The Alvarado score for predicting acute appendicitis: a systematic review

Abstract

BackgroundThe 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.MethodsA 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.ResultsForty-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.ConclusionsThe 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.

The Validity of Alvarado Score in Diagnosis of Acute Appendicitis among Sudanese Patients

“…Group 1: comprising patients with Alvarado score (1, 2, 3) Group 2: comprising patients with Alvarado score (4,5,6) Group 3: comprising patients with Alvarado score (7,8,9, and 10)…”

Dilemma of Acute Appendicitis

“…The appendicolith, a radio-opaque concretion located within the appendix, which is deemed to be the most specific finding of appendicitis on plain radiographs, is visualized in only 5%-15% of patients with appendicitis [21]. Ultrasonography in expert hands is perhaps the most useful investigation [2,3,21]. Although computed tomography (CT) scan is superior to ultrasound (US) scan, the risk of radiation-induced malignancy renders it not of particular use in paediatric patients [21].…”

“…Ultrasonography in expert hands is perhaps the most useful investigation [2,3,21]. Although computed tomography (CT) scan is superior to ultrasound (US) scan, the risk of radiation-induced malignancy renders it not of particular use in paediatric patients [21]. Laparoscopy is essentially an operation rather than an investigation.…”

“…A white cell count is usually elevated but a normal white cell count especially in the elderly does not exclude appendicitis [19,20]. The appendicolith, a radio-opaque concretion located within the appendix, which is deemed to be the most specific finding of appendicitis on plain radiographs, is visualized in only 5%-15% of patients with appendicitis [21]. Ultrasonography in expert hands is perhaps the most useful investigation [2,3,21].…”

“…Delay in diagnosis is common because the classical signs and symptoms may be absent or unobtainable, and perforation is common as host defenses including the omentum are not fully developed. The development of fever associated with any abdominal tenderness should always raise the suspicion of acute appendicitis [2,21]. ' Active observation' is reasonable, safe and effective in early appendicitis, if peritonism is absent and the diagnosis uncertain.…”