Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The New International Gold Standard
Professor Mohannad Al-Fallouji, PhD (London), FRCS, FRCSI
Director: www.ihams.org
Director: www.qamoosalfordous.wordpress.com
User: Mohannadfallouji Wikipedia
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Acute Appendicitis, an Epidemiological indicator
• AA higher in developed than developing countries.
There are 250,000 new cases each year in United States.
• Appendiceal fecalith is commonly associated with AA.
Fecal stasis (constipation) plays important role, as
demonstrated by lower number of bowel movements
per week in patients with AA compared with healthy controls.
• Epidemiologically, it has been stated that diverticular disease,
familial adenomatous polyposis, and colonic cancer are rare
in communities exempt from AA.
• AA shown to occur antecedent to cancer of colon & rectum.
• Studies confirmed a low fiber intake in pathogenesis of AA.
This histological transverse section through the appendix and labeled magnified view shows diffusely
scattered masses of lymphoid tissue throughout the lamina propria (LP). Scattered infiltrates within
the submucosa (SM) and to a lesser degree in the muscularis layer suggest immune function. Despite
rich lymphoid aggregations within the appendix, no specific function has yet been ascribed to it.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The New International Gold Standard
(The Clinical Need)
1. ِAcute Appendicitis is the Commonest Abdominal Emergency, the commonest
curable life-threatening condition , and remains the most common cause of
abdominal pain and Acute Abdomen.
2. Confusing Diagnosis has led to a risky approach: (When in doubt take it out),
subjecting patients to totally unnecessary operations (with M/M) –
for histologically normal appendix.
3. Appendix vermiformis is an integral part of Lymphatic System of Human Body.
Appendicectomised patients may be at risk of right colonic carcinoma (anecdotal
evidence for disturbed lymphatic balance and immuno-compromise locally).
4. Appendix can be used as catheterisable continent conduit in paediatric faecal
incontinence or intractable constipation. Appendix can also be used as a good
alternative to ileal conduit diversion ; thus used as a urinary conduit in Mitrofanoff
continent cystostomy (catheterisable).
5. One doctor was imprisoned 6 months because of saying: (‫)اشتباه الزائدة تحت المشاهدة‬
showing the danger of muddling Politics in Medical Practice.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Do not insult my Intelligence !?
Imaging: Ultrasound, CT scan, MRI.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Ultrasound
Graded Compression UltraSound:
reported sensitivity 94.7%
and specificity 88.9%
Basis of this technique is that
normal bowel and appendix can be
compressed, whereas an inflamed
appendix can not be compressed.
DX: non-compressible > 6mm
appendix, appendicolith, and/or
peri-appendiceal abscess
(Figure above) Sagittal graded compression transabdominal sonogram shows
an acutely inflamed appendix. The tubular structure is non-compressible,
lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present. These features are diagnostic of Acute Appendicitis.
Left: Longitudinal ultrasound image of the appendicular abscess (Acute Appendicitis).
This image demonstrates a diseased appendix and the infection is seen tracking through
the surrounding tissues. Right: This ultrasound image demonstrates the appendix in
cross-section; this is the typical “target-like” appearance. A normal appendix is
considered to have a diameter of less than 6mm, whereas a fluid filled appendix adds to
the diagnosis of appendicitis. A fluid filled appendix will be non-compressible and may
have a wall thickness upward to 2 cm has been demonstrated in appendicitis. Notice the
fluid within the appendix (center of image) and thick appendicular wall.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Ultrasound
•
Diagnostic accuracy range form 71 - 97%.
Accurate in staging peri-appendiceal abscesses
Sensitive for detecting normal appendix.
•
Safe - Does not use ionizing radiation.
 Can be used in pregnancy
 Children and women are primary candidates.
 Is more often than not inconclusive in adults.
•
Highly dependant on sonographer's skill.
•
Limitations of US: retro-cecal appendix may not be
visualized, perforations may be missed due to return to
normal diameter
These two axial CT slices (radiographs A, B
above)
demonstrates an inflamed fluid filled appendix. The two CT
images show an appendicolith blocking the lumen at its
junction to the caecum (arrows). There is a significant
amount of swelling of the appendix as a result of this
blockage due to cyclic changes of edema, ischemia, and
bacterial invasion. The appendicoliths, wall enhancement
with surrounding infiltrate are consistent with a diagnosis of
