Can we rule out appendicitis with a low ALVARADO score?

Abdominal pain is a common ED presentation and one of the top differential for RLQ pain is Acute Appendicitis. Early in the course, examination findings are often subtle and bloods may not show a raised WCC or CRP. One way to further risk stratify patients is by using 
the Alvarado score or the Modified Alvarado Score.

The original Alvarado score was on a 10 point scale. It has been modified to exclude criteria of a left shift. The sensitivity of the Alvarado score is about 72% and the specificity is 54% and like any other decision rule, this is not flawless. Relying solely on the score may miss about a third of patients with Appendicitis. Since multiple organ systems are represented in the abdomen, it is hard to create a clinical decision rule which can precisely identify the diagnosis. 

Additionally, using this score in females can be tricky due to possible OBGYN pathologies. 

Bottomline

• Use your clinical acumen and utilize Alvarado score only as an adjunct.
• Use Alvarado Score as more of a "rule-in' test, not "rule-out" test. 
• It is worth doing and documenting serial abdomen exams in non-specific abdo pains. d/w Surgical in-patient teams for possible admission for observation rather than directly jumping to imaging. 
• If discharging, give strong worsening statements and explain uncertainty about the diagnosis and need for review if symptoms change. 

References

1. Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis. Annals of emergency medicine. 2013 Aug 1;62(2):126-31.
2. Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC medicine. 2011 Dec;9(1):139.

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic