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Three Part Question

In [children with suspected appendicitis] is [the Alvarado scoring system] [sufficiently sensitive and specific to enable rule in and/or rule out of acute appendicitis])?

Clinical Scenario

A 10-year-old girl presents to the emergency department (ED) with pain in her right lower quadrant. She states that the pain started 2 days ago when it was diffuse across her lower abdomen. She has had a decreased appetite but no nausea or vomiting. On examination, her abdomen is soft, non-distended, with no guarding and no rebound tenderness. Rovsing\'s sign is negative, but she has positive obturator and psoas signs. Murphy\'s sign is negative. Bowel sounds are heard throughout her abdomen. She is afebrile and her basic laboratory tests show a leucocytosis of 11 000 white blood cells/µl with a left shift. You wonder how likely it is that this patient has appendicitis and how best to manage this individual. You wonder if the Alvarado scoring system used for this purpose in adults is supported by evidence in paediatrics.

Search Strategy

Ovid MEDLINE 1946 to September week 3 2012
(exp Appendicitis/or appendicitis.mp.) and (Alvarado or Mantrels).mp. and (exp Pediatrics/or exp Adolescent/or exp Child/or exp Infant/or exp, Child, Preschool/or exp Infant, Newborn/or \"p?ediatric$.mp. OR child$.mp.)

Search Outcome

Sixty-six papers were identified, of which eight were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rezak et al, 2011, USA	122 patients (ages 3-16) with suspected acute appendicitis and imaged with abdominal CT	Retrospective Case-Control	Value of Alvarado score in predicting appendicitis in children	Alvarado score 7-10: Sensitivity = 92% Specificity = 82% Alvarado score 8-10: Sensitivity = 93% Specificity = 97%	Small sample size. Possible selection bias.
Shera et al, 2011, India	90 consecutive patients (ages 10-12) with suspected acute appendicitis	Prospective Cohort	Value of Alvarado score in predicting appendicitis in children	Alvarado score 7-10: Sensitivity = 97% Specificity = 75% PPV = 93% NPV = 88%	Small sample size.
Schneider et al, 2007, USA	350 Patients (aged 8–14 years) with suspected acute appendicitis	Prospective Cohort	Value of Alvarado score in predicting appendicitis in children	Alvarado score 7–10: sensitivity=86.4% specificity=64.8% PPV=75.6% NPV=79.1%	68 Patients were discharged without surgical intervention and advised to attend the outpatient clinic after 24 h for re-evaluation. Actual follow-up was unclear in the methods
			Value of Alvarado score in ruling out appendicitis in children	Alvarado score 0–6: sensitivity=100% specificity=84.4% PPV=83% NPV=100%
Macklin et al, 1997, UK	118 consecutive patients (median age 10) with suspected acute appendicitis	Prospective Cohort	Value of Alvarado score in predicting appendicitis in children	Alvarado score 7-10: Sensitivity = 76.3% Specificity = 78.8%	Small sample size.
Ohle et al, 2011, Ireland	Nine studies investigating the diagnostic value of the Alvarado score in children with suspected appendicitis	Systematic review and meta-analysis	Pooled sensitivity of the Alvarado score (cut point 5)	99% (95% CI 83% to 100%)	Significant heterogeneity between studies (I2 >50%), suggesting that pooling of the data may not have been appropriate Wide CI suggest more data still needed Total number of included children not reported
			Pooled specificity of the Alvarado score (cut point 7)	76% (95% CI 55% to 89%)
Mandeville et al, 2011, USA	287 Children aged 4–17 years who presented to a paediatric ED with suspected appendicitis. Alvarado score recorded at presentation	Prospective diagnostic cohort study	Sensitivity of the Alvarado score	At a cut point of 5, sensitivity 89.7% (NPV 74%). At a cut point of 1, sensitivity 94.2%	High prevalence of appendicitis (54%)
			Specificity of the Alvarado score	At a cut point of 7, specificity 72% (PPV 76%). At a cut point of 8, specificity 84.1% (PPV 81%)
Hsiao et al, 2005, Taiwan	111 Patients aged under 14 years with confirmed acute appendicitis (from operative and pathology reports) and 111 controls who had acute appendicitis excluded	Retrospective case–control study	Alvarado scores in cases	12.6% of cases had a score of 0–3; 27.9% of cases had a score of 4–6; and 59.5% of cases had a score of 7–10	Retrospective Suboptimal design to calculate sensitivity and specificity No mention of investigator blinding to case–control status
			Alvarado scores in controls	21.6% of controls had a score of 0–3; 39.6% had a score of 4–6; and 38.8% had a score of 7–10
Bond et al, 1990, USA	189 Episodes from 187 children aged 2–17 years presenting to the ED with abdominal pain	Prospective diagnostic cohort study	Diagnostic performance at cut point of 5	Sensitivity 100%; specificity 38%	All patients with abdominal pain included, regardless of suspicion of appendicitis CI around the sensitivity and specificity not reported
			Diagnostic performance at cut point of 7	Sensitivity 90%; specificity 72%

