Top

BMC Emergency Medicine

Published in:

Open Access 01-12-2023 | Appendicitis | Research

Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis

Authors: Eszter Mán, András Szilágyi, Zsolt Simonka, Ferenc Rárosi, Zoltán Pető, György Lázár

Published in: BMC Emergency Medicine | Issue 1/2023

Abstract

Introduction

The aim of our prospective study was to confirm validity and diagnostic accuracy of the modified Alvarado score, which was developed at the Department of Surgery, University of Szeged, on patients presenting with symptoms suggestive of acute appendicitis (right lower quadrant complaints) at the A&E department.

Patient population, methods

138 patients were included in our study between 01.01.2019 and 01.01.2020. For patients attending A&E, the first medic calculated and recorded the modified Alvarado score before surgical consultation. The consulting surgeon decided on further treatment without knowing the score. Validation of the score was based on the pathology report of the removed appendix (whether the operation was warranted, and if the score also supported indication for surgery), if there was readmission or surgery due to worsening symptoms after discharge from A&E. We also examined if there was any connection between the value of the Alvarado score and the severity of inflammation. Our aim was to prove that using modified Alvarado score at the A&E Units helps to reduce patient’s waiting time and avoid unnecessary surgical consultations. Furthermore our study included measuring the diagnostic accuracy of the ultrasound examination (specificity, sensitivity).

Results

Based on the results, patients presenting at A&E had a mean modified Alvarado score of 6.5. Comparing the score to histological results showed that the specificity of the modified Alvarado score was 100%, and its sensitivity was 80.7%. Based on Spearman’s rank correlation (0.796) and ROC analysis (AUC 0.968), the modified Alvarado score has an excellent predictive value in diagnosing acute appendicitis. When comparing the patients’ waiting times with the use of modified Alvarado score and without it we found that there was a significant difference in group also in group under 4 points and in group over 7 points when using modified Alvarado score, so the diagnostic and therapeutic algorithm should be much quicker with the help of the score. We found a correlation between the severity of inflammation based on the Fisher’s exact test. Rank correlation of the same question also showed a significant connection. All patients had an US examination during their diagnostic course, its sensitivity was 82.6%, specificity was 87%. Based on this, we can conclude that the predictive value of the imaging method is good.

Conclusions

We can conclude according to our results that the predictive value of the modified score is excellent, and it can be safely applied by non-surgeons in urgent care in the differential diagnosis of acute appendicitis. The new score incorporates the results of an easily obtainable, ionising radiation free imaging method, the ultrasound, which was not included in previous scores. With the help of the new score, the number of unnecessary surgical referrals and waiting times for patients are reduced, excess examinations will become avoidable.

Ferris M, Quan S, Kaplan BS, Molodecky N, Ball CG, Chernoff GW, Bhala N, Ghosh S, Dixon E, Ng S, Kaplan GG. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg. 2017;266:237–41. https://doi.org/10.1097/SLA.0000000000002188CrossRefPubMed

Eurostat. Surgical operations and procedures Surgical operations and procedures statistics. In: Eurostat Statistics Explained. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Surgical_operations_and_procedures_statistics Accessed: 2020 September.

Antal A. Változások az akut appendicitis epidemiológiájában, etiológiájában, diagnózisában és terápiájában. [Changes in epidemiology, etiology, diagnostics, and therapy of acute appendicitis]. Orv Hetil. 2009;150:443–6. https://doi.org/10.1556/oh.2009.28570. [Article in Hungarian].CrossRefPubMed

Saverio S, Di, Birindelli A, Kelly MD. Et. Al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. W Journ Em Surg. 2016;11:34. https://doi.org/10.1186/s13017-016-0090-5CrossRef

Saverio S, Di, Podda M, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. W J Em S. 2020;15:27. https://doi.org/10.1186/s13017-020-00306-3CrossRef

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15:557–64. https://doi.org/10.1016/S0196-0644(86)80993-3CrossRefPubMed

Kularatna M, Lauti M, Haran C, MacFater W, Sheikh L, et. al. Clinical prediction rules for appendicitis in Adults: Which is the best? World J Surg. 2017; 41:1769–1781. https://academic.oup.com/bjs/article/107/12/e594/6120985?login=true

