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ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 29-32

Outcome analysis of acute abdominal pain and correlation of Alvarado score with diagnosis


Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Hemanshi Shah
Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.175213

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  Abstract 


Background: Abdominal pain is a very common symptom in pediatric age group. Not all patients presenting with acute pain abdomen require surgical intervention. Hence, an accurate diagnosis based on appropriate investigations is absolutely necessary. Methods: One hundred admitted patients with acute abdominal pain were analyzed, and Alvarado score was calculated for each of them. Conservative or operative management was done depending on the diagnosis thus obtained from these investigations as per the set departmental protocols. Alvarado score was correlated with diagnosis in these children. Results: The mean age of presentation was 70.4 months; range of age being 4 months and 144 months. They were 69 males and 31 females. The most common presenting symptoms besides abdominal pain were vomiting (83), anorexia (73), and nausea (36). The most common diagnoses were intussusception (26), mesenteric lymphadenitis (21), acute appendicitis (13), and appendicular perforation (7). Operative intervention was required in 38 patients out of which 23 were emergency explorations. There were 78 patients in Alvarado score of 5–6; 15 patients in Alvarado score 7–8; and 7 patients in Alvarado score 9 or more. The diagnosis of patients with lower Alvarado Score was mostly intussusception and mesenteric lymphadenopathy whereas as the score increased, the diagnosis of acute appendicitis and appendicular perforation became more common. There was no mortality and all patients are doing well on follow-up. Conclusion: Though most of the patients of acute pain abdomen present with symptoms mimicking acute appendicitis, the most common definitive diagnosis in the pediatric age group with lower Alvarado score are intussusception and mesenteric lymphadenitis which can be managed conservatively most of the times.

Keywords: Abdominal pain, Alvarado score, conservative, operative


How to cite this article:
Tiwari C, Sandlas G, Jayaswal S, Shah H. Outcome analysis of acute abdominal pain and correlation of Alvarado score with diagnosis. Saudi Surg J 2015;3:29-32

How to cite this URL:
Tiwari C, Sandlas G, Jayaswal S, Shah H. Outcome analysis of acute abdominal pain and correlation of Alvarado score with diagnosis. Saudi Surg J [serial online] 2015 [cited 2022 May 27];3:29-32. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/29/175213




  Introduction Top


Acute abdominal pain is one of the common presenting complaints in the pediatric age group. The possible causes are varied and numerous. Some problems are self-limiting, while others can be life-threatening. The assessment and diagnosis of acute abdominal pain in childhood continues to be a clinical challenge. In general, it is accepted that acute abdominal pain prevents personal activity and has an unexpected onset which causes stress to both the child as well as the parents. In this study, analysis of 100 admitted patients with acute abdomen was done with respect to age, presenting symptoms, diagnosis, investigations, management, and follow-up. Alvarado score was calculated for all and correlated with the diagnosis.


  Methods Top


In this prospective observational study, the outcome of every admitted patient of abdominal pain with respect to diagnosis, investigation, and management was analyzed. A total of consecutive 100 patients up to 12 years of age who presented in the Paediatric Surgery Outpatient Department and Emergency were included in the study. The clinical symptoms and signs of each of these patients were analyzed and Alvarado score [Table 1] was calculated for each of them. Complete hemogram, abdominal X-ray erect, and ultrasonography (USG) were done for all patients as per the departmental protocol. When diagnosis was in doubt, a computed tomography (CT) scan of abdomen was advised. The course and complications of each of these patients in the ward and on follow-up were observed.
Table 1: Alvarado score

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  Results Top


The mean age at presentation was 70.4 months; range of age being 4 months and 144 months. They were 69 males and 31 females. The most common associated presenting symptoms along with abdominal pain were vomiting (83), anorexia (73), and nausea (36). The most common definitive diagnoses were intussusception (26), mesenteric lymphadenitis (21), acute appendicitis (13), and appendicular perforation (7). The least common diagnosis was pelvic abscess, which was seen in only one patient. Operative intervention was required in 38 patients of which, 23 were emergency explorations and 15 were planned procedures [Figure 1].
Figure 1: Pie chart depicting the outcome of 100 patients presenting with abdominal pain

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There were 9 patients of liver abscess; 6 patients were managed by external drainage via an ultrasound-guided placement of a drainage catheter, and 3 were managed by ultrasound-guided aspiration. Less common diagnoses were choledochal cyst, habitual constipation, Hirsch sprung disease, primary peritonitis, enteric duplication cyst, abdominal Koch's, and septic ileus.

