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Bangladesh Journal of Medical Science Vol. 14 No. 04 October’15

Original article
Usefulness of Modified Alvarado Score in Diagnosis of Acute Appendicitis in Adults 

Mondal HP1, Hadiuzzaman M2, Mukhopadhyay C3,  Chattopadhyay S4,  Biswas SK5,  Bhoj SS6

Abstract:
Background: Definitive diagnosis of acute appendicitis preoperatively is sometimes difficult. 
Failure to make a diagnosis is the main reason for persistent rate of morbidity and mortality. 
Various scoring systems are devised to aid diagnosis of acute appendicitis. In some studies the 
modified Alvarado score was helpful, reliable and practical in minimizing unnecessary 
appendectomy. Objective: The purpose of this study was to evaluate the usefulness of 
modified Alvarado score for the diagnosis of acute appendicitis. Materials and Method: A 
prospective study of 89 adult patients, admitted with abdominal pain suggestive of acute 
appendicitis, from July 2011 to June 2012, was conducted. Data including clinical signs and 
symptoms and laboratory findings were recorded in modified Alvarado score record form. All 
89 patients underwent appendectomy. Final diagnosis was confirmed by histopathological 
examination. Reliability of scoring system was assessed by negative appendectomy rate and 
positive predictive value. Results: Out of 89 patients who underwent appendectomy, 85 had 
acute appendicitis on histopathology. Positive predictive value was 95.5% and negative 
appendectomy rate was 4.5%. 52.8% had score 7 or above and 47.2% had score less than 7. 
From score it is difficult to predict which patient warranted appendectomy and who may be 
safely observed or discharged. Conclusions: Diagnosis of acute appendicitis remains mainly 
clinical evaluation and it is more helpful than modified Alvarado scoring system in adults.

Keywords: Modified Alvarado Score; acute appendicitis; adults

Corresponds to:	Corresponds	to:	Dr.Hari	Pada	Mondal.	Associate	Professor,	Dept.	of	Surgery,	North	Bengal	
Medical	College,	Sushrutanagar,	Darjeeling.	3/1,RajanikantaSarani,	Hakimpara,	Siliguri.	Dist.	Darjeeling.	
Pin-734001.	Email:	drhpmondal@gmail.com

1. Hari	Pada	Mondal,	Associate	Professor,
2. Md.	Hadiuzzaman,	PGT,
3. Chandranath	Mukhopadhyay,	RMO-cum-Clinical	Tutor,

Dept.	of	Surgery,	North	Bengal	Medical	College,	Sushrutanagar,	Darjeeling.
4. Shibram Chattopadhyay,	Assistant	Professor,	Dept.	of	G&O,	Burdwan	Medical	College,	Burdwan.
5. Sajal	Kumar	Biswas,	Assistant	Profesor,
6. Sudhansu	Sekhar	Bhoj,	Professor,

Dept.	of	Surgery,	North	Bengal	Medical	College,	Sushrutanagar,	Darjeeling.

Introduction:
Acute	 appendicitis	 is	 a	 common	 cause	 of	 acute	
abdominal	 pain	 in	 emergency.	 Failure	 to	 make	 an	
early	diagnosis	is	a	main	reason	for	the	persistent	rate	
of	 morbidity	 and	 mortality.	 Prompt	 diagnosis	 and	
surgical	 intervention	reduce	the	risk	of	perforation	
and	infectious	complications.	Emergency	physicians	
may	find	it	difficult	 to	diagnose	acute	appendicitis	
based on clinical grounds alone. Various scoring 
system have been devised to aid diagnosis and to 
determine	earlier	and	more	convincingly	the	group	
of	 patients	 who	 will	 require	 further	 investigation,	
observation or urgent surgery1-7.Alvarodo Score 

was	 devised	 in	 19867.Good diagnostic validity of 
Alvarado	Score	has	been	reported	in	diagnosing	acute	
appendicitis(chan2001)8.	Although	some	reports	have	
found	that	the	Alvarado	Score	alone	is	inadequate	as	a	
single	diagnostic	test(ohman1995)9.Classic Alvarado 
Score	included	shift	to	left	of	neutrophil	maturation	
(score	 1)	 yielding	 a	 total	 score	 of	 102,7 . Kalan et 
al,	omitted	this	parameter	and	produced	a	modified	
score6	.The	purpose	of	this	study	is	to	evaluate	the	
usefulness	of	Modified	Alvarado	Score	in	predicting	
acute	appendicitis	in	adults	in	our	set	up.
Materials and Methods:
	This	is	a	prospective	study	conducted	on	89	patients	

Bangladesh Journal of Medical Science Vol. 14 No. 04 October’15. Page: 336-338
 DOI: http://dx.doi.org/10.3329/bjms.v14i4.16257 

http://dx.doi.org/10.3329/bjms.v14i4.16257


337

Usefulness	of	Modified	Alvarado	Score	of	Acute	Appendicitis

above	12	yrs.	admitted	through	emergency	surgical	
dept.	of	North	Bengal	Medical	college,	Darjeeling	
with	clinical	diagnosis	of	acute	appendicitis	during	
the	 period	 from	 July,	 2011	 to	 June,	 2012.	 Data	
including	 age,	 sex,	 symptoms,	 physical	 signs	 and	
laboratory	findings	such	as	white	blood	counts	were	
recorded	in	Modified	Alvarado	Score	form	(table	1).	
All	the	patients	underwent	emergency	appendectomy.	
Definite	diagnosis	of	acute	appendicitis	was	based	on	
post-operative	pathologic	study.