Acute Appendicitis.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Computerised Tomography
 Risk of Radiation.
 Accuracy of CT relies in part on its ability to reveal a
normal appendix.
 Results are reproducible from institution to institution.
 Diagnostic accuracy is between 93-99% among
institutions.
Acute suppurative appendicitis in a 15-year-old boy;
contrast-enhanced, fat-suppressed, T1-weighted,
spin-echo coronal magnetic resonance image MRI.
A markedly enhanced and thickened inflamed
appendix (arrows) with peri-caecal enhancement due
to the extent of inflammation is shown.
The drawing on the right demonstrates the location of the appendix, meso-appendix, and arterial supply in relation to
the large intestine. Appendicular and ileocolic arteries branches supply the appendix from the superior mesenteric
artery (arrow). The radiograph on the left is a mesenteric arteriogram that shows the rich arterial supply to the gut.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Biomarkers in the Diagnosis of Acute Appendicitis
Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased
risk of appendiceal rupture among patients with acute appendicitis according to
a cohort study.
MMP-1 was higher in gangrenous (p<0.05) and perforated appendicitis (p<0.01)
compared with controls.
MMP-9 was most abundantly expressed in inflamed appendix and reached a
tenfold higher expression in all groups with appendicitis compared with
controls (p<0.001).
HIAA levels increase significantly in acute appendicitis and decrease when the
inflammation shifts to necrosis of the appendix. Therefore, such decrease could
be an early warning sign of perforation of the appendix.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
Pathophysiology is the Key to Clinical Diagnosis
Clinical Diagnosis is the key to Scoring System
Stages of Pathophysiology
1.
2.
3.
4.
5.
Stage
Stage
Stage
Stage
Stage
of
of
of
of
of
Obstruction
Local Infection (VP)
Spread of Infection (PP)
Perforation --► Peri-Appendicular Abscess
Perforation --► General Peritonitis
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
1. Stage of Obstruction
Appendicitis is caused by obstruction of appendiceal lumen (fecalith,
submucosal hyperplasia, worm, lymph node). Elasticity of appendix wall has
limitations, that leads to increased intraluminal pressure. Pressure rise will
impede the flow of lymph resulting in oedema. With continuous mucus
secretion, further intraluminal pressure increase leads to venous outflow
obstruction, more oedema and transmural bacterial growth due to stasis.
Intestinal bacteria within the appendix multiply, leading to the recruitment of
WBCs and pus formation, resulting in focal acute appendicitis, due to
obstruction.
Since innervation of the appendix enters spinal cord at the same level as the
umbilicus, the pain begins stomach-high. Initial luminal distention triggers
visceral afferent pain fibers, which enter at 10th thoracic vertebral level.
This pain is generally vague and poorly localized, typically felt in the
periumbilical or epigastric area, and associated with visceral pain attributes:
anorexia, nausea and vomiting.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
Ascaris in the small bowel in a
13 year-old girl with appendicitis.
Fecalith or Appendicolith, main cause
of obstruction in Acute Appendicitis.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
2. Stage of Local Infection
Transmural invasion of bacteria E. Coli and bacteroids from
the lumen to the mucosal layer, submucosa, muscularis layer
and serosa into of local inflammation of visceral peritoneum
and finally (acute suppurative appendicitis) with local
peritonitis into RLQ.
This causes pain in RLQ. Body temperature starts to rise.
In 90% of patients WBC >10,000 cells/µL.
However, in infants and elderly patients, a WBC count is
especially unreliable because these patients may not mount a
normal response to infection.
In pregnant women, the physiologic Leucocytosis renders the
CBC count useless for diagnosis of appendicitis.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
3. Stage of Spread of Infection
As inflammation continues, the adjacent structures lined by parietal
peritoneum become inflamed. This triggers somatic pain fibers,
innervating the parietal peritoneal structures; this change in stimulation form
visceral to somatic pain fibers explains the classic migration of pain from the
periumbilical area to pain localised over several hours settling into RLQ,
(except in children under 3 years). The Initial Epigastric/ Periumbilical pain
with subsequent shift to RIF is called Kocher's sign.
The pain gets worse with moving, taking a deep breath, coughing, sneezing,
walking, or being touched. This pain can be elicited through various signs
localized in RIF. RLQ tenderness at McBurney's point is the classical sign of
