Role of alvarado score in diagnosis and treatment of suspected acute appendicitis

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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 2 • March 2000

that our patient's severe hyponatremia could be attributed to the thiazide diuretics which were subsequently discontinued. In conclusion, rhabdomyolysis can result from the correction of severe hyponatremia. This extremely rare late-onset complication should be kept in mind in this setting. Close patient follow-up and extreme caution should be exercised in this setup owing to the morbidity and mortality associated with rhabdomyolysis. GALIAMENASHE,MD ABRAHAMBORER,MD JACOBGtLAD,MD JACOBHOROWlTZ,MD

Department of Internal Medicine A Soroka Medical Center and the Ben-Gurion University of the Negev Beer-Sheva, Israel

TABLE 1. TheAIvarado Score (MANTRELS)

Score Symptoms Migratory RLQ pain Anorexia Nausea & Vomiting Signs Tenderness (RLQ) Rebound tenderness (RLQ) Elevated temperature Laboratory Leukocytosis Shift to the left Total

1 1 1 2 1 1 2 1 10

References 1. Adler S: Hyponatremia and rhabdomyolysis: A possible relationship. South Med J 1980;73:511-512 2. Mor F, Mor-Snir I, Wysenbeek AJ: Rhabdomyolysis in selfinduced water intoxication. J Nerv Ment Dis 1987;175:742-743 3. Brown PM: Rhabdomyolysis and myoglobinuria associated with acute water intoxication. West J Med 1979;130:459-461 4. Bywaters EGL, Beall D: Crush injuries with impairment of renal function. Br Med J 1941 ;1:427-432 5. Knochel J: Catastrophic medical events with exhaustive exercise "white collar" rhabdomyolysis. Kidney Int 1990;38:709-719 6. Kuipers H: Exercise induced muscle damage. Int J Sports Med 1994;15:132-135 7. Gabow PA, Kaehny WD, Kelleher SP: The spectrum of rhabdomyolysis. Medicine 1982;61:141-152 8. Haapanen E, Partanen J, Pellinen TJ: Acute renal failure following nontraumatic rhabdomyolysis. Scan J Urol Nephrol 1988;22: 305-308 9. Walker CP, Duddy MJ, Sagar G: Rhabdomyolysis following grand mal seizures presenting as a delayed and increasingly dense nephrogram. Clin Radio11993;47:139-140 10. Singhal PC, Chugh KS, Gulati DR: Myoglobinuria and renal failure after status epilepticus. Neurology 1978;26:200-201 11. Os I, Lyngdal PT: General convulsions and rhabdomyolysis. Acta Neurol Scand 1989;79:246-248 12. Rizzieri DA: Rhabdomyolysis after correction of hyponatremia due to psychogenic polydipsia. Mayo Clin Proc 1995;70:473-476 13. Horowitz J, Keynan A, Ben-lshay D: A syndrome of inappropriate ADH secretion induced by cyclothiazide. J Clin Pharmacol New Drugs 1972; 12:337-341 14. Wierzbicki AS, Ball SG, Singh NK: Profound hyponatremia following an idiosyncratic reaction to diuretics. Int J Clin Pract 1998;52:278-279

were evaluated prospectively. The patients' score were determined based on the system described by Alvarado (Table 1).6 Of the 128 patients admitted in the ED, 69 (54%) were kept for observation and treated nonoperatively. In this group, we used extended nonoperative observation for the decision and no other diagnostic studies were done. Because Valyasr Hospital is the only hospital in the region, we are unaware of any patient who subsequently required appendectomy tbr appendicitis. If a patient was admitted twice, his or her first records were also evaluated. Of the 128 patients, 59 (46%) underwent laparatomy. Of these, 45 patients (76%) had acute appendicitis and 14 patients (24%) did not (negative appendectomy). Four patients in the later group of patients had ruptured ovarian cysts, one patient had ectopic pregnancy, and the remainder of the patients had normal operative findings. From 14 patients with negative appendectomy, 2 were men and 12 women. All of the patients who had score 9 or 10 had acute appendicitis (Table 2). From those with scores 6 to 8 (36 patients) 73% had appendicitis. Only 4% of patients with scores 1 to 5 had appendicitis. Therefore, we consider those with score 6 or above to have higher probability of appendicitis. Of the 45 patients with appendicitis, 42 (93%) had scores of 6 or above. Conversely, only 13 (15%) of 83 patients without appendicitis had those scores (Table 3). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate of Alvarado score was 76%, 95%, 93%, 84%, and 87% respectively (Table 4). The results for men and women and children are also shown in Table 3. The accuracy rate of Alvarado score in men, women, and children was 96%, 82% and 90% respectively.

