost of patients' management and the abusive surgical procedures.

Role of C-Reactive Protein, White Blood Cell Counts, Bilirubin Levels, and Imaging in the Diagnosis of Acute Appendicitis as a Cause of Right Iliac Fossa Pain

Background Right iliac fossa (RIF) pain is one of the most common modalities of presentation to surgical emergency. It remains a challenge to the treating clinicians to accurately diagnose or to rule out appendicitis. Objective The aim of the study was to compare the efficacy of clinical impression, biochemical markers, and imaging in the diagnosis of RIF pain with special reference to appendicitis and their implication in reducing the negative appendicectomy rates. Methods All patients presenting to casualty with RIF pain were included in the study. Blood investigations including C-reactive protein (CRP), serum bilirubin, white blood cell counts (WBC), and ultrasound (USG) were done. Based on the clinical impression, patients were either posted for appendicectomy or observed in equivocal cases. Patients who had recurrent pain on follow-up underwent appendicectomy or underwent contrast-enhanced computed tomography (CECT) in equivocal cases. Patients who only had a single self-limiting episode with no other alternative diagnosis or had a normal CECT report were included in a non-specific RIF pain group. Results The negative appendicectomy rate was 8.2%. The mean value of WBC counts (9.57x109/L vs 7.88x109/L; p<0.05) and that of serum bilirubin (1.37 mg/dl vs 0.89mg/dl; p<0.05) in the appendicitis and non-appendicitis group, respectively, were statistically significant. The percentage of CRP positivity was higher in the appendicitis group (51.9% vs 15%; p<0.05). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for USG (84.2%, 77.17%, 85.4%, and 75.5%), for CRP (51.8%, 85%, 82%, and 57%), for WBC count (45.1%, 88%, 86.6%, and 48.3%), and for serum bilirubin (69.2%, 75%, 81.4%, and 60.5%) were statistically significant between the groups. Conclusion Imaging and biochemical investigations including bilirubin can act as useful adjuncts to the clinical diagnosis of appendicitis.

A Simplified Appendicitis Score in the Diagnosis of Acute Appendicitis

Introduction

Scoring systems such as the Modified Alvarado Score (MAS) can help in the early diagnosis of acute appendicitis (AA) but is cumbersome to use and has not found widespread popularity. A more robust, user-friendly Simplified Appendicitis Score (SAS) was investigated.

Methods

Patients presenting with suspected AA were prospectively enrolled. The performance of the SAS (using only 5 variables – migratory pain, right lower quadrant tenderness, rebound pain, fever >37.3 degrees Celsius and leucocytosis >12,000/uL) was analysed and compared to the MAS.

Results

Out of 238 patients enrolled over four months, 95 (39.9%) patients underwent appendectomy, of which 81 patients had histologically proven AA. A MAS of ≥8 was 92.4% specific for ruling in AA, while a score of <5 was 91.4% sensitive in ruling out AA. A SAS of ≥6 was 91.7% specific for ruling in AA, while a score of <4 was 90.1% sensitive in ruling out AA.

Conclusions

The performance of the MAS can be maintained by omitting the two subjective variables – “anorexia” and “nausea/vomiting”, and increasing the leucocytosis cut-off level. A SAS using only 5 variables performed as well as the original MAS.

Comparison of Alvarado score evaluation and clinical judgment in acute appendicitis

Background:

Acute appendicitis is the most common surgical emergency in children, but its diagnosis is sometimes difficult.

The aim:

of this study is to evaluate retrospectively the Alvarado score in relation to the surgical management based on clinical judgment.

Methods:

Medical files of 232 children who underwent appendectomy at Makassed General Hospital from January 1997 till December 2006 were reviewed. Demographic characteristics, symptoms and signs, laboratory results and imaging findings for all children were recorded.

Results:

The positive predictive value of our clinical judgment was 86.4% and the negative appendectomy rate was 13.6% based on the pathology results. The reliability of Alvarado score in our population found a PPV of 80.7% and a negative appendectomy rate of 11.3%. A multivariate analysis revealed that anorexia, neutrophils left shift and rebound tenderness are significantly correlated with a correct diagnosis of appendicitis (p = 0.012, 0.023 and 0.046 respectively).

Conclusion:

Although, Alvarado score provides measurably useful diagnostic information in evaluating children with suspected appendicitis, we found that good clinical judgment remain the main stay of correct diagnosis of appendicitis.

Validation of the diagnostic score for acute lower abdominal pain in women of reproductive age

Background. The differential diagnoses of acute appendicitis obstetrics, and gynecological conditions (OB-GYNc) or nonspecific abdominal pain in young adult females with lower abdominal pain are clinically challenging. The present study aimed to validate the recently developed clinical score for the diagnosis of acute lower abdominal pain in female of reproductive age. Method. Medical records of reproductive age women (15-50 years) who were admitted for acute lower abdominal pain were collected. Validation data were obtained from patients admitted during a different period from the development data. Result. There were 302 patients in the validation cohort. For appendicitis, the score had a sensitivity of 91.9%, a specificity of 79.0%, and a positive likelihood ratio of 4.39. The sensitivity, specificity, and positive likelihood ratio in diagnosis of OB-GYNc were 73.0%, 91.6%, and 8.73, respectively. The areas under the receiver operating curves (ROC), the positive likelihood ratios, for appendicitis and OB-GYNc in the validation data were not significantly different from the development data, implying similar performances. Conclusion. The clinical score developed for the diagnosis of acute lower abdominal pain in female of reproductive age may be applied to guide differential diagnoses in these patients.