Of the total 100 patients, 78 patients had an Alvarado score of 5–6; 15 patients had an Alvarado score of 7–8, and 7 patients had Alvarado score of 9 or more [Figure 2],[Figure 3],[Figure 4]. The diagnosis in patients with lower Alvarado score was mostly intussusception and mesenteric lymphadenopathy whereas as the score increased, the diagnosis of acute appendicitis and appendicular perforation became more common [Table 2]. Exploration was required in 24% of patients with a score of 5–6, in 33% of patients with a score of 7–8, and in 43% of patients with a score of 9 or more. The most common conditions requiring emergency exploration were persistent intussusception not responding to ultrasound-guided hydrostatic reduction (8) and appendicular perforation (7) [Table 3].
Table 2: Number of patients as per Alvarado score

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Table 3: Alvarado score and acute appendicitis

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Figure 2: Bar chart depicting the diagnosis and conservative and operative management in 78 patients with Alvarado score of 5–6

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Figure 3: Bar chart depicting the diagnosis and conservative and operative management in 15 patients with Alvarado score of 7–8

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Figure 4: Bar chart depicting diagnosis and conservative and operative management in 7 patients with Alvarado score of 9 or more

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One patient had negative exploration who presented with acute pain abdomen with guarding and his X-ray and CT scan were suggestive of pneumoperitoneum, but no perforation was found on laparotomy and was finally diagnosed as nonspecific ileitis. Only 3 patients had superficial surgical site infection. There was no mortality and all patients are doing well on follow-up.


  Discussion Top


Abdominal pain is a very common symptom in the pediatric age group. Not all patients presenting with acute pain abdomen require surgical intervention. Hence, an accurate diagnosis based on appropriate investigations is absolutely necessary. Abdominal X-ray erect and USG were the primary radiological diagnostic modalities. Alvarado score was also calculated for all our patients. In case of persistent diagnostic dilemma, a CT scan was done. This was usually done for most of the patients of acute appendicitis and/or appendicular perforation who were clinically stable and had low Alvarado scores. Previous studies in literature have also laid this point regarding CT scan in patients of acute appendicitis with low Alvarado scores.[1]

Of the total 100 patients, 38 required operative intervention out of which, 23 were emergency explorations. Thus, it is clear that there are only a few diagnoses which are life-threatening and require urgent exploration, and the identification of such children may be difficult but essential.[2] A careful history, physical examination, and appropriate laboratory and radiological studies provide a rational basis for effective management in most cases.[3] The operative intervention rate of 38% in this study is more than that of Western data.[2]

The mean age of presentation, 70.4 months, correlates well with the literature and with the Western data.[2],[4] The most common associated presenting symptoms along with abdominal pain were vomiting, anorexia, and nausea. The most common definitive diagnoses were intussusception, mesenteric lymphadenitis, acute appendicitis, and appendicular perforation, and the most common conditions requiring emergency exploration were persistent intussusception not responding to hydrostatic reduction and appendicular perforation. This is in contrast with the Western literature where acute appendicitis is the most common diagnosis requiring operative exploration.[2],[4] The least common diagnosis was pelvic abscess seen in one patient.

Alvarado score was applied to all these 100 patients because the most common associated presenting symptoms of vomiting, anorexia, and nausea were pointing toward the diagnosis of acute appendicitis. There were more number of patients with lower Alvarado scores (78 patients with score of 5–6; 15 with a score of 7–8; and 7 with a score of 9 or more). However, on correlation with the diagnosis, the most common definitive diagnoses were intussusception and mesenteric lymphadenitis. But, these diagnoses were more common for lower Alvarado scores. As the score increased, the diagnosis of acute appendicitis and appendicular perforation became more common.

