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Association Between the Alvarado Score and Surgical and Histopathological Findings in Acute Appendicitis

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Association Between the Alvarado Score and Surgical and Histopathological Findings in Acute Appendicitis DOI: 10.1590/0100-6991e-20181901 Original Article Association between the Alvarado score and surgical and histopathological findings in acute appendicitis. Associação entre o escore de Alvarado, achados cirúrgicos e aspecto histopatológico da apendicite aguda. RICARDO REIS DO NASCIMENTO1; JAIME CÉSAR GELOSA SOUZA, TCBC-SC1; VANESSA BASCHIROTTO ALEXANDRE1; KELSER DE SOUZA KOCK1; DARLAN DE MEDEIROS KESTERING1 ABSTRACT Objective: to compare the results of the Alvarado score with the surgical findings and the results of the histopathological examination of the appendix of patients operated on for acute appendicitis. Methods: we conducted an observational study with a cross-sectional design of 101 patients aged 14 years and over undergoing emergency appendectomy. The evaluation comprised the Alvarado score, gender, age, ethnicity and time of evolution. We obtained data regarding the surgical aspect of the appendix, postoperative complications and the result of the histopathological examination. The pre- established confidence interval was 95%. We calculated sensitivity, specificity, positive and negative predictive values of the score, and performed an analysis through the ROC curve. Results: we found a statistically significant (p=0.002) association between the Alvarado score and the diagnostic confirmation using a cutoff score of six or greater, with a sensitivity of 72% and a specificity of 87.5%. A score greater than or equal to six showed a greater tendency to present more advanced stages of acute appendicitis in both surgical and histopathological findings when compared with a score lower than six. Males presented greater chances of complications when compared with females (p=0.003). Conclusion: the Alvarado score proved to be a good method for diagnostic screening in acute appendicitis, since scores greater than or equal to six are associated with a higher probability of diagnostic confirmation and more advanced stages of the acute disease. Keywords: Appendectomy. Diagnosis. Emergencies. Appendicitis. INTRODUCTION patients, especially during the initial stages1. In such cases, imaging research may be useful in bdominal pain is the most prevalent establishing a correct diagnosis7. Among the exams, 1 Apresentation in emergency care , acute there is a limited role in radiological examination, appendicitis (AA) being the most common cause which is useful to rule out other diseases that cause 2 of abdominal urgency , and appendectomy, acute abdomen. Ultrasonography has a high rate of the gold standard for AA treatment, is the most false positive and false negative results8. Computed frequently performed emergency surgery in the tomography is the exam of choice due to its high world3. Approximately 90 to 100 patients per sensitivity and specificity9, but it is expensive and 100,000 inhabitants will have this disease per year4 not available in all centers. In addition, in cases of and it is estimated that the risk of developing AA typical AA, its use may delay appendectomy and throughout life is between 7% and 8%3, 8.6% in increase the risk of perforation10. The definitive men and 6.7% in women5. This incidence is higher method for confirming the diagnosis of AA is the in adolescents and young adults, the population histopathological examination of the appendix11. most affected between 25 and 35 years of age6. Clinical diagnosis may lead to a non- The classic form of AA can be readily therapeutic appendectomy rate of 15% to 30%12, diagnosed and treated. However, the presence and the rate of undiagnosed perforated AA may of atypical features may make diagnosis difficult, reach 3.4%, since AA symptoms may overlap with since typical symptoms and compatible laboratory urologic, abdominal, and gynecological ones13. abnormalities may be absent in 20% to 33% of Thus, late or incorrect diagnosis can result in multiple 1 - UNISUL - University of Southern Santa Catarina, School of Medicine, Tubarão, SC, Brazil. Rev Col Bras Cir 45(5):e1901 do-Nascimento 2 Association between the Alvarado score and surgical and histopathological findings in acute appendicitis. complications, such as surgical site infections, southern Santa Catarina. We excluded patients perforation, abscesses, sepsis and death14. Correct that had missing data and those unable to provide diagnosis and early surgical intervention are the the information necessary for the study. best methods to reduce morbidity and mortality, The applied interview contained the hospitalization time and treatment costs15. patients' gender, age and ethnicity, time of It is relevant to incorporate in clinical evolution and the Alvarado score. The latter practice tests such as scores that aid in the included migration of pain, anorexia, nausea and/ diagnosis of AA16. There are numerous risk or vomiting, pain at decompression of the right iliac classifications whose objective is to identify low, fossa (FID), increase in temperature and leukogram medium and high-risk