Sensitivity and specificity of the Alvarado Score for the timely differential diagnosis of acute appendicitis for a case series in Samoa

Diagnostic Efficacy Study Comparing Tzanakis Scoring System With Alvarado Scoring System in Effective Diagnosis of Acute Appendicitis

Objective Among the common causes of abdominal emergencies, acute appendicitis ranks at the top, particularly in the young population. While negative appendectomy is not uncommon, the risk of appendicular perforation is substantial if the diagnosis is missed or delayed. This study evaluated the diagnostic efficacy of the Tzanakis scoring system for acute appendicitis, comparing it with the Alvarado scoring system, considering the histopathological finding as the gold standard. Materials and methods This prospective observational study, conducted in the General Surgery department in a tertiary care hospital in India, included clinically diagnosed acute appendicitis cases posted for open or laparoscopic appendicectomy. Results The mean age for the 60 participants included in the study was 30.97±13.44, and the median was 24.5 yrs. The sensitivity of ultrasonography (USG) in diagnosing histopathological positive acute appendicitis was 89%, and the specificity was 50%. The sensitivity, specificity, positive, and negative predictive values of the Tzanakis score were 87%, 50%, 96%, and 22%, respectively, and those of the Alvarado score were 54%, 75%, 96%, and 10%, respectively. Conclusion The receiver operator characteristic (ROC) curve for the Alvarado and Tzanakis scores showed that the area under the curve (AUC) was greater for the Tzanakis scoring system (0.670) than for the Alvarado scoring system (0.598). Differences between the AUCs were not statistically significant. Although the Tzanakis scoring system is more sensitive than the Alvarado scoring system in diagnosing acute appendicitis, studies with larger samples are needed to show the superiority of this scoring system over the Alvarado scoring system.

Predictive Factors of Acute Appendicitis in Children With Non-Visualized Appendix on Ultrasound: A Prospective Cohort Study

Background: Most studies have demonstrated the high accuracy of ultrasound for the diagnosis of acute appendicitis (AA) in children. However, the lack of visualization of the appendix on ultrasound is usually a challenge. The aim of this study was to identify any factors that might help the physician make the right decision when dealing with a child with suspected appendicitis and an appendix not seen on ultrasound. Patients and Methods: After receiving Institutional Review Board approval, we conducted a prospective study in a pediatric emergency department from January 1, 2022, to December 31, 2022. All children under 14 years of age with suspected AA and an appendix not visualized on ultrasound were included. Results: During the study period, 333 children presented with suspected AA. Of these patients, 106 had an appendix not seen on ultrasound. Our patients' median age was 10 years (interquartile range [IQR], 8-11 years), with 54.7% (n = 58) of children being female. Twenty-five (23.6%) were ultimately diagnosed with AA based on pathologic examination. Multivariable logistic regression analysis revealed that Alvarado score ≥6 and increased peri-appendiceal fat echogenicity were predictive for AA. The combination of these two factors provided a positive predictive value of 100%. A white blood cell (WBC) count ≤10 × 109/L and/or a C-reactive protein (CRP) level ≤6 mg/L makes the diagnosis of appendicitis unlikely. Conclusions: In conclusion, our study demonstrated that an Alvarado score at or above six and increased peri-appendiceal fat echogenicity are independent predictive factors of AA in children with non-visualized appendix on ultrasound. The combination of these two factors would confirm the diagnosis of AA in these patients.

Diagnosis of Acute Appendicitis: A Cross-sectional Study on Alvarado's Score from a Low Income Country

Background

Alvarado score is the most widely used scoring system for diagnosing acute appendicitis, globally. There have been concerns regarding the diagnostic accuracy of this score as it was shown to have lower sensitivity in certain populations like Blacks and Asians. Despite its wide clinical use in the Ethiopian set up, the diagnostic accuracy of this score remained largely unexamined in this population.

Methodology

A prospective cross-sectional study was conducted and all adult patients who presented with right lower quadrant abdominal pain and evaluated with a clinical impression of acute appendicitis were enrolled in the study. Data was collected by trained surgical residents over a period of six months (August 2019- January 2020) and analysed using SPSS version 25.