Acute Appendicitis (McBurney's sign present in 96% of patients, but
nonspecific).
The abdominal wall overlying RLQ becomes very sensitive to gentle pressure
(Palpation). Also, there is severe pain on sudden release of deep pressure in
the lower abdomen (rebound tenderness: pain on percussion, rigidity are
the Most specific finding & represent Positive Blumberg's sign).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
Appendicitis (distended pus-filled
appendix) with calcified, shadowing
appendicolith (arrowhead) near the
base of the appendix on ultrasound.
Appendicitis (inflamed distended
pus-filled appendix, arrows) with
calcified appendicolith (arrowhead)
on CT in an adult.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
4. Stage of Perforation --► Peri-Appendicular Abscess
Continued intraluminal pressure rise causes Ischemia of the
appendiceal wall, resulting in compromise of arterial blood
flow, causing gangrene (gangrenous appendicitis).
Thrombosis of appendicular artery and veins together with
continuing rise of intraluminal pressure rapidly rupture the
fragile wall (perforated appendicitis).
As this process continues slowly, it can be localized and
walled off by the omentum (policeman) and the adjacent
bowel moving toward appendix, thus a peri-appendicular
abscess develops. RIF Abscess can turn into chronic
fibrosis (appendicular mass) with recurrent appendicitis.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
Perforated appendicitis with formation of an abscess (arrows),
with appendicolith (arrowhead) within the abscess (CT scan).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
5. Stage of Perforation --► General Peritonitis
Alternatively, when the infected appendix bursts, the contents of
lower GIT enters abdominal cavity, and infects the entire peritoneal
cavity, causing generalized peritonitis (If untreated, can be fatal).
When this happens, the patient gets a high fever and the pain may
suddenly stop.
As inflammation progresses in later stages, loops of bowels are
bathed in pus, resulting in paralytic ileus presenting with Acute
Abdomen, with painless abdominal distension and constipation
(patient unable to pass gas).
In children, their shorter omentum, longer appendix & thinner wall,
coupled with the poor immune system, all facilitate speedy
perforation of the appendix.
The elderly are predisposed to perforation too, because their poor
blood vessels and arterial flow can easily be compromised by
obstruction and increased intraluminal pressure within the appendix.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
perforated appendicitis causing general
peritonitis with small bowel inflammation
due to free pus leading to Paralytic Ileus
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Pathophysiology of Clinical Findings
A wide open abdominal wound following a
perforated appendicitis covered with a bag
Perforated appendicitis patient closed with a
mesh about 3 months post appendectomy.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
McBurney sign
named for American surgeon Charles McBurney (1845–1913). McBurney himself did not locate "his" point in
his original article:
(The seat of greatest pain, determined by the pressure of one finger, has been very
exactly between an inch and a half and two inches from the anterior spinous process of
the ilium on a straight line drawn from that process to the umbilicus) —Charles McBurney,
"Experience with Early Operative Interference in Cases of Disease of the Vermiform Appendix"; New York Medical Journal, 1889, 50: 676-684 [pg 678].
1. Deep RIF tenderness at McBurney's point, known as McBurney's sign, is a sign of acute appendicitis.
The clinical sign of referred pain in the epigastrium when pressure is applied is also known as Aaron’s sign.
2. Specific localization of tenderness to McBurney's point indicates that inflammation is no longer limited to the lumen
of the bowel (which localizes pain poorly), and is irritating the lining of Peritoneum at the place where the peritoneum
comes into contact with the appendix.
3. Tenderness at McBurney's point suggests the evolution of acute appendicitis to a later stage, and thus, the
increased likelihood of rupture.
4. Coughing causes tenderness in this area (McBurney's point).
5. Other abdominal processes can also sometimes cause tenderness at McBurney's point. Thus, this sign is
highly useful but neither necessary nor sufficient to make a diagnosis of acute appendicitis.
6. Also, in retrocaecal appendix (appendix behind caecum), which also limits the use of this sign as many
cases of appendicitis do not cause point tenderness at McBurney's point.
7. For most open appendicectomies (as opposed to laparoscopic appendectomies), the incision is made at
McBurney's point.
Surface projections of the organs of the Trunk, with McBurney's point labeled with