ROLE OF ALVARADOSCORE IN DIAGNOSISAND TREATMENT OF SUSPECTEDACUTEAPPENDICITIS

TABLE2. Results of AIvarado Score

To the Editor:--Early diagnosis is a primary goal to prevent mortality and morbidity in acute appendicitis. 1 The history and physical examination are at least as accurate as any laboratory modality in diagnosing and excluding appendicitis. 1Although aids exist to enhance diagnosis, these are either complex or not easily available. Despite of recent advances in diagnosis of acute appendicitis, improvement in outcome has not been shown with routine use of new technology. 2-5A scoring system described by Alvarado was designed to facilitate early diagnosis of acute appendicitis, reduce negative appendectomy rate without increasing morbidity and mortality. 6-8 Over a year (June 1997 to June 1998), 128 patients with preliminary diagnosis of acute appendicitis who admitted at the emergency department (ED) of Valyasr Hospital in Bafgh, Iran

All

Men

Women

Children

Score

Total

AA (%)

NAA (%)

9-10 6-8 1-5 9-10 6-8 1-5 9-10 6-8 1-5 9-10 6-8 1-5

19 36 73 11 15 23 8 21 50 4 2 14

100% 73% 4% 100% 93% 5% 100% 42% 4% 100% 50% 7%

0 27% 96% 0 7% 95% 0 58% 96% 0 50% 93%

Abbreviations: AA, acute appendicitis; NAA, not acute appendicitis.

CORRESPONDENCE

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TABLE3. Alvarado Score in Patients With and Without Appendicitis Diagnosis

AS -> 6

AS< 6

AA NAA AA NAA AA NAA AA NAA

42 13 25 1 17 12 5 1

3 70 1 22 2 48 1 13

All* Ment Women:l: Children§

Abbreviations: AS, AIvarado score; AA, acute appendicitis; NAA, not acute appendicitis. NOTE. *The mean, standard deviation (SD) and 95% confidence interval (CI) of Alvarado Score (AS) in patients with appendicitis were 8.0222, 1.4998, 7.5716 to 8.4728 and in those without appendicitis were; 4.6506, 1.3654, and 4.3525 to 4.9484. -j-The mean, SD, and CI of AS in men with appendicitis were 8.1154, 1.4513, and 7.5292 to 8.7016 and in men without appendicitis were 4.2917, 0.9546, and 3.8886 to 4.6948. SThe mean, SD, and CI of AS in women with appendicitis were 7.8947, 1.5949, and 7.1260 to 8.6635 and in women without appendicitis were 4.7966, 1.4830, and 4.4101 to 5.1831. §The mean, SD, and CI of AS in children with appendicitis were 9.0000, 0.8944, and 8.0614 to 9.9386 and in children without appendicitis were 4.7857, 1.1217, and 4.1381 to 5.4334. There were 12 cases of complicated appendicitis (gangrenous, perforated, phlegmon, and abscess) which all had score 6 or above. Three of the four patients with ovarian cysts had score 6 or above. The score of the woman with an ectopic pregnancy was 8. From nine patients with totally normal operative findings, eight of them had scores lower than 6. The accuracy of clinical preoperative diagnosis of appendicitis has been reported from 50% to 95%. 9-I2 The accuracy of Alvarado score in our study was 87% (men 96%, women 82%, and children 90%). Owen et al used the Alvarado scoring system had the overall diagnostic accuracy of 87.4%, 7 The Alvarado score is simple to use and easy to apply, because it relies only on history, clinical examination, and a basic laboratory test. Our study showed that this simple scoring system in patients suspected to have acute appendicitis worked well in men and children. However, in women, particularly those of child bearing age, it had high rate of false-positive. In this study, more than 40% of women with scores of 6 or more, did not have appendicitis (Table 3). The goal in proper diagnosis and management of patients with suspicious diagnosis of acute appendicitis is to separate patients who have a high likelihood of appendicitis and in whom early surgical treatment is warranted from those who may be safely observed or discharged, s Alvarado score can be used as a guide for the above purpose. A male patient with a score of 6 or higher most likely requires surgery because the probability of appendicitis is TABLE4. Statistical Values of Alvarado Score

