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Modified Alvarado Scoring System in the

Diagnosis of Acute Appendicitis

Article · July 2008

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 Original Article

Modified Alvarado Scoring System in the Diagnosis of

Acute Appendicitis
Khalid Munir, Javaid Iqbal, Umar Mushtaq, Irfan Ishaque, Mudassar Jabeen, Afshan Khalid

ABSTRACT
Introduction: Appendectomy is a common Results: In group A, overall negative appendectomy
emergency procedure. Negative appendectomy rate rate was 20 % while gender based negative
is up to 33 %. As it is associated with the risks of appendectomy rate was 28.5% in Females and 12 %
anesthesia like any operation, it should be avoided in males. In group B overall negative appendectomy
where possible. Modified Alvarado score is one of rate was 14 % while gender based negative
the probable ways to reduce this rate. Our objective appendectomy rate was l7.6% in females and 7.6%
of the study was to evaluate its value in reducing the in males. Over all reduction through modified
percentage of the negative appendectomy. Alvarado score was insignificant (chi-square 0.480,
Methods: A non randomized controlled trial was df 1, p value 0.488). Similarly, statistically
conducted at Emergency Department of DHQ significant reduction could not be found both in
Hospital Faisalabad over the period of 6 months. 60 female (chi-square 0.524, df 1, p value 0.469) and
patients were divided into two groups. In group A, male (chi-square 0.179, df 1, p value 0.672) groups.
1st consecutive 30 patients were included who had Conclusion: Modified Alvarado score is not helpful
indication for appendectomy based on the choice of in significant reduction of the over all percentage of
the surgeon while in group, B 30 patients having the negative appendectomy. Similarly, statistically
indication for appendectomy based on modified significant reduction could not be found both in
Alvarado score 7 or more were included. Surgically female and male groups. Further methods of
removed appendix was evaluated by histopathology evaluation should be used especially in females.
for the presence or absence of inflammation. Both Key Words: Modified Alvarado score, Negative
groups were compared for the percentage of the Appendectomy.
negative appendectomy.

INTRODUCTION
Pain in the right iliac fossa is a common negative appendectomy such as use of modified
presentation in the emergency. Acute appendicitis is Alvarado score [2] and evaluation by CT scan [3].
one of the differential diagnoses. Emergency According to the modified Alvarado scoring system
appendectomy is usually done in these patients if there (Table-1), symptoms, signs and increased total
is decision to operate on the choice of the surgeon or
leukocyte count (TLC) are given numerical values and
surgical resident on the overall clinical suspicion. It
has been observed that many patients undergoing patients are scored out of 9. Surgery is indicated in
appendectomy prove to be negative [1] on the patients with score 7 or more.
histopathology of the surgically removed appendix, The use of this scoring system was intended to
which is gold standard for the diagnosis of the improve the decision making and to reduce the
appendicitis. As negative appendectomy is a big issue percentage of the negative appendectomy in this
associated with the risks related with any of the common condition. The performance of this system
surgical procedures under general anesthesia, so it however had not been uniform [4, 5]. Our intention
should be avoided where possible. Many suggestions was to evaluate the role of this system in reducing the
have been given to reduce the percentage of the percentage of the negative appendectomy.
A.P.M.C Vol: 2 No.2 July-December 2008 91
MATERIALS AND METHODS All the data was entered in SPSS version 10 and was
A non randomized controlled trial was subjected to analysis. Percentage of negative
conducted at emergency department of DHQ hospital appendectomy among the patients undergoing
attached with Punjab medical college Faisalabad over emergency appendectomy based on the choice of
the period of 6 months. 60 patients were included in surgeon and those based on the modified Alvarado
the study. They were divided in to two groups. In scoring systems was calculated by using descriptive
group A, 1st consecutive 30 patients presenting with statistics. Chi-square was used to compare percentage
pain in right iliac fossa, in Emergency Department of of negative appendectomy between the two groups. A
DHQ Hospital and having indication for value less than .05 was considered as significant.
appendectomy based on the choice of the surgeon after
evaluation through history, examination, and lab RESULTS
investigation, but not having mass in the right iliac In group A [Table 2] negative appendectomy
fossa clinically as well as on ultrasonography were rate was 20 %. This group comprised of 30 patients,
included. While in group B, next consecutive 30 out of which 16 were males and 14 were females.
patients presenting with pain in right iliac fossa, in Mean age was 30 ranging from 8 years to 80 years. 6
Emergency Department of DHQ and having indication out of 30 patients had negative appendectomy, out of
for appendectomy based on Alvarado score 7 or more
which 4 were females (negative appendectomy rate
were included after exclusion of mass in right iliac
fossa on physical examination and ultrasound. On the 28.5%) and two were males (negative appendectomy
basis of history, examination and increased TLC, rate 12%). Females with negative appendectomy had
Alvarado scoring was calculated according to the PID (2 cases), ruptured ovarian cyst (1 case), no
Table-1. detectable pathology (1 case).
Table-1 Table-2
The Modified Alvarado Score Group A
Symptoms Score No. of No. of patients Percentage
Migratory right iliac fossa pain 1 Patients with negative
Anorexia 1 appendectomy
Nausea/vomiting 1 Males 16 2 12 (among
Signs males)
Tenderness right lower abdomen 2 Females 14 4 28.5
Rebound tenderness right iliac fossa 1 (among
Pyrexia greater than or equal to 37.5º 1 females)
Investigations Total 30 6 20
Leucocytosis 2
Total Score 9 In group B [Table 3], negative appendectomy rate was
14%.
Patients were provided with details of appendectomy
Table-3
along with risk benefit ratio (hazards of anesthesia,
Group B
duration of procedure, chances of complication,
hospital stay and pain) to get informed consent, after No. of No. of patients Percentage
approval from ethical committee. Emergency Patients with negative
appendectomy was done by the resident surgeon or by appendectomy
the senior registrar in both the groups. Per operative Males 13 1 7.6 (among
findings were noted. After removal, appendix was sent males)
for histopathology. Negative appendectomy was Females 17 3 17.6
labeled in the cases having no signs of inflammation (among
on histopathology of surgically removed appendix. females)
Proforma was used to collect data. Total 30 4 14

A.P.M.C Vol: 2 No.2 July-December 2008 92

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A.P.M.C Vol: 2 No.2 July-December 2008 93

 AUTHORS
• Dr. Khalid Munir • Dr. Irfan Ishaque
Postgraduate Resident Surgery Postgraduate Resident Plastic Surgery
Allied Hospital, Faisalabad. Services Hospital, Lahore.
• Dr. Javaid Iqbal • Dr. Mudassar Jabeen
Professor of Surgery & Postgraduate Resident Surgery
Head of Surgical Unit-III Allied Hospital, Faisalabad.
PMC/Allied Hospital, Faisalabad. • Dr. Afshan Khalid
• Dr. Umar Mushtaq Postgraduate Resident Gynae & Obst.
Demonstrator Physiology Allied Hospital, Faisalabad.
Sheikh Zayed Medical College,
Rahim Yar Khan.  

A.P.M.C Vol: 2 No.2 July-December 2008 94

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