a red circle at bottom left at the inferior part of the caecum.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Accessory signs in a minority of patients
Rovsing's sign: RLQ pain experienced when LLQ is palpated. It is not simple palpation of LIF causing pain to
be felt in RIF. Nor is it peritoneal irritation that is elicited; instead, Rovsing's original description was an attempt
to distend the caecum and appendix by pushing on the left colon in anti-peristaltic direction.
Dunphy's sign: sharp pain in RLQ elicited by cough: Suggests localized peritonitis.
Obturator sign: RLQ pain with passive internal and external rotation of the flexed right hip; Suggests the
inflamed appendix is located deep in the right Hemi-pelvis.
Psoas sign or "Obraztsova's sign”: RLQ pain produced with either passive extension of right hip (patient lying
on left side, with knee in flexion) or by the patient's active flexion of right hip while supine. The pain elicited is
due to inflamed appendix located along the course of the right psoas muscle with extended inflammation to
peritoneum overlying iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out
the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore
also causes pain.
Massouh sign: Firm swish of examiner’s index and middle finger across the patient’s abdomen from
Xiphisternum to first LIF and then RIF. Positive Massouh sign is a grimace of patient upon right sided (and not
left) sweep, because initial stage appendicitis usually causes localised irritation of the well-innervated
peritoneum.
Markle sign: pain elicited in a certain area of the abdomen when the standing patient drops from standing on
toes to the heels with a jarring landing: Has a sensitivity of 74%
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Aure-Rozanova sign
Increased pain on palpation with
finger in right Petit triangle (or inferior
lumbar triangle bound by Iliac crest
inferiorly, and margins of 2 muscles –
Latissimus dorsi posteriorly and
External Abdominal Oblique anteriorly,
with Internal Abdominal Oblique
muscle forming the floor) –
typical in retrocecal appendix.
Also referred as rebound tenderness.
Deep palpation of the viscera over the
suspected inflamed appendix followed
by sudden release of the pressure
causes the severe pain on the site
indicating positive Blumberg's sign
and peritonitis.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Urine
1. Pregnancy testing
especially ectopic pregnancy in childbearing
females.
2. Ruling out urinary tract infection
(presence of more than 20 WBC per high-power
field in urine is suggestive of a urinary tract
disorder).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Classical Acute Appendicitis
First symptoms of appendicitis:
Pain first, vomiting next (visceral associates: nausea, vomiting,
loss of appetite), and fever last (low-grade following other
symptoms 37.7 -38.3 ºC (100-101 ºF)) has been described as
classic presentation of acute appendicitis
Typical appendicitis usually includes abdominal pain beginning
in the region of the umbilicus for several hours, associated with
anorexia, nausea or vomiting.
The pain then "settles" into the right lower quadrant
(or the left lower quadrant in patients with situs inversus totalis)
where tenderness develops.
Combination of pain, anorexia, fever, and leukocytosis is classic.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Exceptions:
Deviations from classic presentation are due to the appendix anatomic variability:
1. In retrocecal appendix (appendix localized behind caecum), even deep pressure in the
right lower quadrant may fail to elicit tenderness (silent appendix), because caecum,
distended with gas, protects the inflamed appendix from the pressure.
2.
Appendix can be high retrocaecal causing the pain to localize to the right loin / flank.
See Aure-Rozanova sign.
3.
In pregnancy, the appendix can be shifted in latter half of pregnancy; patient can present
with pain in RUQ or right flank .
4.
In some males, retroileal appendicitis can irritate the ureter and cause testicular pain,
frequent and/or painful urination
5.
Pelvic appendix may irritate the bladder causing supra-pubic pain, pain with urination.
6.
If the appendix lies entirely within the pelvis, there is usually complete absence of
abdominal rigidity, with feeling the need to defecate and diarrhoea.
PR digital examination elicits tenderness in the recto-vesical pouch.
7.
Male infants and children occasionally present with an inflamed hemiscrotum
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Background to Scoring
Differentiation between AA & NSAP
Alvarado Score of AA & Interpretation
Modified Alvarado scoring system
Tzanakis scoring system
Bengezi/Al-Fallouji’s Scoring System & Interpretation
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Differentiation of appendicitis vs Non-Specific Abdominal Pain (NSAP)



