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BET 1: An evaluation of the Alvarado score as a diagnostic tool for appendicitis in children


A short-cut systematic review was carried out to establish whether the Alvarado score could be used to rule in or rule out a diagnosis of appendicitis in children. A literature search identified eight studies that were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that the Alvarado score does effectively risk stratify children with suspected appendicitis. Children with an Alvarado score of less than 5 are unlikely to have acute appendicitis, although wide confidence intervals mean that more evidence is still needed before this alone can be used to exclude the diagnosis.

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Report by: John Heineman1

Search checked by: David Drake2

Institution: 1Oregon Health & Science University, Oregon, USA, 2Central Manchester University Hospitals NHS Foundation Trust

Clinical scenario

A 10-year-old girl presents to the emergency department (ED) with pain in her right lower quadrant. She states that the pain started 2 days ago when it was diffuse across her lower abdomen. She has had a decreased appetite but no nausea or vomiting. On examination, her abdomen is soft, non-distended, with no guarding and no rebound tenderness. Rovsing's sign is negative, but she has positive obturator and psoas signs. Murphy's sign is negative. Bowel sounds are heard throughout her abdomen. She is afebrile and her basic laboratory tests show a leucocytosis of 11 000 white blood cells/µl with a left shift. You wonder how likely it is that this patient has appendicitis and how best to manage this individual. You wonder if the Alvarado scoring system used for this purpose in adults is supported by evidence in paediatrics.

Three-part question

In (children with suspected appendicitis) is (the Alvarado scoring system) (sufficiently sensitive and specific to enable rule in and/or rule out of acute appendicitis)?

Search strategy

Ovid MEDLINE 1946 to September week 3 2012

(exp Appendicitis/or and (Alvarado or Mantrels).mp. and (exp Pediatrics/or exp Adolescent/or exp Child/or exp Infant/or exp, Child, Preschool/or exp Infant, Newborn/or "p?ediatric$.mp. OR child$.mp.)


Sixty-six papers were identified, of which eight were relevant to the three-part question. Details of these papers are shown in table 1.

Table 1

Relevant papers


In diagnosing appendicitis, clinicians balance the risk of removing a normal appendix against the risk of perforation. The Alvarado scoring system is a convenient tool for aiding the diagnosis of appendicitis. It is known by the mnemonic ‘MANTRELS’ and is scored as follows: migration of pain (1 point); anorexia (1 point); nausea or vomiting (1 point); right lower quadrant tenderness (1 point); elevation in temperature (≥37.3°C); leucocytes (≥10 000; 2 points); differential white blood cell count with 75% polymorphonuclear cells (1 point).

The Alvarado score has previously been shown to be relatively sensitive and specific in the adult population (with better results in men than women) presenting with right lower quadrant pain. As a diagnostic tool for appendicitis in the paediatric population, a cut point of 5 points appears to be fairly sensitive (99% in the systematic review by Ohle et al, albeit with wide 95% CI (83% to 100%); 89.7% in the study by Mandeville et al, which was not included in the systematic review). Using scores of 7–10 has shown sensitivities ranging from 72% to 92% and specificities ranging from 64.4% to 82%. The one paper using scores of 8–10 showed a sensitivity of 93% and specificity of 97%, but more studies of this modified score are necessary. Imaging appears still to be warranted on a routine basis for children with a score of 5–7 (preferably first ultrasound and only followed by CT if negative to avoid unnecessary radiation exposure). However, only one paper has studied this modified score and more studies are necessary.

Clinical bottom line

The Alvarado score can be used to risk stratify children with suspected appendicitis in the ED. Children with an Alvarado score of less than 5 are unlikely to have acute appendicitis, although more evidence is still needed before this alone can be considered to exclude the diagnosis safely in practice.

  • Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557–64.

  • Rezak A, Abbas HM, Ajemian MS, et al. Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg 2011;146:64–7.

  • Ohle R, O'Reilly F, O'Brien KK, et al. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139.

  • Mandevillem K, Pottker T, Bulloch B, et al. Using appendicitis scores in the pediatric ED. Am J Emerg Med 2011;29:972–7.

  • Shera AH, Nizami FA, Malik AA, et al. Clinical scoring system for diagnosis of acute appendicitis in children. Indian J Pediatr 2011;78:287–90.

  • Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med 784;49:778–84.

  • Macklin CP, Radcliffe GS, Merei JM, et al. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl 1997;79:203–5.

  • Hsiao KH, Lin LH, Chen DF. Application of the MANTRELS scoring system in the diagnosis of acute appendicitis in children. Acta Paediatr Taiwanica 2005;46:128–31.

  • Bond GR, Tully SB, Chan LS, et al. Use of the MANTRELS score in childhood appendicitis: a prospective study of 187 children with abdominal pain. Ann Emerg Med 1990;19:1014–18.


  • Provenance and peer review Commissioned; internally peer reviewed.

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