Alvarado Score 2

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MODIFIED ALVARADO SCORE;ACCURACY IN DIAGNOSIS OF ACUTE APPENDICITIS IN ADULTS.

DR. SYED WARIS ALI SHAH DR. AJMEL MUNIR TARRAR

DR. CHAUDHRY AHMED KHAN DR. IRTIZA AHMED BHUTTA

Department of General SurgeryDR. SIKANDER ALI MALIKCombined Military Hospital,Rawalpindi

DR. AHMED WAQAS

ORIGINALPROF-1633

Professional Med J Dec 2010;17(4): 546-550. (www.theprofesional.com) 546

ABSTRACT... objective: To compare the frequency of inflamed appendix in suspected patients of acute appendicitis having Modified AlvaradoScore (MAS) of 7 or more with patients having MAS of 6 or below.Design: Comparative cross sectional study.Place and duration of study:The study was carried out at Surgical Departments of Combined Military Hospital (CMH) and Military Hospital (MH) Rawalpindi from Aprito April 2007.Material and Methods: This study involved 100 patients who were operated with provisional diagnosis of acute appendicitis.Preoperatively MAS of each patient was calculated and the patients were divided in two groups. Group-I had MAS of 7 or more while Grouphad MAS of 6 or below. Postoperatively appendices of all the patients were sent for histopathological examination and its result regardingpresence or absence of acute appendicitis was then compared with MAS of respective group.Results: (a) Group-I:- A total of 72 patients with64(88.9%) positive inflamed appendices on histology. Negative appendicectomy rate 8(11.1%), (b) Group-II:- A total of 28 patients with 8(28positive inflamed appendices. Negative appendicectomy rate 20(71.4%). There is statistical significant difference of positive appendicectomrate between two groups with (p-value


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system like MAS will aid junior doctors. This will help in (28%) had normal appendix. Most common age grdeciding upon a course of action in suspected cases of was 21 30 years (Figure I), and most common MAS wasacute appendicitis and thus help in reducing the seven (40%) (Figure II).incidence of negative appendicectomies.

In MAS, score is given to few important points (1 9) outof history, clinical examination and laboratoryinvestigations (Table-I). Diagnosis of acute appendicitisis then established based upon the score attained by thepatient i-e., 1 4 Appendicitis unlikely, 5 6 Probablyappendicitis, 7 9 Most likely acute appendicitis.

The study was carried out in surgical departments ofCMH and MH Rawalpindi which are tertiary care militaryhospitals Patients of age 16 years or above who wereadmitted and operated with provisional clinical diagnosisof acute appendicitis were included in this study. A totalnumber of 100 patients were included in this study. Allthose patients who were treated conservatively were notincluded and five patients were dropped out becausethey had appendicular mass at the time of admission. Another two female patients were not included in the Out of total 65 male patients, 52 (80%) had acutestudy because they had developed florid signs of pelvic appendicitis on histopathological examination, while 13inflammatory diseases. patients (20%) had normal appendix. Out of total 35Patients were initially evaluated by history, physical female patients 20 (57.14%) had acute appendicitis onexamination, Total Leucocyte Count, and MAS of each histopathological examination, while 15 (42.85%)

patient was calculated. The decision to operate was patients had normal appendix (Figure III).made independently by the surgeon on call / surgicalteam. All operated appendices were sent forhistopathological examination.

For the purpose of statistical analysis the patients weredivided in two groups. Group-I consisted of patientshaving MAS of 7 or more while Group-II consisted ofpatients having MAS of 6 and below. z-test is used tocompare the proportion of group-I and group-II.P-valueless than or equal to 0.05 consider significant. Sensitivity

and specificity of overall MAS of all patients included inthe study was calculated by using MAS of 7 or more as ascreening test.

Out of 100 patients, 65 (65%) were males and 35 (35%)Group-I:- A total of 72 patients had MAS of 7 or more,were females. A total of 72 (72%) patients had acuteamong them 46(63.9%) were males and 26 (36.1%) wereappendicitis on histopathological examination and 28

PATIENTS AND METHODS

RESULTS

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females. Out of these 28 patients, 8 (28.6%) hadhistologically proven acute appendicitis, while 20patients (71.4%) had normal appendix. All eight patientswith positive histopathology were males while in patientswith normal appendix, 11 (55%) were males and nine(45%) were females. Negative appendicectomy rate inthis group was 71.4% and positive appendicectomy ratein this group was 28.6%.

Patients of both the groups were analyzed for frequencyof positive histopathological appendicitis by applying z-test which shows statistically significant differencebetween two groups of patients (p-value


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in Spain. As compared to MAS, Ramirez and Deus17 It is thus concluded that MAS is a simple aid for thesystem is complicated , and junior doctors may get

diagnosis of acute appendicitis and patients with MAS ofconfused during the calculation. Other scoring systems7 or above will have more chances of having acutelike Ohmann, Eskelinen and SIRS score are also under

18,19,20 appendicitis than patients having MAS of 6 or below.trial at different centres .

It is recommended that MAS should be introduced andIn this study there were 65 males and 35 females. This13 practiced in emergency departments as this simplegender ratio is almost similar to Muzafaruddin and Al-

12 scoring system will be of great help to junior doctors.Hashemy . The most common age group is 21 251years which is comparable to published literature .