___________________________________________________________________________________________________________________
Clinical feature
Appendicitis
NSAP
___________________________________________________________________________________________

Sore Throat
Absent
Present

Site of pain
Moves from midline
To RIF
Always in RIF or
diffuse
Aggravated by
Movement and
coughing
Neither
Nausea, vomiting
And anorexia
All present
1 or more absent
Facial complexion
Flushed
Normal/pale
Tenderness
Focal in RIF
Shifting tenderness
Or more diffuse
Rebound and
Guarding
Both present
Both absent
Rectal examination
Tender on right
Tenderness diffuse/absent


















Alvarado Score
M A N T R E LS
SYMPTOMS
(3)
SIGNS
(3)
LABORATORY
(2)
(Old Confusing Score)
Migratory right Iliac Fossa pain
Scoring Value
1
Anorexia
Nausea/Vomiting
Tenderness Right Lower Quadrant
1
Rebound tenderness
Elevation of temperature
Leucocytosis
1
Shift to the Left of Neutrophils
Total Score
1
2
1
2
1
_____________
10
MODIFIED ALVARADO SCORE;
ACCURACY IN DIAGNOSIS OF ACUTE APPENDICITIS IN ADULTS
(by just deleting: Shift to Left, leaving score of 9 !?)
DR. SYED WARIS ALI SHAH DR. AJMEL MUNIR TARRAR
DR. CHAUDHRY AHMED KHAN DR. IRTIZA AHMED BHUTTA
DR. SIKANDER ALI MALIK DR. AHMED WAQAS From Rawalpindi
Professional Med J Dec 2010;17(4): 546-550
MODIFIED ALVARADO SCORE;
ACCURACY IN DIAGNOSIS OF ACUTE APPENDICITIS IN ADULTS
Disadvantages
Al-Hashemy AM, Seleem MI. Appraisal of the
modified Alvarado Score for acute appendicits in
adults. Saudi Med J. 2004 Sep;25(9):1229-31.
(From the results, the MASS is not sufficiently sensitive
adopted as a method of diagnosing of acute appendicitis in
adults in our environment. Further, requirements may be
needed to improve its sensitivity and specificity).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Tzanakis scoring system to aid AA diagnosis
Nikolaos Tzanakis, M.D., Stamatis Efstathiou, M.D., Kecaris Danulidis, M.D., et al. (A New
Approach to Accurate Diagnosis of Acute Appendicitis) World J. Surg. 29, 1151–1156 (2005)
It incorporates the presence of four variables made up of
specific signs and symptoms:
Presence of R. lower abdominal tenderness = 4 points and
Rebound tenderness
=3
Laboratory findings (presence of white blood cells greater
than12,000 in the blood) = 2
Ultrasound findings (presence of positive ultrasound scan
findings of appendicitis) = 6
The maximum score is a total score of 15;
where a patient scores 8 or more points, there is greater
than 96% chance that acute appendicitis exists.
Alvarado Score
M A N T R E LS
SYMPTOMS
(3)
SIGNS
(3)
LABORATORY
(2)
(Old Confusing Score)
Migratory right Iliac Fossa pain
Scoring Value
1
Anorexia
Nausea/Vomiting
Tenderness Right Lower Quadrant
1
Rebound tenderness
Elevation of temperature
Leucocytosis
1
Shift to the Left of Neutrophils
Total Score
1
2
1
2
1
_____________
10
Alvarado A. A practical score for the early diagnosis of
acute appendicitis. Ann Emerg Med 1986, 15: 557-564.
Alvarado Score: Interpretation
Vague with No Clear Action Plan
Score 1-3:
Score 4-6:
Score 7-8:
Score 9-10:
Acute Appendicitis unlikely;
Acute Appendicitis maybe;
Acute Appendicitis probable;
Acute Appendicitis highly probable
Surgical Physical Signs, Better Avoided!
1. Homan’s sign.
2. Invagination Test.
3. Rebound Tenderness.
Alvarado A. A practical score for the early diagnosis
of acute appendicitis. Ann Emerg Med 1986, 15: 557-564.
Disadvantages
1. Retrospective study of 305 patients with AA.
2. Actual score relies on 3 symptoms, 3 signs, and
2 laboratory (30% of Diagnosis depends on Investigations).
3. Interpretation of 4 groups, is very confusing .
Correlation with Operative findings more than
correlation with Histology.
4. Old-fashioned (Rebound tenderness and shift to left).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Methods: Advantages
1. Prospective study of 345 patients with AA.
2.
Actual score relies on 3 symptoms 4 signs and 1
Laboratory thus it is more clinically orientated, thus
80% of Diagnosis depends on Clinical Findings(S+S).
3.
Interpretation is based on 3 easy groups with reliable
even better (The Best) accuracy and predictive value
in correlation with Histology.
Bengezi / Al-Fallouji Predictive Score of Acute Appendicitis
MANTREEL
SYMPTOMS
(3)
SIGNS (4)
Scoring Value
Migratory pain
from epigatrium or
umbilical area to Right Iliac Fossa (RIF)
Anorexia
Nausea/Vomiting
Tenderness Right Lower Quadrant
Rigidity and/or
1
1
1
2
1
Rebound tenderness RIF
Elevation of temperature
Extra sign(s) e.g. Cough test
1
and/or
1
Rovsing’s sign and/or
Rectal tenderness (on Per Rectal exam)
LABORATORY (1)
Leucocytosis
2
___________
Total Score
10
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Results: Interpretation
Our score was assessed in PROSPECTIVE STUDY OF 345 CONSECUTIVE
PATIENTS admitted with the diagnosis of AA. The scoring was
correlated with histopathology reports in 297 operated patients (out of total 345).
