ANZ J. Surg.

2004; 74: 324329

ORIGINAL ARTICLE
ORIGINAL ARTICLE

PROTOCOL-BASED APPROACH TO SUSPECTED APPENDICITIS,

INCORPORATING THE ALVARADO SCORE AND
OUTPATIENT ANTIBIOTICS
ROBERT D. WINN, SHARON LAURA, CHARLES DOUGLAS, PATRICIA DAVIDSON AND JON S. GANI
Division of Surgery, John Hunter Hospital and John Hunter Childrens Hospital; and University of Newcastle, Newcastle,
New South Wales, Australia

Background: There is evidence that antibiotics can be used as primary treatment for appendicitis, however, delayed surgical treatment might still be associated with perforation. Most patients at risk of perforation have high Alvarado scores. We designed a
protocol-based approach to suspected appendicitis, in which the Alvarado score was used to select patients for early treatment with
surgery or outpatient antibiotics.
Methods: Patients included in the present study were adults and children referred to the surgical service at John Hunter Hospital
(Newcastle, Australia) with suspected appendicitis in the 12 months from July 2000. Treatment groups: no treatment (Alvarado score
14); antibiotics alone (Alvarado 57); early surgery (Alvarado 810). Outcome measures: time to operation; duration of hospital
stay; non-therapeutic operations; delayed treatment in association with perforation; recurrent appendicitis (for those treated with antibiotics). Comparison group: 142 patients managed with best clinical practice as part of an earlier trial.
Results: One hundred and twenty-two patients were enrolled. Median time to operation was 3.9 h (comparison group 7.3 h,
P = 0.014). Median length of stay was 38.5 h (comparison group 44.2 h, P = 0.041). There were two cases of delayed treatment in
association with perforation (2/122 = 1.6%, comparison group 2/142 = 1.4%, P = 0.88) and 10 non-therapeutic operations (10/122 =
8.1%, comparison group 15/142 = 10.6%, P = 0.51). Of those whose initial illness was treated successfully with antibiotics, 2/42
(4.8%) subsequently required appendicectomy.
Conclusions: This protocol-based approach to suspected appendicitis is feasible. A prospective controlled study would be
required to confirm potential benefits (in terms of short hospital stay) and to confirm that there is not an increase in adverse
outcomes.
Key words: Alvarado score, antibiotic, appendicitis, diagnosis, imaging.
Abbreviations: CT, computed tomography; DTAP, delayed treatment in association with perforation; RCT, randomized

control trial; RIF, right iliac fossa.

INTRODUCTION
The differential diagnosis and management of patients presenting
with right iliac fossa (RIF) pain is a continuing surgical challenge. Imaging modalities might improve diagnostic accuracy,
however, their use has not been shown to improve outcomes
in acute appendicitis when compared to clinical management
alone.13
There is some evidence that antibiotics can be used as primary
treatment for appendicitis,4,5 and that antibiotics might make it
possible to safely delay surgery in some patients.6 Intuitively,
antibiotics might therefore add a margin of safety in the nonoperative management of patients with RIF pain, especially those
who are unlikely to already have perforation. This could increase
the confidence of the surgeon in allowing patients to be
observed as outpatients.
The Alvarado score is a 10 point scoring system for the diagnosis of appendicitis based on clinical signs and symptoms and a
R. D. Winn; S. Laura; C. Douglas; P. Davidson; J. S. Gani.
Correspondence: Dr Jon Gani, Top Floor Lake Macquarie Specialist Medical Centre, 8 Sydney Street, Gateshead, NSW 2290, Australia.
Email: gani16@castle.net.au
Accepted for publication 26 September 2003.

differential leucocyte count (Table 1).7 In our experience this

score has been an effective means of stratifying patients according to risk of appendicitis.1 Of particular importance, no patient
in our previous study with an Alvarado score of less than 8 had
perforated appendicitis, and none of those with an Alvarado score
of 4 or less had appendicitis that required operative treatment
(Charles Douglas and Jon Gani, unpubl. obs., 2000).
In the present study we have endeavoured to establish a
protocol-based approach to RIF pain, which is independent of
imaging, that minimizes unnecessary hospital admissions and
which expedites appropriate operations, by incorporating the
Alvarado score to select patients for immediate surgery, antibiotic treatment, or no treatment at all. Others have used a similar
protocol but chose to observe patients with mid-range Alvarado
scores in hospital.8 The present study aimed to manage this group
with antibiotics and on an outpatient basis whenever possible.
The control group (clinical management, no imaging) from
our previous randomized study were used as a comparison
group.1 The previous study used the same inclusion criteria and
endpoints.