Modifications in MAS are also recommended, e.g.assigning more points to pain and tenderness in rightThe negative appendicectomy rate in group-I waslower abdominal quadrant for which further studies11.11% which is less than the similar studies carried out

12 3 should be carried out.by Al-Hashemy and Saidi HS .When the results of group-I are compared with group-II, itis seen that negative appendicectomy rate decreaseswith the rise in score, which supports the hypothesis of

1. Russel RCG, William NS, Bulstrode CJK.The vermiformthis study.appendix. In: OConnell PR. Bailey & Loves Shortpractice of surgery. 24th ed. London : Arnold, 2004: 1203-In this study the overall sensitivity was 88.9%. Similar 18.13results have been found by Muzaffaruddin and Saeed

14 2. Ahmad N, Abid KJ, Khan AZ, Shah STA.Acute Amer in their respective studies. As a highly sensitivea p p e n d i c i t i s . I n c i d e n c e o f n e g a t i v etest is required for the diagnosis of a condition where theappendicectomies. Ann KE Med Coll 2002; 8(1): 32-4.consequences of a false positive test are serious,

therefore, this sensitivity of 88.9% suggests MAS to be 3. Saidi HS, Chavda SK.Use of a modified Alvarado scorean effective tool in the diagnosis of acute appendicitis in in the diagnosis of acute appendicitis. East Afr Med Jadults. 2003; 80(8):411-4.

4. Ahmad M, Ghuncha AR, Ahmed M, Mubarik A, Mushtaq S.Right lower quadrant abdominal pain with or withoutClinicopathological spectrum of appendicectomyshifting, and tenderness right iliac fossa with or without specimens. J Coll Physicians Surg Pak 2002; 12:549-51

rebound tenderness were the most common symptomsand signs in this study and almost every patient had 5. Fenyo G, Lindberg G, Blind P, Enochsson L, Oberg A.

Diagnostic decision support in suspected acutethem.appendicitis. Validation of a simplified scoringsystem. Eur J Surg.1997;163(11): 831-8.In the study 8 patients (28.6%) out of group-II had acute

appendicitis which is a significant number and this could 6. Alvarado A.A practical score for the early diagnosis ofbe missed if totally relied upon the scoring system, so it acute appendicitis. Ann Emerg Med 1986; 15: 557-64.should be kept in mind that no scoring system is 100%

7. Arain GM, Sohu KM, Ahmad E, Hamer W, Naqi SA. Roleeffective but modifications may increase the accuracy in of AlvaradoScore in diagnosis of acute appendicitis. future. Pak J Surg 2001; 17(3): 41-6.

When the results of this study were statistically analyzed, 8. Bukhari SAH, Rana SH.Alvarado Score: a newapproach to acute appendicitis. Pak Armed Forces Medby z-test which is statistically significant(p-value


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score in diagnosis of acute appendicitis. J Coll of acute appendicitis. J Indian Med Assoc. 2002; 100(5):Physicians Surg Pak 2000;10:392-4. 310-1, 314.

10. Kalan M, Rich AJ, Talbot D, Cunliffe WJ.Evaluation of the 16. Ramirez JM, Deus J.Practical score to aid decisionmodified Alvarado score in the diagnosis of acute making in doubtful cases of appendicitis. Br J Surgappendicitis: a prospective study. Ann R Coll Surg 1994;81:680-3.Engl 1994; 76(6): 418-19.

17. Khan ML, Manzar S.Evaluation of Ramirez and Deus11. Horzic M, Salamon A, Kopljar M, Skupnjak M, Cupurdija K, clinical diagnostic scoring or acute appendicitis at

Vanjak D. Analysis of scores in diagnosis of acute Civil Hospital, Karachi. Pak J Surg.2003,19(1): 3-8.appendicitis in women. Coll Antropol. 2005;29(1):133-8. 18. Zielke A, Sitter H, Rampp TA, Schafer E, Hasse C, Lorenz

W, Rothmund M.Validation of a diagnostic scoring12. Al-Hashemy AM, Seleem MI.Appraisal of the Modified system (Ohmann score) in acute appendicitis. Chirurg.

Alvarado Score for acute appendicitis in adults. Saudi 1999; 70(7): 777-84.Med J. 2004; 25(9):1299-31.

19. Sitter H, Hoffmann S, Hassan I, Zielke A.Diagnostic13. Sadiq M, Amir S.Efficacy of modified Alvarado scoring score in appendicitis. Validation of a diagnostic score

system in the diagnosis of acute appendicitis. J (Eskelinen score) in patients in whom acute

Postgrad Med Inst 2002;16(1):72-7. appendicitis is suspected. Langenbecks Arch Surg.2004; 389(3): 213-8.14. Saeed Amer. Protocol based diagnosis of

Appendicitis. J Postgrad Med Inst 2004;18(2):280-3. 20. Nozoe T, Matsumata T, Sugimachi K.Significance ofSIRS score in therapeutic strategy for acute

15. Bhattacharjee PK, Chowdhury T, Roy D.Prospective appendicitis. Hepatogastroenterology. 2002;evaluation of modified Alvarado score for diagnosis 49(44):444-6.


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Correspondence Address:Dr. Syed Waris Ali ShahSurgical Specialist,HIT Hospital, Taxila [email protected]

Article Citation:Shah SWA, Khan CA, Malik SA, Waqas A, Tarrar AM,Bhutta IA. Modified alvarado score; Accuracy in

diagnosis of acute appendicitis in adults. ProfessionalMed J Mar 2011;18(1):546-550.

Lord Mancroft

A speech is like a love affair. Any fool can start one, but to end it requires

considerable skill.

MODIFIED ALVARADO SCORE

Received after proof reading: 13/11/2010 Accepted for Publication: 21/05/2010 Article received on: 27/03/2010

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