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The appendicitis inflammatory response score: A tool for the diagnosis of acute appendicitis that outperforms the Alvarado score
Department of Surgery, County Hospital Ryhov, 551 85 Jönköping, Sweden.
Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Surgery .
2008 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 32, no 8, 1843-1849 p.Article in journal (Refereed) Published
Abstract [en]

Background: The clinical diagnosis of appendicitis is a subjective synthesis of information from variables with ill-defined diagnostic value. This process could be improved by using a scoring system that includes objective variables that reflect the inflammatory response. This study describes the construction and evaluation of a new clinical appendicitis score. Methods: Data were collected prospectively from 545 patients admitted for suspected appendicitis at four hospitals. The score was constructed from eight variables with independent diagnostic value (right-lower-quadrant pain, rebound tenderness, muscular defense, WBC count, proportion neutrophils, CRP, body temperature, and vomiting) in 316 randomly selected patients and evaluated on the remaining 229 patients. Ordered logistic regression was used to obtain a high discriminating power with focus on advanced appendicitis. Diagnostic performance was compared with the Alvarado score. Results: The ROC area of the new score was 0.97 for advanced appendicitis and 0.93 for all appendicitis compared with 0.92 (p = 0.0027) and 0.88 (p = 0.0007), respectively, for the Alvarado score. Sixty-three percent of the patients were classified into the low- or high-probability group with an accuracy of 97.2%, leaving 37% for further investigation. Seventy-three percent of the nonappendicitis patients, 67% of the advanced appendicitis, and 37% of all appendicitis patients were correctly classified into the low- and high-probability zone, respectively. Conclusion: This simple clinical score can correctly classify the majority of patients with suspected appendicitis, leaving the need for diagnostic imaging or diagnostic laparoscopy to the smaller group of patients with an indeterminate scoring result. © 2008 Société Internationale de Chirurgie.

Place, publisher, year, edition, pages
2008. Vol. 32, no 8, 1843-1849 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-45600DOI: 10.1007/s00268-008-9649-yOAI: diva2:266496
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2015-01-30
In thesis
1. Structured management of patients with suspected acute appendicitis
Open this publication in new window or tab >>Structured management of patients with suspected acute appendicitis
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background. Acute appendicitis (“appendicitis”) is one of the most common abdominal surgical emergencies worldwide. In spite of this, the diagnostic pathways are highly variable across countries, between centres and physicians. This has implications for the use of resources, exposure of patients to ionising radiation and patient outcome. The aim of this thesis is to construct and validate a diagnostic appendicitis score, to evaluate new inflammatory markers for inclusion in the score, and explore the effect of implementing a structured management algorithm for patients with suspected appendicitis. Also, we compare the outcome of management with routine diagnostic imaging versus observation and selective imaging in equivocal cases.

Methods. In study I, the Appendicitis Inflammatory Response (AIR) score was constructed from eight variables with independent diagnostic value (right lower quadrant pain, rebound tenderness or muscular defence, WBC count, proportion of polymorphonuclear granulocytes, CRP, body temperature and vomiting). Its diagnostic properties were evaluated and compared with the Alvarado score. In study II, we performed an external validation and evaluation of novel inflammatory markers for inclusion in the score on patients with suspected appendicitis at two Swedish hospitals. In study III we externally validated and evaluated the impact of an AIR-scorebased algorithm assigning patients to a low or high risk of having appendicitis in an interventional multicentre study involving 25 Swedish hospitals and 3791 patients. In study IV, we compared the efficiency of routine diagnostic imaging with repeated clinical assessment followed by selective imaging in a randomised trial of 1028 patients with equivocal signs of appendicitis, as indicated by an intermediate AIR score, from study III.

Main results. In study I we found that the AIR score could assign 63% of the patients to either a high- or low-risk group of appendicitis with an accuracy of 97%, which compared favourably with the Alvarado score. In study II, the diagnostic properties of the AIR score proved to be  reproducible, but the inclusion of novel inflammatory markers did not improve the diagnostic accuracy. In study III, the AIR-score-based algorithm led to a reduction in negative explorations, operations for nonperforated appendicitis and hospital admissions in the low-risk group and reduced use of imaging in both low- and high-risk groups. In study IV, routine imaging led to more operations for nonperforated appendicitis but had no effect on negative explorations or perforated appendicitis.

Conclusions. The AIR score was found to have promising diagnostic properties that were not improved further with the inclusion of novel inflammatory variables. Structured management of patients with suspected appendicitis according to an AIR-score-based algorithm may improve outcome while reducing hospital admissions and use of imaging. Patients with equivocal signs of appendicitis do not benefit from routine imaging which may lead to an increased detection of, and treatment for, uncomplicated cases of appendicitis that are otherwise allowed to resolve spontaneously.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 110 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1442
National Category
Clinical Medicine Surgery
urn:nbn:se:liu:diva-113766 (URN)10.3384/diss.diva-113766 (DOI)978-91-7519-137-9 (print) (ISBN)
Public defence
2015-03-06, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 13:00
Futurum - Academy for Health and Care, Jönköping County Council, SwedenMedical Research Council of Southeast Sweden (FORSS)
Available from: 2015-01-30 Created: 2015-01-30 Last updated: 2015-11-16Bibliographically approved

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