Appendix by drdamodhar.m.v

Appendicitis- Alvarado score

Presented by,

Dr. Damodhar. M.V

Objectives

• Alvarado Score:• Interpretation,• Review

• Consider what you would do next• Imaging choices

• US• CT

• Non-contrast vs oral contrast vs rectal

– MRI

Statistics

• Incidence Rate: approximately 1 in 400 or 0.25% or 680,000 people in USA*

• Lifetime risk for Acute Appendicitis:

• Males- 8.6%

• Female- 6.7%.

• Negative Appendectomy Rate (NAR)-15.3%.*

*Rothrock et al, 2000

*Schwartz's Principles of Surgery Part II. 9th edition

Statistical Analysis

• Recently with the improvement in diagnostic modalities the rate of negative appendectomy reduced to 8.4%.*

• NAR in Females- 71.6%

• NAR in Male- 28.4%

• Removing a normal appendix is associated with a 4% risk of fetal loss and 10% risk of early delivery

*Howard Hospital for Outcome research, Dept of Surgery AMJ-Surgery 2011

Qualities of effective scoring scale

• It should be simple

• It should be capable of being administered by all strata of medical personnel

• It should be possible to assess quickly

• There should be no ambiguity

Scoring system for Appendicitis

• The Alvarado scoring,

• Modified Alvarado scoring,

• Tzanakis scoring,2005

• Simplified Appendicitis score

• Pediatric Appendicitis score

Right lower abdominal tenderness = 4 points

Rebound tenderness = 3

Presence of white blood cells greater than 12,000 in the blood = 2,

Presence of positive ultrasound scan findings of appendicitis = 6,

The maximum score is a total score of 15; where a patient scores 8 or more points, there is greater than 96% chance that appendicitis exists.

Alfredo Alvarado, MD

Plantation General Hospital, Florida.

Accepted for publication November 11,1985.

This scoring uses Bayesian analysis

The Alvarado score:

•Three symptoms

•Three signs

•Two laboratory finding

*Alvarado A:A practical score for the early diagnosis of acute appendicitis. Ann Emerg-Med May 1986;15:557-564.]

The Alvarado Score• Symptoms Score

Migratory right iliac fossa pain 1

Nausea/vomiting 1 Anorexia 1

• Signs RIF tenderness 2

Fever >37.30C 1 Rebound pain in RIF 1 Laboratory test Leucocytosis (>10 X 109/L) 2

Neutrophilic shift to the left >75% 1

• Total score 10

*Alvarado A:A practical score for the early diagnosis of acute appendicitis. Ann Emerg-Med May 1986;15:557-564.]

The Alvarado Score

• Those with a score of 5 or 6 require observation and further investigation

• Score of 7 or above needed to proceed to surgery as it is likely to be appendicitis.

*Clinical Presentation of Acute Appendicitis: Clinical Alvarado Score and Derivate Scores by David J. Humes and John Simpson Springer-Verlag Berlin Heidelberg 2011

Analysis of Alvarado score

• Al-Hashemy A M, Seleem M I, (2004). Appraisal of the modified Alvarado Score for acute appendicits in adults. Saudi Med J., 25: 1229-31

• Antevil J, Rivera L, Langenberg B, Brown C V, (2004). The influence of age and gender on the utility of computed tomography to diagnose acute appendicitis.Am Surg., 70:850-3

• Bolandparvaz S, Vasei M, Owji AA, Ata-Ee N, Amin A, Daneshbod Y, Hosseini S V, (2004). Urinary 5-hydroxy indole acetic acid as a test for early diagnosis of acute appendicitis. Clin Biochem., 37:985-9

• Esmer-Sanchez D D, Martinez-Ordaz J L, Roman-Zepeda P, Sanchez-Fernandez P, Medina-GonzalezE. Cir, (2004). Appendiceal tumors. ClinicopathologicRreview of 5,307 appendectomies. 72:375-8

• Garfield J L, Birkhahn R H, Gaeta T J, Briggs W M, (2004), Diagnostic pathways and delays on route to operative intervention in acute appendicitis. Am Surg., 70(11):1010-3

• Hong J J, Cohn S M, Ekeh A P, Newman M, Salama M, Leblang S D, (2003). Miami Appendicitis Group. Surg Infect (Larchmt). A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Fall.,4:231-9

• Iwahashi N, Kitagawa Y, Mayumi T, Kohno H. World, (2004) Intravenous Cont


• Analysis indicates that the Alvarado score has moderate to high sensitivity (all studies 82%, men 88%, women 86% and children 87%) and

• Moderate specificity (all studies 81%, men 57%, women 73% and children 76%)

• *A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. This study was funded by the Health Research Board of Ireland (HRB) under grant reference HRC/2007/1.


• The Alvarado score is a useful diagnostic 'rule out' score at a cut off 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.

• As a decision rule in relation to surgery the Alvarado score cannot be used to 'rule in' a diagnosis of appendicitis without surgical assessment and further diagnostic testing.

*A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. This study was funded by the Health Research Board of Ireland (HRB) under grant reference HRC/2007/1.

