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Modified Alvarado Scoring System in the Diagnosis of Acute Appendicitis

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Modified Alvarado Scoring System in the Diagnosis of Acute Appendicitis acuteappendicitis during July 2005 to June 2008 in BDR Original Paper Hospital, Peelkhana, Dhaka. Data including age, sex, symptoms, physical sings and laboratory findings such as white blood cell total and differential count were recorded MODIFIED ALVARADO SCORING SYSTEM in modified Alvarado form (Table-1)9. IN THE DIAGNOSIS OF ACUTE APPENDICITIS In addition, urine for routine examination (R/E) was done for all cases. Plain X-ray Kidney-Urinary bladder (KUB) 1 2 Talukder DB , Siddiq AKMZ region was done in selected cases. Ultra-sonogram (USG) of abdomen was performed when diagnosis was doubtful, Abstract "when in doubt take it out" has resulted in increased especially in female patients to exclude gynaecological Acute appendicitis is one of the common surgical negative laparotomies3. Presentations of acute disease. The diagnosis of acute appendicitis was made emergencies. Different scoring systems are there in appendicitis can mimic variety of acute medical and clinically and the decision for appendicectomy was taken use to diagnose appendicitis. The purpose of this study surgical abdomino-thoracic conditions. Early diagnosis is by the qualified surgeon. Though all the patients were was to evaluate the diagnostic accuracy of the a primary goal to prevent morbidity and mortality in acute scored using the modified Alvarado score, it had no modified Alvarado scoring system in clinical practice appendicitis4. Another important issue is decreasing the implications on the decision to go for surgery. for acute appendicitis. A prospective study was negative appendicectomy rate. Subsequently, the score of each patient was correlated conducted on 100 patients hospitalized with In spite of advancements in medical diagnostics, its with the clinical, operative and histopathological findings. abdominal pain suggestive of acute appendicitis and diagnosis is mainly clinical one. Over the last two Sex were subsequently operated, from July 2005 to June decades different protocols have been introduced and Results 2008 at Bangladesh Rifles (BDR) hospital, Dhaka. tested by different researchers which include Lidverg, Age of the patients ranged from 7 year to 55 year with the Both male and female patients from 7 years to 55 Fenyo, Christian, Ohman and Alvarado scoring system to majority of the patients in the third decades (42%) years of age were enrolled in the study. Preoperatively, make an early diagnosis of this sometimes very elusive followed by second decades (26%) (Table-II). modified Alvarado score was assigned to all, and the disease. Alvarado in 1986 introduced a criterion for the Out of 100 patients, 58 (58%) were male and 42 (42%) results were compared with operative and histo- diagnosis of acute appendicitis which was later modified were female. Clinically males were more susceptible pathological diagnosis. Out of 100 operated patients to accommodate additional parameters along with than female with a male-female ratio of 1.38:1 (Table-III). Sex 84 were diagnosed as a case of acute appendicitis on original Alvarado scoring system5-8. All the specimen of total 100 operated cases were sent to the basis of histopathological report. Patients with The aim and objective of this study is to evaluate the modified Alvarado score of 8-10, 5-7 and 1-4 have the sensitivity of modified Alvarado scoring system in the Table-II: Distribution of patient as per Age group (n=100). accuracy of 95%, 78%, and 0% respectively. In the diagnosis of acute appendicitis, to reduce the rate of Age group (years) No of patients Percentage (%) higher score group the accuracy is more and negative appendiectomy and to reduce the complications Upto-10 03 03 acceptable. Lower score group should be kept under of acute appendicitis due to misdiagnosis and delay in 11-20 26 26 observation. Score sensitivity is more in male than surgery. 21-30 42 42 31-40 17 17 female patients. This scoring system is a reliable and 41-50 10 10 practicable diagnostic modality to increase the Materials And Methods 51-60 02 02 accuracy in diagnosis of acute appendicitis and thus to This prospective study was carred out on 100 patients Total 100 100 minimize unnecessary appendicectomy. hospitalized with abdominal pain suggestive of Table-III: Distribution of patient as per Sex group (n=100). Key Words: Alvarado scoring system, Acute Table-I: Modified Alvarado Score. Sex No of patients Percentage (%) Male: Female Clinical Features Score Male 58 58 appendicitis. 1.38 : 1 Migratory right iliac fossa pain 1 Female 42 42 Introduction Symptoms Anorexia 1 Total 100 100 In 1886 Reginald Heber Fits described the classical signs Nausea/Vomiting 1 and symptoms of acute appendicitis as a disease entity1. Tenderness at right iliac fossa 2 Table-IV: Post-operative (per-operative and histopathological Since then acute appendicitis has remained the most Rebound tenderness 1 findings) diagnosis (n=100). Elevated temperature 1 Findings No of patients Percentage common acute surgical condition of the abdomen in all Signs Extra sign(s), e.g. cough test and/or 1 Inflammation 45 45 ages and of course, a common disease in surgical Rovsing's sign and/or rectal tenderness Suppurative 33 33 practice2. Even after elapse of more than 120 years since Acute appendicitis Gangrenous 04 04 Laboratory Leucocytosis 2 its first description this common surgical disease Perforation 02 02 Total score 10 Total 84 84 continues to remain a diagnostic problem and can baffle Interpretation of the Modified Alvarado score was summarized as follows: Ruptured ovarian cyst 02 02 best of the clinician. Delay in diagnosis definitely Salpingitis 01 01 Score 1-4: acute appendicitis very unlikely Normal appendix Score 5-7: acute appendicitis probable Pelvic inflammatory increases the morbidity, mortality and cost of treatment. with other diagnosis disease 01 01 Score 8-10: acute appendicitis definite In equivocal cases, however, aggressive surgical approach Meckel's diverticulitis 01 01 No pathology found 11 11 Total 16 16 1. Lt Col David Bibhutosh Talukder, MBBS, FCPS , Surgical Specialist, UN Mission, Sudan, 2. Maj Gen AKM Zafrullah Siddiq, MBBS, FCPS, DGMS, Total 100 100 Bangladesh Armed Forces JAFMC Bangladesh. Vol 5, No 1 (June) 2009 JAFMC Bangladesh. Vol 5, No 1 (June) 2009 18 acuteappendicitis during July 2005 to June 2008 in BDR laboratory for histopathological examination. The reports modern era of surgery many surgeons opined that Hospital, Peelkhana, Dhaka. Data including age, sex, showed features of acute appendicitis in 84 (84%) cases and maximum 15-20% negative appendicectomy is symptoms, physical sings and laboratory findings such as 16 (16%) patients did not have acute appendicitis. Out of 16 acceptable17. Removal of normal appendices is inevitable white blood cell total and differential count were recorded cases, 2 had ruptured ovarian cyst, one had salpingitis, one to lower the rate of perforation and consequent mortality. in modified Alvarado form (Table-1)9. had pelvic inflammatory disease, one had Meckel`s On the other hand unnecessary appendicectomy carries diverticulitis and 11 had no pathology. In this series the long term risks to the patients18. In addition, urine for routine examination (R/E) was done negative appendicectomy rate was 16% (Table-IV). From this study it was found that higher the score, more for all cases. Plain X-ray Kidney-Urinary bladder (KUB) of its sensitivity. Patients with the Alvarado score ranges region was done in selected cases. Ultra-sonogram (USG) Table-V: Sensitivity of different score range groups (n=100). 8-10, 5-7 and 1-4 have the accuracy 95%, 78%, and 0% of abdomen was performed when diagnosis was doubtful, No of Acute Normal respectively (Table-V). Fengo et al19 reported a sensitivity Score patients appendicitis appendix Sensitivity especially in female patients to exclude gynaecological of 90.2% and others reported a sensitivity of 73% with 8-10 55 52 03 95% disease. The diagnosis of acute appendicitis was made negative laparotomy rate of 17.5%. In this series the clinically and the decision for appendicectomy was taken 5-7 41 32 09 78% sensitivity of the patients with the score 7 and above was by the qualified surgeon. Though all the patients were 1-4 04 00 04 00% 93% in male and 84% in female and the combined scored using the modified Alvarado score, it had no sensitivity was 89%. Whereas it was 73% and 60% in implications on the decision to go for surgery. Table-VI: Sensitivity of modified Alvarado score 7 and male and female respectively and the combined Subsequently, the score of each patient was correlated above (n=75). sensitivity is 68% in the patients with score less than 7. In a study of Lone et al16 has shown the sensitivity of the with the clinical, operative and histopathological findings. No of patients Acute Normal Sex with score > 7 appendicitis appendix Sensitivity patients with the score 7 and above was 94% in male and 81% in female and the combined sensitivity was 88%. Results Male 43 40 3 93% Whereas it was 69% in male and 63% in female and the Age of the patients ranged from 7 year to 55 year with the Female 32 27 5 84% combined sensitivity was 67% in the patients with score majority of the patients in the third decades (42%) Total 75 67 8 89% less than 7. Similar sensitivity was found in another followed by second decades (26%) (Table-II). study20. Out of 100 patients, 58 (58%) were male and 42 (42%) This study also reveals that this scoring system was more Table-VII: Sensitivity of modified Alvarado score < 7 (n=25). were female. Clinically males were more susceptible helpful in male patients by showing high accuracy rate as than female with a male-female ratio of 1.38:1 (Table-III). No of patients Acute Normal compared to female patients (Table-VIII).
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