The Alvarado score for predicting acute appendicitis: a systematic review

Background: The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. Methods: A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. Results: Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. Conclusions: The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.Peer reviewe

Radiological imaging to improve the emergency department diagnosis of acute appendicitis

To determine the institution’s current non-therapeutic (negative) appendicectomy rate; the frequency of clinical predictors for appendicitis in patients who underwent appendicectomy; and the utilization and accuracy of ultrasound scans (USS) and computed tomography (CT) in the diagnosis of appendicitis. Methods: A retrospective chart review was conducted in an adult, metropolitan teaching hospital. Patients who presented to the ED and underwent an appendicectomy over a 12-month period were analysed. Symptoms and signs predictive of appendicitis, results of USS and CT scans if performed, and histopathology findings were abstracted from patient records. Results: Two hundred and forty patients had appendicectomies, 147 (61%) were male and the median age was 25 years (range 14–78 years). The negative appendicectomy rate was 14.3% (95% CI 9.1–21.0%) and 18.3% (95% CI 11.0–26.7%) in males and females, respectively. Abdominal pain shifting to the right iliac fossa (RIF), anorexia and RIF rebound tenderness were found more frequently in patients with positive than negative appendicectomies (P < 0.05). USS and CT scans were performed in 68 (28%) and 15 (9.5%) patients, respectively. The likelihood ratio for appendicitis in patients with a normal USS or a normal CT scan was 0.83 (95% CI 0.56–1.24) and 0.08 (95% CI 0.01– 0.60), respectively. There were no false positive CT scan results. Conclusion: Computed tomoraphy scanning should play an increasing role in the ED management of suspected appendicitis. Our negative appendicectomy rate could potentially be halved by the introduction of CT scans in the diagnostic work up of these patients