Among 45 patients with Score 1-4 :
only one patient had resolving AA (98% diagnostic accuracy).
Among 104 patients with Score 5-7: only 61 patients had AA.
Among 196 patients with Score 8-10:
190 patients had AA (97% diagnostic accuracy).
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Results: Interpretation
Score 1-4:
Acute Appendicitis very unlikely;
Discharge patient home with Instructions
(persistent pain, vomiting, or fever)
Score 5-7:
Acute Appendicitis probable;
Admit for observation and re-scoring 6-8 hourly.
Score 8-10: Acute Appendicitis definite;
Operate immediately
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The Unstable group of Score 5-7
1. Re-scored 6 hourly until switch into score 8 (60%) or
switched into score 4 (40% approximately).
2. Persistent score of 7 after 24 hr is better operated on.
3. Thus, by adopting this safe policy, one can obviate
41.35% rate of negative Laparotomy.
4. Policy of (When in doubt, observe and conserve)
can now safely replace the old policy
(When in doubt, take it out).
Bengezi / Al-Fallouji Predictive Score of Acute Appendicitis
SYMPTOMS
(3)
Migratory pain from epigatrium or umbilical area to
Right Iliac Fossa (RIF)
SIGNS (4)
LABORATORY (1)
Anorexia
1
Nausea/Vomiting
1
Tenderness Right Lower Quadrant
2
Rigidity and/or
Rebound tenderness RIF
1
Elevation of temperature
1
Extra sign(s) e.g. Cough test and/or
Rovsing’s sign and/or
Rectal tenderness (on Per Rectal exam)
1
Leucocytosis
2
___________
Total Score
Score 1-4:
Score 5-7:
1
10
Acute Appendicitis very unlikely; Discharge patient home with Instructions
(persistent pain, vomiting, or fever)
Acute Appendicitis probable; Admit for observation & re-scoring 6-8 hourly.
Score 8-10: Acute Appendicitis definite;
Operate immediately
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Conclusions:
Our modified score, based on 3 groups, is:
* Cheap.
* Safer Scoring System.
* Simpler to fill and computerise (flow sheets are part of Patient’s Case Note).
* Easier to read and interpret (by junior surgeons).
* More practical in clinical discipline and auditing.
* Excellent aid for understanding the underlying Pathophysiology of AA.
* Better for Accurate Decision-making.
* More reliable than Alvarado score, reaching a Perfection Level.
* Rate of unnecessary hospitalization is reduced by 13%.
* Logical scoring system
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The New International Gold Standard
(Original Publications 1997)
1. Al-Fallouji M and Bengezi O : Modified Alvarado Score in Diagnosis of Acute
Appendicitis. (May 1997). Annual Meeting of Association of Surgeons of Great
Britain and Ireland Bournmouth, ENGLAND.
2. Bengezi O A and Al-Fallouji M: Modified Alvarado Score in Diagnosis of Acute
Appendicitis. Association of Surgeons of Great Britain and Ireland. British
Journal of Surgery May 1997; vol. 84, supplement 1: 30.
3. O. Bengezi and M. Al-Fallouji. In Postgraduate Surgery, The Candidate's Guide.
By M. Al-Fallouji, 2nd Ed. Oxford: Butterworth- Heinemann; 1998. Pages 388-9.
4. Salam IM, Al-Fallouji MA, El Ashaal, et al: Early patient discharge following
appendicectomy: safety and feasibility. Journal of the Royal College of Surgeons
of Edinburgh Oct 1995; 40(5): 300-302
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The New International Gold Standard
(Confirming Publications 2000-2009)
Our Modified Alvarado Score is now the World's Gold Standard, confirmed objectively and
validated independently by surgeons world-wide:
1. ACUTE APPENDICITIS: AN OVERVIEW. H.S. Saidi, BSc. (Anat), MBChB and J.A. Adwok, MMed (Surg),
FRCSEd, Professor, Department of Surgery, College of Health Sciences, University of Nairobi, P.O.
Box 19676, Nairobi, Kenya East African Medical Journal Vol. 77 No. 3 March 2000
2. Fente, B.G. Echem, R.C. Prospective Evaluation of The Bengezi and Al-Fallouji Modified Alvarado
Score for Presumptive Accurate Diagnosis of Acute Appendicitis in University Of Port Harcourt
Teaching Hospital, Port Harcourt. Niger J Med. 2009 Oct-Dec;18(4):398-401. CONCLUSION: The
Bengezi and Al-Fallouji modified Alvarado score is a simple, safe and cost effective aid in diagnosis
of acute appendicitis and decreases NAR. [PubMed - indexed for MEDLINE]
3. MODIFIED ALVARADO SCORING SYSTEM IN THE DIAGNOSIS OF ACUTE APPENDICITIS Talukder
DB, Siddiq AKMZ. JAFMC (June) 2009; Vol 5, No 1:18-20
4. Fast-track Packages in Colorectal Surgery: An Examination and Development of the Evidence
Supporting Their Use. A thesis submitted for the degree of DOCTOR OF MEDICINE (M.D.) by
Catherine Jane Walter at The University of Hull. 2008
5. Haider Kamran, Danish Naveed, Shawana Asad, Muhammad Hameed, Umar Khan. EVALUATION OF
MODIFIED ALVARADO SCORE FOR FREQUENCY OF NEGATIVE APPENDICECTOMIES . J Ayub
Med Coll Abbottabad 2010;22(4)
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
Interactive Clinical Scenarios
Case studies:





Teach you Theory in decision-making,
Polish your Proper Clinical Practice,
Consolidate Safety in your Experience,
Widen your Horizons in Life &
They are also Great Fun to do.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
1. A Case Study
A 15 year-old girl felt unwell and presented with lower abdominal pain from
start; and without anorexia.
On examination: temperature 37.5 ْC, abdomen was soft, and there was no
localized tenderness and no muscle rigidity.
No pain on coughing or movement.
FBC revealed normal range leucocytes count. The surgeon discharged patient
home with instructions.
The girl’s mother was very keen on appendicectomy to be performed for her
daughter. She took her girl elsewhere where the hospital performed
appendicectomy on her daughter.
The Mother lodged a formal complaint against the surgeon of First Hospital.
Discuss the Management indicating B/A score when First seen by surgeon?
Was the surgeon right in discharging her and Why?
What do you think about 2nd Hospital Appendicectomy?
What is your expectation about the histology of removed appendix?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
1. Answer




BA score = 2
1st Surgeon was absolutely right in discharging patient
with instructions.
2nd Hospital Surgeon was wrong in doing totally
unnecessary Appendicectomy, following an old principle
(when in doubt take it out).
Histology of removed appendix was NORMAL.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
2. A Case Study
A 89 year-old Man presented with migratory abdominal
pain which started initially in epigastric area and settled
later in RLQ. Pain started 3 days prior to consultation.
Pain was followed by anorexia and vomiting.
On Examination, patient was febrile. There was tender
well-defined mass in the RIF with minimal overlying
muscle rigidity . Cough test was still positive. Patient’s
blood test reveals WBC count of 18000 cell/µL.
Discuss the Management indicating B/A score?
What do you recommend for him NOW, and in the NEAR
and FAR FUTURE, discussing all eventualities in detail?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
2. Answer

BA score = 10

This is inflamed perforated appendicular abscess walled off by
omentum and bowel loops of 3 days duration. It is risky to operate
now so treat with antibiotics and put on W/L for interval
appendicectomy after 3 months. Meanwhile, prepare patient in view
of old age for enema or colonoscopy later when inflammation
settled to exclude carcinoma of caecum.

If patient fails to improve on antibiotics (amount of pus greater than
antibiotic ability to deal with) then drain abscess by percutaneous
peritoneal drainage under imaging (by interventional radiologist). If
that is not available then do surgical drainage with possible
removal of appendix in one session. If too much inflammation, then
risky to remove appendix, so drain and close under antibiotic cover
and do interval appendicectomy 3 months later.

If carcinoma of caecum was detected, then right hemi-colectomy.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
3. A Case Study
A 26 year-old female presented with RIF abdominal pain associated with anorexia and
nausea. Low grade fever, Tender RLQ on deep palpation. No muscle rigidity and
cough test was negative. WBC count was 10000 cells/µL with Neutrophilia.
Discuss management and B/A score, What is the incision performed? And Why?
If the appendix is normal during operation, Discuss the various options you take?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
3. Answer

BA score = 8

Lower midline incision, because of bilateral suprapubic
tattoos.

