Jemds.

com Original Research Article

Usefulness of CT Scan in Diagnosing Acute Appendicitis in

Patients with Low Alvarado Scores
Khawaja Bilal Waheed1, Waseem Jan Shah2, Ali Salman Alshehri3, Bilal Altaf4, Muhammad Amjad5,
Muhammad Sohail Amin6, Emad Fouad Mahmoud Said7, Noor Riyadh Bukhamsin8

1Department of Radiology, KFMMC, Dhahran, Saudi Arabia. 2Department of Paediatric Surgery, KFMMC, Dhahran,
Saudi Arabia. 3Department
of Radiology, KFMMC, Dhahran, Saudi Arabia. 4Department of General Surgery, KFMMC,
Dhahran, Saudi Arabia. Department of Gastroenterology, KFMMC, Dhahran, Saudi Arabia. 6Department of Radiology,
5

KFMMC, Dhahran, Saudi Arabia. 7Department of Radiology, KFMMC, Dhahran, Saudi Arabia. 8Department of
Radiology, KFMMC, Dhahran, Saudi Arabia.

ABSTRACT

BACKGROUND
Alvarado score has been routinely used in clinical practice for assessing the Corresponding Author:
Khawaja Bilal Waheed,
probability of acute appendicitis in patients presenting with right lower quadrant
King Fahad Military Medical Complex,
abdominal pain. Computed tomography can be used for equivocal or difficult cases. (KFMMC), P. O. Box 946,
We wanted to evaluate role of computed tomography (CT) in patients with low or Postal Coad 31932, Dhahran,
equivocal Alvarado scores. Saudi Arabia.
E-mail: [email protected]
METHODS
This is a retrospective, observational study conducted in the Department of DOI: 10.14260/jemds/2019/653
Radiology at our Hospital in Dhahran from October 2017 to October 2018. 138
Financial or Other Competing Interests:
patients with equivocal Alvarado scores (AS, 4-6) and negative (non-conclusive or
None.
limited) ultrasounds, were retrospectively reviewed. Pregnant, postoperative
(bowel surgery) cases and chronic appendicitis cases were excluded. Diagnosis of How to Cite This Article:
acute appendicitis on CT was based on a thickened or fluid dilated appendix Waheed KB, Shah WJ, Alshehri AS, et al.
(diameter > 6mm, wall enhancement) with at least one of the associated findings Usefulness of CT scan in diagnosing acute
(like appendicolith, peri-appendiceal fat stranding, free fluid, extra-luminal air foci, appendicitis in patients with low alvarado
caecal base thickening and mesenteric lymph nodes). Imaging findings were scores. J. Evolution Med. Dent. Sci.
reviewed by two radiologists and consensus reporting was made. Findings on CT 2019;8(40):3005-3009, DOI:
10.14260/jemds/2019/653
were categorized as AA (Acute Appendicitis), OD (Other Diagnosis) and NOR
(Normal). Surgical candidates were confirmed on histopathology, while non- Submission 09-08-2019,
surgical cases were followed up on either imaging or clinical grounds. Chi-square Peer Review 17-09-2019,
test was used to determine association. The main outcome measure was diagnosis Acceptance 25-09-2019,
on CT and histopathology. Published 07-10-2019.

RESULTS
29.7% (41 patients) were found to have acute appendicitis on CT imaging. Majority
of patients with AS of 5 were having OD, while most of AA cases were having AS of 6.
All patients with AS of 4 were having normal CT scans.

CONCLUSIONS
Computed tomography helps to diagnose acute appendicitis or establish an
alternate diagnosis in patients with equivocal Alvarado scores.

KEY WORDS
Computed Tomography, Alvarado Score, Acute Appendicitis

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Jemds.com Original Research Article

BACKGROUND such stratum of patients (i.e., with clinical suspicion of acute

appendicitis and equivocal AS).