Elsherbiny MW, Emile SH, Abdelnaby M, Khafagy W, Elshobaky A. Assessment of the Diagnostic Accuracy of Alvarado Scoring System Combined with Focused Ultrasound in the Diagnosis of Acute Appendicitis. BR J Surg. 2020; 107:e594-e595. https://academic.oup.com/bjs/article/107/12/e594/6120985?login=true

Gupta S, Kolli VS, Da Costa K, Javed S, Ammar A, Rasheed A. A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis. Ann Med Surg (Lond). 2023;85(2):111–21. https://doi.org/10.1097/MS9.0000000000000238. eCollection 2023 Feb.CrossRefPubMed

10.

Eszter M, Zsolt S, Ákos V, Ferenc R, György L. Impact of the Alvarado score on the diagnosis of acute appendicitis: comparing clinical judgment, Alvarado score, and a new modified score in suspected appendicitis: a prospective, randomized clinical trial. Surg Endosc. 2014;28:2398–405. https://doi.org/10.1007/s00464-014-3488-8CrossRef

11.

Denizbasi A, Unluer EE. The role of emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med. 2003;10:296–301. https://doi.org/10.1097/00063110-200312000-00011CrossRefPubMed

12.

Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, Kim DW, Kim YH, Lee KH, Kim SY, Lee CC, Singer AJ. The accuracy of emergency medicine and surgical resident in the diagnosis of acute appendicitis. Am J Emerg Med. 2010;28:766–70. https://doi.org/10.1016/j.ajem.2009.03.017CrossRefPubMed

13.

Ünlüer EE, Urnal R, Eser U, Bilgin S, Hacıyanlı M, Oyar O, Akoğlu H, Karagöz A. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis. World J Emerg Med. 2016;7:124–9. https://doi.org/10.5847/wjem.j.1920-8642.2016.02.007CrossRefPubMedPubMedCentral

14.

Chang ST, Jeffrey RB, Olcott EW. Three-step sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use. AJR Am J Roentgenol. 2014;203:1006–12. https://doi.org/10.2214/AJR.13.12334. https://www.ajronline.org/doi/CrossRefPubMed

15.

Hwang ME. Sonography and computed tomography in diagnosing Acute Appendicitis Radiol Technol. 2018;89:224–37. http://www.radiologictechnology.org/content/89/3/224.long

16.

Altomare M, Cimbanassi S, Chiara O, Salvi PF. Acute Appendicitis. Update of clinical scores. Ann Ital Chir. 2019;90:231–7. https://www.annaliitalianidichirurgia.it/wp-content/uploads/2019/07/08_2944blocco.pdfPubMed

17.

Ohle R, O’Reilly F, O1Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting appendicitis: a systematic review. BMC Med. 2011;9:139. https://doi.org/10.1186/1741-7015-9-139CrossRefPubMedPubMedCentral

18.

McKay R, Shepherd J. The use of clinical scoring system by Alvarado in the decision to perform computed tomograpy for acute appendicitis in the ED. Am J Emerg Med. 2007;25:489–93. https://doi.org/10.1016/j.ajem.2006.08.020CrossRefPubMed

19.

Jones RP, Jeffrey RB, Shah BR, Desse TS, Rosenberg J, Olcott EW. Journal club: the Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults. AJR Am J Roentgenol. 2015;204:519–26. https://doi.org/10.2214/AJR.14.12864CrossRefPubMed

20.

Reddy SB, Kelleher M, Bokhari SAJ, Davis KAD, Schuster KM. A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis. J Trauma Acute Care Surg. 2017;83:643–9. https://doi.org/10.1097/TA.0000000000001551CrossRefPubMed

21.

Tan WJ, Pek W, Kabir T, Goh YC, Chan WH, Wong WK, Ong HS. Alvarado score: a guide to computed tomography utilization in appendicitis. ANZ J Surg. 2013;83:748–52. https://doi.org/10.1111/ans.12076CrossRefPubMed

22.

