Criteria

There are multiple validated decision tools utilized in the diagnosis of appendicitis. These include the Alvarado, AIR, and RIPASA scoring systems.

The Alvarado score is commonly used and has undergone the most validation studies. The AIR score performed well in one systematic review of clinical prediction rules. The RIPASA score was more sensitive than the Alvarado score, with improved diagnostic odds ratio, but lower specificity.[26][27]

Alvarado (MANTRELS) score[25]

Score is based on clinical characteristics of the patients. The higher the score out of a possible total of 10, the greater the chance of having acute appendicitis.

M: Migration of pain to right lower quadrant = 1 point.

A: Anorexia = 1 point.

N: Nausea and vomiting = 1 point.

T: Tenderness in right lower quadrant = 2 points.

R: Rebound tenderness = 1 point.

E: Elevated temperature = 1 point.

L: Leukocytosis = 2 points.

S: Shift of WBC count to left = 1 point.

Appendicitis Inflammatory Response (AIR) score[53]

Vomiting = 1 point.

Pain in right inferior fossa = 1 point.

Rebound tenderness: light = 1 point; medium = 2 points; strong = 3 points.

Body temperature ≥38.5 = 1 point.

Polymorphonuclear leukocytes: 70% to 84% = 1 point; ≥85% = 2 points. 

WBC count: 10.0 to 14.9 ×10⁹/L = 1 point; ≥15.0 ×10⁹/L = 2 points. 

CRP concentration: 10 mg/L to 49 mg/L = 1 point; ≥50 = 2 points. 

(Maximum 12 points.)

Sum 0 to 4 = low probability. Outpatient follow-up if unaltered general condition.

Sum 5 to 8 = indeterminate group. In-hospital active observation with rescoring/imaging or diagnostic laparoscopy according to local traditions.  

Sum 9 to 12 = high probability. Surgical exploration is proposed. 

RIPASA Score for Acute Appendicitis[54]

The higher the score out of a possible total of 16, the greater the chance of having acute appendicitis. The scoring system was developed for Asian populations.

Female = 0.5 points.

Male = 1 point.

Age <39.9 years = 1 point.

Age >40 years = 0.5 points. 

Right iliac fossa (RIF) pain = 0.5 points.

Migration of pain to RIF = 0.5 points.

Anorexia = 1 point.

Nausea and vomiting = 1 point.

Duration of symptoms <48 hours = 1 point.

Duration of symptoms >48 hours = 0.5 points.

RIF tenderness = 1 point.

Guarding = 2 points.

Rebound tenderness = 1 point.

Rovsing sign = 2 points. 

Fever = 1 point.

Raised WBC = 1 point.

Negative urine analysis = 1 point.

(Maximum 16 points.)

Acute Physiology and Chronic Health Evaluation II (APACHE II) score[55]

The APACHE score is commonly used to establish illness severity in the intensive care unit (ICU) and predict the risk of death.[ APACHE II scoring system ] There is a high risk of death if the score is 25 or above.

There are several other models that have been developed for use in the ICU, including APACHE III, Mortality in Emergency Department Sepsis score, Simplified Acute Physiology Score, Sepsis-related Organ Failure Assessment, and Mortality Probability Model II.[56][57][58]

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