Parameters Score
Symptoms Migratory of pain 1 

Anorexia 1 
Nausea/vomiting 1 

Signs RLQ pain 2 
Rebound tenderness 1 
Elevation temp 1 

Investigation Leucocytosis 2 
  Total score 9 

Table 1: Modi�ed Alvarado Score Forms

Results:
We	conducted	our	study	on	89	adult	patients	with	
clinical	 features	 suggestive	 of	 acute	 appendicitis.	
Among	this	30	were	female	(33.7%)	and	59	were	male	
(66.3%).	Incidence	of	acute	appendicitis	was	most	
frequent	in	21-29	yrs.	age	group	(39.3%)	and	least	in	
age	group	48-55	yrs.(1.1%).	Frequency	of	symptoms,	
signs	and	investigation	findings	in	accordance	with	
Modified	Alvarado	Score	are	shown	in	table	2	and	
table	5.	It	showed	most	of	 the	parameters	are	less	
commonly	found	in	acute	appendicitis	patients.

Table 2: Frequency distribution of patients 
according to symptoms/signs/investigation

Parameters Frequency Percentage 
Migration of pain 67 75.3 
Anorexia 55 61.8 
Nausea/ vomiting 56 62.9 
RLQ pain 86 96.6 
Rebound tenderness 65 73 
Elevation temperature 52 58.4 
Leucocytosis 49 55.1 

Modified	Alvarado	Score	of	89	patients	who	had	acute	
abdominal	pain	suggestive	of	acute	appendicitis	are	
recorded	in	table3.	47	patients	had	score	7	and	above,	
42	patient	had	score	less	than	7.
Pathological	 stages	 in	 89	 patients	 who	 underwent	
appendectomy	 with	 confirmed	 appendicitis	 by	
histopathology	are	summarized	in	table	4.	95.5%	of	

appendectomy	 patient	 had	 appendicitis,	 only	 4.5%	
had	negative	appendectomy	rate.
Table 3: Frequency distribution of patients 
according to Modified Alvarado Score

Score Frequency Percentage 
1 0 0 
2 1 1.1 
3 6 6.7 
4 13 14.6 
5 11 12.4 
6 11 12.4 
7 19 21.3 
8 13 14.6 
9 15 16.9 

Total 89 100 

Table 4: Pathological stage of acute appendicitis
Stage Frequency Percentage 

Acute appendicitis 45 50.6 
Gangrenous Appendiciti 9 10.1 

Recurrent appendicitis 31 34.8 
Normal 4 4.5 
Total 89 100 

Table 5:    Age incidence of acute appendicitis

Age Frequency % 
12-20 13 14.7 
21-29 35 39.3 
30-38 22 24.7 
39-47 13 14.6 
48-55 1 1.1 
55-64 2 2.2 
>65 3 3.4 

Total 89 100 

Discussion:
Accurate	diagnosis	is	the	key	to	decrease	morbidity	
and mortality in any disease condition. Various 
scoring	 system	 are	 developed	 to	 aid	 preoperative	
diagnosis	of	acute	appendicitis.	Among	these	most	
famous	 ones	 are	 Alvarado	 score	 and	 its	 modified	
form6,7	.	Modified	Alvarado	score	is	based	on	patient	
history,	 physical	 examination	 and	 blood	 leucocyte	
counts	(table1).	Previous	studies	showed	80percent	of	
acute	appendicitis	cases	may	present	with	migratory	
pain.	It	may	range	from	61-92%	for	nausea/vomiting	
and	74-78%	to	loss	of	appetite.	Pyrexia	found	in	96%	
case10	.	In	our	study	these	were	75.3%,	62.9%,	61.8%	
and	 58.4%	 respectively.	 Negative	 appendectomy	
ranges	from	8-33percent	in	different	studies	11-13. In 
our	 study	 95.5%	 of	 patient	 had	 acute	 appendicitis	



338

Mondal	HP,	Hadiuzzaman M,	Mukhopadhyay	C,	Chattopadhyay	S,	Biswas	SK,	Bhoj	SS

according	to	histopathology	reports.
In	 our	 study	 21.3%	 of	 patient	 have	 score	 7	 and	
16.9%	 have	 score	 9	 only.	 52.8%	 had	 score	 7or	
above	 and	 47.2%	 had	 score	 less	 than	 7.	 Modified	
Alvarado	Score	was	neither	sensitive	nor	specific	in	
our	study.	There	are	studies	who	agree	or	disagree	
with	modified	Alvarado	Score	as	its	usefulness	as	a	
reliable	prediction	system	for	preoperative	diagnosis	
of	acute	appendicitis14,6,11 .
In	our	study	many	of	the	parameters	are	not	commonly	
found,	thereby	lower	scoring	of	Modified	Alvarado	
score	.Lower	scoring	may	be	the	result	of	inability	
of	the	patient	to	define	the	symptoms	well	for	low	
socioeconomic	status.	Traditional	system	of	clinical	

diagnosis	of	acute	appendicitis	was	highly	sensitive	
(95.5%)	in	our	study	which	was	in	concordance	with	
previous	studies	where	accuracy	is	between	76	and	
92%15-17.

Conclusion:
	 Diagnosis	 of	 acute	 appendicitis	 depends	 on	
experience	 and	 clinical	 judgement.	 Modified	
Alvarado	 scoring	 system	 does	 not	 predict	 clearly	
which	 patient	 warrants	 surgical	 intervention	 and	
who	 may	 be	 safely	 observed	 or	 discharged.	 Thus	
less	 helpful	 than	 clinic	 based	 surgeons’	 decision	
to	 improve	 diagnostic	 accuracy	 and	 consequently	
reduce	complication	rate.

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