Combination of Alvarado score and ultrasound findings in diagnosis of acute appendicitis in children

Tamer Fakhry, Mohamed Shawky


Appendicitis is the most common cause of emergency abdominal surgeries in children. Ultrasound (US) has been proven to be a helpful imaging modality in patient evaluation, especially in children suspected of appendicitis. The Alvarado score is a 10-point scoring system for the diagnosis of appendicitis based on clinical data and differential leukocyte count. The aim of the present study was to evaluate a combination of clinical scoring (Alvarado score) and US findings for accurate diagnosis of appendicitis in children. The study was done in Menoufia University Hospitals from March 2011 to January 2013. 322 children with abdominal pain clinically suspected of having appendicitis were included in the study and clinically assessed to calculate the Alvarado score. Patients were referred to the radiology department for abdominal US. Among the 153 of the 322 patients who were operated on, 149 patients were diagnosed pre-operatively with acute appendicitis and 4 girls were diagnosed with complex ovarian cysts. Of the 149 patients diagnosed with appendicitis, the percentage of appendicitis was 93% (139/149) and 10 (7%) patients had normal appendix. The prevalence of appendicitis among the patients of the study was 43% (139/322). In conclusion, a combination of Alvarado scores and abdominal US is a good approach for the diagnosis of appendicitis in children to reduce the number of laparotomies for normal appendix. In the case of normal appendix or nonvisualization of the appendix via abdominal US without a high Alvarado score, appendicitis can be safely ruled out. If it is proven as an inflamed appendix on US or a high Alvarado score, patient should be subjected for appendectomy without delay.


Alvarado; appendicitis; ultrasound

Full Text:



Treutner KH, Schumpelick V. Epidemiologie der appen-dicitis (German) [Epidemiology of appendicitis]. Chirurg 1997; 68(1): 1–5. doi: 10.1007/s001040050142.

Berlin SC, Sivit CJ, Stringer DA. Large bowel. 2nd ed. In: Stringer DA, Babyn PS (editors). Pediatric gastroin-testinal imaging and intervention. London: B.C. Decker Inc.; 2000. p. 475–549.

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, et al. Does this child have appendicitis? J Am Med As-soc 2007; 298(4): 438–451. doi: 10.1001/jama.298.4.438.

Wong KKY, Cheung TWY, Tam PKH. Diagnosing acute appendicitis: Are we overusing radiologic investigations? J Pediatr Surg 2008; 43(12): 2239–2241. doi: 10.1016/ edsurg.2008.08.054.

Dilley A, Wesson D, Munden M, Hicks J, Brandt M, et al. The impact of ultrasound examinations on the management of children with suspected appendicitis: A 3-year analysis. J Pediatr Surg 2001; 36(2): 303–308. doi: 10.10 53/jpsu.2001.20702.

Sivit CJ, Newman KD, Boenning DA, Nussbaum-Blask AR, Bulas DI, et al. Appendicitis: Usefulness of US in diagnosis in a pediatric population. Radiology 1992; 185(2): 549–552. doi: 10.1148/radiology.185.2.1410371.

Moberg AC, Ahlberg G, Leijonmarck CE, Montgomery A, Reiertsen O, et al. Diagnostic laporoscopy in 1043 patients with suspected acute appendicitis. Eur J Surg 1998; 164(11): 833–840. doi: 10.1080/110241598750005246.

Alvarado A. A practical score for the early diagnosis acute appendicitis. Ann Emerg Med 1986; 15(5): 557–564. doi: 10.1016/S0196-0644(86)80993-3.

Balthazar EJ, Megibow AJ, Siegel SE, Birnbaum BA. Appendicitis: Prospective evaluation with high-resolution CT. Radiology 1991; 180(1): 21–24. doi: 10.1148/radiolo gy.180.1.2052696.

Incesu L, Coskun A, Selcuk MB, Akan H, Sozubir S, et al. Acute appendicitis: MR imaging and sonographic corre-lation. Am J Roentgenol 1997; 168(3): 669–674. doi: 10. 2214/ajr.168.3.9057512.

