A comparison of the accuracy of Tzanakis and Alvarado Score in the diagnosis of acute appendicitis: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Acute appendicitis is one of the most commonly encountered surgical emergencies on a global level. Due to the requirement of an immediate clinical diagnosis and the presence of limited resources, clinicians and diagnosticians refer to scoring systems to diagnose this condition, among which Alvarado and Tzanakis scoring systems are widely used. This meta-analysis aims to compare the diagnostic accuracy of these two systems.

METHODS

We searched PubMed, Google Scholar, and SCOPUS databases. All studies that reported diagnostic parameters of Alvarado and Tzanakis scores in patients with suspected acute appendicitis were selected. Diagnostic values such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were extracted from the selected studies and statistical analysis was performed with Meta Disc 1.4 software. Quality assessment of the selected studies was performed using the QUADAS-2 and QUADAS-C tools. Fourteen studies were included in our meta-analysis which enrolled 2235 patients.

RESULTS

The overall sensitivity of the Tzanakis score was calculated as 0.86 (95% CI; 0.84-00.87) while the specificity was 0.73 (95% CI; 0.69-0.78). In addition, the area under the curve (AUC) was 0.9261 (SE; 0.0169) and the diagnostic Odds Ratio (OR) was 22.52 (95% CI; 9.47-53.56). The pooled sensitivity of Alvarado score was 0.67 (95% CI; 0.65-0.69) and the specificity was 0.74 (95% CI; 0.69-0.79). Moreover, the area under the curve (AUC) of the Alvarado score was 0.7389 (SE; 0.0489) and the diagnostic Odds Ratio was 4.92 (95% CI; 2.48-9.75).

INTERPRETATION AND CONCLUSION

The Tzanakis scoring system has a higher sensitivity, area under the curve, and diagnostic odds ratio when compared to the Alvarado score. However, the Alvarado score has a marginally better specificity making it more reliable in excluding acute appendicitis.

Effect of in-hospital delay on acute appendicitis severity: does time really matter?

Appendicitis is one of the most common abdominal emergencies. Evidence is controversial in determining if the in-hospital time delay to surgery can worsen the clinical presentation of appendicitis. This study aimed to clarify if in-hospital surgical delay significantly affected the proportion of complicated appendicitis in a large prospective cohort of patients treated with appendectomy for acute appendicitis. Patients were grouped into low, medium, and high preoperative risk for acute appendicitis based on the Alvarado scoring system. Appendicitis was defined as complicated in cases of perforation, abscess, or diffuse peritonitis. The primary outcome was correlation of in-hospital delay with the proportion of complicated appendicitis. The study includes 804 patients: 278 (30.4%) had complicated appendicitis and median time delay to surgery in low-, medium-, and high-risk group was 23.15 h (13.51-31.48), 18.47 h (10.44-29.42), and 13.04 (8.13-24.10) h, respectively. In-hospital delay was not associated with the severity of appendicitis or with the presence of postoperative complications. It appears reasonably safe to delay appendicectomy for acute appendicitis up to 24 h from hospital admission. Duration of symptoms was a predictor of complicated appendicitis and morbidity. Timing for appendicectomy in acute appendicitis should be calculated from symptoms onset rather than hospital presentation.

Diagnostic utility of the Alvarado scale in older adults with suspected acute appendicitis

BACKGROUND

Acute appendicitis remains as a differential diagnosis in older patients with abdominal pain. The Alvarado scale may assist to guide the diagnosis and treatment of this entity. The operative characteristics of the scale are little known in this population.

METHOD

We conducted a systematic review of original studies published between 1986 and 2022 evaluating the diagnostic performance of the Alvarado scale in older adults with suspected acute appendicitis. The review was conducted according to the PRISMA statement. The evaluation of the methodological quality of the studies was performed according to the ROBINS-I criteria.

RESULTS

Four original studies of retrospective design including 480 patients were identified. The heterogeneity and poor methodological quality limited an aggregate statistical analysis (meta-analysis). The value of the ROC curve of the scale varies between 0.799 and 0.969. From the available studies, the value of the ROC curve is lower in comparison to the RIPASA scale and comparable to the Lintula scale.

CONCLUSIONS

The evidence on the diagnostic performance of the Alvarado scale in older adults is limited. The poor methodological quality of the available studies calls for a prudent use of this tool in this population. Our findings offer opportunities for future research.

Risk of Conversion from Laparoscopic Appendectomy to Open Surgery: The Role of Clinical and Radiological Factors in Prediction

Introduction: Laparoscopic appendectomy is the most preferred surgical method in the treatment of acute appendicitis. In our study, we aim to determine the clinical and radiological factors affecting conversion from laparoscopic appendectomy to open surgery. Materials and Methods: All patients older than 18 years, who were operated on with the diagnosis of acute appendicitis in the General Surgery clinic of Prof. Dr. İlhan Varank Training and Research hospital between January 2020 and January 2022, were included in the study. The data consisting of clinical, laboratory, and radiological (computed tomography) findings of the patients were evaluated retrospectively. The patients were divided into two groups as those whose surgery was completed laparoscopically (Group 1) and those converted from laparoscopic appendectomy to open surgery (Group 2). The risk of conversion to open surgery was analyzed by binary logistic regression analysis as univariate and multivariate models. Results: Appendectomy was performed in 831 patients within the specified period. The surgery of 31 (3.73%) patients started laparoscopically; however, they were completed by converting to open surgery. Multivariable analysis showed that the risk of conversion to open surgery increased with leukocyte count, Alvarado score and with the presence of periappendiceal fluid and lymphadenopathy on CT. Conclusion: Our study shows that patients with high risk of returning to open surgery can be identified preoperatively with the risk analysis method in which clinical, laboratory, and radiological findings are evaluated together. We conclude that, starting the operation of these patients with the open technique from the beginning will prevent unnecessary expenditures and reduce morbidities.

