Usefulness of Modified Alvarado Score in Diagnosis of A cute Appendicitis in Adults

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.


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 surgery [1][2][3][4][5][6][7] .Alvarodo Score was devised in 1986 7 .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 10

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 form 6,7 .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% case 10 .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][12][13] .In our study 95.5% of patient had acute appendicitis 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 appendicitis 14,6,11 .
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][16][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.

Table 1 : Modi ed Alvarado Score Forms Results
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.
: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.