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Year : 2010  |  Volume : 7  |  Issue : 3  |  Page : 163-165
Alvarado score as an admission criterion in children with pain in right iliac fossa


Department of Pediatric Surgery, Zagazig University, Egypt

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Date of Web Publication18-Sep-2010
 

   Abstract 

Background: Acute appendicitis is an important differential diagnosis in children with pain in the right iliac fossa. Some patients have equivocal signs that make the diagnosis difficult. Many patients with suspected acute appendicitis are admitted for observation and finally discharged because they did not have appendicitis. We decided to design this study to investigate whether the Alvarado score could be used by emergency room doctors as a criterion for admission to hospital. Patients and Methods: This is a prospective study comprising 350 patients who attended the emergency department with suspected acute appendicitis in the period from May 2007 to April 2009. All patients were scored by Alvarado score in the emergency department before admission. The Alvarado score is based on three symptoms, three signs and two laboratory findings. The decision for admission and surgery was made independent of the score. The diagnosis of patients who underwent appendicectomy was confirmed by both operative findings and postoperative histopathology. Results: We studied the Alvarado scores of 350 patients who presented to the emergency department with pain in the right iliac fossa; their age ranged from 8 to 14 years; 182 patients (52%) operated with the aim to treat acute appendicitis, 168 patients (48%) were discharged without surgical intervention and advised to attend the out-patient clinic after 24 hours for re-evaluation. we have found that patients with a low Alvarado score (less than 6) did not have acute appendicitis. Conclusion: Patients with equivocal signs can present a diagnostic challenge and are very often admitted to the surgical department for observation. The Alvarado score can be used as a scoring system that help in taking the decision for admission of cases with suspected acute appendicitis especially by primary healthcare providers.

Keywords: Acute appendicitis in children, Alvarado score

How to cite this article:
Shreef KS, Waly AH, Abd-Elrahman S, Abd Elhafez M A. Alvarado score as an admission criterion in children with pain in right iliac fossa. Afr J Paediatr Surg 2010;7:163-5

How to cite this URL:
Shreef KS, Waly AH, Abd-Elrahman S, Abd Elhafez M A. Alvarado score as an admission criterion in children with pain in right iliac fossa. Afr J Paediatr Surg [serial online] 2010 [cited 2017 Mar 28];7:163-5. Available from: http://www.afrjpaedsurg.org/text.asp?2010/7/3/163/70417

   Introduction Top


The classical Sings and symptoms of acute appendicitis were first reported by Fitz in 1886. [1] Acute appendicitis remained the most common diagnosis for hospital admission requiring laparotomy. [2],[3] Appendicitis is the most common abdominal condition requiring surgery in children accounting for over 320,000 operations per year in the United States. [4] The diagnosis of acute appendicitis in children remains challenging, occasionally taxing the diagnostic skills of even the most experienced surgeon because not all patients present with the classic symptoms. It is also more difficult to obtain a clear history in children. Furthermore, many disorders in the gastrointestinal tract can mimic acute appendicitis. [5] So the diagnosis of acute appendicitis can be difficult, especially in equivocal cases that present a diagnostic challenge and usually require admission and inpatient observation. As a consequence, the management of appendicitis consumes an enormous amount of healthcare resources and accounts for most of the hospital days spent among children.[6],[7] Hospital charges for treatment of this surgical disease have been estimated conservatively in excess of three billion dollars annually within the United States. Not surprisingly, cost-containment efforts in many institutions target this group of patients. [8]

Various scoring systems such as Madan score, Ohmann score, Eskelinen score, DeDombal score and Alvarado score have been devised to aid diagnosis of acute appendicitis. [9] The Alvarado score is the most well known and best performing in validation studies. [10] Alvarado score was described in 1986 and has been validated in children surgical practice. [11] Alvarado followed up patients admitted to surgical unit at the Nazareth Hospital in Philadelphia with suspected acute appendicitis, until surgery confirmed or refuted diagnosis. He found that eight criteria had high diagnostic accuracy for acute appendicitis. [12]

This study aims to evaluate whether the Alvarado score can be used in emergency room as a criterion helps the emergency doctors to take the decision of admission or discharge cases with query acute appendicitis.


   Patients and Methods Top


This prospective study was carried out at the Paediatric Surgery unit, Zagazig University Hospitals, Egypt and Edawdmy General Hospital Saudia Arabia in the period from 2007 to 2009. The study comprising all children attended the emergency department with suspected acute appendicitis during this period, their ages ranged from 8 to 14 years [Table 1]. All patients were evaluated using the Alvarado score in the emergency room before admission. The decision of admission and surgery was made independent of the results of the applied score. The classical Alvarado score is based on three symptoms, three signs and two laboratory finding as shown in [Table 2]. Finally the scores were subsequently correlated with clinical, operative and histopathological findings of the removed appendices [Table 3].
Table 1 :Patient characteristics

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Table 2 :Alvarado scoring system

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Table 3 :Alvarado scoring distribution among all admitted patients compared to final outcome