The Value of the Alvarado Score for the Diagnosis of Acute Appendicitis in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Relevant guidelines recommend the use of the Alvarado score (AS) to assist in the diagnosis of acute appendicitis (AA) in children. To provide reference evidence for the clinical application of AS, we performed a meta-analysis of studies related to the diagnostic accuracy of AS in children with AA.

METHODS

We searched the relevant literature from databases including CNKI, WanFangdata, VIP, CBM, the Cochrane Library, PubMed, Embase, and Web of Science databases from the date of database creation to April 30, 2022, and screened them according to nadir criteria, followed by data extraction and then combined effect sizes to assess the accuracy of AS for diagnosis in children.

RESULTS

Twenty-six studies involving 2579 cases were finally included, including 19 studies with Alvarado score and 8 studies with modified Alvarado Score (1 study included both Alvarado Score and modified Alvarado Score). The combined sensitivity (SE) of AS for diagnosing AA in children was 76.0% (95% CI 74.0-78.0%; I2 = 95.1%); combined specificity (SP) was 71.0% (95% CI 68.0-74.0%; I2 = 86.4%); combined positive likelihood ratio (LR+) was 2.43 (95% CI 1.92- 3.07; I2 = 78.7%); combined negative likelihood ratio (LR-) was 0.28 (95% CI 0.20-0.41; I2 = 94.2%); combined AUC = 0.8092, Q∗ = 0.7439; combined diagnostic ratio (DOR) was 8.96 (95% CI 5.65 -14.21; I2 = 76.2%). The combined effect size I2 was greater than 50% for all children with a modified AS diagnosis of AA, so all analyses used a random-effects model, which showed a combined SE of 87.0% (95% CI 85.0 - 88.0%; I2 = 85.5%); the combined SP was 47.0% (95% CI 43.0 - 51.0%. I2 = 88.7%); combined LR+ was 1.68 (95% CI 1.31-2.17; I2 = 85.9%); combined LR-was 0.28 (95% CI 0.20-0.39; I2 = 74.3%); combined AUC = 0.8672 and Q∗ = 0.7978. The combined DOR was 6.43 (95% CI 3.38-12.26; I2 = 80.0%).

CONCLUSION

The results of this meta-analysis suggest that the accuracy of AS in diagnosing AA in children is moderate, and AS can be an auxiliary tool for the diagnosis of AA in children, relying on AS alone for the diagnosis of AA is not recommended; AS can be further improved scientifically to increase its diagnostic value.

Clinical characteristics and application value of risk prediction models of acute appendicitis in rural Tibet: a retrospective study

INTRODUCTION

Acute appendicitis is the most common general surgical emergency worldwide; however, its diagnosis remains challenging, particularly in rural or remote areas such as Tibet. This study aimed to investigate the clinical characteristics and applicability of the routine risk prediction models of acute appendicitis for rural Tibetan populations.

METHODS

Data of patients who underwent appendectomy at the Chaya People's Hospital between 1 April 2018 and 30 September 2021 were retrospectively collected. Multivariate logistic regression analysis was performed to identify risk factors associated with complicated appendicitis. The appendicitis risk prediction model scores for each patient were calculated by the binary logistic regression model based on the data. The index of union method was applied to identify the optimal cut-off value for the critical values of risk prediction models.

RESULTS

We included 127 patients with suspected acute appendicitis in the study, consisting of 96 surgically and 31 non-surgically treated. The diagnoses of 93 patients who underwent appendectomy included 55 (59.1%) cases of uncomplicated appendicitis. Patients with complicated appendicitis had a significantly longer postoperative hospital stay (11.0 (interquartile range 8.8-13.3) days v 8.0 (interquartile range 6.0-11.0) days; p<0.001) and higher hospital costs (US$2147.2 (interquartile range US$1625.1-2516.6) v US$1487.9 (interquartile range US$1202.6-1809.2); p24 hours, age >30 years, and male sex were independent risk factors associated with complicated appendicitis. The appendicitis inflammatory response score showed the best performance among the prediction models. Incorporating imaging features in the prediction models may provide better diagnostic value for appendicitis.

CONCLUSION

Acute appendicitis in the rural Tibetan population has unique clinical features. To reduce the incidence of complicated appendicitis, local health workers must balance religious beliefs and professional services for residents.

RIPASA versus Alvarado score in the assessment of acute appendicitis: A prospective study

Objectives

This study aimed to compare Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado scoring to accurately identify acute appendicitis.

Material and Methods

A cross-sectional prospective study was carried out in the department of surgery. Patients were enrolled and scored using RIPASA and Alvarado scoring systems. Appendectomy was done, and the specimen was sent for histopathology examination, which was used as the gold standard for diagnosis. Among 400 recruits, 11 patients were lost to follow-up, giving us a sample size of 389 patients. The cut-off value for RIPASA and Alvarado scores was 7.5 and 7.0, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in diagnosing acute appendicitis of both scores were analyzed using SPSS.

Results

Among 389 patients, 256 (66%) were males, and 277 (71%) were under the age of 40 years. RIPASA was more than 7.5 in 345 cases, while Alvarado was more than 7.0 in 261 patients. RIPASA score had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 87.9%, 98.9%, and 65.9%, respectively. In contrast, the ALVARADO score was 71.1% sensitive and 75.8% specific. RIPASA had a diagnostic accuracy of 95.12%, while Alvarado was only 71.46% accurate in diagnosing acute appendicitis.

Conclusion

Compared to the Alvarado scoring system, RIPASA is a better tool in terms of accuracy, sensitivity, and specificity for diagnosing acute appendicitis.

Comparison of outcomes of open and laparoscopic appendectomy: A retrospective cohort study

Background

Open appendectomy has been the conventional choice of treatment for acute appendicitis. However, nowadays laparoscopic approach is emerging for the benefits it provides, like lesser postoperative pain and lesser duration of hospital stay, but at the cost of higher expenses and longer operative duration.

