Value of Ultrasonography in Acute Appendicitis in Patients with Modified Alvarado Scoring System Score of 5 & 6

Ziad Ghanem Mohammed,Mohammed Jawad Mohammed Al- Najjar,Huda Ali Al-Hussaini,Haider Abdulhussain,Saad Abdulla Al-Mosawy,Wasan Ismail Al-Saadi
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Keywords : Appendicitis, Ultrasonography, Modified Alvarado Scoring System (MASS)
Medical Journal of Babylon  13:2 , 2016 doi:1812-156X-13-2
Published :02 September 2016


Acute appendicitis is one of the most common and challenging surgical emergencies. Ultrasound [US] is widely available , highly accurate imaging modality in patients suspected to have acute appendicitis, this study was done to assess the value of US in evaluation of suspected acute appendicitis patients with Alvarado Scoring System [MASS] of 5 & 6 . In this prospective study a total of (100) patients with clinically suspected acute appendicitis and with Alvarado score between 5 &6 underwent US examination of the abdomen The accuracy of ultrasonography in the diagnosis of appendicitis was compared with clinical diagnosis, laparotomy findings and histopathological examination reports.. The patients were divided into two groups: group A included those for whom surgery was done & the final diagnosis was established depending on the surgical finding &/or histopathology results & this group comprised (65) patients . Group B comprises patients who did not underwent surgery ,these patients were followed up until their improvement & discharge from the hospital & this group included (35) patients. The overall specificity of ultrasound was 88% and the sensitivity was 89% in the diagnosis of acute appendicitis in patients with MASS of 5 & 6 . US is a valuable tool in diagnosing acute appendicitis in patients with MASS (5 & 6). When the clinical sign and symptoms are combined with US, the diagnostic accuracy is significantly high.


Acute appendicitis is one of the most common and challenging surgical emergencies and is the primary source of inflammation in acute typhlitis, it can lead to appendiceal perforation and peritonitis, which are concomitant with high mortality and morbidity [1, 2] . An infected appendix appears to be more likely to rupture during pregnancy, especially in the third trimester of pregnancy , possibly because of delay in diagnosis and intervention [3, 4]. Making the decision for surgical operation based only on the patient’s signs and symptoms results in removing normal appendices (negative appendectomy) in 15% to 30% of cases. [5-7]. The rational approach is to decrease the negative appendectomy as well as appendiceal rupture rates ,for this reason, a number of diagnostic modalities have been proposed, including laparoscopy, clinical scoring systems, ultrasonography (US), CT scans and MRI [8-10]. Ultrasound is widely available, inexpensive modality with the potential for highly accurate imaging in the patient suspected to have acute appendicitis, and safe for use in children and pregnant women [11]. To detect the vermiform appendix graded compression technique described by puylaert [12] was used to displace and compress bowel loops ,decrease the distance between the transducer and the bowel and to assess if a lesion is rigid or not. The criteria for the diagnosis of appendicitis by US are Blind-ending tubular structure at the point of tenderness, non-compressible appendix, no peristalsis, diameter 7 mm or greater, appendicolith casting acoustic shadow, high echogenicity non-compressible surrounding fat and surrounding fluid or abscess [13]. A number of scoring systems have been advocated to minimize the number of negative appendectomies; they combine clinical, laboratory, and ultrasound parameters to increase the security of diagnosis [14 ]. In 1986, Alvarado [15] described a scoring system, modified Alvarado scoring system, which has been validated in adult surgical practice. This scoring system includes seven variables: three symptoms (migrating pain from the umbilicus to the right iliac fosse, anorexia, and vomiting), three signs (tenderness, rebound tenderness, and pyrexia) and two laboratory data (leukocytosis ) yielding a total score of 9 [15]. The MASS has been shown to be a quick and inexpensive diagnostic tool in patients suspected of suffering acute appendicitis [16][table1]. It has been suggested that patients with MASS scores of 7 or higher should be operated on [17]. We aimed of the study to assess the value of US in evaluation of suspected acute appendicitis patients with Alvarado Scoring System of 5 & 6.

Materials and methods

This prospective study  was conducted from  October 2013 through  July 2014 at the emergency unit of  Al-Imammain Al- kadhimain medical city, Baghdad, Iraq. A total of (100) individuals (45 males&55 females) with age range between (10-40 years) with clinically suspected acute appendicitis were included in the study. Two general surgeons assessed each individual case clinically & each patient was sent for the necessary laboratory tests . Then for each patient the MASS score was set & only cases with MASS score of 5 &6 were enrolled in the study .The patients underwent US examination of the abdomen by the radiologist using  Philips HD11-XE  high resolution real-time ultrasound machine utilizing 3.5 MHz convex probe and 7.5 MHz linear probe. No special preparation was required. The general abdominal ultrasound examination was followed by focused examination of the right side of the abdomen using graded compression technique starting from the tip of the liver and proceeding to the pelvic brim.  .The appendix, whenever detected by US was assessed   whether inflamed or not by applying according to the conventional signs of acute appendicitis. For those patients who underwent surgery ,  the surgical notes were recorded  and  correlated with the result of histopathology. While for those patients who did not have surgical intervention, follow up was performed until their improvement & discharge from the hospital. The sensitivity and specificity of   US were calculated based on the surgical findings & histopathology results


