Poor Performance of an Appendicitis Decision Rule

Summary and Comment |
June 26, 2013

Poor Performance of an Appendicitis Decision Rule

  1. Daniel J. Pallin, MD, MPHAU721

In this prospective study, the modified Alvarado score had a sensitivity of only 72%.

  1. Daniel J. Pallin, MD, MPHAU721

Appendectomy is the most common emergency surgery, and computed tomography scans are frequently performed to rule out appendicitis. A clinical decision rule sensitive for appendicitis could reduce radiation exposure and make care more efficient. In a prospective observational study, researchers determined the accuracy of the modified Alvarado score for the diagnosis of acute appendicitis. The score assigns one point each for pain migration to the right lower quadrant, anorexia, nausea, rebound tenderness, and fever and two points each for right lower quadrant tenderness and leukocytosis.

Researchers applied the score to 261 patients evaluated for appendicitis at two tertiary care emergency departments. Of these patients, 53 ultimately had a final diagnosis of appendicitis. A modified Alvarado score of <4 had a sensitivity of 72% and a specificity of 54% for appendicitis.


A 28% miss rate likely is worse performance than clinical evaluation by a competent clinician and puts the nail in the coffin of the Alvarado score. When there is concern for appendicitis, the options are ultrasound, computed tomography, exploratory surgery, and serial examinations. Laboratory tests have not been found to help patients and can be misleading.

  • Disclosures for Daniel J. Pallin, MD, MPH at time of publication Grant / research support Agency for Healthcare Research and Quality; Department of Defense; Massachusetts Coalition for the Prevention of Medical Errors; NIH


Reader Comments (2)

Tariq Zafar Physician, Other, Northwest General Hospital & Research Centre, Peshawar, Pakistan.

Clinical evaluation first, absolutely! Specially in developing countries, in the face of large refugee scenarios (socio-economic & tertiary care issues) and ant-terrorist operations.
Even before the time of Alvarado, we would go to the last court of appeal (laparotomy) in case of doubt: rather open three cases of, say ureteric colic, than sweat over the mess of a perforated appendix.

Castillo Andrés Physician, Internal Medicine, SanJose CR

The clínical is first when you evaluate the posibility Of actúe apendicitis.

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