Results

A total of 235 patients were enrolled in this study among whom two thirds were males. The majority of the study participants (61.7%) had an Alvarado score of ≥7 while almost a quarter of them had a score of <4. The mean Alvarado score in this study was 7 ± 1.8 whereas the median and the mode were 7 and 9 respectively. The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score were 99.1%, 55.6%, 98.2% and 62.5% respectively. The sensitivity and specificity of this score was superior in males compared to females (99.3% vs 97.6% and 80% vs 25%). A score of ≥5 was found to have a sensitivity of 98.4%.

Conclusion

Alvarado score was found to have good sensitivity and positive predictive value in this study. A score of ≥5 can be used to "rule in" the diagnosis of acute appendicitis. Hence, the use of Alvarado score's in the Ethiopian setup is to be encouraged.

Assessment of the Diagnostic Reliability of Modified Alvarado Scores and Abdominal Ultrasonography in Acute Appendicitis

Introduction Acute appendicitis is a common surgical emergency. Clinical assessment plays a major role; however, subtle clinical features in early stages and atypical presentation makes diagnosis challenging. Ultrasonography (USG) of the abdomen is a usual investigation that aids in diagnosis, however, it is operator dependent. A contrast-enhanced computed tomography (CECT) of the abdomen is more accurate; however, it exposes the patient to hazardous radiation. The study aimed to combine clinical assessment and USG abdomen in the reliable diagnosis of acute appendicitis. Objectives The objective of this study was to assess the diagnostic reliability of the Modified Alvarado Score and ultrasonography of the abdomen in acute appendicitis. Material and methods All patients with right iliac fossa pain, clinically suspected of having acute appendicitis, admitted to the department of general surgery, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar, between January 2019 and July 2020, who gave consent were included. Clinically, Modified Alvarado Score (MAS) was calculated, after which patients were subjected to USG abdomen, where findings were noted and a sonologic score was calculated. The study group was the patients who needed appendicectomy (n=138). Operative findings were noted. Histopathological diagnosis of acute appendicitis was deemed as confirmatory in these cases and was correlated with MAS and USG scores to determine diagnostic accuracy. Results A combined clinicoradiological (MAS + USG) score of seven showed a sensitivity of 81.8% and a specificity of 100%. The specificity of score seven or above was 100%; however, the sensitivity at 81.8%. The diagnostic accuracy of the clinicoradiological was 87.5%. The negative appendicectomy rate was 4.34%, with a diagnosis of acute appendicitis being confirmed for 95.7% of patients upon histopathological examination. Conclusion The MAS and USG of the abdomen, which is an affordable and non-invasive tool, showed increased diagnostic reliability, and hence it can help reduce the use of CECT abdomen, as CECT abdomen is considered as a gold standard for confirmation or exclusion of diagnosis of acute appendicitis. Use of the combined scoring system of MAS and USG abdomen can be used as a cost-effective alternative.

The Role of Alvarado Score in Predicting Acute Appendicitis and Its Severity in Correlation to Histopathology: A Retrospective Study in a Qatar Population

Background/objective

Acute appendicitis (AA) is one of the most common surgical emergencies that require a proper diagnosis to avoid a negative outcome in the case of missed or delayed diagnosis. Our study aims to assess the diagnostic power of the Alvarado score and the prediction of the severity of acute appendicitis in correlation to intraoperative findings and the final histopathology (HP) result.

Methods

This retrospective study was applied to 1,303 patients with clinically proven acute appendicitis (AA) and available HP results. We correlated Alvarado score to the gold standard HP and intraoperative findings. We selected the cutoff point of Alvarado at 5 and 7 as they were the most frequent cutoff value mentioned in the literature and based on the ROC curve in this study to assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

The mean age of the study cohort is 33.3 ± 9.5 years, with a male predominance (75.8%). The negative appendectomy (NA) rate was 4%. The operative complication rate was 1.2%, and we recorded one mortality case (0.1%). The diagnostic evidence of AA was in 95.9% of cases. Alvarado score ≥ 7 presented sensitivity and specificity of 66.4% and 69.8%, respectively, with PPV of 98.1% and NPV of 8.1%, with an accuracy of 66.5%. For Alvarado score ≥ 5, the sensitivity was 91.2%, specificity was 22.6%, PPV was 96.5%, NPV was 9.8%, and accuracy was 88.4%. In addition, we demonstrated statistical significance between Alvarado risk stratification with HP and intraoperative grades (p = 0.001 each).

Conclusion

The Alvarado scoring system alone is not enough to diagnose AA with unsatisfactory sensitivity and specificity. However, it is a good indicator of the severity of AA that we can depend on to prioritize those patients waiting for surgery.