This study included 100 patients with clinical diagnosis of acute appendicitis with MASS of 5 & 6. The patients were divided into two groups: group A included those for whom surgery was done, this group comprises (65) patients. Group B comprises patients who did not underwent surgery & this group includes (35) patients. Analysis of group A[65 patients] In this group, 25 patients were males & 40 patients were females • The US diagnoses were as follow: 53cases [(81.5%]: acute appendicitis, 2 cases (3 %): appendicular mass, & 10 cases [15.3 %] had normal US scan. • The Surgical results were as follow: 54 patient had Inflammed looking appendix [83%], 2 had Appendicular mass [3%] and 9 cases [13.8%] had negative surgical findings • The histopathological results were as follow: 52 patients [80%] patient had Inflammed appendix, 4 patients [(6.1%] had Lymphoid hyperplasia and 9 cases [13.8 %] had normal appendix. The positive & negative predictive values for US are [90%] & [86%] respectively, the sensitivity , specificity & accuracy are [89%], [88%] & [89%] respectively. The ultrasound findings among true & false positive cases of acute appendicitis [as proved by surgery and HP] are summarized at table 2:


In this study US was found to be a useful imaging tool for suspected appendicitis and it enhances the diagnostic accuracy in equivocal cases and reduce the number of negative appendicectomies. In this study, Of the 65 cases of appendicitis [group A], pain in abdomen, nausea and vomiting were the predominant clinical symptoms, but they are not specific for acute appendicitis. Tenderness in RIF was present in almost all cases [100%], raised temperature in [37%] rebound tenderness in [70%], nausea and vomiting in [90%]. These findings are comparable with the findings of the study by Rosemary Kozar et al [18]. Leucocytosis was present in 73% of the cases correlate with a study of 100 patients by Tauro LF et al who showed that leucocytosis was present in 75% of cases of acute appendicitis [19]. In this study, One or more of US signs were found in 55 cases out of 100 cases can be sub divided into subgroups as follows: In our study, of 100 patients who underwent ultrasonography, appendix was visualized in 55 patients [55%]. Of these, 50 had acute appendicitis on surgical and histological examination giving a positivity of visualization of[ 91%]. These results were similar to Rajat who reported the positivity of visualization of appendix on ultrasonography to be as high as 96%[20]. Visible appendix is not enough for diagnosis of acute appendicitis, because the normal appendix nowadays is frequently visualized. So other criteria are needed for confirmation of diagnosis. Non-visualization of the appendix with sonography does not completely exclude acute appendicitis, particularly in the patients who are obese or where abdomen is difficult to compress. A negative appendicetomy rate of 11% was observed in our study. This is similar to the report by Rajat Patra of 11.2% [20]. non comperessibility: This sign was detected In all visible inflamed appendices (100%). In comparison with The study of Jeffery detectability was [97%] [(21]. Obstructing faecolith or appendiculolith was seen in 10 patients only [20%] approximate to (30%) mentioned by puylaert [22]. We could detect the increase in diameter in all inflamed appendices[100%]. Compared to (100%) by quillin [23]. The range of diameter was 6-24 mm with a mean of 10.8 mm. Inflamed periappendiceal fat sign was detected in 30 patients out of 50 [60%] is considered high specific but low sensitive sign Compared to[51%] by quillin[23]. Abdominal US could diagnose 55 cases as appendicitis out of a total of 100 cases who presented with clinical features similar to appendicitis and modified Alvarado score [5,6], from which true positive cases of appendicitis were found after surgery and HPE. George et al reviewed a total 140 cases of appendicitis in which they could diagnose 70 cases as appendicitis by US [24]. The overall specificity and sensitivity were found to be 88% and %89 respectively, which showed that US has a high specificity and sensitivity in diagnosing appendicitis. The overall specificity and sensitivity rates were at par with the values drawn by Skanne et al [25], Hahn et al [26], Tarzan et al [27] and Puylaert et al [12], whose specificity values varied from 90-100% and sensitivity ranges varied from 70-95%.