Comment(s)

In diagnosing appendicitis, clinicians balance the risk of removing a normal appendix against the risk of perforation. The Alvarado scoring system is a convenient tool for aiding the diagnosis of appendicitis. It is known by the mnemonic ‘MANTRELS’ and is scored as follows: migration of pain (1 point); anorexia (1 point); nausea or vomiting (1 point); right lower quadrant tenderness (1 point); elevation in temperature (≥37.3°C); leucocytes (≥10 000; 2 points); differential white blood cell count with 75% polymorphonuclear cells (1 point).

The Alvarado score has previously been shown to be relatively sensitive and specific in the adult population (with better results in men than women) presenting with right lower quadrant pain. As a diagnostic tool for appendicitis in the paediatric population, a cut point of 5 points appears to be fairly sensitive (99% in the systematic review by Ohle et al, albeit with wide 95% CI (83% to 100%); 89.7% in the study by Mandeville et al, which was not included in the systematic review). Using scores of 7–10 has shown sensitivities ranging from 72% to 92% and specificities ranging from 64.4% to 82%. The one paper using scores of 8–10 showed a sensitivity of 93% and specificity of 97%, but more studies of this modified score are necessary. Imaging appears still to be warranted on a routine basis for children with a score of 5–7 (preferably first ultrasound and only followed by CT if negative to avoid unnecessary radiation exposure). However, only one paper has studied this modified score and more studies are necessary.

Editor Comment

ED, emergency department; NPV, negative predictive value; PPV, positive predictive value.

Clinical Bottom Line

The Alvarado score can be used to risk stratify children with suspected appendicitis in the ED. Children with an Alvarado score of less than 5 are unlikely to have acute appendicitis, although more evidence is still needed before this alone can be considered to exclude the diagnosis safely in practice.

References

1. Rezak A, Abbas HM, Ajemian MS et al. Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg 2011;146(1):64-7.
2. Shera AH, Nizami FA, Malik AA et al. Clinical scoring system for diagnosis of acute appendicitis in children. Indian J Pediatr. 2011;78(3):287-90.
3. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med. 2007;784;49:778–84.
4. Macklin CP, Radcliffe GS, Merei JM et al. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl. 1997;79(3):203-5.
5. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557–64.
6. Ohle R, O Reilly F, O Brien KK, et al. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139.
7. Mandeville K, Pottker T, Bulloch B, et al. Using appendicitis scores in the pediatric ED. Am J Emerg Med 2011;29:972–7.
8. Hsiao KH, Lin LH, Chen DF. Application of the MANTRELS scoring system in the diagnosis of acute appendicitis in children. Acta Paediatr Taiwanica 2005;46:128–31.
9. Bond GR, Tully SB, Chan LS, et al. Use of the MANTRELS score in childhood appendicitis: a prospective study of 187 children with abdominal pain. Ann Emerg Med 1990;19:1014–18.