Modified Alvarado's Score incorporating C-reactive protein for Acute Appendicitis

  • Musharraf Husain Prof. & Head, Department of Surgery, HIMSR, Jamia Hamdard
  • Huda Islam MBBS Student, HIMSR, Jamia Hamdard
  • Sabina Khan Associate Professor, Department of Pathology, HIMSR, Jamia Hamdard
  • Raja Nadeem Assistant Professor, Department of Surgery, HIMSR, Jamia Hamdard
Keywords: Acute appendicitis, Modified Alvarado's Score, C-reactive protein


Background: Acute appendicitis is one of the commonest surgical conditions requiring emergency appendectomy. The diagnosis is usually suspected clinically and confirmed on either ultrasound or Computed tomography. The aim of our study is to improve the diagnostic accuracy of acute appendicitis and reduce the rate of negative appendectomy. We have modified the Alvarado’s score by incorporating C- reactive protein and deleting two of its components (leukocyte shift to left and migration of pain from umbilical region to right iliac fossa). Methods: We successfully used this scoring system on a sample size of 100 patients. Out of 100 patients, diagnosis was confirmed on histopathological examination in 76 patients. Neutrophilic infiltration of the muscularis layer was considered as the diagnostic criteria for acute appendicitis. Ten patients were diagnosed only on CECT abdomen as Appendicular lump. These patients were not operated. Alternate diagnoses were made in twelve patients with MAS score of 5 or less and in two patients with MAS score of more than 6. Results: On statistical analysis, the result showed that the MAS is a very specific (85.7%) and highly sensitive (95.3%) in detecting Acute Appendicitis, taking Histopathology or CT as gold standard test. While, the positive predictive value is 97.6%, negative predictive value is only 75%. Conclusions: This means that it is difficult to rule out acute appendicitis in patients with lower scores. However, for such patients further investigations can be done to reach to a final diagnosis.


Download data is not yet available.


1. Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, et al., eds. Surgery: scientific principles and practice. 2d ed. Philadelphia: Lippincott-Raven, 1997:1246-61.
2. Schwartz SI. Appendix. In: Schwartz SI, ed. Principles of surgery. 6th ed. New York: McGraw Hill, 1994:1307-18.
3. Graffeo, Counselman. Appendicitis. Emergency medicine clinics of North America14:653-71
4. Murphy J. Two thousand operations for appendicitis, with deductions from his personal experience. AM J Med Sci 1940;128:187-211
5. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007;298:438-451.
6. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. N Y Med J 1889;50:676-84.
7. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg. 2007;205(4):534-40.
8. Schuler JG, Shortsleeve MJ, Goldenson RS, Perez-Rossello JM, Perlmutter RA, Thorsen A. Is there a role for abdominal computed tomographic scans in appendicitis? Arch Surg 1998;133:373-76.
9. Robert Ohle, Fran O'Reilly, Kirsty K O'Brien, Tom Fahey, Borislav D Dimitrov. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Medicine 2011;9:139
10. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91:28-37.
11. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr. Emerg Care. 2005;21:165-169.
12. Graves EJ, Kozak LJ. National hospital discharge survey: annual summary, 1996. National Center for Health Statistics. Vital Health Stat 1998;13:140.
13. David R. Flum, Arden Morris, Thomas Koepsell, E. Patchen Dellinger. Has Misdiagnosis of Appendicitis Decreased Over Time? JAMA. 2001;286(14):1748-1753.
14. Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg. 1992;158:37-41.
15. Hale DA, Molloy M, Pearl RH. Appendectomy: a contemporary appraisal. Ann Surg.1997;225:252-261.
16. Wagner PL, Eachempati SR, Soe K, et al. Defining the current negative appendectomy rate: for whom is preoperative computed tomography making an impact? Surgery. 2008;144:276-282.
17. Hoffman JO, Rasmussen O. Aids in the diagnosis of acute appendicitis. Br J Surg1989;76:774-9.
18. Terasawa T, Blackmore CC, Bent S, et al. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann
Intern Med. 2004;141:537-46.
19. Flum DR, McClure TD, Morris A, et al. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg. 2005;201:933-939.
20. Ikramullah Khan, Ata ur Rehman. Application of alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med collabbottabad 2005;17(3)
21. S. Eriksson; L. Granström. The Diagnostic Value of Repetitive Preoperative Analyses of C-Reactive Protein and Total Leucocyte Count in Patients with Suspected Acute Appendicitis. Scandinavian journal of gastroenterology. 1994;29(12);1145-1149
22. S. M. M. de Castro, Ç. Ünlü, E. Ph. Steller, B. A. van Wagensveld, and B. C. Vrouenraets. Evaluation of the Appendicitis Inflammatory Response Score for Patients with Acute Appendicitis World J Surg. 2012;36(7):1540-45
How to Cite
Husain M, Islam H, Khan S, Nadeem R. Modified Alvarado’s Score incorporating C-reactive protein for Acute Appendicitis. Int Arch BioMed Clin Res [Internet]. 2017Jun.18 [cited 2021Jul.25];3(2):20-4. Available from: