Background: The gold standard treatment of acute appendicitis is appendectomy. Early surgery reduces a number of complications such as appendicular mass formation, abscess and perforation. However, diagnostic inaccuracy especially in female gender can lead to negative appendectomy because other gynecological diseases have quite similar presentation. The objective of our study is to determine the diagnostic accuracy of Alvarado scoring system in the diagnosis of acute appendicitis in comparison to the gold standard histopathology in patients with acute pain right iliac fossa. Methods: This descriptive Cross-sectional study was carried out on 253 patients with acute pain in right iliac fossa at Surgical Department of MTI, Lady Reading Hospital from 14th July 2020 to 14th January 2021. Results: Mean age was 37 years with standard deviation ± 10.09. 111(44%) patients were male and 142(56%) patients were female. 129(51%) patients were married while 124(49%) patients were unmarried. Based on Alvarado scoring Acute appendicitis was diagnosed in 197(78%) patients and missed in 56(22%) patients. Diagnosis of Acute appendicitis was confirmed by histopathology report in 245(97%) patients while in 8 (3%) patients histopathology did not reveal acute infection. Diagnostic accuracy of Alvarado scoring analyzed with histopathological diagnosis was 78.65%. Conclusion: Alvarado scoring has a sensitivity of 79.18%, specificity 62.5%, PPV 98.47%, NPV 8.92% and diagnostic accuracy of 78.65% in diagnosis of acute appendicitis taking histopathology as gold standard in patients with acute pain right iliac fossa. Keywords: Acute Appendicitis, Alvarado, Histopathology, Diagnostic accuracy

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