METHODS
Ethics approval was obtained from the Hunter Area Research
Ethics Committee before the study commenced. Adults and children referred to the surgical service of the John Hunter Hospital/

PROTOCOL-BASED APPROACH TO APPENDICITIS

325

Table 1. Symptoms and signs used to calculate the Alvarado score

Sign/symptom
Migratory right iliac fossa pain
Anorexia
Vomiting/nausea
Temperature 37.3
Tenderness right lower quadrant
Percussion tenderness right iliac fossa
White cell count = 10.0 109/L
Neutrophils >75% or left shift
Total

1
1
1
1
2
1
2
1
10

Comparison group
This group comprised 142 adults and children admitted between
10 September 1997 and 9 October 1998 to the same institution,
who were managed along conventional clinical lines. These
patients satisfied the same exclusion and inclusion criteria used
for the present study, but were part of a trial in which they had
been randomized to best clinical practice.1 They were thus
managed according to the judgement of the surgical team with no
restrictions except that they were not allowed to undergo ultrasonography within 36 h of admission (as they formed the control
group for a study of the efficacy of ultrasound diagnosis).
Outcome measures

John Hunter Childrens Hospital (Newcastle, Australia) with a

provisional diagnosis of acute appendicitis, between 6 July 2000
and 1 July 2001, were considered for inclusion in the study.
Almost all of these patients were referred from the emergency
department. Patients were excluded if they: were aged less than
5 years; had evidence of generalized peritonitis; had a palpable
mass in the RIF; had evidence of acute confusional state or
dementia; had already had an ultrasound or computed tomography (CT) scan; or if the patient or admitting surgeon refused entry
into the study. If agreement was obtained for enrolment in the
study, written informed consent was obtained, and the duty surgical registrar performed a structured clinical assessment and
calculated the Alvarado score (Table 1). The score was then used
to triage patients into management subgroups:
Group 1 Alvarado score 4 or less. Discharge, no follow up.
Group 2 Alvarado score 57. Antibiotics and observation
as an outpatient where feasible.
Group 3 Alvarado score 810. Urgent surgery.
Management details
Group 1: patients with an Alvarado score of 4 or less were discharged with no hospital follow up. Group 2: patients with an
Alvarado score of 57 were allocated to the antibiotic group.
They were given one dose of i.v. gentamicin (6 mg/kg) and metronidazole (500 mg for adults or 15 mg/kg as a loading dose for
children). If not contra-indicated by pain, vomiting, clinical concern, or social circumstances, patients in this group were sent
home on a 7-day course of amoxycillin (875 mg) and clavulanate
(125 mg), twice daily (Augmentin Duo Forte (GlaxoSmithKlein,
Melbourne, Australia), 22 mg/kg for children), and reviewed
within 24 h in the surgical outpatient clinic. The antibiotic
regimen was based on advice from our infectious diseases service, using drugs with a similar antimicrobial spectrum to those
used in a clinical trial of antibiotic treatment of appendicitis.5
Management of these discharged patients continued from the surgical outpatient clinic until resolution of symptoms. Children
aged 510 years in the antibiotic group were admitted to hospital
and treated initially with antibiotics and observed. Antibiotics for
admitted patients could be oral or i.v.. Antibiotic side-effects
were monitored (rash, thrush, nausea, diarrhoea, etc.). Group 3:
patients with an Alvarado score of 810 were allocated to the
urgent surgery group and were scheduled directly for emergency
surgery following a single dose of i.v. antibiotics as outlined
above.
Clinical judgement was always allowed to override the protocol (although analysis was on an intention to treat basis).

There were four major outcome measures for the present study:
duration of hospital stay, time to operation, non-therapeutic operation rate; and rate of delayed treatment in association with perforation (DTAP). The definitions are identical to those previously
reported and are listed in Appendix I.1 In addition, we followed
up all patients treated with antibiotics to determine the rate of
recurrent appendicitis.
Statistics
Using a two tailed t-test, a significance of 0.05 and enrolling
150 patients we expected to have an 80% power to detect a 15 h
difference in mean duration of hospital stay, and a 3.4 h difference in mean time to surgery for those undergoing a therapeutic
operation. The data for the outcomes: duration of hospital stay
and time to operation were skewed, so were analyzed using the
Mann Whitney U-test and compared as medians. Group similarities were compared using two-sided t-test for normally distributed variables and the MannWhitney U-test for nonparametric variables.

