MODIFIED ALVARADO SCORE IN CHILDREN WITH DIAGNOSIS OF APPENDICITIS

Mehran PEYVASTEH Shahnam ASKARPOUR Hazhir JAVAHERIZADEH Sepideh BESHARATI About the authors

ABSTRACT

Background:

Appendicitis is one of the most common abdominal emergency. Some predictive scoring systems are recommended to decrease the rate of negative appendectomy.

Aim:

To evaluate sensitivity, specificity, positive predictive value, and negative predictive value of modified Alvarado score in children who underwent appendectomy.

Methods:

Four hundred children with initial diagnosis of appendicitis were randomly selected from patients who underwent appendectomy. Modified Alvarado score was used for evaluation of the appendicitis, that was confirmed using histology.

Results:

Of modified Alvarado score components, anorexia; nausea and vomiting and rebound tenderness were significantly more common in children with positive appendectomy in contrast to patients with negative appendectomy. Sensitivity, specificity, positive predictive value, and negative predictive value for modified Alvarado score were: 91.3%; 38.4%; 87.7%; and 51.2% respectively.

Conclusion:

Alvarado score has high sensitivity but low specificity for diagnosis of acute appendicitis in children.

HEADINGS -
Appendicitis; Nausea; Appendectomy.

RESUMO

Racional:

A apendicite é uma das emergências abdominais mais comuns. Alguns sistemas de pontuação preditivos são recomendados para diminuir a taxa de apendicectomia negativa.

Objetivo:

Avaliar a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo do escore de Alvarado modificado em crianças submetidas à apendicectomia.

Métodos:

Quatrocentos crianças com diagnóstico inicial de apendicite foram selecionadas aleatoriamente de pacientes submetidos à apendicectomia. A pontuação de Alvarado modificada foi utilizada para avaliação do quadro, que foi confirmado por meio de histologia.

Resultados:

Anorexia; náuseas, vômitos e desconforto abdominal foram significativamente mais comuns em crianças com apendicectomia positiva, em contraste com casos negativos pelo escore de Alvarado modificado. A sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo para o escore de Alvarado modificado foram: 91,3%; 38,4%; 87,7%; e 51,2%, respectivamente.

Conclusão:

O escore de Alvarado possui alta sensibilidade, mas baixa especificidade para o diagnóstico de apendicite aguda em crianças.

DESCRITORES -
Apendicite; Náusea; Apendicectomia

INTRODUCTION

Appendicitis is one of the important surgical emergency among children. Both pediatrician and surgeons should be aware the possibility of appendicitis in children with appendicitis. Despite its high incidence, diagnosis is difficult due to non specific symptoms and atypical presentations33 Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Acad Emerg Med 2007,14:124-129..

Variety of different approaches are recommended to decrease negative appendectomies such as predictive scoring system2, computer aided diagnosis, inflammatory marker1010 Shoshtari MHS, Askarpour S, Alamshah M, Elahi A. Diagnostic value of Quantitative CRP measurement in patients with acute appendicitis. Pak J Med Sci 2006,22:300., ultrasonography88 Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986,158:355-360., and computed tomography.

Alvarado described a clinical scoring system on the basis of eight predictive clinical factors to improve the accuracy of physicians' clinical assessments in diagnosing acute appendicitis. This scoring system produces a maximum total score of 10 points and includes clinical symptoms (nausea and anorexia), signs( fever, shifting pain, right lower quadrant pain, and rebound tenderness) and laboratory findings( leukocytosis and neutrophilia). Right lower quadrant pain and leukocytosis contribute 2 points while the rest contributes 1 point22 Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986,15:557-564.. Kalan et al. omitted shift to left parameter because is not routinely available in many laboratories, and produced a modified score44 Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994,76:418-419.. The modified Alvarado score (MAS) has been widely accepted after it was successfully tested in different studies11 Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado Score for acute appendicits in adults. Saudi Med J 2004,25:1229-1231..

The aim of this study was to evaluate sensitivity, specificity, positive predictive value, and negative predictive value of modified Alvarado score in children who underwent appendectomy.

METHODS

This study was approved by research affairs of Ahvaz Jundishapur University of Medical Sciences. This cross sectional study was carried out in Imam Khomeini Hospital, Ahvaz-Iran. It included 400 children with diagnosis of appendicitis during 2006-2012. Of children who underwent appendectomy 400 children were randomly selected. Appendicitis was confirmed according to pathology report. Modified Alvarado score was used to evaluate appendicitis44 Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994,76:418-419.. Modified Alvarado score is based on three symptoms, three signs, and one laboratory investigation and ranged from 1-9 (Table 1)

TABLE 1
Modified Alvarado score

Appendicitis was confirmed using histopathology evaluation.