Operative intervention was required in 24% of patients with a score of 5–6, in 33% of patients with a score of 7–8, and in 43% of patients with a score of 9 or more. However, emergency explorations were required only in 1.3% in lower Alvarado score group which increased to 26.66% for Alvarado score of 7–8 and to 42.8% for a score of 9 or more. This suggests that higher Alvarado score is very good for predicting the diagnosis of acute appendicitis and/or appendicular perforation and predicting the need for emergency operative intervention. This also correlates well with the fact that application of Alvarado scoring system in the diagnosis of acute appendicitis can provide high degree of positive predictive value and thus diagnostic accuracy, a fact which is well stated in the literature and is also true for pediatric patients.[5],[6],[7],[8]

A lower Alvarado score should prompt toward diagnosis other than appendicitis (such asintussusception and mesenteric lymphadenitis) especially in children, whereas a higher score can be correlated well with appendicitis and/or appendicular perforation.[6] This is essential for the appropriate management as children with intussusception are usually given a trial of nonoperative intervention in the form of USG-guided hydrostatic reduction and the mesenteric lymphadenitis can be managed conservatively, but acute appendicitis and/or appendicular perforation generally needs operative intervention.

In our study, we gave a trial of intravenous antibiotics to all patients of acute appendicitis and monitored them closely for signs of improvement or deterioration. The patients who responded to this trial of antibiotics but had intermittent persistent symptoms had interval appendicectomy done by laparoscopic approach after 6 weeks. If the patients showed signs of deterioration such as persistent fever, leukocytosis, and rebound tenderness in right iliac fossa with/without guarding at the initial admission, then they were taken for emergency exploration. Out of the total 13 patients with acute appendicitis, only 1 patient did not respond to intravenous antibiotics and was taken up for emergency appendicectomy after 48 h of admission. Rest of the 12 patients responded and underwent interval laparoscopic appendicectomy.

The negative exploration rate of 1% is lower than that reported in literature.[9],[10],[11] The complication rate was 3% and there was no mortality. All the patients are on regular follow-up and doing well.


  Conclusion Top


An acute complaint of abdominal pain in children is usually attributed to a self-limited disease, but an early diagnosis is essential to prevent unwanted complications and avoid unnecessary operations. Though most of the patients of acute pain abdomen present with symptoms mimicking acute appendicitis, the most common definitive diagnoses in this study are intussusception and mesenteric lymphadenitis, especially for lower Alvarado scores, which can be managed conservatively most of the times. Hence, a correct diagnosis is essential in children for appropriate management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

1.
McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007;25:489-93.  Back to cited text no. 1
    
2.
Erkan T, Cam H, Ozkan HC, Kiray E, Erginoz E, Kutlu T, et al. Clinical spectrum of acute abdominal pain in Turkish pediatric patients: A prospective study. Pediatr Int 2004;46:325-9.  Back to cited text no. 2
    
3.
Lucassen PL, Assendelft WJ, van Eijk JT, Gubbels JW, Douwes AC, van Geldrop WJ. Systematic review of the occurrence of infantile colic in the community. Arch Dis Child 2001;84:398-403.  Back to cited text no. 3
    
4.
Sanders MR, Shepherd RW, Cleghorn G, Woolford H. The treatment of recurrent abdominal pain in children: A controlled comparison of cognitive-behavioral family intervention and standard pediatric care. J Consult Clin Psychol 1994;62:306-14.  Back to cited text no. 4
    
5.
Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: A prospective study. Ann R Coll Surg Engl 1994;76:418-9.  Back to cited text no. 5
    
6.
Malik KA, Khan A, Waheed I. Evaluation of the Alvarado score in diagnosis of acute appendicitis. J Coll Physicians Surg Pak 2000;10:392-4.  Back to cited text no. 6
    
7.
Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J R Soc Med 1992;85:87-8.  Back to cited text no. 7
    
8.
Rehman I, Burki T. Alvarado scoring system in the diagnosis of acute appendicitis in children. J Med Sci 2003;11:37-41.  Back to cited text no. 8
    
9.
Khan I, ur Rehman A. Application of Alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17:41-4.  Back to cited text no. 9
    
10.
Ohmann C, Yang Q, Franke C. Diagnostic scores for acute appendicitis. Abdominal Pain Study Group. Eur J Surg 1995;161:273-81.  Back to cited text no. 10
    
11.
Arian GM, Sohu KM, Ahmad E, Haider W, Naqi SA. Role of Alvarado score in diagnosis of acute appendicitis. Pak J Surg 2001;17:41-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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