Lower abdominal pain is a common condition with wide

range of causes. However, when it comes to right lower
ME T H O D S
quadrant abdominal pain, acute appendicitis is undoubtedly
the most common emergency condition requiring immediate
management to avoid possible risks of perforation and This retrospective observational study was conducted in
peritonitis.1,2 Incidence of this condition seems to be stable in Radiology department at our Hospital in Dhahran from
Western countries (between 6-9%), but it appears to be October 2017 to October 2018.
rising in newly industrialized countries.3 Although the cause All patients (N=138) with equivocal clinical Alvarado
of such trend might be multifactorial, yet less consumption of scores (AS) between 4-6 on presentation, and initial negative
dietary fibers has been theorized.3 It commonly occurs at (Non-conclusive, technically difficult or limited) ultrasound
early teens and late 40s with slight male to female studies, were retrospectively reviewed for abdominal
predominance, however, no age is spared. Various clinical computed tomography (CT) findings. Pregnant patients and
scoring systems have been used in clinical practice for postoperative (bowel surgery or previous history of
assessing probability of acute appendicitis.4 One of these, appendicectomy) cases were excluded. As the study was
namely the Alvarado score (AS), was introduced in 1986,5 is retrospective and did not involve disclosure of any patient
based on history, clinical examination findings and a few information and privacy, the ethics committee of our Hospital
laboratory tests. This scoring method has been widely waived the need for patient consent. The study was
assessed and utilized for evaluation of acute appendicitis to conducted in accordance with the Helsinki Declaration.
avoid negative appendicectomies.6 However, it is critical to Clinical information regarding Alvarado scores was obtained
understand applications and limitations of such methods. through initial assessment on patient’s first presentation
High AS scores (more than 6) in adult males are well from clinical notes and Hospital Information System (HIS).
validated while lower scores (less than 6) in other Literature review was performed through electronic search
populations (like females and children) require clinical (google scholar, pubmed).
suspicion and often further investigation including radiologic Computed tomography examinations were performed on
imaging.6-8 128-slice scanner machine (SOMATOM Definition, Siemens
Ultrasound is still important for an initial diagnostic work Healthcare, Germany), acquiring portovenous phase of the
up patients with right lower quadrant pain,9 in particular for abdomen and pelvis (from xiphisternum to symphysis pubis),
the paediatric age group and female patients,10,11 to avoid after administration of intravenous contrast (Iomiron, GE
radiation risks and to exclude any gynaecologic cause in the Healthcare, Cork, Ireland). No oral contrast was given as per
later group. However, it is operator dependent. and can also department protocol. Images were acquired in axial/
be limited or technically difficult because of patient (large, transverse planes, and reconstructed in coronal and sagittal
fatty or obese) habitus or bowel gases.12 Advances in planes.
diagnostic imaging and early utility of computed tomography Radiologic CT criteria for diagnosis of acute appendicitis
(CT) have reduced incidences of negative appendectomies.13 was based on a thickened or fluid dilated appendix (of
Many of the patients are found to have either mild degree of diameter more than 6mm and wall enhancement) with
acute appendicitis or an alternate aetiology, guiding towards presence of at least one of the associated findings (like
either a non-operative medical management (by observation appendicolith, peri-appendiceal fat stranding, free fluid,
and/or antibiotic course) or a specific treatment targeting an caecal base thickening and mesenteric lymph nodes). Imaging
alternate diagnosis. However, radiation concerns with CT findings were reviewed by two radiologists (each having
imaging are still to be considered with caution particularly in more than 7 years of body imaging experience) and final
paediatric and female patients,14 where sometimes decision was made on consensus reporting.
ultrasound or magnetic resonance imaging (MRI) might be a Alvarado scores were obtained through the clinical notes
better option. Also, contrast related issues (like contrast at the time of presentation, that were based on the following
reactions and contrast induced nephropathy) might be method [Table 1]. Results of CT scans were categorized as
important limitation in few of vulnerable or elderly having AA (Acute Appendicitis), OD (Other Diagnosis) and
patients.15 Despite few reservations or contra-indications to NOR (Normal) studies against Alvarado scores of 4 to 6.
CT imaging, it remains a crucial examination in difficult cases
and in patients with equivocal AS.(4-6) Computed tomography Symptoms Score
Migratory right iliac fossa pain 1
has already shown to improve diagnostic yield in such Anorexia 1
patients with high sensitivity and specificity.16 Nausea/Vomiting 1
Although various studies have documented validity of CT Signs
Tenderness at right iliac fossa 2
against higher AS,17 however, only a few have emphasized
Rebound tenderness 1
upon its prime utility in patients with low AS or equivocal Elevated temperature 1
cases that may end up in having aetiologies other than acute Laboratory Findings
appendicitis.18 Prompt identification of an alternate diagnosis Leucocytosis 2
Shift to the left neutrophils 1
in such patients is strategic not only to reduce patient anxiety
Total score 10
and hospital stay but also to guide clinicians towards specific
Table 1. Alvarado Score for Clinical Assessment of Patients with
treatment and avoid negative surgery (appendectomy). Right Lower Quadrant Abdominal Pain
Therefore, we aim to highlight usefulness of CT imaging in