Methods

A retrospective cohort study was done at Shree Birendra Hospital from January 2018 to December 2021, with a total study population of 450 participants (300 in open appendectomy and 150 in laparoscopic appendectomy). Preoperative. Intraoperative and postoperative parameters were compared and analyzed between two groups using SPSS-25.

Results

The mean age was 26.72 ± 9.70 in the open appendectomy (OA) and years 23.89 ± 6.32 in the laparoscopic appendectomy (LA) group. (p = 0.010) There was a significant difference between the mean operative time (46.08 ± 13.10 min in OA and 56.86 ±  11.70 min in LA, p = 0.000), length of hospital stay (1.28 ± 0.80 days in OA and 1.07 ±  0.25 days in LA, p = 0.000), course of oral analgesics (3.55 ± 0.68 days in OA and 3.00 days in LA p = 0.000) between OA groups and LA groups, while the total number of complications was less in the LA group however there was no statistically significant difference postoperative complications (p = 0.124) between the two groups in the surgical findings.

Conclusion

All in all, the laparoscopic approach is a better option for uncomplicated appendicitis due to its less postoperative pain and shorter duration of hospital stay.

Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis

Background

Acute Appendicitis (AA) is the most common abdominal surgical emergency. It requires proper management to decrease mortality and morbidity. Clinical scoring systems for diagnosing AA aimed to decrease the use of radiological scans and the rate of negative appendectomies (NA). We aim to assess the adult appendicitis score (AAS) in the diagnosis prediction of AA.

Method

A retrospective study with 1303 cases of AA is performed. We compared the correlation of AAS and Alvarado scores to postoperative histopathology. Specificity, sensitivity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were assessed. ROC was used.

Results

AAS risk stratification was applied to the study population. Group I for a low probability, and groups II and III for an intermediate and high probability of AA. We found that 159 patients were matched in group I, 505, and 639 were in groups II and III of AAS, respectively. The correlation between Alvarado and AAS with HP was significant. AAS ≥ 16 presented sensitivity and specificity of 50 % and 75.47 %, respectively, with PPV of 97.96 % and NPV of 6.02 %, with an accuracy of 51.04 %. Regarding AAS ≥ 11, the sensitivity was 88.96 %, specificity was 39.62 %, PPV was 97.2 %, NPV was 13.21 %, and accuracy was 86.95 %.

Conclusion

AAS is relatively more accurate than Alvarado's score, especially in selecting a safe candidate for discharge from an emergency. In addition, AAS is found to decrease the need for radiological images and NA rate more than Alvarado.

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.

The diagnostic value of the systemic immune-inflammatory index in acute appendicitis cases in the emergency department

BACKGROUND AND AIM

Acute appendicitis (AA) is one of the most common causes of acute abdomen conditions and continues to cause mortality and morbidity despite all the improvements. There is still a necessity for inexpensive and easily calculable index and scoring systems with fewer side effects for the diagnosis of AA and the detection of complications. Since the systemic immune-inflammation index (SIII) is an index that could be used in this context, we aimed to measure the success and reliability of SIII for the diagnosis of AA and related complications and to contribute to the literature.

METHODS

Our study was carried out retrospectively in a tertiary care hospital and conducted with 180 AA patients (study group-SG) and 180 control group (CG) patients. Demographic data, laboratory data, and clinical data of the cases, as well as the Alvarado score (AS), adult appendicitis score (AAS), and SIII and neutrophil/lymphocyte ratio (NLR) values calculated from laboratory data, were recorded in the previously created study form. p<0.05 was accepted as the significance level for the study.

RESULTS

In this study, age and gender were similar in the SG and CG groups. SIII and NLR levels calculated in SG cases were found to be significantly higher than CG. In addition, SIII and NLR levels were found to be significantly higher in complicated AA cases than in complicated cases. Although SIII was more significant in the diagnosis of AA, NLR was more successful than SIII in detecting the presence of complications. SIII, NLR, AAS, and AS were significantly positively correlated in the diagnosis of AA. In the presence of peritonitis, SIII and NLR were also found to be significantly higher when compared to cases without peritonitis.

CONCLUSIONS

We found that SIII is a usable index in the diagnosis of AA and the prediction of complicated AA. However, NLR was found to be more significant than SIII in estimating complicated AA. In addition, it is recommended to be careful in terms of peritonitis in cases with high SIII and NLR levels.

A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis

The Alvarado score (AS) has not been widely used for diagnosing acute appendicitis although it has shown to be a good predictor for diagnosing appendicitis. The aim was to perform a systematic review of the available literature and synthesize the evidence.

Methods

A systematic review was performed as per the PRISMA guidelines using search engines like Ovid, PubMed, and Google Scholar with predefined, strict inclusion and exclusion criteria. The quality assessment of included studies was performed using the QUADAS 2 tool. Summary statistics were performed for all variables. A linear regression model was performed between dependent and independent variables using STATA software. Heterogeneity testing showed significant heterogeneity within the included studies; hence, a forest plot with pooled estimates could not be constructed, and therefore a meta-regression was performed.

Results

Seventeen full-text articles met inclusion and exclusion criteria. Ten of which were identified as low-risk studies. Five studies were included in final data pooling with total patients being 2239 and mean age of 31.9 years. (1) Linear regression demonstrated an association between 'histological appendicitis' and 'AS 7-0' with patients receiving intervention, with a significant P value of less than 0.005. (2) Meta-regression demonstrated a positive coefficient (0.298), a positive Z score of 2.20 with a significant P value of 0.028 for patients with 'high AS' who received interventions that were significantly proven to be 'histologically appendicitis', indicating a cause-and-effect relationship.

Conclusion

High AS (7 and above) is a significant predictor of acute appendicitis. The authors recommend further prospective randomized clinical trials to establish a cause-and-effect relationship.