US is a valuable tool in diagnosing acute appendicitis in patients with MASS [5&6]. when the clinical sign and symptoms are combined with US the diagnostic accuracy is significantly high. US helps in diagnosis other causes of RIF pain which helps in excluding appendicular pathology. It should be emphasized that US does not replace clinical diagnosis, but is a useful adjunct in the diagnosis of acute appendicitis


Binneb?sel M, Otto J, Stumpf M, Mahnken AH, Gassler N, Schumpelick V, Truong S: Acute appendicitis. Modern diagnostics–surgical ultrasound. Chirurg 2009, 80(7): 579–587.
2. Dox I, Melloni BJ, Eisner GM. Mellonis` illustrated medical dictionary 1979 Baltimore. William and 58.
3.Richards, C, Daya, S. Diagnosis of acute appendicitis in pregnancy. Can J Surg 1989; 32:358.
4 . Bickell, NA, Aufses, AH Jr, Rojas, M, Bodian, C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006; 202:401.
5. Chan I, Bicknell SG, Graham M: Utility and diagnostic accuracy of sonography in detecting appendicitis in a community hospital. AJR Am Roentgenol 2005, 184 (6): 1809–1812
6. G?kçe AH, Aren A, G?kçe FS, Dursun N, Barut AY: Reliability of ultrasono-graphy for diagnosing acute appendicitis. Ulus Travma Acil Cerrahi Derg 2011, 17(1):19–22.
7. Flum DR, McClure TD, Morris A, Koepsell T: Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg. 2005, 201:933.
8. Olsen JB, Myren CJ, Haahr PE: Randomized study of the value of laparoscopy before appendicectomy. Br J Surg 1993, 80:822–923.
9. Teicher I, Landa B, Cohen M, Cabnick LS, Wise L: Scoring system to aid in the diagnosis of appendicitis. Ann Surg 1983, 198:753–759.
10. Kalan M, Rich AJ, Talbot D, Cunliffe WJ: Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl 1994, 76:418–419.
11- Soda K.Konishi F.Diagnosing Appendicitis: the role of Ultrasonography with new criteria.Med imagin inter 2002;4.7-8:13-15.
12- Puylaert JBCM. Acute Appendicitis: US evaluation using graded compression. Radiology 1986;158:355 -360
13- Freld S, Morrison I, The abdomen: the Plain abdominal radiograpth: the acute abdomen in Grainger RG, Allison DJ, Adam A, Dixon AK, ends. Grainger and Allison s Diagnostic Radiology 6 th ed. London, Churchill Livingstone 2014; 977-1003.
14 –Styrud J, Eriksson S, Segelman J, et al. Diagnostic accuracy in 2351 patients undergoing appendecectomy for suspected acute appendecitits: a retrospective study 1986-1993. Dig Surg 1999;16:39-44
15. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15: 557-564
16- Shirzad Nasiri, Fatemeh Mohebbi , Nassim Sodagari and Anushiravan Hedayat Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis International Journal of Emergency Medicine Jun 6, 2012, 5:26
17- Seymor I Schwartz, G.Tom Shires, Frank C.Spenner. Appendix ; Schwartz Principles ofSurgery, international edition, Mc. Graw –Hill INC, Health Professions division, 7th edn. 1999; 1383-94.
18- Rosemary A.Kozar, Schwartz, s ,principle of surgery; 8th edition 2005 ,New York:Mc Graw-Hill;appendix,part two appendix.
19- Tauro LF, Premanand TS, Aithala PS, George C Suresh HB, Acharya D, John P. Ultrasongraphy is
still a useful diagnostic tool in acute appendicitis. Journal of clinical and diagnostic research 2009;3(5):1731-6.
20- Rajat K Patra. Clinicopathological and ultrasonographic correlation of acute appendicitis in emergency Year : 2014 | Volume : 4 | Issue : 1 | Page : 11-14.
21-Jeffrey RB, Laing FR acute appendicitis :high resolution real time US findings. Radiology 1987; 163 :11-14.
22- Puylaert JB, Van der Werf SDI, Ulrich C, Veldhuizen RW. Crohn s disease of the ileocaecal region; US visualization of the appendix. Radiology 1988;166:741-743
23- Quillin SP, Siegel MJ. Appendicitis :Efficacy of color Doppler sonography. Radiology 1994;may191:557-560.
24- George MJ, Siba PP, Charan PK, Rao RRM. Evaluation of Ultrasonography as a useful Diagnostic Aid in Appendicitis. Indian JSurg. 2002; 64: 436 – 9.
25-Skanne P, Amland P.F., Nordshus T. et al. Ultrasonography in patients with suspectedacute appendicitis. A prospective study.Br. Jr. Radiol, 1990; 63:787-93.
26- Hahn HB, Hoepner FU., Kalle T et al. Sonography of acute appendicitis in children: 7-years experience. Paediatr. Radiol 1998; 28:147-51
27- Tarjan Z., Mako E., Winternitz T., et al.The value of ultrasonic diagnosis in acute appendicitis. Orv. Hetil . 1995; 136:

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