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Jemds.com Original Research Article
Imaging diagnosed surgical cases were confirmed on post-ileal (n=39, 28.2%), followed by less common sites in
histopathology, while non-surgical cases were confirmed on order as pelvic (n=16), paracaecal (n=15), promontric (n=8)
follow up imaging and stability (asymptomatic status) in next and subhepatic (n=4). Out of 138 patients, 40% were having
3-6 months. The statistical analysis was carried out using surgeries while 60% were non-surgical candidates. No
Statistical Package for Social Sciences (SPSS, version 22). Chi- negative appendectomies were seen. Most of patients with
square test and t-test were used to determine association, NOR, OD, and AA were having Alvarado scores of 4, 5, and 6
and p-values less than 0.05 were considered significant. respectively [table 4], and these findings were found
significant (p value of 0.0005).

RESULTS
D I SC U S SI O N
Out of 138 patients, 74% (53.6%) were males and remaining
(N=64, 46.4%) were females, aged between 10-66 years. Acute appendicitis, a common surgical emergency, remains
Computed tomography was able to indicate an abnormality in challenging in terms of diagnosis and management.
nearly 90% of the cases [table 2], and was found helpful in Computed tomography has become the imaging choice in
identifying difficult cases that were difficult to detect on these patients particularly in adult male patients.19 Children,
ultrasound [fig. 1]. women and pregnant patients, for whom radiation risks need
to be considered, another imaging (like ultrasound or MRI)
Findings on Computed Tomography remain an initial or sometimes the only appropriate
Diagnoses No. Diagnoses No. option.15,20 However, if deemed necessary, a low dose-CT may
Acute appendicitis 41 Terminal ileitis 07
Colitis (infectious) 17 Ruptured ovarian follicle/cyst 09 be considered in these patients.16,18 CT has shown to reduce
Caecal diverticulitis 03 Pyelonephritis 04 negative appendectomies from 25% to 1-3%.17 Clinical
Ovarian cyst (complex) 04 Mesenteric lymphadenitis 02
Ovarian torsion 03 Abdominal wall hernia 03 Alvarado scoring is seen helpful to categorize patients for
Pelvic inflammatory disease 08 Foreign body ingestion 01 observation, imaging and surgery. Alvarado scores have been
Polycystic ovaries 03 Meckel’s diverticulum 01
Epiploic appendagitis 04 Neoplasm (colon, appendix) 02
found to correlate well with the diagnostic screening and
Omental infarction 03 Inflammatory bowel disease 03 histopathologic findings.21 They found scores higher than 6 to
Ureteric stone 05 No abnormality detected 15 be present with more advanced stages of acute appendicitis. We
Table 2. Findings on Computed Tomography in Patients
observed similar trend of such higher scores to be associated
Presented with Right Lower Abdominal Quadrant Pain
more with acute appendicitis on CT imaging. Many other
studies have evaluated role of imaging compared to Alvarado
scores, and demonstrated high Alvarado scores correlating