Tan WJ, Acharyya S, Goh YC, Chan WH, Wong WK, Ooi LL, Ong HS. Prospective comparison of the Alvarado score and CT scan in the evaluation in suspected appendicitis: a proposed algorithm to guide CT use. J Am Coll Surg. 2015;220:218–24. https://doi.org/10.1016/j.jamcollsurg.2014.10.010CrossRefPubMed

23.

Noori IF, Jabbar AS, Noori AF, Clinical Scores. (Alvarado and AIR scores) versus imaging (ultrasound and CT scan) in the diagnosis of equivocal cases of acute appendicitis: a randomized controlled study. Ann Med Surg (Lond). 2023 Mar;14(4):676–83. https://doi.org/10.1097/MS9.0000000000000270. eCollection 2023 Apr.

24.

Bass AG, Mohseni S, Ryan ÉJ, Forssten MP, Tolonen M, Cao Y, Kaplan LJ. ESTES Snappapy Group Clinical Practice selectively follows acute appendicitis guidelines. Eur J Trauma Emerg Surg. 2023;49(1):45–56. https://doi.org/10.1007/s00068-022-02208-2. Published online 2023 Jan 31.CrossRefPubMedPubMedCentral

25.

Teng TZJ, Thong RX, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis- advances and controverseries. World J Gastrointest Surg 20213(11):1293–314. https://doi.org/10.4240/wjgs.v13.j11.1293

26.

Andersson M, Kolodziej B, Andersson RE. Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis. Br J Surg. 2017;104:1451–61. https://doi.org/10.1002/bjs.10637CrossRefPubMed

27.

Sammalkorpi HE, Mentula P, Leppäniemi A. A new adult appendicitis score improves diagnostic accuracy of acute appendicitis - a prospective study. BMC Gastroenterol. 2014;14:114. https://doi.org/10.1186/1471-230X-14-114CrossRefPubMedPubMedCentral

28.

Kollar D, McCartan DP, Bourke M, Cross KS, Dowdall J. Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory response score and clinical assessment. World J Surg. 2015;39:104–9. https://doi.org/10.1007/s00268-014-2794-6CrossRefPubMed

29.

Coleman JJ, Carr BW, Rogers T, Field MS, Zarzaur BL, Savage SA. The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain. J Trauma Acute Care Surg. 2018;84:946–50. https://doi.org/10.1097/TA.0000000000001885CrossRefPubMed

30.

Andert A, Alizai HP, Klink CD, Neitzke N, Fitzner C, Heidenhain C, et al. Risk factors for morbidity after appendectomy. Langenbecks Arch Surg. 2017;402:987–93. https://doi.org/10.1007/s00423-017-1608-3CrossRefPubMed

31.

Pedro GT, Sivrikoz E, Inaba K, Talving P, Lam L, Demetriades D. Appendectomy timing: waiting until the next morning increases the risk of surgical site infections. Ann Surg. 2012;256:538–43. https://doi.org/10.1097/SLA.0b013e318265ea13CrossRef

32.

Quevedo-Fernandez E, Gonzalez-Urquijo M, Hinojosa-Gonzalez DE, Morales-Flores LF, Morales-Morales CA, Zambrano-Lara M, Guajardo-Nieto D, Rodarte-Shade M. Analysis of deferral times in patients diagnosed with acute appendicitis. Asian J Surg. 2023;46:1187–92. https://doi.org/10.1016/j.asjsur.2022.08.053CrossRefPubMed

Title: Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis
Authors: Eszter Mán
András Szilágyi
Zsolt Simonka
Ferenc Rárosi
Zoltán Pető
György Lázár
Publication date: 01-12-2023
Publisher: BioMed Central
Keywords: Appendicitis
Appendicitis
Ultrasound
Ultrasound
Published in: BMC Emergency Medicine / Issue 1/2023
Electronic ISSN: 1471-227X
DOI: https://doi.org/10.1186/s12873-023-00846-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis

Abstract

Introduction

Patient population, methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Patient population, methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2023

Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites

Editorial: Optimizing opioid prescriptions in the emergency department

Real-time monitoring of vitamin C levels in trauma patients by electron-spin resonance spectrometry

Teledermatology in an emergency department: benefits and gaps

Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea

Prehospital factors associated with out-of-hospital cardiac arrest outcomes in a metropolitan city: a 4-year multicenter study