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   Results Top


Three hundred and fifty patients were admitted with clinical features suggestive of acute appendicitis. The mean age was 9.3 years (ranged from 8 to 14 years); 182 patients (52%) were operated on with to treat acute appendicitis, 132 of them (72.5%) had inflamed appendices, which proved during surgery and by histopathological examination, in the remaining 50 patients (27.4%) that appendices were normal [Table 4]. A total of 168 patients (48%) were discharged without surgical intervention and advised to attend the out-patient clinic after 24 hours for re-evaluation and those who did not attend the outpatient clinic were contacted by telephone. None of the discharged patients required re admission as their symptoms improved or they developed other specific symptoms and diagnosed as gastroenteritis or acute tonsillitis.
Table 4 :Distribution of proven acute appendicitis among operated patients in relation to Alvarado score

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   Discussion Top


Acute appendicitis is a common surgical emergency that the emergency physician faces. It causes a problem when the patient presents with pain in right iliac fossa with equivocal signs. In such questionable cases the decision making for admission or discharge of these patients is always difficult, especially if the examining doctor is a junior staff with little experience. [13] Although there has been some improvement in the diagnosis of acute appendicitis over the paste several decades, the percentage of normal appendices reported in various series varies from 8-33%. [14],[15] The Alvarado score, is a simple scoring system that can be instituted easily in out-patient setting to decrease high false-positive appendectomy. In a prospective study of children in Gradiff, use of Alvarado score decreased an unusually high false-positive appendectomy of 44-14%. [16] These results match with our statistics as with cut off at score of 6 (either > 6 or ≤ 6), sensitivity will be 86.4%, specificity will be 26%, positive predictive value of 75.5% and negative predictive value of 41.9% and total accuracy of 69.8% [Table 4].

This study is designed to evaluate the use of Alvarado score as an objective criterion that helps the emergency doctor to take the decision regarding patient admission. According to this study, no patients with a score below 6 had acute appendicitis; these results are nearly similar to other studies. [13] Statistical analysis of our results proved that with cut off at score of 6 (either > 6 or ≤ 6), sensitivity will be 100%, specificity will be 84.4%, positive predictive value of 83% and negative predictive value of 100% and accuracy of 91.1%.

According to our results if the Alvarado score was used as an admission criterion, 40 (48%) patients who were admitted could have been observed as out-patient with reduction of admission rate and cost.


   Conclusion Top


The Alvarado score can be used as an objective criterion to help the emergency room doctor in taking the decision regarding admission or discharge of the patients with query acute appendicitis [Figure 1]. If this criterion is applied, the discharged patients are instructed to attend the out-patient clinic after 24 hours for follow-up and re-evaluation.
Figure 1 :lgorithm to use Alvarado score as an objective criterion for admission to the paediatric surgical department

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   References Top

1.Fitz RH. Perforating inflammation of the vermiform appendix: With special reference to its early diagnosis and treatment. Am J Med Sci 1886;92:321-46.  Back to cited text no. 1      
2.Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158:355-60.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Pearson RH. Ultrasonography for diagnosing appendicitis. BMJ 1988;297:309-10.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: A survey of North American Pediatric Surgeons. J Pediatr Surg 2004;39:875-9; discussion 875-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Wong KK, Cheung TW, Tam PK. Diagnosing acute appendicitis: Are we overusing radiologic investigations? J Pediatr Surg 2008;43:2239-41.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Pearl RH, Hale DA, Molloy M, Schutt DC, Jaques DP. Pediatric appendectomy. J Pediatr Surg 1995;30:173-8; discussion 178-81.   Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Chabra A, Chavez GF. A comparison of long pediatric hospitalizations in 1985 and 1994. J Community Health 2000;25:199-210.   Back to cited text no. 7      
8.Mushinski M. Laparoscopic and open appendectomies: Average charges, 1997. Stat Bull Metrop Insur Co 1999;80:23-31.  Back to cited text no. 8  [PUBMED]    
9.Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 2005;390:164-70.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Andersson M, Andersson RE. The appendicitis inflammatory response score: A tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 2008;32:1843-9.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64.   Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Sanjot B, Kurane M, Sangolli S, Gogate A. A one year prospective study to compare and evaluate diagnostic accuracy of modified Alvarado score and ultrasonography in acute appendicitis, in adults. Indian J Surg 2008;70:125-9.  Back to cited text no. 12      
13.Chan MY, Tan C, Chiu MT, Ng YY. Alvarado score: An admission criterion in patients with right iliac fossa pain. Surgeon 2003;1:39-41.  Back to cited text no. 13  [PUBMED]    
14.Chang FC, Hogle HH, Welling DR. The fate of the negative appendix. Am J Surg 1973;126:752-4.   Back to cited text no. 14  [PUBMED]    
15.Deutch AA, Shani N, Reiss R. Are some appendectomies unnecessary? An analysis of 319 white appendices. J R Coll Surg Edinb 1983;28:35-40.   Back to cited text no. 15      
16.Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of Alvarado score in acute appendicitis. J R Soc Med 1992;85:87-8.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Khalid S Shreef
42-Farouk Haggag Street, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.70417

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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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    Abstract
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