RESULTS
One hundred and twenty-two patients were enrolled in the protocol group during the 12 months of the study.
Similarity of groups
There were no significant differences between the protocol group
and the comparison group with respect to sex and mean Alvarado
score. There was a significant difference in the median age
between the two groups (P = 0.037, Z = 2.084, U = 7319.0
MannWhitney U) because of fewer children being recruited in
the protocol group.
Main outcome measures
The protocol group had a significantly shorter median time to
operation (3.9 h vs 7.3 h MannWhitney U, P = 0.014, Table 2
and Fig. 1) and significantly shorter median duration of hospital
stay (38.5 h vs 44.2 h MannWhitney U, P = 0.041, Table 3 and
Fig. 2) than the comparison group. The rate of DTAP for the protocol group was 1.6% (2/122) compared to 1.4% (2/142) for the
comparison group (P = 0.88, 2 d.f. = 1). The non-therapeutic
rate for the protocol group was 8.1% (10/122) compared to 10.6%
(15/142) for the comparison group (P = 0.51, 2 d.f. = 1). The
recurrence rate of appendicitis in the Alvarado 57 group treated

326

WINN ET AL.

successfully with antibiotics on their initial admission was 4.8%

(2/42) at median follow up of 11 months.
Protocol breaches occurred in 12% of cases (15/122). (Protocol
breaches occurred in 33% of those in the Alvarado 04 group,
8% in the Alvarado 57 and 12% in the Alvarado 810).

Table 2. Time to operation (h)

Group

Mean

Protocol
Comparison

53
60

6.6
10.2

Standard Median
deviation
7.6
8.9

3.9
7.3

Range
0.438.3
0.233.7

Difference between two groups: MannWhitney U-test P = 0.014, z = 2.46,

U = 1162.5.

No patient with a true Alvarado score of 7 or less suffered

perforated appendicitis (although two patients had their scores
miscalculated initially and did have perforated appendicitis).
Those on antibiotics recorded no rashes or episodes of thrush.
The few brief episodes of diarrhoea that did occur were difficult
to separate from the abdominal complaint. There were no cases of
pseudomembranous colitis recorded.
Table 4 shows the outcomes for patients in the study group
according to Alvarado score.
Table 5 lists the final discharge diagnoses of all patients.

DISCUSSION
We have shown that a protocol-based approach to the management of RIF pain is feasible, and might reduce the time to operation and the overall hospital stay of patients, without increasing
the number of adverse outcomes. The role of antibiotics in the
protocol remains unclear. However, this was not a randomized
trial, and there are a number of factors that could have influenced
the differences in outcomes between the group studied here, and
the historical comparison group.

Fig. 1. Comparison of time to operation between () protocol and

() comparison groups.

Table 3. Duration of hospital stay (h)

Group
Protocol
Comparison

Mean

122
142

44.9
54.5

Standard Median
deviation
55.9
49.4

38.5
44.2

Range
0.2511
0.43343

Difference between two groups: MannWhitney U-test P = 0.041, z = 2.04,

U = 7400.0.

Fig. 2. Comparison of duration of hospital stay between () protocol and () comparison groups (two outliers, one from the protocol
group and one from the comparison group, are not represented on this
graph).

Table 4. Patients grouped by initial Alvarado Score

Alvarado score

Patients

Admissions

Antibiotics

Operations

Appendicitis

DTAP

Non-TOp

04
57

12
53

1
49

810

57

4
22 initially
4 next day
1 interval
57 initially

2
5
4 next day
1 interval
50 urgently
2 delayed

0
4
3
1
44
2

0
1
0
0
0
1

2
1
1
0
6
0

DTAP, delayed treatment in association with perforation; Non-TOp, non-therapeutic operation.

PROTOCOL-BASED APPROACH TO APPENDICITIS

327

Table 5. Final discharge diagnoses

Protocol group
Alvarado score
Appendicitis
Unknown
Infective diarrhoea
Viral illness/cough
Urinary tract infection
Gynaecological pathology
Non-therapeutic laparotomy
Total

