II. Indications: Not recommended due to low Test Sensitivity (listed for historical purposes only)
- Appendicitis Evaluation
III. Criteria: Alvarado Score
- Major criteria (assign 2 point for each positive)
- Right lower quadrant tenderness to palpation
- Leukocytosis (WBC Count >10,000)
- Minor criteria (assign 1 point for each positive)
- Abdominal Pain migrates to the right lower quadrant
- Anorexia or (Urine Ketones positive)
- Nausea or Vomiting
- Rebound Abdominal Tenderness
- Increased Temperature (37.3 °C or 99.1 F)
- 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)
- Migration to the right lower quadrant
- Anorexia
- Nausea or Vomiting
- Tenderness in the right lower quadrant (2 points)
- Rebound Pain
- Elevated Temperature
- Leukocytosis (2 points)
- Shift Left of Leukocytes
V. Interpretation
- Score <4: Appendicitis unlikely
- Score 5-6: Possible Acute Appendicitis
- Score 7-8: Probable Appendicitis
- Score 9-10: Very probable Acute Appendicitis
VI. Protocol: Alvarado Score directed management
- Score <4: Low Risk
- No imaging required (Appendicitis unlikely)
- Positive Likelihood Ratio: 0.03 (0.02 in children)
- Probability Appendicitis: 3.7% (1.9% in children)
- Score 4-6: Moderate Risk
- Appendix Ultrasound (consider MRI Abdomen or CT Abdomen)
- Positive Likelihood Ratio: 0.42 (0.27 in children)
- Probability Appendicitis: 45% (12% in children)
- Score >6: High Risk
- Surgical Consultation
- Positive Likelihood Ratio: 3.4 (4.2 in children)
- Probability Appendicitis: 87% (67% in children)
- McKay (2007) Am J Emerg Med 25(5):489-9 [PubMed]
VII. Efficacy
- Alvarado Score is not reliable in younger children
- Alvarado Score misses up to one third of Appendicitis cases
- Test Sensitivity: 72% (unreliable for risk stratifying possible Appendicitis cases)
- Meltzer (2013) Ann Emerg Med 62(2): 126-31 [PubMed]