Comparison of Alvarado score, appendicitis inflammatory response score (AIR) and Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score in predicting acute appendicitis

Introduction

Acute Appendicitis is the most common surgical emergency encountered in emergency departments. To prevent the rate of negative appendectomies, different systems i.e. Alvarado score and Appendicitis Inflammatory Response Score (AIR) scores were used, but their diagnostic accuracy in Asian population is questionable. Raja Isteri Pengiran Anak Saleha (RIPASA) score has showed promising results in the recent literature. The purpose of this study is to compare the efficacy of Alvarado, AIR and RIPASA scores in the diagnosis of acute appendicitis.

Methods

Alvarado, AIR and RIPASA scores were prospectively applied to 132 included patients that were admitted with provisional diagnosis of acute appendicitis and then their surgery was performed in General Surgery Unit, Hayatabad Medical Complex Peshawar, Pakistan from 1st January 2022 to 31st July 2022. Final diagnosis was confirmed by histopathology report and scores were correlated with final report. Cut off value of score >7, >5 and >7.5 were set for Alvarado, AIR and RIPASA score, respectively according to previous literature. Statistics analysis was done for all 3 scoring systems on SPSS version 23.

Results

Of 132 patients, there were n = 79(59.8%) males and n = 53(40.2%) females. Mean age was 24 years (SD ± 11.6) with youngest patient of 9 years and oldest one was 70 years old. Negative Appendectomy rate was 8.3%(n = 11). RIPASA score was superior to AIR and Alvarado score in Sensitivity, NLR, Accuracy and Area under the Curve. AIR score performed better in specificity, NPV, PLR compared to RIPASA and Alvarado score.

Conclusion

RIPASA score is an overall better scoring system in diagnosing acute appendicitis in compared to Alvarado and AIR score.

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

Background

Timely diagnosis of acute appendicitis (AA) is essential for optimal management of abdominal pain emergency presentations. Improved diagnostic procedures should minimise progression to complicated appendicitis, as well as reduce the number of unwanted surgical interventions. The Alvarado Score is an important tool to assist with the management of AA based on clinically predictive values. The aim of the present study was to evaluate the sensitivity and specificity of the Alvarado Score as an instrument for the diagnosis of AA in our low-resourced context of Samoa.

Materials and methods

The lead investigator performed a retrospective clinical data review design of all patients admitted to the Tupua Tamasese Meaole Hospital Surgical Unit for AA from January 2015 to December 2016. Exclusion criteria were appendiceal abscess and/or mass, and final diagnosis ‘not acute appendicitis’. Age, sex, village, Alvarado Score, Ultrasound Scan Result, surgical management, and histopathology result were the main variables entered into the SPSS statistical software package for analysis.

Results

Of the 225 patients (2–86 years) admitted for AA, 67.1% (N = 151) underwent appendicectomy, and the remaining 32.9% (N = 74) were treated with antibiotics. An Alvarado Score (≥5) showed 91.7% sensitivity and 50% specificity for AA. There was a significant relationship between the Alvarado Score and the Ultrasound Scan for AA (p < 0.05). Histology results showed complicated AA in 68.6% (N = 94) of cases. The negative appendicectomy rate was 2.6%.

Conclusions

The Alvarado Score is an effective tool for the timely differential diagnosis of AA in our Samoan context. The high rate of complicated acute appendicitis warrants investigation to further improve the management of AA in the Pacific Island setting.

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Effective instrument required for the timely diagnosis of appendicitis in low-resource contexts

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Alvarado Score is an effective tool for the differential diagnosis of acute appendicitis

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High specificity demonstrated for use of Alvarado Score in the emergency department of Samoa

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Histology results showed high rate of complicated acute appendicitis in Samoa

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Surgical outcomes showed low negative appendicectomy rate

Non-diagnostic sonography may reduce negative appendicectomy rate in women when combined with abbreviated Alvarado score

BACKGROUND

The diagnosis of acute appendicitis (AA) remains a clinical one, with selective use of adjunct imaging. Patients with equivocal clinical presentation often undergo a diagnostic laparoscopy. To help reduce negative appendicectomy rates in women, we aimed to develop a simple scoring system based on the Alvarado score (AS) and ultrasound scan (US), as a diagnostic aid for AA in females.

METHODS

All patients who underwent appendicectomy for AA at The Alfred Hospital Melbourne between 1 July 2012 and 30 June 2017 were included for this case-control study. Logistic regression was used to identify pre-operative parameters predictive of AA. Histopathological identification of AA was interpreted as the gold standard. Statistical analysis was performed using IBM SPSS Statistics V26.

RESULTS

A total of 1194 patients were included, with 26% negative appendicectomy rate in women. Of the 8 parameters in the AS, logistic regression identified migratory pain, leukocytosis and leukocyte left shift as most significant predictors for AA. These three parameters were used in a 3-point test which carried a sensitivity of 92.1% and specificity of 28.7%. In women, a negative or non-diagnostic US improved the negative predictive value of the 3-point test from 57% to 82%.

CONCLUSION

The 3-point abbreviated AS in combination with US may be clinically useful in women to exclude appendicitis without diagnostic laparoscopy. Further large-scale prospective studies are required to validate the utility across different subgroups.

Is "pain before vomiting" useful?: Diagnostic performance of the classic patient history item in acute appendicitis

BACKGROUND

In most surgical textbooks, it has been stated that pain almost always precedes vomiting in patients with appendicitis. However, the usefulness of this classic history item, "pain before vomiting", has been investigated in only one study nearly 50 years ago, in which the cause of abdominal pain could not be identified in more than 40% of patients. Accordingly, our objective was to evaluate the performance of pain before vomiting for the diagnosis of acute appendicitis in patients who presented with both acute abdominal pain and vomiting.

METHODS

A retrospective chart review of adult outpatients with abdominal pain and vomiting at three acute care hospitals was performed. The reference standard for appendicitis was a CT scan evaluated by two radiologists. Diagnostic performance of pain before vomiting and the value it added to the Alvarado score were evaluated.

