Diagnosis of Acute Appendicitis: A Cross-sectional Study on Alvarado’s Score from a Low Income Country

Abstract

Background Alvarado score is the most widely used scoring system for diagnosing acute appendicitis, globally. There have been concerns regarding the diagnostic accuracy of this score as it was shown to have lower sensitivity in certain populations like Blacks and Asians. Despite its wide clinical use in the Ethiopian set up, the diagnostic accuracy of this score remained largely unexamined in this population. Methodology A prospective cross-sectional study was conducted and all adult patients who presented with right lower quadrant abdominal pain and evaluated with a clinical impression of acute appendicitis were enrolled in the study. Data was collected by trained surgical residents over a period of six months (August 2019 – January 2020) and analysed using SPSS version 25. Results A total of 235 patients were enrolled in this study among whom two thirds were males. The majority of the study participants (61.7%) had an Alvarado score of ≥7 while almost a quarter of them had a score of <4. The mean Alvarado score in this study was 7 ± 1.8 whereas the median and the mode were 7 and 9 respectively. The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score were 99.1%, 55.6%, 98.2% and 62.5% respectively. The sensitivity and specificity of this score was superior in males compared to females (99.3% vs 97.6% and 80% vs 25%). A score of ≥5 was found to have a sensitivity of 98.4%. Conclusion Alvarado score was found to have good sensitivity and positive predictive value in this study. A score of ≥5 can be used to “rule in” the diagnosis of acute appendicitis. Hence, the use of Alvarado score’s in the Ethiopian setup is to be encouraged.

Diagnostic pathways in acute appendicitis; clinical score plus ultrasound outperform CT‐scan or upfront surgery especially in doubtful cases

“…However, clinical examination still has a role in screening low-risk patients, especially considering that in low income health services, the US and CT scan are not always readily available. 4 Coccolini and coworkers, who are surgeons with consolidated experience in the diagnosis and treatment of abdominal diseases in emergency, presenting the results of a study on 3123 patients with acute appendicitis, highlight that the association of clinical scores and US seems to be the most appropriate preoperative strategy to reach a correct diagnosis in patients with clinical suspicion of acute appendicitis. 6 In many patients with right iliac fossa pain, the clinical diagnosis, especially of exclusion, is straightforward, but what is left is the challenging patients, such as women in fertile age (differential diagnosis with mittelschmerz and ovarian pathology), pregnancy, children, and elderly patients, where a complicated colonic neoplasm, a disease more common in aged patients can mimic the symptoms of appendicitis.…”

“…The incidence and severity of complications after removal of an inflamed or non‐inflamed appendix seem to carry a similar morbidity. It is common knowledge nowadays that negative appendicectomy should not be undertaken routinely during laparoscopy for right iliac fossa pain 4 . In the meantime, the historical role of the “senior” surgeon, who has been for years in charge of the diagnosis and the ultimate decision for surgery, has been somehow reconsidered.…”

“…Taking into account that complication rate in elderly patients with negative appendectomy is higher than in younger patients, the preoperative diagnosis in these patients should be as accurate as possible. However, clinical examination still has a role in screening low‐risk patients, especially considering that in low income health services, the US and CT scan are not always readily available 4 …”