A comparison of clinical judgment vs the modified Alvarado score in acute appendicitis

Abstract

Aims: To investigate the value of the modified Alvarado score (MAS) in helping Accident & Emergency (A&E) doctors decide which patients with suspected acute appendicitis need surgical referral.

Methods: 11,258 patients presented to a University Hospital A&E Department over a two-month period; 82 were triaged as 'abdominal pain' or 'suspected appendicitis'. Ten patients self-discharged prior to seeing a doctor. The remaining case notes (72) were reviewed and MAS's calculated. The Alvarado guidelines suggested an MAS > or = 5 (high) needed admission and an MAS < 5 (low) excluded appendicitis and was appropriate for discharge.

Results: Two patients had proven pancreatitis and were excluded. 24/70 patients were admitted for suspected appendicitis; all were referred by the A&E doctor (sensitivity 100%) but only 12 had a high MAS (sensitivity 50%). Twelve patients were therefore admitted despite having a low MAS on retrospective analysis. 46/70 patients were discharged (none re-presented with the same complaint) of which 40/46 were sent home without surgical referral (specificity 87%), but only 44/46 patients discharged had a low MAS (specificity 96%).

Conclusions: It is more important to refer every case that needs referral (sensitivity) than to discharge those not needing referral (specificity). We cannot exclude the possibility that morbidity would result were the MAS used in lieu of clinical judgment in deciding whether referral is necessary in cases of suspected acute appendicitis.