patients for AA, allowing left shift. One point was added to each filled later investigations to be stratified according to the criterion, but leukocytosis and defense in the lower same17. Among these tests, the Alvarado score was right quadrant, which adding two points each19. designed with the intention of reducing the number After the end of the interview collection period, we of requested imaging tests18. Alvarado described a consulted the electronic medical records to obtain scoring system based on eight predictive clinical the surgical aspect of the appendix and the data factors to improve the assessment in the diagnosis regarding possible postoperative complications. of AA, which produces a maximum score of ten Subsequently, we accessed the data system of the points and includes symptoms and clinical signs, region reference laboratory for the results of the and laboratory findings19. histopathological examination, which provided The present study aims to compare the the report with classification in normal appendix, results of the Alvarado score with the surgical findings incipient AA, AA, purulent AA and gangrenous and the results of the histopathological examination AA20. We calculated the Alvarado score at the time of patients operated on for acute appendicitis. of the database construction. We archived and tabulated the data in METHODS a spreadsheet, using the EpiInfo 3.5.4 program The study followed the guidelines and and analyzing it with the statistical software regulatory norms for research involving human SPSS (Statistical Package for the Social Sciences) subjects proposed by Resolution nº 466/2012 of version 20.0. We present the quantitative data in the National Health Council. We collected the data measures of central tendency and dispersion and after approval of the Unisul Ethics in Research the qualitative ones in percentages and in absolute Committee - CEP - under the opinion 2,362,539, numbers. To verify the association between the and by having the consent form signed by the variables of interest, we used the Chi-square test for participants or by their guardians in cases of minors the comparison of proportions and the Student's under 18 years of age. This is an observational T-test or Man-Whitney test for comparison of means. study with a cross-sectional design. The sample The pre-established confidence interval was 95%, consisted of 101 patients aged 14 years and older p=0.05. We calculated the sensitivity and specificity with suspected acute appendicitis who underwent of the score in the studied population, as well as appendectomy in the period from April 1st to its positive and negative predictive values, and then September 30, 2017, attended at a hospital in performed an analysis through the ROC curve. Rev Col Bras Cir 45(5):e1901 do-Nascimento Association between the Alvarado score and surgical and histopathological findings in acute appendicitis. 3 RESULTS 37.5%, PPV and NPV, 94.25% and 21.43%, respectively. For values greater than or equal to Of the 101 patients evaluated, 49 seven, the sensitivity, specificity, PPV and NPV were patients were female (48.5%) and 52 male 38.71%, 87.5%, 97.3% and 10.94%, respectively. (51.5%). The median age was 29 years, with an interquartile range of 19. As for ethnicity, the majority of the patients were Caucasians, 92.1%. Regarding the Alvarado score, the most frequent presentation was sudden decompression pain in the right iliac fossa, in 92%, followed by leukocytosis in 84.2%, anorexia in 77.2%, nausea and/or vomiting in 75.2%. Migration of the pain, right lower quadrant defense of the abdomen, elevation of temperature and leukogram left shift were present at a lower frequency, 56.4%, 47.5%, 38.6% and 15.8%, respectively. For the evaluation of the Alvarado score, computing the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), as well as for the association of the Figure 1. ROC Curve. score with the other study variables, we adopted cutoff points of the score greater than or equal to The time between onset of pain and five, six and seven, according to the ROC curve. appendectomy was mostly (77.2%) between one This indicated a cutoff greater than 5.5 as being and three days, being shorter than one day in statistically significant (Figure 1). Thus, 86.1% 13.9% and greater than three days in 8.9%. The obtained a score greater than or equal to five, surgical aspect found was mostly phases I and II, 67.3% obtained a score greater than or equal to with distribution of 4% phase 0, 36.6% phase I, six, and 36.6%, greater than or equal to seven. 35.6% phase II, 20.8% phase III and 3% phase IV. Considering the analysis of the Alvarado Diagnostic confirmation with histopathology score data of the 101 participants, we observed occurred in 92.1%, with a non-therapeutic that 2% scored two points, 1% scored three appendectomy rate of 7.9%, totaling eight patients, points, 10.9% scored four points, 18.8% scored of whom 75% were female. The results of the five points, 30.7% scored six points, 17.8% scored histopathological findings were incipient AA in seven points, 5.9% scored eight points, 10.9% 7.9%, AA in 53.5%, suppurative AA in 29.7% and scored nine points, and 2.0% scored ten points.
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