57
9
36
1
1
1
3
2
53

810
46
3

8
57

Comparison
group
57
12
34

2
9
57

810
43
15

3
6
67

The difference in median age between the two groups might

be explained by the choice of two of four paediatric surgeons
not to participate in the present study. A retrospective coding
search identified 277 patients eligible for recruitment to the protocol group during the study period. This relatively low enrolment rate during the protocol phase of the study was essentially
caused by the lack of funding for a dedicated project officer
during the recruitment of the protocol group. Some loss of
potential candidates occurred when registrars neglected to enrol
patients in the present study. Some patients declined to be
involved in the study, and there were 19 registrars who enrolled
patients in the present study. Alvarado scores might have been
influenced by the experience of the registrars. This is probably
also the reason for the miscalculation of the Alvarado score
in 3% (4/122) of patients. However, this was realized only in
retrospect and all analyses include the original allocated Alvarado score. In three of the cases the Alvarado score was underestimated, which had the effect of delaying an operation in each
case. In the one case where the Alvarado was over-estimated the
registrar ignored the result.
The time to theatre and duration of hospital stay could have
been influenced by a number of factors including: enthusiasm of
registrars, availability of operating theatres, or changes in discharge planning practices (although none of these were overtly
different in the comparison and study groups).
There were two cases of perforation with an Alvarado score in
the intermediate range. In both cases the score was, in retrospect,
9 on admission. One of these cases was a case of DTAP. The one
other case of DTAP occurred in the high range Alvarado group
(810). In this case the consultant ignored the protocol. Had the
Alvarado scores been correctly calculated perforations in the
intermediate group would have been zero. Had the protocol been
followed, the DTAP rate for the whole protocol group would
have been zero.
Protocol breaches occurred frequently. This is an inevitable
consequence of any system that encourages clinical judgement to
override the protocol when the treating physician feels it is indicated for the patients benefit.
The final diagnosis of patients whose symptoms resolved
without surgery is not known with certainty. Some patients with
non-specific abdominal pain might have received antibiotics.
The role of antibiotics in modifying the development of acute
appendicitis is yet to be defined.9 The appendiceal intraluminal
pressure prior to surgical removal for appendicitis syndrome is
raised in only a minority of cases.10 Sisson et al. demonstrated
mucosal ulceration in the majority of patients in their case series

but less than 50% of appendixes showed obstruction or luminal

dilation.11 Once the mucosal surface is breached, the potential for
bacterial invasion of the mucosa with secondary infection and
inflammation, has been established but the cause of the mucosal
ulceration itself is unknown.9 The role of antibiotics might be to
control inflammation in an end artery organ while mucosal repair
takes place.
Some epidemiological data supports the theory that perforating
and non-perforating appendicitis are separate entities and that the
rate of perforated appendicitis is independent of laparotomy
rate.12 Spontaneous resolution of appendicitis13 and recurrent
appendicitis14 have both been reported.
Jones describes the decrease in non-therapeutic laparotomy
rate, which has been achieved by a policy of active observation
(in hospital), without an increase in the overall perforation rate.15
Overall perforation rate can be related to a number of uncontrollable factors such as the aggressiveness of the inflammatory process, prehospital duration of symptoms16 and other patient factors.
A more meaningful indicator of quality of care for patients
presenting with appendicitis is a measure of delayed treatment of
patients with perforated appendicitis (we have defined this as
DTAP1). The severity of the inflammation process in appendicitis
is the main determinant of postoperative hospital stay.17 The ultimate goal in treating suspected appendicitis is to minimize the
number of non-therapeutic operations without increasing the
number of cases of DTAP.1
Diagnostic scores for acute appendicitis have been claimed
to lower the non-therapeutic operation rate in some studies,
however, these are not randomized trials.18,19 Many studies have
shown their limitations,20,21 especially in women where the
number of alternative diagnoses is greater.22,23 The Alvarado
score7 has been used more successfully as a triage tool for the
further investigations of laparoscopy,8,23 and graded compression
ultrasound.1 Our study utilized the Alvarado score to extend the
success of active observation15 to an outpatient basis and to
explore the role of antibiotics in this group.
When selecting a group of patients with RIF pain whom it is
safe to observe Owen et al.18 found that of 215 patients, none of
those with an Alvarado score less than 6 perforated when
observed for 24 h. Using the modified Alvarado score Kalan
et al.23 found that no patient with a modified Alvarado score less
than 5 required surgery. We found in analysis of our previous
prospective study that no patient with an Alvarado score of 7 or
less had perforation,1 and the same was found during the present
study, apart from two patients who had had their scores incorrectly calculated.
Imaging of people with suspected appendicitis involves an
unavoidable delay in treatment. Graded compression ultrasound,
though achieving sensitivity and specificity rates of 94.7% and
88.9%, has not been shown to improve patient outcome.1 CT
imaging has only improved on these values of sensitivity and
specificity if rectal contrast is used.2426 Avoiding imaging in our
protocol limits delays and expands its applicability to institutions
with fewer resources.
The initial success of antibiotics in the treatment of all presentations with appendicitis is reported in a case series of 473
patients4 and one randomized control trial (RCT).5 Although a
37% recurrence rate occurred in the antibiotic arm of the one
RCT within 13.2 months27 the effect of antibiotics on those with
mild symptoms of appendicitis and their rate of recurrence is not
known. Our data suggest that the use of antibiotics in a group of
patients with Alvarado scores under 8 (who may have mild

328

WINN ET AL.

appendicitis) is safe and associated with a recurrence rate of 4.8%

(2/42) at median follow up of 11 months.
14.

