Acute Appendicitis · Alvarado Score Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Alvarado score
   Which Alvarado (MANTRELS, 10-point) band? (Migratory RLQ pain (1), anorexia (1), nausea/vomiting (1), RLQ tenderness (2), rebound (1), fever ≥37.3°C (1), WBC >10×10⁹ (2), left shift of neutrophils (1). 0–4 low, 5–6 intermediate, 7–10 high. Low scores have strong rule-out value (sensitivity ~99%) but limited specificity — do not decide surgery on the score alone.)
   • High (7–10) → High-risk (7–10)
   • Intermediate (5–6) → Intermediate (5–6)
   • Low (0–4) → Low-risk (0–4)
2. [End] Low-risk (0–4)
   Low probability of appendicitis — observation/outpatient follow-up, symptomatic care, re-evaluation or imaging if needed; look for other causes of abdominal pain. The elderly present atypically — still consider imaging.
3. [End] Intermediate (5–6)
   Diagnostic gray zone — image (ultrasound/CT) to clarify, then decide surgery or continued observation by the result; better scores such as AIR/AAS can help.
4. [End] High-risk (7–10)
   High probability of appendicitis — surgical consult; most can go directly to surgery (imaging adds little at high scores), with selective CT as needed (especially to assess perforation/complicated disease). Perioperative antibiotics, fluids and analgesia. The elderly/atypical still warrant imaging.

Source guidelines & references

• Alvarado A. A practical score for acute appendicitis. Ann Emerg Med 1986
• WSES 2020 guideline on acute appendicitis (recommends AIR/AAS scores)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways