Point-of-Care Guides

Diagnosis of Appendicitis: Part I. History and Physical Examination



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Am Fam Physician. 2008 Mar 15;77(6):828-830.

  This is part I of a two-part piece on the diagnosis of appendicitis. Part II, “Laboratory and Imaging Tests,” will appear in the April 15, 2008, issue of AFP.

Clinical Question

What are the most useful elements of the patient history and physical examination in the diagnosis of appendicitis?

Evidence Summary

Appendicitis is a relatively uncommon, but potentially serious, cause of abdominal pain in the primary care setting. An accurate diagnosis is important to prevent unnecessary surgery and avoid complications.

The probability of appendicitis depends on patient age, setting, and symptoms. A retrospective study, including three family practice centers, identified 556 adults with abdominal pain, of whom six (1.1 percent) were diagnosed with appendicitis.1 Studies of children with abdominal pain, largely in the emergency department setting, found that 10 to 25 percent of patients had appendicitis.2 In studies of patients with abdominal pain who underwent computed tomography and ultrasonography, 31 percent of children and 40 percent of adults had appendicitis.3 The percentage of patients with appendicitis ranges from 60 to 90 percent in patients who undergo surgery. Perforation rates range from 4 to 28 percent.4

Individual signs and symptoms are of some value in the evaluation of patients with suspected appendicitis. In many patients, signs and symptoms are useful at ruling in appendicitis when findings are positive or abnormal, but the absence of signs and symptoms does not necessarily reduce the risk of appendicitis (Table 12,5). In adults, right lower quadrant pain and migration of pain from the umbilicus area to the right lower quadrant are the symptoms that best predict appendicitis, whereas the absence of pain before vomiting greatly reduces the likelihood of appendicitis.5 The accuracy of history and physical examination findings is somewhat different in children. Vomiting, rectal tenderness, rebound tenderness, and fever are more helpful (greater positive likelihood ratio) in children than in adults, whereas right lower quadrant tenderness is somewhat less helpful.2 The usefulness of the finding of pain before vomiting has not been evaluated in children.

Table 1

Accuracy of Individual Findings from the History and Physical Examination in the Diagnosis of Appendicitis

Clinical finding Likelihood ratio*
Adults Children

Helpful for ruling in appendicitis

Right lower quadrant pain

8.4

Migration (periumbilical to right lower quadrant)

3.6

1.9 to 3.1

Initial clinical impression of the surgeon

3.5

3.0 to 9.0†

Psoas sign

3.2

2.5

Fever

3.2

3.4

Pain before vomiting

2.7

Rebound tenderness

2.0

3.0

Rectal tenderness

2.3

Vomiting

2.2

Helpful for ruling out appendicitis

Absence of pain before vomiting

0.02

Absence of right lower quadrant pain

0.18

Absence of vomiting

0.33

Absence of fever

0.42

0.32

Absence of rebound tenderness

0.28


*— Only shown if 2 or more for positive likelihood ratio or less than 0.5 for negative likelihood ratio.

†— Estimated from data using a pretest probability of 10 to 25 percent and rate of appendicitis in children undergoing ultrasonography and computed tomography for undifferentiated abdominal pain.

Information from reference 2 and 5.

Table 1   Accuracy of Individual Findings from the History and Physical Examination in the Diagnosis of Appendicitis

View Table

Table 1

Accuracy of Individual Findings from the History and Physical Examination in the Diagnosis of Appendicitis

Clinical finding Likelihood ratio*
Adults Children

Helpful for ruling in appendicitis

Right lower quadrant pain

8.4

Migration (periumbilical to right lower quadrant)

3.6

1.9 to 3.1

Initial clinical impression of the surgeon

3.5

3.0 to 9.0†

Psoas sign

3.2

2.5

Fever

3.2

3.4

Pain before vomiting

2.7

Rebound tenderness

2.0

3.0

Rectal tenderness

2.3

Vomiting

2.2

Helpful for ruling out appendicitis

Absence of pain before vomiting

0.02

Absence of right lower quadrant pain

0.18

Absence of vomiting

0.33

Absence of fever

0.42

0.32

Absence of rebound tenderness

0.28


*— Only shown if 2 or more for positive likelihood ratio or less than 0.5 for negative likelihood ratio.

†— Estimated from data using a pretest probability of 10 to 25 percent and rate of appendicitis in children undergoing ultrasonography and computed tomography for undifferentiated abdominal pain.

Information from reference 2 and 5.

The Alvarado score (also known as the MANTRELS [Migration of pain, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation of temperature, Leukocytosis, Shift to the left] score; Table 2 2,6) has been prospectively validated in several populations of children610 and adults.11 Variations include the modified Alvarado score, which excludes the left shift of the white blood cell (WBC) count,12 and the Pediatric Appendicitis Score, which substitutes right lower quadrant pain with cough, hopping, or percussion for rebound tenderness.7 However, these modifications have not been shown to perform better than the original Alvarado score.

Table 2

Alvarado (MANTRELS) Score for the Diagnosis of Appendicitis in Children

Clinical Finding Points

Migration of pain to the right lower quadrant

1

Anorexia

1

Nausea/vomiting

1

Tenderness in the right lower quadrant

2

Rebound pain

1

Elevated temperature (≥ 99.1º F [37.3º C])

1

Leukocytosis (≥ 10,000 WBCs per mm3 [10 × 109 per L])

2

Shift of WBC count to the left (> 75 percent neutrophils)

1

Total:

_______


note: A score of 7 points or more has a positive likelihood ratio of 4.0, whereas a score of less than 7 points has a negative likelihood ratio of 0.2. Given a baseline 20 percent probability of appendicitis in a child with acute abdominal pain, that corresponds to a probability of 50 percent if the score is 7 points or higher and 5 percent if the score is less than 7 points. Patients with a score of less than 4 points have a very low risk of appendicitis.

Adapted with permission from Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emer Med. 1986;15(5):561, with additional information from reference 2.

Table 2   Alvarado (MANTRELS) Score for the Diagnosis of Appendicitis in Children

View Table

Table 2

Alvarado (MANTRELS) Score for the Diagnosis of Appendicitis in Children

Clinical Finding Points

Migration of pain to the right lower quadrant

1

Anorexia

1

Nausea/vomiting

1

Tenderness in the right lower quadrant

2

Rebound pain

1

Elevated temperature (≥ 99.1º F [37.3º C])

1

Leukocytosis (≥ 10,000 WBCs per mm3 [10 × 109 per L])

2

Shift of WBC count to the left (> 75 percent neutrophils)

1

Total:

_______


note: A score of 7 points or more has a positive likelihood ratio of 4.0, whereas a score of less than 7 points has a negative likelihood ratio of 0.2. Given a baseline 20 percent probability of appendicitis in a child with acute abdominal pain, that corresponds to a probability of 50 percent if the score is 7 points or higher and 5 percent if the score is less than 7 points. Patients with a score of less than 4 points have a very low risk of appendicitis.

Adapted with permission from Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emer Med. 1986;15(5):561, with additional information from reference 2.

Another score, which includes nine clinical variables and does not require a WBC count, accurately predicted the likelihood of appendicitis in the initial validation study of 109 children.13 However, this and several other proposed diagnostic scores have not been prospectively validated in large, clinically relevant populations.