well with imaging even in paediatric population,9 and
pregnant women.22 However, the beneficial role of CT
imaging in patients with equivocal AS scores, where an
alternate diagnosis may be established and treated
accordingly, is not well emphasized. We all have experienced
a trend towards a more imaging based medical practice,
Figure 1. Two Different Patients of Epiploic Appendagitis, One with possibly because of many reasons (Including availability of
Inflamed Fat in Right Lower Abdomen Adjacent to Sigmoid Colon
(Image on the Right), and other one Showing Inflamed Omental Fat at
imaging techniques, patient satisfaction and better
Right Subhepatic Region (Image on the Left). Note that this Entity management), however, early utilization of imaging might be
along with Omental Infarction (Not Shown Here) are Sometimes helpful in guiding clinicians towards prompt diagnosis and
Grouped Under Broader Umbrella Term of Intraperitoneal Focal Fat
Infarction. Treatment is Medical, Unlike Acute Appendicitis.
directed management avoiding prolonged hospital stay and
patient anxiety.
CT Findings Frequency Percentage We observed in our study that majority of patients
AA 41 29.7 (nearly 60%, n=82) were having AS of 5, while less than a
NOR 15 10.9
OD 82 59.4
third of patients were diagnosed with acute appendicitis on
Total 138 100.0 CT imaging and most of these were having AS of 6. Also, most
Table 3. Distribution of Patients on the Basis of their CT Diagnosis. of the patients with lower score (4) were NOR cases. These
AA- Acute Appendicitis, NOR- Normal, OD- Other Diagnosis
findings were found to be significant denoting importance of
lower (4) and higher (6) values of equivocal AS and strategic
Alvarado Scores
4.0 5.0 6.0 Total role of CT imaging in establishing an alternate diagnosis in
n(%) n(%) n(%) n(%) middle value of equivocal AS (i.e., 5) patients. Many of the
AA 2 4.9% 13 31.7% 26 63.4% 41 100.0% studies have documented utilization AS, and compared its
NOR 15 100.0% 0 0.0% 0 0.0% 15 100.0%
Diagnosis scoring with CT and surgical outcomes.23-25 Better clinical
OD 3 3.7% 55 67.1% 24 29.3% 82 100.0%
Total 20 14.5% 68 49.3% 50 36.2% 138 100.0% assessment and higher scores may help to avoid unnecessary
Table 4. Distribution of Patients by Alvarado Scores and CT Findings. CT examinations.25 However, this may not be true in difficult
AA- Acute Appendicitis, NOR- Normal, OD- Other Diagnosis
cases and further imaging may be warranted to establish a
diagnosis. It should be noted that diagnosis of right lower
More than half (59.4%) of patients were found to have OD
abdominal quadrant pain may be quite challenging
on CT imaging while nearly one-third of patients (30%) were
depending upon wide range of other aetiologies, and that too
having diagnosis of AA [table 3]. Common locations of
are different for different age groups. These may range from
appendix on CT were seen as retrocecal (n=56, 40%) and
simple benign condition like mesenteric lymphadenitis in