Clearly Imaging Reduces NARGuss et al., “Impact of Abdominal Helical CT on the Rate of Negative Appendicitis” JEM 2008; 34(1) - Retrospective review of before and after frequent CT- Decrease in NAR from 15.5% to 7.6%- 12% CT rate before readily available, 81% after

Kim, K. et al, “The Impact of Helical CT on Negative Appendectomy Rate: A Multi-Center Comparison; JEM 2008; 34(1) - CT Rate and NAR inversely related- NAR decreased 20% to 6%- Limited by no follow up on negative scans

Wagner et al., Surgery. 2008; 144(2) - Retrospective review of four-year time periods before and after frequent CT- NAR decreased 16% to 6%- NAR decreased mostly due to adult women- No change in NAR with kids (8%)- Adult male decreased from 9% to 5% (NSS)- Adult women decreased 20% to 7%

Ultrasound

• Very safe! No radiation, no contrast required

• Sensitivity and Specificity:

– Sensitivity – 74-83%,

– Specificity – 93-97%

• If can’t visualize – need to move on to the next step

Findings on US for appendicitis

- Non-compressible appendix- Appendix >6mm diameter- Signs of perforation

-Free fluid-Abscess

Ultrasound

• All studies should be performed in both the transverse and longitudinal planes with a technique referred to as "graded compression,"

• Examiner exerts gentle pressure using the ultrasound probe and either one or two hands to palpate the RLQ in the same way as when performing an abdominal examination.

• Utilizing varying pressure, this method is used to decrease the distance between the ultrasound probe and the pathology and eliminate overlying bowel gas, which can cause overlying bowel gas artifact.

Ultrasound- Graded Compression method

*Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score BMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7266.919 (Published 14 October 2000)Cite this as: BMJ 2000;321:919

Computed Tomography

• Advantages:• Sensitivity 94-98% / specificity 95-99%

• Alternative diagnoses

• May see extravasation

• Better if little intra-abdominal fat

• Fluid collections

Computed Tomography

• Disadvantages:

• Large volume contrast• What if vomiting?

• If not, probably will• Risk of aspiration• Aren’t they NPO?

• Increased lifetime cancer risk

• Increases difficulty of assessing bowel wall

• 2 hour delay:

• Delays surgical decision

• Risk of perforation

CT with or without contrast

• For diagnosis of appendicitis

• No need to drink contrast – no delay

• No change in diagnostic accuracy with IV Contrast

• Sensitivity 94-98% Specificity – 95-99%• No difference in making the diagnosis with IV or no

contrast• Some even thought IV obscured the intra-abdominal

structures

*Keyzer, C., et al, Am J Roent. August 2008*Basak S, et al., J Clin Imag. 2002; 26. *Hoecker CC, et al, JEM. May 2005*Lowe LH, et al., Am J Roent. Jan 2001*Ege G, et al., Br J Radiology. 2002; 75

Females of Child bearing age

Modified Alvarado Score

• Medical facilities that are unable to perform a differential white blood cell count use Modified Alvarado Score with a total of 9.

• Modified Alvarado score and the Alvarado score are useful complementary methods in the diagnosis of patients suspected to have acute appendicitis. The diagnostic value of the modified Alvarado score is higher than the Alvarado score in this study.*

*The Modified Alvarado Score Versus the Alvarado Score for the Diagnosis of Acute Appendicitis

The THAI Journal of SURGERY 2005; 26:69-72. The Royal College of Surgeons of Thailand

Modifications to Alvarado score

• Diagnosing appendicitis can be very challenging. Neutrophilic leucocytosis and a raised Alvarado score of >5 were the only two findings that were significantly associated with appendicitis

*Utility of Alvarado score in diagnosing appendicitis and its modification to make it more useful Gastroenterology Today 2005 Issue 3

Conclusion

Conclusion

• The diagnosis of acute appendicitis depends on experience and clinical judgment. The diagnosis of acute appendicitis remains a challenging task for surgeons.

• Alvarado scoring system is a non-invasive, safe diagnostic procedure that is simple, fast, cheap and reliable.

• The application of this scoring system improves diagnostic accuracy and can be used as an objective criterion in screening patients with suspected appendicitis for admission.

*International Journal of Basic and Applied Medical Sciences ISSN: 2277-2103 2012 Vol. 2

*Alvarado score as an admission criterion for suspected appendicitis in adults . Gastroenterol 2004;10:86-91

Conclusion

• Classic presentation of Anorexia, Pain and Nausea should always be kept in mind.*

• Thorough clinical examination cannot be replaced to any diagnostic modalities or scoring.

• No imaging – take to the OR*


*Kalliakmans V, et al., Scan J Surg. 2005; 94(3Guss DA, et al., JEM. 2008; 34(1)

*Wagner PL, et al., Surgery. 2008 Aug; 144(2)


Conclusion

• Classic presentations do not require imaging• Reserve imaging for equivocal cases• Abdominal CT estimated increase cancer risk 1 in 2000

• Keep in mind CT not shown to decrease NAR in men and children.

• Oral or IV contrast provides no added value.

• Consider US first for kids, women, and pregnant

• MRI is a reasonable alternative if available

• Cut it, ligate it but never burry it!!!

Appendicitis is a pocket size time bomb!!!

Thank you

Healthcare

Appendix by drdamodhar.m.v