RESULTS

Among 310 patients, 24 patients were diagnosed with appendicitis. Diagnostic performance of pain before vomiting was a sensitivity of 95.8% (95% confidence interval [CI] 79.8-99.3) and a specificity of 16.6% (95% CI 12.6-21.4). When combined with the Alvarado score, it ruled out appendicitis in an additional 12% (increased from 32% to 44%) of patients without any false negatives.

CONCLUSIONS

"Pain before vomiting" is useful for ruling out appendicitis in patients with abdominal pain and vomiting.

Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care

INTRODUCTION

Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes.

METHODS

An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained.

CONCLUSION

The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.

Does alvarado score reduce the need for ultrasonography in the diagnosis of acute appendicitis?

Aims

We aimed to evaluate the correlation between Alvarado scoring and ultrasonographic findings in the diagnosis of acute appendicitis and its role in reduction of the rate of negative appendectomy.

Methods

A total of 2772 patients operated between January 2010 and September 2016 with the presumed diagnosis of acute appendicitis were retrospectively evaluated. Patients with appendicitis detected in histopathologic examination were assessed as Group 1, and those with no appendicitis detected were assessed as Group 2.

Results

The rate of negative appendectomy was 5.3%. Alvarado score was ≥7 in 2226 and <7 in 399 patients in Group 1. Alvarado score was ≥7 in 92 and < 7 in 55 patients in Group 2 (P < 0.0001). Among the patients with acute appendicitis identified in histopathologic examination, USG revealed acute appendicitis in 1804 and no acute appendicitis in 422 of the patients with an Alvarado score >7. Among the patients without acute appendicitis in histopathologic examination, USG revealed acute appendicitis in 74 and no acute appendicitis in 18 of the patients with an Alvarado score >7, while acute appendicitis was detected in USG in 29 and was not detected in 26 of the patients with an Alvarado score <7.

Conclusion

While possibility of correct diagnosis is high in patients with an Alvarado score ≥7, the diagnosis should not be ruled out in patients with a low Alvarado score. Instead of using alone, the use of Alvarado scoring and ultrasonography together could reduce the rate of negative appendectomy and increase specificity.

Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway

BACKGROUND/PURPOSE

Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department.

METHODS

We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy.

RESULTS

One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%).

CONCLUSION

Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities.

LEVELS OF EVIDENCE

Level IV.

Randomized control trial comparing an Alvarado Score-based management algorithm and current best practice in the evaluation of suspected appendicitis

BACKGROUND

An objective algorithm for the management of suspected appendicitis guided by the Alvarado Score had previously been proposed. This algorithm was expected to reduce computed tomography (CT) utilization without compromising the negative appendectomy rate. This study attempts to validate the proposed algorithm in a randomized control trial.

METHODS

A randomized control trial comparing the management of suspected acute appendicitis using the proposed algorithm compared to current best practice, with the rate of CT utilization as the primary outcome of interest. Secondary outcomes included the percentage of missed diagnosis, negative appendectomies, length of stay in days, and overall cost of stay in dollars.

RESULTS

One hundred sixty patients were randomized. Characteristics such as age, ethnic group, American Society of Anesthesiologist score, white cell count, and symptom duration were similar between the two groups. The overall CT utilization rate of the intervention arm and the usual care arm were similar (93.7% vs 92.5%, p = 0.999). There were no differences in terms of negative appendectomy rate, length of stay, and cost of stay between the intervention arm as compared to the usual care arm (p = 0.926, p = 0.705, and p = 0.886, respectively). Among patients evaluated with CT, 75% (112 out of 149) revealed diagnoses for the presenting symptoms.

CONCLUSION

The proposed AS-based management algorithm did not reduce the CT utilization rate. Outcomes such as missed diagnoses, negative appendectomy rates, length of stay, and cost of stay were also largely similar. CT utilization was prevalent as 93% of the study cohort was evaluated by CT scan.

TRIAL REGISTRATION

The study has been registered at ClinicalTrials.gov (NCT03324165, Registered October 27 2017).

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

Comparative Study of Alvarado Score and its Modifications in the Preoperative Diagnosis of Acute Appendicitis at a Tertiary Center in Sokoto, Nigeria

BACKGROUND

Decision-making in patients suspected of having acute appendicitis has remained a diagnostic challenge worldwide despite the advances in imaging and appendiceal surgery. There have been efforts to improve the diagnosis of appendicitis using clinical scoring systems.

AIM

We evaluated and compared the diagnostic accuracy and role of Alvarado score (AS) and two of its modification (Kalan and Al-Fallouji) in the preoperative diagnosis of acute appendicitis.

MATERIALS AND METHODS

This was a prospective study conducted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, of all adult patients operated for acute appendicitis from July 2014 to June 2017. The results were analyzed on computer using Statistical Package for the Social Science version 15.

RESULTS

One hundred and eleven patients were studied. Sixty-six (59.5%) patients were males and 45 (40.5%) were females. The male-to-female ratio was 1.5:1. The mean age was 23.89 ± 4.93 years. The AS sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 90.3%, 83.3%, 96.6%, 62.2%, and 89.2%, respectively, were similar to the findings of Kalan score (90.3%, 83.3%, 96.6%, 62.5%, and 89.2%, respectively) and Al-Fallouji score (96.8%, 66.7%, 93.8%, 80%, and 91.9%, respectively). The receiver operating curve and area under the curve show that Alvarado, Kalan, and Al-Fallouji are accurate scores in the preoperative diagnosis of acute appendicitis with an area under the curve of 0.88, 0.86, and 0.85, respectively.

CONCLUSION

Kalan and Al-Fallouji scores have comparably good diagnostic accuracy as the AS among our patients. Any of these scores can be used as an adjunct in the preoperative diagnosis of acute appendicitis.

