II. Indications: Not recommended due to low Test Sensitivity (listed for historical purposes only)

  1. Appendicitis Evaluation

III. Criteria: Alvarado Score

  1. Major criteria (assign 2 point for each positive)
    1. Right lower quadrant tenderness to palpation
    2. Leukocytosis (WBC Count >10,000)
  2. Minor criteria (assign 1 point for each positive)
    1. Abdominal Pain migrates to the right lower quadrant
    2. Anorexia or (Urine Ketones positive)
    3. Nausea or Vomiting
    4. Rebound Abdominal Tenderness
    5. Increased Temperature (37.3 °C or 99.1 F)
    6. Neutrophilia (cell count with Left Shift) - removed from revised version

IV. Criteria: MANTRELS mnemonic - same as Alvarado Score (all assigned 1 point except for the two where noted)

  1. Migration to the right lower quadrant
  2. Anorexia
  3. Nausea or Vomiting
  4. Tenderness in the right lower quadrant (2 points)
  5. Rebound Pain
  6. Elevated Temperature
  7. Leukocytosis (2 points)
  8. Shift Left of Leukocytes

V. Interpretation

  1. Score <4: Appendicitis unlikely
  2. Score 5-6: Possible Acute appendicitis
  3. Score 7-8: Probable Appendicitis
  4. Score 9-10: Very probable Acute appendicitis

VI. Protocol: Alvarado Score directed management

  1. Score <4: Low Risk
    1. No imaging required (Appendicitis unlikely)
    2. Positive Likelihood Ratio: 0.03 (0.02 in children)
    3. Probability Appendicitis: 3.7% (1.9% in children)
  2. Score 4-6: Moderate Risk
    1. Appendix Ultrasound (consider MRI Abdomen or CT Abdomen)
    2. Positive Likelihood Ratio: 0.42 (0.27 in children)
    3. Probability Appendicitis: 45% (12% in children)
  3. Score >6: High Risk
    1. Surgical Consultation
    2. Positive Likelihood Ratio: 3.4 (4.2 in children)
    3. Probability Appendicitis: 87% (67% in children)
  4. McKay (2007) Am J Emerg Med 25(5):489-9 [PubMed]

VII. Efficacy

  1. Alvarado Score is not reliable in younger children
    1. Bond (1990) Ann Emerg Med 19(9):1014-8 [PubMed]
  2. Alvarado Score misses up to one third of Appendicitis cases
    1. Test Sensitivity: 72% (unreliable for risk stratifying possible Appendicitis cases)
    2. Meltzer (2013) Ann Emerg Med 62(2): 126-31 [PubMed]

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