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Jemds.com Original Research Article
young children to worrisome colonic malignancy in elderly. we found either normal or benign findings (like mesenteric
Also, conditions related to urinary tract (ureteric stone), lymphadenitis or ruptured ovarian follicle) in most of these
gallbladder (acute cholecystitis), omental fat (epiploic children. Therefore, in case of an initial limited, difficult or a
appendagitis, infarction), tubo-ovarian (Physiologic follicular non-conclusive ultrasound study, a low-dose CT or MRI may
rupture, ovarian stimulation, ovarian cyst, haemorrhagic cyst, be considered in this age group to avoid radiation risks
torsion cyst, ectopic pregnancy, hydrosalpinx, complicated associated with CT imaging. Yazar AS and colleagues found a
large fibroid or pelvic inflammatory disease), ileum (terminal higher AS with positive ultrasonography in children with
ileitis, Crohn’s disease, foreign body), colon (cecal histopathologically proven acute appendicitis.9 Moreover,
diverticulitis, colitis or mass), and even retroperitoneum paediatric appendicitis score (PAS) may be used to estimate
(psoas abscess, lipomatous mass) or bony abnormalities better clinical condition in these patients.29,30 Paediatric
(Iliac bone osteomyelitis, bony tumour) may only be patients with a stable and low AS may benefit from simple
confirmed on further imaging. Except for bony abnormalities observation after an initial negative ultrasound study, and
and ectopic gestation cases that were directly referred to may be offered a low-dose CT or MR imaging in case of
orthopaedics and Ob-gynae respectively, we found nearly worsening of AS.
every aforementioned cause of OD in our study [table.2]. Limitations to our study include single center,
Although we did not include pregnant patients, however, we retrospective study not including chronic or complicated
emphasize that MRI or low dose CT could be helpful in these appendicitis cases (that might have a variable AS at
cases depending upon the gestational stage if initial presentation). Length of hospital stay was not documented,
ultrasound remains non-conclusive. Poletti PA et al found although patients with negative CT studies or benign findings
that an algorithm integrating ultrasound and low dose CT (not requiring surgeries) presumably would have
was highly sensitive and specific for pregnant patients.20 theoretically less hospital stays. Also, surgical cases were not
Aguilera F found that MRI was very specific for acute categorized as open or laparoscopic procedures, as some of
appendicitis though with low sensitivity.14 Eng KA et al found the patients might only had required diagnostic laparoscopy
in a metanalysis that second-line ultrasound, CT and MRI evaluation. Categories of OD were also not defined as surgical
have comparable and high accuracies in helping to diagnose or non-surgical and benign or malignant, adding to important
appendicitis in children and adults, including pregnant information set. Future studies adding these information sets
women.18 Esparaz JR et al results were in favour of utilization on a larger scale would be of interest to provide further
of CT and avoiding overuse of ultrasound in children with information for clinicians to adopt optimal diagnostic
higher white blood cell counts and surgical consult.15 strategy and for directed patient management.
We observed that our CT criteria for acute appendicitis In summary, we conclude that based on our study results,
was very helpful in determining acute appendicitis in all CT scan after an initial negative or limited ultrasound study in
surgically proven cases. Different studies have documented patient with suspected acute appendicitis can be extremely
similar CT criteria matching with the histopathologic findings helpful not only to diagnose acute appendicitis but also to
of acute appendicitis by using combination of primary criteria establish an alternate diagnosis, particularly in patients with
of thickened or dilated appendix (diameter of more than equivocal AS. Although CT may be time-consuming or impact
6mm) with wall enhancement, along with the secondary resource utilization, however, it presumably reduces length
findings like presence of appendicolith, peri-appendiceal fat of stay by avoiding prolonged observation in cases where a
stranding, enlarged adjacent mesenteric lymph nodes, free diagnosis cannot be ascertained clinically or remain difficult.
fluid, and extra-luminal air foci, supportive of acute
appendicitis.26-28 It should be noted that in our study the
patients’ referral for further imaging (In particular the CT
scan) by the general surgeon (GS) rather than by the CONCLUSIONS
emergency room (ER) physician. Yazıcı P et al found that AS
of patients who were referred from GS for the CT imaging Computed tomography helps to identify a specific or an
were having higher scores (5 or above) than those who were alternate diagnosis in patients with low or equivocal
referred from the ER physician.13 They also observed that Alvarado scores.
frequency of a negative CT was found higher with negative
appendectomy, and a diagnosis of appendicitis with a rate of
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