Modification of Alvarado score with pain semiology for the diagnosis of acute appendicitis

Background

Acute appendicitis is the most frequent surgical pathology in the emergency services. It affects approximately 9% of the population. Its differential diagnosis is extremely difficult especially in the elderly, children and women of childbearing age. The Alvarado score (AS) is a useful tool for suspected diagnosis of appendicitis. Our experience suggests the possibility of improving the diagnostic performance of this scale by including pain semiology.

Objective

To compare the diagnostic utility of AS with and without including pain semiology used in the general surgery service of the high specialty naval hospital, as well as to identify fewer useful variables for the diagnosis.

Method

The files of all the patients operated for the suspicion of acute appendicitis from March 2015 to March of the year 2017 were reviewed. The included patients have complete file and histopathological report. For each patient, diagnosis of appendicitis was established with the application of the AS and another, adding the pain semiology, and the result was contrasted with the histopathological diagnosis. The parameters of diagnostic utility were estimated, based on the cut points determined by the logistic regression model and the ROC curves.

Results

AS modified with pain semiology showed greater diagnostic utility than the original scale. Six variables were also identified with a satisfactory performance.

Conclusion

Pain semiology can improve the diagnostic utility of the current AS.

Acute Appendicitis or Lymphoid Hyperplasia: How to Distinguish More Safely?

PURPOSE

Lymphoid hyperplasia can be an important mimicker of acute appendicitis by creating a non-compressible appendix more than 6 mm in diameter. The aim of this study was to evaluate methods of distinguishing lymphoid hyperplasia and appendicitis on the basis of sonography, lamina propria thickness, and Alvarado scoring.

METHODS

This retrospective study included 259 patients (142 appendicitis, 117 lymphoid hyperplasia). The US (ultrasound) reports of the patients were reviewed and the maximum diameter of the appendix, the presence or absence of increased echogenicity of the surrounding pericaecal fat, local fluid collection, the presence of reactive lymph nodes in the periappendiceal area, and mural hyperemia within the appendix were recorded.

RESULTS

The use of additional sonographic criteria, lamina propria thickness (≤1 mm is indicative for appendicitis), or Alvarado scoring (>6 mm is indicative for appendicitis) provided a true-positive diagnosis for acute appendicitis.

CONCLUSION

The presence of local fluid collection in the periappendiceal area and a lamina propria thickness ≤ 1 mm are the most successful parameters for distinguishing appendicitis from lymphoid hyperplasia.

Evaluation of Alvarado score in diagnosing acute appendicitis

Using a practical scoring system for diagnosing acute appendicitis can help reduce the rate of unnecessary surgery. This prospective study was carried out to evaluate Alvarado scoring system for diagnosing of acute appendicitis in our set up. Out of total 100 patients, appendicitis was confirmed in 80 patients, thus giving negative appendectomy rate of 20% (male 6%, female 14%). Perforation rate was 4%. Positive predictive value was 89%. The sensitivity was 54% and specificity 75%. Alvarado score is not a sensitive tool for aiding diagnosis of acute appendicitis.

Acute appendicitis during pregnancy: differences in clinical presentation, management, and outcome

OBJECTIVES

To analyze the clinical presentation, management, and outcome of acute appendicitis (AA) in pregnant and nonpregnant women of childbearing age.

MATERIAL AND METHODS

Descriptive study of 2 cohorts of women (pregnant -P- and nonpregnant -NP-). The women, who were matched according to risk factors, were included when they underwent an emergency appendectomy based on clinical suspicion of AA. We recorded age, medical history, clinical presentation, management, and outcome. Pregnant women were classified according to gestational age of the fetus (trimester).

RESULTS

. We included 153 women (51 P, 102 NP). The mean (SD) age was 28.8 (6.5) years (P women, 29.7 [5.8] years; NP, 28.3 [6.8]; P=.242). The mean Alvarado score was 7.1 (1.6) (P, 6.7 [1.7]; NP, 7.3 [1.5]; P=.016). The rate of complicated AA was higher in P (19.6%) than NP (2.9%) women (P<.001). Pregnancy was also associated with higher rates of surgical wound infection (P, 14.0%; NP, 3.0%; P=.016) and a longer mean hospital stay (P, 5.1 [4.8] days; NP, 1.7 [1.0]; P<.001). In the third trimester of P, poorer outcomes were recorded in relation to these risks (P=.031; P=.003, and P<.001, respectively).

CONCLUSION

The atypical clinical presentation of AA during pregnancy makes diagnosis difficult and may lead to a higher incidence of complicated AA and surgical wound infection as well as longer hospital stays, particularly when AA presents in the third trimester.

Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis

Background

The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis.

Methods

This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve.

Results

Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations.

Conclusion

Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.

The Alvarado Score is accurate in pregnancy: a retrospective case-control study

BACKGROUND

Acute appendicitis is the most frequent abdominal condition that requires non-obstetric surgical intervention during pregnancy. This study aims to scan pregnant patients operated on for acute appendicitis to evaluate the efficiency of using the Alvarado Score (AS) for diagnosis.

METHODS

Our study included 48 pregnant patients who were pre-diagnosed with acute appendicitis and operated on at our department of general surgery from January 2010 to July 2016 and whose files were accessed. Fifty-three non-pregnant female patients of reproductive age who were operated on for appendicitis during the same period were included in the study as the control group. The patients in both groups were divided into two groups based on their AS total score being 7 and ≥ 7.

RESULTS

The mean age of the 48 pregnant patients was 28 (19-42) years, while the mean age of the 53 control patients was 31 (18-45) years. Among pregnant and non-pregnant women, about a third of patients had an AS < 7 (16 of 48 versus 18 of 53). There was no significant difference when the AS scores of both groups were compared (p = 0.947). Using pathology results as reference test, the sensitivity and specificity of the AS in pregnant women was 79 and 80%.

