The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED.

STUDY OBJECTIVE Appendicitis is part of the differential of an acute abdomen and can be a difficult diagnosis to make. Strategies to suggest which patients presenting to the emergency department (ED) should undergo computed tomography (CT) scan to confirm appendicitis have not been addressed. We develop guidelines for CT scanning based on Alvarado clinical scores for patients with suspected and confirmed cases of appendicitis. METHODS A retrospective review of 150 charts of patients aged 7 and older who presented with abdominal pain to the ED of a 392-bed acute care facility over a 6-month period were evaluated by ED physicians and underwent CT to rule out appendicitis. Patient demographics, presenting signs, and symptoms were documented. Using the scoring system for appendicitis, developed by Alvarado, each chart was retrospectively scored. The Alvarado scores were correlated with positive pathology findings, as well as Alvarado scores with a negative CT scan. Equivocal scores, having neither high sensitivity nor specificity for appendicitis were calculated. RESULTS Computed tomography scans with Alvarado scores of 3 or lower were performed in 37% (55/150) of patients to rule out appendicitis. The sensitivity of Alvarado scores 3 or lower for not having appendicitis was 96.2% (53/55), and the specificity 67% (2/3). Patients with Alvarado scores 7 or higher had an incidence of acute appendicitis of 77.7% (28/36). The sensitivity of Alvarado scores 7 or higher for appendicitis was 77% (28/36), and the specificity 100% (8/8). The sensitivity of equivocal Alvarado scores, defined as scores of 4 to 6, for acute appendicitis was 35.6% (21/59), and the specificity 94% (36/38). The sensitivity and specificity of CT scans in patients with equivocal Alvarado scores remained high, at 90.4% and 95%, respectively. CONCLUSIONS In the equivocal clinical presentation of appendicitis as defined by Alvarado scores of 4 to 6, adjunctive CT is recommended to confirm the diagnosis in the ED setting. If clinical presentation suggests acute appendicitis by an Alvarado score of 7 or higher, surgical consultation is recommended. Computed tomography is not indicated in patients with Alvarado scores of 3 or lower to diagnose acute appendicitis.

[1]  L. V. Van Hoe,et al.  Effectiveness of imaging studies in acute appendicitis: a simplified decision model , 2000, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[2]  H. Ho,et al.  Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. , 2001, Archives of surgery.

[3]  A. Mangram,et al.  Are negative appendectomies still acceptable? , 2004, American journal of surgery.

[4]  Gerald J Berry,et al.  Imaging for suspected appendicitis: negative appendectomy and perforation rates. , 2002, Radiology.

[5]  H. Ho,et al.  Ultrasonography and computed tomography in suspected acute appendicitis. , 2003, Seminars in ultrasound, CT, and MR.

[6]  J. G. Schuler,et al.  Is there a role for abdominal computed tomographic scans in appendicitis? , 1998, Archives of surgery.

[7]  D. Smink,et al.  Diagnosis of acute appendicitis in children using a clinical practice guideline. , 2004, Journal of pediatric surgery.

[8]  W. Briggs,et al.  Diagnostic Pathways and Delays on Route to Operative Intervention in Acute Appendicitis , 2004, The American surgeon.

[9]  Dirk J Gouma,et al.  Scoring and diagnostic laparoscopy for suspected appendicitis. , 2003, The European journal of surgery = Acta chirurgica.

[10]  T. Moteki,et al.  CT is useful for identifying patients with complicated appendicitis. , 2004, Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver.

[11]  D. Oller,et al.  Is appendiceal CT scan overused for evaluating patients with right lower quadrant pain? , 2001, The American journal of emergency medicine.

[12]  L. Enochsson,et al.  Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. , 1997, The European journal of surgery = Acta chirurgica.

[13]  Stephen M Cohn,et al.  A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. , 2003, Surgical infections.

[14]  I. Ringqvist,et al.  The Fenyö-Lindberg scoring system for appendicitis increases positive predictive value in fertile women—A prospective study in 455 patients randomized to either laparoscopic or open appendectomy , 2004, Surgical Endoscopy And Other Interventional Techniques.

[15]  Amy Berrington de González,et al.  Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries , 2004, The Lancet.

[16]  Alfredo Alvarado,et al.  A Practical Score for the Early Diagnosis of Acute Appendicitis , 1986 .

[17]  E. Halpern,et al.  The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. , 2005, AJR. American journal of roentgenology.

[18]  Soumitra R. Eachempati,et al.  A prospective evaluation of the use of emergency department computed tomography for suspected acute appendicitis. , 2001, Surgical infections.

[19]  C. Ohmann,et al.  Diagnostic scores for acute appendicitis. Abdominal Pain Study Group. , 1995, The European journal of surgery = Acta chirurgica.

[20]  C. Feltmate,et al.  Helical computed tomography in differentiating appendicitis and acute gynecologic conditions. , 1999, Obstetrics and gynecology.

[21]  B. Nan,et al.  Incidence of acute appendicitis in patients with equivocal CT findings. , 2005, AJR. American journal of roentgenology.

[22]  B. Doust,et al.  The CT diagnosis of acute appendicitis. , 2003, Seminars in ultrasound, CT, and MR.

[23]  F Christian,et al.  A simple scoring system to reduce the negative appendicectomy rate. , 1992, Annals of the Royal College of Surgeons of England.

[24]  Daniel J. Johnson,et al.  Histologic severity of appendicitis can be predicted by computed tomography. , 2004, Archives of surgery.

[25]  E. Ghersin,et al.  The Role of Selective Computed Tomography in the Diagnosis and Management of Suspected Acute Appendicitis , 2002, The American surgeon.