The Ohmann score (Table 3) includes seven clinical variables and a WBC count.14 The score was developed in a group of 870 patients at German and Austrian hospitals and was validated four months later in a second group of patients at the same hospitals. In the prospective validation, the Ohmann score successfully identified patients at low, moderate, and high risk of appendicitis.14

Table 3

Ohmann Score for the Diagnosis of Appendicitis in Adults and Children Older Than Six Years

Clinical Finding Points

Tenderness in the right lower quadrant

4.5

Rebound tenderness

2.5

No difficulty with micturition

2.0

Steady pain

2.0

Leukocytosis (≥ 10,000 white blood cells per mm3 [10 × 109 per L])

1.5

Age less than 50 years

1.5

Migration of pain to the right lower quadrant

1.0

Abdominal rigidity

1.0

Total:

_______

Risk group Score Appendicitis (%)

Low

< 4

0

4.0 to 5.5

3

Moderate

6.0 to 7.5

10

8.0 to 9.5

15

10.0 to 11.5

24

High

12.0 to 13.5

38

> 13.5

74


Adapted with permission from Ohmann C, Franke C, Yang Q, for the German Study Group of Acute Abdominal Pain. Clinical benefit of a diagnostic score for appendicitis: results of a prospective interventional study. Arch Surg. 1999;134(9):994.

Table 3   Ohmann Score for the Diagnosis of Appendicitis in Adults and Children Older Than Six Years

View Table

Table 3

Ohmann Score for the Diagnosis of Appendicitis in Adults and Children Older Than Six Years

Clinical Finding Points

Tenderness in the right lower quadrant

4.5

Rebound tenderness

2.5

No difficulty with micturition

2.0

Steady pain

2.0

Leukocytosis (≥ 10,000 white blood cells per mm3 [10 × 109 per L])

1.5

Age less than 50 years

1.5

Migration of pain to the right lower quadrant

1.0

Abdominal rigidity

1.0

Total:

_______

Risk group Score Appendicitis (%)

Low

< 4

0

4.0 to 5.5

3

Moderate

6.0 to 7.5

10

8.0 to 9.5

15

10.0 to 11.5

24

High

12.0 to 13.5

38

> 13.5

74


Adapted with permission from Ohmann C, Franke C, Yang Q, for the German Study Group of Acute Abdominal Pain. Clinical benefit of a diagnostic score for appendicitis: results of a prospective interventional study. Arch Surg. 1999;134(9):994.

The Alvarado and Ohmann scores alone are not accurate enough to diagnose or exclude appendicitis. However, they provide a useful starting point by identifying children and adults at low, moderate, and high risk of appendicitis. Most patients at low risk can be observed without further diagnostic study; patients at moderate risk may benefit from further diagnostic testing, including imaging studies; and patients at high risk should receive urgent surgical evaluation. Part II of this series addresses diagnostic testing in the context of the Alvarado and Ohmann scores.

Address correspondence to Mark H. Ebell, MD, MS, at ebell@uga.edu. Reprints are not available from the author.

REFERENCES

1. Adelman A. Abdominal pain in the primary care setting. J Fam Pract. 1987;25(1):27–32.

2. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA. 2007;298(4):438–451.

3. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241(1):83–91.

4. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91(1):28–37.

5. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589–1594.

6. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557–564.

7. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med. 2007;49(6):778–784.

8. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J R Soc Med. 1992;85(2):87–88.

9. Bond GR, Tully SB, Chan LS, Bradley RL. Use of the MANTRELS score in childhood appendicitis: a prospective study of 187 children with abdominal pain. Ann Emerg Med. 1990;19(9):1014–1018.

10. Hsiao KH, Lin LH, Chen DF. Application of the MANTRELS scoring system in the diagnosis of acute appendicitis in children. Acta Paediatr Taiwan. 2005;46(3):128–131.

11. Ohmann C, Yang Q, Franke C. for the Abdominal Pain Study Group. Diagnostic scores for acute appendicitis. Eur J Surg. 1995;161(4):273–281.

12. Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl. 1997;79(3):203–205.

13. Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg. 2005;390(2):164–170.

14. Ohmann C. Franke C, Yang Q, for the German Study Group of Acute Abdominal Pain. Clinical benefit of a diagnostic score for appendicitis: results of a prospective interventional study. Arch Surg. 1999;134(9):993–996.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.



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