Sivit CJ, Applegate KE, Stallion A, Dudgeon DL, Salvator A, et al. Imaging evaluation of suspected appendicitis in a pediatric population: Effectiveness of sonography versus CT. Am J Roentgenol 2000; 175(4): 977–980. doi: 10.2214/ajr.175.4.1750977.

Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 2006; 241(1): 83–94. doi: 10.1148/radiol.2411050913.

Garcia Peña BM, Mandl KD, Kraus SJ, Fischer AC, Fleisher GR, et al. Ultrasonography and limited computed tomography in the diagnosis and management of ap-pendicitis in children. J Am Med Assoc 1999; 282(11): 1041–1046. doi: 10.1001/jama.282.11.1041.

Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, et al. Ultrasonography/MRI versus CT for diagnosing app-endicitis. Pediatrics 2014; 133(4): 586–593. doi: 10.1542/ peds.2013-2128.

Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in paediatric patients: Methodology and pic-torial overview of findings seen. Insights Imaging 2013; 4(6): 741–751. doi: 10.1007/s13244-013-0275-3.

Lee JH, Jeong YK, Park KB, Park JK, Jeong AK, et al. Operator-dependent techniques for graded compression sonography to detect the appendix and diagnose acute appendicitis. Am J Roentgenol 2005; 184(1): 91–97. doi: 10.2214/ajr.184.1.01840091.

Winn RD, Laura S, Douglas C, Davidson P, Gani JS. Protocol-based approach to suspected appendicitis, in-corporating the Alvarado score and outpatient antibiotics. ANZ J Surg 2004; 74(5): 324–329. doi: 10.1111/j.1445-1 433.2004.02993.x.

Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: A systematic review. BMC Med 2011; 9: 139. doi: 10.1186 /1741-7015-9-139.

Abdus Salam A, Shahidul A, Quamruzzaman SM, Anisur Rahman M. Diagnosing acute appendicitis in children using Alvarado score. AKMMC J 2011; 2(2): 11–13.

Nielsen JW, Boomer L, Kurtovic K, Lee E, Kupzyk K, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultra-sonography report template. J Pediatr Surg 2015; 50(1): 144–148. doi: 10.1016/j.jpedsurg.2014.10.033.

Bachur RG, Hennelly K, Callahan MJ, Chen C, Monu-teaux MC. Diagnostic imaging and negative appendec-tomyrates in children: effects of age and gender. Pediatrics 2012; 129(5): 877–884. doi: 10.1542/peds.201 1-3375.

Tsze DS, Asnis LM, Merchant RC, Amanullah S, Linakis JG. Increasing computed tomography use for patients with appendicitis and discrepancies in pain manage-ment between adults and children: An analysis of the NHAMCS. Ann Emerg Med 2012; 59(5): 395–403. doi: 10.1016/j.annemergmed.2011.06.010.

Parker L, Nazarian LN, Gingold EL, Palit CD, Hoey CL, et al. Cost and radiation savings of partial substitution of ultrasound for CT in appendicitis evaluation: A national projection. Am J Roentgenol 2014; 202(1): 124–135. doi: 10.2214/AJR.12.9642.

Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, et al. The use of computed tomography in paediatrics and the associated radiation exposure and es-timated cancer risk. JAMA Pediatr 2013; 167(8): 700–707.doi: 10.1001/jamapediatrics.2013.311.

Howell JM, Eddy OL, Lukens TW, Thiessen MEW, Weingart SD, et al. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med 2010; 55(1): 71–116. doi: 10.1016/j.annemergmed.2009.10.004.

Toorenvliet B, Vellekoop A, Bakker R, Wiersma F, Mertens B, et al. Clinical differentiation between acute appendicitis and acute mesenteric lymphadenitis in children. Eur J Pediatr Surg 2011; 21(2): 120–123. doi: 10.10 55/s-0030-1267979.

Yildirim E, Karagülle E, Kirbaş I, Türk E, Hasdoğan B, et al. Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis. Diagn Interv Radiol 2008; 14(1): 14–18.

Mandeville K, Pottker T, Bulloch B, Liu J. Using appen-dicitis scores in the pediatric ED. Am J Emerg Med 2011; 29(9): 972–977. doi: 10.1016/j.ajem.2010.04.018.



  • There are currently no refbacks.

Copyright (c) 2017 Tamer Fakhry, Mohamed Shawky

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.