RESULTS

In this study, 400 children aged <12 years with primary diagnosis of appendicitis were included. Of these cases, 337(84.3%) had confirmed appendicitis. Of all cases, 63(15.8%) had negative appendectomy. As seen in Table 2, anorexia, nausea and vomiting, and rebound tenderness were significantly more common in children with appendicitis than children without appendicitis. Migratory right iliac fossa pain was the most sensitive part of MAS (Table 3). Of 48 children with score 1-4, 45 had negative histopathology (Table 4). As seen in Table 4, all children with score 7-9 had positive histopathology.

TABLE 2
Signs and symptoms of modified Alvarado score in the sample

TABLE 3
Sensitivity, specificity, PPV, and NPV of Alvarado score components

TABLE 4
Distribution of modified Alvarado scores among children

DISCUSSION

In the current study, sensitivity of MAS was 91.3%. In the study by Khanafer et al., sensitivity of MAS was 83.3%66 Khanafer I, Martin DA, Mitra TP, Eccles R, Brindle ME, Nettel-Aguirre A, et al. Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016,16:147.. In the study by Macklin et al, sensitivity of modified Alvarado score ≥7 was 76.377 Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl 1997,79:203-205.. In another study from India in adult patients, MAS was sensitive but with a relatively low specificity99 Shafi S, Malah M, Malah H, Reshi F. Evaluation of the modified Alvarado score incorporating the C-reactive protein in the patients with suspected acute appendicitis. Annals of Nigerian Medicine 2011,5:6-11.. Specificity of MAS was 38.4 in the current study which is slightly higher than Khanafer et al. study66 Khanafer I, Martin DA, Mitra TP, Eccles R, Brindle ME, Nettel-Aguirre A, et al. Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016,16:147.. Specificity of MAS in Macklin et al study was 78.8%. Macklin et al.77 Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl 1997,79:203-205. calculated specificity for MAS ≥7 but we calculated overall specificity.

PPV of MAS in our study was 87.7% which is significantly higher 36.0% in Khanafer et al. study66 Khanafer I, Martin DA, Mitra TP, Eccles R, Brindle ME, Nettel-Aguirre A, et al. Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016,16:147.. NPV was 51.2% in our report which was significantly lower than 83.6% in Khanafer et al. study66 Khanafer I, Martin DA, Mitra TP, Eccles R, Brindle ME, Nettel-Aguirre A, et al. Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016,16:147..

In the current study, all children with MAS ≥7, had appendicitis according to pathology report. In our study, 100% of children scored >7 had positive appendicitis. In the study by Kanumba et al.55 Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC Surg 2011,11:4., among children with MAS ≥7, 97.3% had appendicitis which is slightly lower than our study. This difference may be due to age of the patients.

CONCLUSION

Modified Alvarado score has high sensitivity but low specificity for diagnosis of acute appendicitis in children.

ACKNOWLEGMENT

Our thanks to research affair of Ahvaz Jundishapur University of Medical Sciences for support. Data used in this study was from general physician thesis of Sepideh Besharati (No#U-92103)

REFERENCES

  • 1
    Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado Score for acute appendicits in adults. Saudi Med J 2004,25:1229-1231.
  • 2
    Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986,15:557-564.
  • 3
    Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Acad Emerg Med 2007,14:124-129.
  • 4
    Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994,76:418-419.
  • 5
    Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC Surg 2011,11:4.
  • 6
    Khanafer I, Martin DA, Mitra TP, Eccles R, Brindle ME, Nettel-Aguirre A, et al. Test characteristics of common appendicitis scores with and without laboratory investigations: a prospective observational study. BMC Pediatr 2016,16:147.
  • 7
    Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl 1997,79:203-205.
  • 8
    Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986,158:355-360.
  • 9
    Shafi S, Malah M, Malah H, Reshi F. Evaluation of the modified Alvarado score incorporating the C-reactive protein in the patients with suspected acute appendicitis. Annals of Nigerian Medicine 2011,5:6-11.
  • 10
    Shoshtari MHS, Askarpour S, Alamshah M, Elahi A. Diagnostic value of Quantitative CRP measurement in patients with acute appendicitis. Pak J Med Sci 2006,22:300.

  • Fonte de financiamento:

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Publication Dates

  • Publication in this collection
    Jan-Mar 2017

History

  • Received
    08 Sept 2016
  • Accepted
    17 Jan 2017
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