CONCLUSIONS

As a result, when the data collected by our study are evaluated, we see that pregnancy does not have a negative effect on the efficacy of AS. Therefore, the AS system can be an easy, non-invasive auxiliary diagnostic tool with high diagnosis accuracy rates that can be used in pregnant patients suspected of having acute appendicitis.

How much Reliable Is Alvarado Scoring System in Reducing Negative Appendectomy?

There is still an ongoing debate, especially regarding early diagnosis of acute appendicitis. Early surgery leads to inadequate evaluation of acute abdominal pain and negative appendectomy, whereas delayed surgery leads to appendicitis perforation complications. The diagnosis of this condition is considerably difficult, especially due to subtle early symptoms and clinical condition. The aim of the present study was to identify whether the Alvarado scoring system could reduce the incidence of negative appendectomy in patients who will undergo surgery for acute appendicitis. Patients who underwent surgery with acute appendicitis prediagnosis were retrospectively classified as negative appendectomies (group A) and positive appendectomies (group B) according to histological diagnosis. All groups were evaluated for age, gender, Alvarado scores, and parameters. Two hundred eighty-one patients were included in the study. Group A contained 71 (25.3 %) patients, and group B contained 210 (74.7 %) patients. There was a significant difference in WBC, left shift, rebound, and change of pain localization between the groups (p = 0.002, p < 0.001, p < 0.001, and p = 0.023, respectively). Alvarado scores were significantly different between the groups (p < 0.001). In logistic model examination, the major factor was the Alvarado score (7 or above) and the minor factor was spreading pain. The Alvarado scoring system can be used to reduce negative appendectomy in patients who will undergo surgery with acute appendicitis.

The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a western population

AIM

The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA.

METHODS

All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate.

RESULTS

Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort.

CONCLUSION

The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the Eastern population, RIPASA demonstrated a high-sensitivity, specificity, positive predictive value and diagnostic accuracy in our cohort and was more accurate than the commonly used Alvarado score.

Dilemma of mucosal appendicitis: a clinico-pathological entity? A retrospective cohort study

BACKGROUND

The presence of mucosal inflammation within appendicectomy specimens is poorly described in the literature, and there is debate regarding the clinical significance of this histological finding. The aim of this study is to correlate clinical and radiological data with histologically confirmed acute mucosal appendicitis (MA).

METHODS

A retrospective cohort study was performed to identify all patients who underwent appendicectomy over 5 years at Caboolture Hospital. Data were collected in regards to clinical Alvarado score, pathological specimen findings, radiological findings and coincidental conditions, and comparison made between MA and negative appendicectomy groups.

RESULTS

A total of 1347 appendicectomy specimens and data were reviewed. Of these, 219 (16%) specimens were microscopically confirmed to have acute mucosal inflammation, 150 (68%) were females. Median age was 19 ± 14 years. A total of 243 (18%) were histologically negative. There was a statistically significant difference in mean Alvarado score in the MA group (5.0 ± 1.9 versus 4.3 ± 1.8, P = 0.0002). Patients with MA are more likely to report migratory pain (48.4 versus 31.4%, P = 0.0001) and rebound tenderness (24.9 versus 14.6%, P = 0.002). Computed tomography and ultrasound scans were negative in 74.1 and 72.6%, respectively, in patients with MA. More MA patients benefited from appendicectomy compared with the negative appendicectomy group (82 versus 63%, P = <0.0001).

CONCLUSION

There is a subgroup of patients with MA who are young females with have low Alvarado scores, have non-diagnostic imaging, and may represent almost one-fifth of appendicectomy specimens. This study supports the probability that MA is a pathological entity.

The Alvarado score versus computed tomography in the diagnosis of acute appendicitis: A prospective study

BACKGROUND

To assess and compare performance of the Alvarado score and computed tomography scan in the diagnosis of acute appendicitis at King Hussein Medical Center.

METHODS

A total of 320 patients with suspected acute appendicitis were included in this study over a period of 2 years. The Alvarado score was calculated for all of these patients and 112 CT scans were requested selectively by surgeons caring for the patients. The histopathology diagnosis was used as the gold standard against which diagnostic performance of Alvarado score and CT scan were compared.

RESULTS

The complete data of 196 males and 124 females were analyzed at the end of the study period. The mean age was 26.1 ± 11.3 years. Appendectomy was performed in 263 patients with a negative appendectomy rate of 14.83% overall (12.28 in males and 19.56 in females). The remaining 57 patients were assumed to have no appendicitis. The diagnostic performance of CT scan was superior to that of Alvarado score with sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 94.2 versus 85.4%, 90 versus 65%, 9.42 versus 2.44, and 0.065 versus 0.224, respectively (p-value < 0.05). The overall diagnostic accuracy of CT scan was 92.6% compared to 77.5% for Alvarado score.

CONCLUSION

The Alvarado score was far from good and CT scan is more accurate in diagnosis of acute appendicitis in our patient population.

Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis

BACKGROUND

Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis.

METHODS

Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital.

RESULTS

The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis.

CONCLUSION

BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.

How to improve the clinical diagnosis of acute appendicitis in resource limited settings

This article is a general review of the diagnostic tools that the clinician can use for the early diagnosis of acute appendicitis with emphasis on the Alvarado Score, and it is aimed principally to the medical practitioners in different parts of the world where the diagnostic facilities and technological resources are limited.

The comparison of the effectiveness of tomography and Alvarado scoring system in patients who underwent surgery with the diagnosis of appendicitis

OBJECTIVE

The aim of this study is to compare the effectiveness of computed tomography and Alvarado scoring system in the diagnosis of acute appendicitis in patients who underwent appendectomy with the preliminary diagnosis of acute appendicitis.