What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review

STUDY OBJECTIVE

The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and high-risk populations.

METHODS

We performed a systematic review of the literature and identified 26 studies of the accuracy of the Alvarado score and Pediatric Appendicitis Score. Data were abstracted in parallel, and only prospective, cohort studies that avoided verification bias were included. We calculated summary likelihood ratios for low-, moderate-, and high-risk groups, using all possible cutoffs based on available data, even if not reported in the original study.

RESULTS

The pretest probability of appendicitis was approximately 33% in studies of children and approximately 66% in studies of adults. Likelihood ratios at different cutoffs for the Alvarado score in adults were as follows: 0.03 (<4 points), 0.42 (4 to 6 points), and 3.4 (≥ 7 points); and 0.01 (<5 points), 0.98 (5 to 8 points), and 6.7 (≥ 9 points). Likelihood ratios for the Alvarado score in children were as follows: 0.02 (<4 points), 0.27 (4 to 6 points), and 4.2 (≥ 7 points); and 0.04 (<5 points), 1.2 (5 to 8 points), and 8.5 (≥ 9 points). For the Pediatric Appendicitis Score, likelihood ratios were 0.13 (<4 points), 0.70 (4 to 7 points), and 8.1 (≥ 8 points).

CONCLUSION

For children with a pretest probability of acute appendicitis of 60% or less, an Alvarado score below 4 rules out the diagnosis; this is also true for a score less than 5 if the pretest probability is up to approximately 40%. In adults with a pretest probability greater than or equal to 60%, an Alvarado score of 8 or higher rules in the diagnosis, whereas one of 9 or higher rules in the diagnosis at pretest probabilities greater than or equal to 40%. The Pediatric Appendicitis Score did not identify clinically useful low- or high-risk groups at typical pretest probabilities.

Re-evaluation of Alvarado score in diagnosis of acute appendicitis using transumbilical single-port laparoscopic exploration

AIM: To re-evaluate the Alvarado score in the diagnosis of acute appendicitis using transumbilical single-port laparoscopic exploration.

METHODS: Clinical data for 210 patients with acute appendicitis who underwent transumbilical single-port laparoscopic exploration and Alvarado scoring were retrospectively reviewed. The correlation between Alvarado score and operative outcome was analyzed.

RESULTS: 101 had an Alvarado score above 9, of whom appendicitis was excluded by exploration in only 2 cases, and the diagnostic accuracy of Alvarado score was 98.1% in these patients. 85 patients had an Alvarado score between 7 and 8, of whom 74 were confirmed to have acute appendicitis by exploration, and the diagnostic accuracy of Alvarado score was 87.1% in these patients. Of 24 patients who had a positive CT or ultrasound finding and an Alvarado score between 5 and 6, 23 were confirmed to have acute appendicitis, and the diagnostic accuracy of Alvarado score was 95.8% in these patients. No port-site hernia or constipation was found during a follow-up period of 1 year.

CONCLUSION: Alvarado score is useful in the diagnosis of acute appendicitis, especially when the score is above 9. When the score is between 7 and 8, there is a false positive rate as high as 13% if the Alvarado system is used alone. Alvarado scoring combined with imaging examination is associated with a higher accuracy in the diagnosis of acute appendicitis.

The Alvarado score for predicting acute appendicitis: a systematic review

BACKGROUND

The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score.

METHODS

A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children.

RESULTS

Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata.

CONCLUSIONS

The Alvarado score is a useful diagnostic 'rule out' score at a cut 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 across all strata of risk.

A comparison of clinical judgment vs the modified Alvarado score in acute appendicitis

AIMS

To investigate the value of the modified Alvarado score (MAS) in helping Accident & Emergency (A&E) doctors decide which patients with suspected acute appendicitis need surgical referral.

METHODS

11,258 patients presented to a University Hospital A&E Department over a two-month period; 82 were triaged as 'abdominal pain' or 'suspected appendicitis'. Ten patients self-discharged prior to seeing a doctor. The remaining case notes (72) were reviewed and MAS's calculated. The Alvarado guidelines suggested an MAS > or = 5 (high) needed admission and an MAS < 5 (low) excluded appendicitis and was appropriate for discharge.

RESULTS

Two patients had proven pancreatitis and were excluded. 24/70 patients were admitted for suspected appendicitis; all were referred by the A&E doctor (sensitivity 100%) but only 12 had a high MAS (sensitivity 50%). Twelve patients were therefore admitted despite having a low MAS on retrospective analysis. 46/70 patients were discharged (none re-presented with the same complaint) of which 40/46 were sent home without surgical referral (specificity 87%), but only 44/46 patients discharged had a low MAS (specificity 96%).

CONCLUSIONS

It is more important to refer every case that needs referral (sensitivity) than to discharge those not needing referral (specificity). We cannot exclude the possibility that morbidity would result were the MAS used in lieu of clinical judgment in deciding whether referral is necessary in cases of suspected acute appendicitis.