CONCLUSIONS

15.

This protocol, using the Alvarado score and selective outpatient

management with antibiotics, is simple and requires no imaging.
It resulted in a very short median time to operation. By using
outpatient management of less severe cases, the percentage of
patients admitted was low and thus the median duration of hospital
stay was also low. This did not appear to be achieved at the
expense of an increase in the number of non-therapeutic operations or cases of delayed treatment in association with perforation,
in the population studied. For patients with an Alvarado score of
47 inclusive, treated with antibiotics, there was a very low rate of
re-presentation with appendicitis (about 5% at 11 months follow
up). This protocol may be an effective approach for managing
patients with suspected acute appendicitis that optimizes the use of
available hospital resources. A randomized controlled trial would
be required to confirm these potential benefits.

16.

ACKNOWLEDGEMENTS
The Charitable Trust of John Hunter Hospital provided financial
support for the present study. Thank you to Dr S. Oakley for
assistance with statistical analysis.

17.
18.
19.
20.
21.
22.
23.
24.

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appendicitis, incorporating the Alvarado score. BMJ 2000; 321:
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of preoperative computed tomography on patients undergoing
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3. Ford RD, Passinault WJ, Morse ME. Diagnostic ultrasound for
suspected appendicitis: does the added cost produce a better outcome? Am. Surg. 1994; 60: 8958.
4. Coldrey E. Five years conservative treatment of acute appendicitis. J. Int. Coll. Surg. 1959; 32: 25561.
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6. Surana R, Quinn F, Puri P. Is it necessary to perform appendectomy in the middle of the night in children? BMJ 1993; 306:
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7. Alvarado A. A practical score for the early diagnosis of acute
appendicitis. Ann. Emerg Med. 1986; 15: 55764.
8. Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB. A prospective
evaluation of the combined use of the modified Alvarado score
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9. Williams RA, Myers P. Pathology of the Appendix. 1st edn.
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12. Anderson R, Hugander A, Thulin A, Nystrom PO, Olaison G.
Indications for operation in suspected appendicitis and incidence
of perforation. Br. Med. J. 1994; 308: 10710.
13. Heller MB, Skolnick LM. Ultrasound documentation of sponta-

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Barber MD, McLaren J, Rainey JB. Recurrent appendicitis. Br.
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Jones PF. Suspected acute appendicitis: trends in management
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Temple CL, Huchcroft SA, Temple WJ. The natural history of
appendicitis in adults. A prospective study. Ann. Surg. 1995;
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Foulds KA, Spencer W, Maoate B, Maoate K. Factors that influence length of stay after appendicectomy. Aust. N. Z. J. Surg.
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Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J. R. Soc. Med.
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APPENDIX I
Denition of terms
Surgery: Operations were considered therapeutic if pathology was
found, the pathology was thought to be the cause for the patients
pain, and surgery was the appropriate treatment for the patients
pain. All other operations were classed as non-therapeutic. (Elective interval operations for undiagnosed abdominal pain were
excluded from time to surgery calculations).
Perforation: The appendix or bowel, was considered to be perforated if the surgeon clearly identified a perforation or a peritoneal swab grew at least one definite bowel organism or the
histopathologist identified a perforation in association with gangrene or full thickness necrosis.
Measurement: All times were measured from when the patients
were first seen by the surgical registrar in the emergency department and calculated in hours.
Time to operation for therapeutic operations was measured to
skin preparation.
Duration of hospital stay was measured to discharge from hospital, or emergency department for those managed as an outpatients. Where a patient was readmitted for ongoing management

PROTOCOL-BASED APPROACH TO APPENDICITIS

of a complication of acute appendicitis, or for interval or elective

appendicectomy the duration of the subsequent admission was
added to the first.
Nontherapeutic operation rate was calculated as a proportion
of the total number in each group and included only operations
occurring on the patients first admission.

329

Delayed treatment in association with perforation (DTAP) for

patients with perforation, treatment, was considered to be delayed
if surgery had not commenced within 10 h of being seen by the
surgical registrar.
DTAP rate was defined as the number of DTAP cases in a
group divided by the total number of that group.