Acute appendicitis–advances and controversies

Table 1 Various scoring systems for acute appendicitis

Scoring system	Patient features	Clinical features	Laboratory/imaging features	Sensitivity		Specificity	Risk strata/recommended action
Alvarado	-	RIF tenderness (2); Elevated temperature (1); Rebound tenderness (1); Migration of pain to RIF (1); Anorexia (1); Nausea or vomiting (1)	Leucocytosis (2); Leukocyte left shift (1)	94.1%		90.4%	1-4: Discharge; 5-6: Admit and observe; 7-10: Surgery
AIR	-	Elevated temperature (1); Rebound tenderness: Light (1), medium (2), strong (3); RIF pain (1); Vomiting (1)	Leucocytosis, × 109/L: 10-14.9 (1); ≥ 15 (2); Polymorphonuclear leucocytosis, %: 70-84 (1); ≥ 85 (2); CRP level, mg/L: 10-49 (1); ≥ 50 (2)	97%			0-4: Outpatient follow-up; 5-8: Admit and observe; 9-12: Surgery
AAS	-	RIF tenderness: Women 16-49 yr (1); all other patients (3); Migration of pain (2); RIF pain (2); Guarding: Mild (2); moderate or severe (4)	Leucocytosis, × 109/L: ≥ 7.2 and < 10.9 (1); ≥ 10.9 and < 14.0 (2); ≥ 14.0 (3). Neutrophilia, %: ≥ 62 and < 75 (2); ≥ 75 and < 83 (3); ≥ 83 (4). CRP level, mg/L and symptoms < 24 h: ≥ 4 and < 11 (2); ≥ 11 and < 25 (3); ≥ 25 and < 83 (5); ≥ 83 (1). CRP level, mg/L and symptoms > 24 h: ≥ 12 and < 53 (2); ≥ 53 and < 152 (2); ≥ 152 (1)				1-10: Discharge without imaging; 11-15: Imaging; ≥ 16: Surgery
RIPASA	Age: < 40 (1); Age > 40 (0.5). Gender: Male (1); female (0.5). Foreign nationality registration identity card (1)	RIF tenderness (1); Elevated temperature (1); Rebound tenderness (1); Migration of pain to RIF (0.5); Anorexia (1); Nausea or vomiting (1); RIF pain (0.5); Duration of symptoms: < 48 h (1); > 48 h (0.5); Guarding (2); Rovsing sign (2)	Leucocytosis (1); Negative urine analysis (1)	91.67%		93.18%	-
Ohmann	Age < 50 (1.5)	RIF tenderness (4.5); Rebound tenderness (2.5); Migration of pain (1); No micturition difficulties (2.0); Steady pain (2); Rigidity (1)	Leucocytosis (1.5)	98.1% at cut-off score 9; 82.9% at cut-off score 13		94% at cut-off score 12	< 6: Low risk; 6-11.5: Monitoring; ≥ 12: Surgery
Lintula	Gender: Male (2); female (0)	Elevated temperature (3); Rebound tenderness (7); Migration of pain (4); Vomiting (2); RIF pain (4); Guarding (4); Pain intensity: severe (2); mild or moderate (0); Bowel sounds absent, tinkling or high-pitched (4)	-	79.0% at cut-off score 21		58.3% at cut-off score 21	≤ 15: Discharge; 16-20: Monitoring; ≥ 21: Surgery
Tzanakis	-	RIF tenderness (4); Rebound tenderness (3)	Leucocytosis (2); US imaging showing appendiceal inflammation (6)				0-4: Discharge; 5-7: Monitoring; 8-15: Surgery
Fenyo-Lindberg	Gender: Male (8); female (-8)	Rebound tenderness: Yes (5); no (-10); migration of pain to RIF: Yes (7); no (-9); Vomiting: Yes (7); no (-5); Duration of pain: < 24 h (3); > 48 h (-12); Progression of pain: Yes (3); no (-4); Aggravation with cough: Yes (4); no (-11); Rigidity: Yes (15); no (-4); Pain outside RIF: Yes (-6); no (4)	Leucocytosis, × 109/L: < 8.9 (-15); 9-13.9 (2); > 14 (10)	In a cross-sectional study including 100 patients with RIF pain, Sahu reported a sensitivity of 72% and specificity of 71%			≤ -17: Non-specific abdominal pain; ≥ -2: AA likely
Modified Alvarado Score	-	RIF tenderness (2); Elevated temperature (1); Rebound tenderness (1); Migration of pain to RIF (1); Anorexia (1); Nausea or vomiting (1)	Leucocytosis (2)				< 5: Surgery not required; 5-6: Monitor; 7-9: Surgery indicated
Christian	-	RIF tenderness (1); Elevated temperature (1); Vomiting (1); Abdominal pain (1)	Polymorphonuclear leucocytosis (1)				< 4: Monitoring; ≥ 4: Surgery
van den Broek et al[14]	Gender: Male (2)	Elevated temperature (1); Rebound tenderness (2); Duration of symptoms ≤ 48 h (1)	Leucocytosis (3)				0-3: Observe; 4-6: Diagnostic laparoscopy
Simplified Appendicitis Score	-	RIF tenderness (1); Elevated temperature (1); Rebound tenderness (1); Migration of pain to RIF (1)	Leucocytosis (1)				< 4: AA excluded with 90.1% sensitivity; ≥ 6: AA included with 91.7% specificity

RIF: Right iliac fossa; CRP: C-reactive protein; US: Ultrasound; AIR: Appendicitis inflammatory response; RIPASA: Raja Isteri Pengiran Anak Saleha.