Sensitivity Specificity PPV NPV Accuracy

All

Male

Female

Children

76% 95% 93% 84% 87%

96% 95% 96% 95% 96%

58% 96% 89% 80% 82%

83% 92% 83% 92% 90%

Abbreviations: PPN, positive predictive value; NPV, negative predictive value.

more than 95% (Table 2). However, a women or a child with a score of 6 to 8 needs more of an observation period because the chance to have appendicitis is 42% and 50%, respectively. Regardless of age and gender, those with scores of 1 to 5 were unlikely to had acute appendicitis. Delay in diagnosis and treatment will lead to increase morbidity and mortality of acute appendicitis. Concern regarding delay in diagnosis has increased because most of patients initially seen by nonsurgeon physicians in the office or emergency departments. The Alvarado score may prove of inestimable value especially to the less experienced clinician in deciding on the appropriate line of treatment.~3 REZA R SAID1,MD

MITRAGHASEMI,MD

Valyasr General Hospital Emergency Department Shahid Sadughi University of Medical Sciences Bafgh, Yazd, Iran

References 1. Wagner JM, McKinney WP, Carpenter JL: Does this patient have appendicitis? JAMA 1996;276:1589-1594 2. Hale DA, Molly M, Pearl RH, et al: Appendectomy: A contemporary appraisal. Ann Surg 1997;225:252-261 3. Sarfati MR, Hunter-GC, Witzke-DB, et al: Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis. Am J Surg 1993;166:664-665 4. Delany HM: Appendicitis: trends and risks, 1996. J Assoc Acad Minor Phys 1996;7:70 5. Wicox RT, Traverso LW: Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clinic North Am 1997;77:1355-1370 6. Alvarado A: A practical score for early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-565 7. Owen TD, Williams H, Stiff G, et ai: Evaluation of the AIvarado score in acute appendicitis. J R Soc Med 1992;85:87-88 8. Ohmann C, Yang Q, Franke C: Diagnostic scores for acute appendicitis. Abdominal Pain Study Group. Eur J Surg 1995;161:273281 9. Senbanjio RO: Management of patients with equivocal signs of appendicitis. J R Coil Surg Edinb 1997;42:85-88 10. Walker SJ, West CR, Colmer MR: Acute appendicitis: Does removal of a normal appendix matter, what is the value of diagnostic accuracy and is surgical delay important? Ann R Coil Surg Engl 1995;77:358-363 11. Wen SW, Naylor CD: Diagnostic accuracy and short-term surgical outcomes in cases of suspected acute appendicitis. Can MedAssoc J 1995;152:1617-1626 12. Izbicki JR, Knoefel WT, Wilker DK, et al: Accurate diagnosis of acute appendicitis: A retrospective and prospective analysis of 686 patients. Eur J Surg 1992;158:227-231 13. Tobias M, Samuel E: Ultrasound and the Alvarado score. J R Soc Med 1992;85:508

ACUTE ST. JOHN'S WORT TOXICITY To the Editor.'--St John's wort (SJW) is one of many herbal remedies available without a prescription in the United States. Touted somewhat illogically by many as natural and therefore safe, the protean benefits attributed to SJW attract many users. M.A.B. a 33-year-old woman and new mother with no past psychiatric, medical, or surgical history decided to try SJW for mild anxiety. She took no prescription or over-the-counter medications, and neither smoked nor used alcohol. Although not suffering from a distinct anxiety disorder, she thought she might feel more relaxed with SJW. On the first day, she took one dose of the SJW preparation. The next day, she took one dose in the morning, and another in the evening. She never again took SJW. About 1 a.m. the day after her last dose of SJW, she awakened with extreme anxiety