Alvarado Score For Appendicitis Symptoms

Helps diagnose acute appendicitis based on results from clinical tests and present appendicitis symptoms.

In the text below the calculator there is more information about the items included in the score, how the result is interpreted and about most common symptoms of this medical emergency.

The Alvarado score is based on appendicitis diagnosis criteria: signs, symptoms and clinical determinations.

It allows the calculation of a score which is then interpreted as ruling out or not appendicitis.

The score was created following a retrospective study of 305 patients presenting with suspicion of appendicitis.

The presence of each of the 8 items in the score is awarded a number of points (either 1 or 2, depending on severity and implications of the item) which is then summed to provide the final score.

The Alvarado score considers appendicitis unlikely at a score of 3 or below, possible at scores of 4 or 5, probable/ likely at scores of 6 - 8 and most likely at scores of 9 or above.


Tenderness in the right lower quadrant


Rebound tenderness


Elevated temperature (>37.3C or >99.1F)


Pain migration to the right lower quadrant




Nausea or vomiting


Leukocytosis >10,000


Leukocyte left shift

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Alvarado score items

The score consists of 3 categories of items as introduced by the table below:

Type of item Item (points awarded if present)
Signs Tenderness in the right lower quadrant (2)
Rebound tenderness (1)
Elevated temperature (>37.3C or >99.1F) (1)
Symptoms Pain migration to the right lower quadrant (1)
Anorexia (1)
Nausea or vomiting (1)
Clinical determinations Leukocytosis >10,000 (2)
Leukocyte left shift (1)

The first two signs, tenderness in the right lower quadrant and rebound tenderness refer to findings upon physical examination revealing abdominal pain in right iliac fossa and pain upon the removal of pressure (the Blumberg sign).

The migration of pain to the right lower quadrant, towards the right iliac fossa also counts as a symptom. It is important however for clinicians to use clinical judgement and exclude other causes of right lower quadrant pain from the ovarian, renal or gastrointestinal pathology.

The loss of appetite from the anorexia symptom can be correlated with presence of ketones in urine.

High leukocytosis is characteristic to infection, in this case present with leukocyte left shit (in the ratio between the immature and mature neutrophils).


Score interpretation

When any of the 8 signs, symptoms of clinical determination results are positive, they are awarded a number of points. Most are awarded 1, the tenderness sign and leucocytosis are awarded 2 points.

The numerical score is then interpreted as to the possibility of the patient to suffer from acute appendicitis.

There are two cut off points for ruling out appendicitis, presented below with their sensitivity percentage:

■ Scores <4 with a sensitivity of 96%;

■ Score <7 with a sensitivity of 58-88%.

The Alvarado score guidelines are:

Appendicitis … Alvarado score
Unlikely 3 or below
Possible 4 or 5
Probable/ Likely 6, 7 or 8
Most likely 9 or above

About the study

The score was created by Alvarado in 1986 after conducting a retrospective study involving 305 patients who were hospitalized with abdominal pain suggestive of acute appendicitis.

Each of the items in the score has been analysed for specificity, sensitivity, predictive value, and joint probability. The last criteria: total joint probability, which is the sum of a true-positive and a true-negative result, was chosen as diagnostic weight indicative of the accuracy of the test.

The items have also been ranked in order of importance based on the diagnostic weight: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain.


Symptoms of appendicitis

Appendicitis is considered a medical emergency. An appendicitis crisis is usually started by an intermittent pain localized in the middle of the abdomen which migrates towards the lower right side of the abdomen.

This pain may be aggravated by pressure, effort or in some cases simple actions such as walking.

Other accompanying symptoms include a general sensation of sickness, fever, nausea, lack of appetite or diarrhea.

Differential diagnosis should take place with conditions of the gastro intestinal track or female reproductive tract, which present with similar pain patterns. Examples of such conditions include Crohn’s disease, urinary infections or the possibility of an ectopic pregnancy.


Original study

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986; 15(5):557-64.

Other references

1. Alvarado A. How to improve the clinical diagnosis of acute appendicitis in resource limited settings. World J Emerg Surg. 2016; 11:16.

2. Tan WJ, Acharyya S, Goh YC, Chan WH, Wong WK, Ooi LL, Ong HS. Prospective comparison of the Alvarado score and CT scan in the evaluation of suspected appendicitis: a proposed algorithm to guide CT use. J Am Coll Surg. 2015; 220(2):218-24.

Specialty: Gastroenterology

System: Digestive

Objective: Diagnosis

Type: Score

No. Of Items: 8

Year Of Study: 1986

Article By: Denise Nedea

Published On: April 8, 2017

Last Checked: April 8, 2017

Next Review: April 8, 2023