MATERIAL AND METHODS

One hundred and one patients who underwent appendectomy with the diagnosis of acute appendicitis between January and December 2011 were included in the study. Alvarado scores were calculated, and abdominal tomography scans were obtained for each patient before surgery. Patients with Alvarado score ≥7 were considered to have appendicitis while patients with a score <7 were considered not to have appendicitis. Patients were classified into two groups based on the presence of appendicitis findings on abdominal tomography. Histopathological examination of the appendices was performed following appendectomy. All patients were classified into groups according to pathology results, Alvarado score and tomography findings. The effectiveness of Alvarado score and tomography were compared using the McNemar test.

RESULTS

Sixty patients (59.4%) were male and 41 (40.6%) were female, with a mean age of 32 years (5-85 years). The rate of negative appendectomy was 3.9%. In 78 patients (77.3%) the Alvarado score was ≥7, while 23 patients (22.7%) had Alvarado scores <7. The presence of appendicitis was determined by histopathology in 22 out of 23 patients whose Alvarado score was <7. Tomography indicated appendicitis in 97 patients (95.9%) whereas four patients (4.1%) exhibited no signs of appendicitis by tomography. However, histopathological evaluation indicated the presence of appendicitis in those four patients as well.

CONCLUSION

The study results imply that tomography is a more effective means of diagnosing acute appendicitis as compared to the Alvarado scoring system.

Body mass index, pain score and Alvarado score are useful predictors of appendix visualization at ultrasound in adults

The study objective was to find factors predictive of ultrasound visualization of the appendix in patients with suspected appendicitis. A total of 238 consecutive adult patients (178 women, mean age 38.9 y, weight 58.2 kg, body mass index 22.7) who underwent appendiceal ultrasound from January to December 2011 were included. Appendicitis was confirmed in 171 patients (171/238, 71.9%). Ultrasound sensitivity, specificity and accuracy were 64%, 90% and 71%, respectively. The appendix was visualized at ultrasound in 126 patients (group 1) and not visualized in 112 patients (group 2). Group 1 had a lower body mass index, higher pain score and higher Alvarado score. The chances of visualizing the appendix in patients with body mass indexes ≤22, pain scores ≥6, and Alvarado scores ≥6 were 2.3, 2.9, and 3.8 times higher than those of their counterparts, respectively. Therefore, in patients with these factors, the use of ultrasound may be beneficial in the diagnosis of acute appendicitis.

The predictive value of Alvarado score, inflammatory parameters and ultrasound imaging in the diagnosis of acute appendicitis

OBJECTIVE

Acute appendicitis (AA) is one of the most common surgical emergencies. Despite extraordinary advances in modern investigations, the accurate diagnosis of AA remains an enigmatic challenge. The aim of this study was to compare and evaluate the diagnostic accuracy of inflammatory parameters [C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR)], ultrasound (US) and Alvarado score (AS) in reducing the rate of negative appendectomies.

MATERIAL AND METHODS

Two hundred seventy-eight patients were included in this study. Patients were separated into two main groups as the surgery group (n=184) and non-operative group (n=94). Complete blood count, ESR and PCT levels were assessed, abdominal US was performed and AS was calculated for all patients.

RESULTS

In the surgery group, clinical predictive factors for histopathologic results such as AS ≥7, AA signs on US, neutrophilia and leukocytosis were significant. Neutrophilia and leukocytosis had the highest accuracy rate among these factors. Inflammatory parameters were not predictive for histopathologic results, although higher CRP and PCT levels were significant in perforated and necrotizing appendicitis. Multifactorial regression analyses showed that AS was not of significant predictive value in the non-operative group.

CONCLUSION

There was no superiority of AS and/or US in the diagnosis of AA. Recent findings have shown the most reliable parameters in the diagnosis of AA to be primarily 'neutrophilia' and secondarily 'leukocytosis'. Other results of this study indicated that inflammatory parameters (CRP, PCT, ESR) were not superior to other parameters but CRP and PCT levels were significantly high in complicated cases.

Integration of ultrasound findings with Alvarado score in children with suspected appendicitis

BACKGROUND

The aim of this study was to investigate the integration of ultrasound (US) findings with Alvarado score in diagnosing or excluding acute appendicitis.

METHODS

Data were analyzed in 122 pediatric patients with suspected appendicitis who had undergone US. The US findings were classified into four groups, and the patients were classified into three groups according to Alvarado score. US results and Alvarado score were compared.

RESULTS

Alvarado score was a good predictor of appendicitis for scores ≥7.

CONCLUSION

In the case of non-visualization of the appendix without a high Alvarado score, appendicitis can be safely ruled out.

Re-evaluation of Alvarado score in diagnosis of acute appendicitis using transumbilical single-port laparoscopic exploration

AIM: To re-evaluate the Alvarado score in the diagnosis of acute appendicitis using transumbilical single-port laparoscopic exploration.

METHODS: Clinical data for 210 patients with acute appendicitis who underwent transumbilical single-port laparoscopic exploration and Alvarado scoring were retrospectively reviewed. The correlation between Alvarado score and operative outcome was analyzed.

RESULTS: 101 had an Alvarado score above 9, of whom appendicitis was excluded by exploration in only 2 cases, and the diagnostic accuracy of Alvarado score was 98.1% in these patients. 85 patients had an Alvarado score between 7 and 8, of whom 74 were confirmed to have acute appendicitis by exploration, and the diagnostic accuracy of Alvarado score was 87.1% in these patients. Of 24 patients who had a positive CT or ultrasound finding and an Alvarado score between 5 and 6, 23 were confirmed to have acute appendicitis, and the diagnostic accuracy of Alvarado score was 95.8% in these patients. No port-site hernia or constipation was found during a follow-up period of 1 year.

CONCLUSION: Alvarado score is useful in the diagnosis of acute appendicitis, especially when the score is above 9. When the score is between 7 and 8, there is a false positive rate as high as 13% if the Alvarado system is used alone. Alvarado scoring combined with imaging examination is associated with a higher accuracy in the diagnosis of acute appendicitis.