Remove appendix even if normal looking. Mickel’s
diverticulum was inflamed in this case, so remove it
with wedge excision of its base or do excision of
Mickel’s divericulum- bearing segment with end-to-end
small bowel anastomosis. Examine caecum for
diverticulum or carcinoma, terminal ileum for Crohn’s
disease, and tubo-ovarian appendices.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
4. A Case Study
A 35 year-old Man presented with migratory abdominal epigastric pain
settling ultimately in RLQ. Pain started 12 hours prior to consultation.
Pain was followed by anorexia and nausea.
On Examination, patient was afebrile. There was mild tenderness with
minimal overlying muscle rigidity . Cough test was positive. Patient’s
blood test reveals WBC count of 9000 cell/µL. About 3 hr following
admission, patient developed low grade fever.
At surgery, ballooned cystic lesion filled with fluid measuring 2.5 cm in
diameter representing a non-inflamed but obstructed appendix by a
nodular lesion within the base of appendix.
Discuss the Management indicating final B/A score?
What is the nature of fluid?
What is the single most important precaution you should take when
operating. What is the consequence?
How do you plan future treatment?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
4. Answer

BA score was 7 on admission but final BA score = 8

Mucinous cystadenoma. Careful removal for fear of
rupture and pseudo-myxoma peritonii.

Treatment (in special centres) with extensive
peritonectomy with radical omentectomy and inside
gastro-epiploic arcades, with extensive stripping of
visceral and parietal peritoneum using diathermy
dissection and intra-peritoneal chemotherapy.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
5. A Case Study
A 29 year-old Man presented with migratory abdominal
pain settling in RLQ of one day duration. Pain was
followed by anorexia and nausea.
On Examination, patient was febrile. There was RLQ
tenderness with no muscle rigidity. Positive Rovsing’s
sign & Cough test. Patient’s blood test reveals WBC
count of 11000 cell/µL. At operation, double pathology
in the appendix: acute appendicitis with another
obstructing solid nodular lesion less than 2 cm in
diameter close to appendicular base but well clear of
the base at 2 cm distal to the ileo-caecal junction.
Discuss the Management indicating B/A score?
Explain the findings and discuss your plan of treatment?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
5. Answer

BA score = 9

Carcinoid tumour

Appendicectomy will suffice for tumour less than 2 cm
in diameter and well clear off the base or distal to ileocaecal junction. Otherwise, right hemicolectomy if the
tumour is more than 2 cm in diameter or if involving the
base or ileo-caecal junction.
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
6. A Case Study
A 23 year-old female presented with migratory pain, anorexia and vomiting. On Examination, findings
of temperature of 38 ºC, McBurney sign, +ve Blumberg sign, and Rovsing sign . Blood testing
reveals WBC count of 12000 cell/µL. After suprapubic shaving, there was a Tattoo: 4 u David only
(instead of butterflies).
Discuss your management indicating B/A score, and your incision in view of her tattoo?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
6. Answer



BA score = 10
Appendicectomy via higher transverse skin crease
incision, because of high tattoo in RIF.
Story of 4u David only (Postoperative, it was Richard !)
and in OPD it was John !! (multiple boyfriends)!!!
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
7. A Case Study
A 25 year-old-female was unwell and presented with Atypical upper and lower abdominal pain
without anorexia. O/E Pale patient. Abdomen was soft but palpation was uncomfortable
suprapubically. Contrast-enhanced axial CT scan at the level of the upper abdomen showing a
heterogeneous hypervascular mass at the hilum of the spleen (arrows).
What is B/A score and Is it applicable here? What operative findings do you expect in this patient?
Discuss your management , indicating the type of incision you have to do.
Mention One most important preoperative test needed here?
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
7. Answer

BA score is NOT applicable because the pain never
settled in RLQ or RIF.

Urine examination for pregnancy test.

Ruptured ectopic pregnancy on the spleen.

Story of Splenic Pregnancy.
Bengezi / Al-Fallouji Predictive Score of Acute Appendicitis
SYMPTOMS
(3)
Migratory pain from epigatrium or umbilical area to
Right Iliac Fossa (RIF)
SIGNS (4)
LABORATORY (1)
Anorexia
1
Nausea/Vomiting
1
Tenderness Right Lower Quadrant
2
Rigidity and/or
Rebound tenderness RIF
1
Elevation of temperature
1
Extra sign(s) e.g. Cough test and/or
Rovsing’s sign and/or
Rectal tenderness (on Per Rectal exam)
1
Leucocytosis
2
___________
Total Score
Score 1-4:
Score 5-7:
1
10
Acute Appendicitis very unlikely; Discharge patient home with Instructions
(persistent pain, vomiting, or fever)
Acute Appendicitis probable; Admit for observation & re-scoring 6-8 hourly.
Score 8-10: Acute Appendicitis definite;
Operate immediately
Bengezi/Al-Fallouji Predictive Score of Acute Appendicitis
The New International Gold Standard
(References)
1. Al-Fallouji M and Bengezi O : Modified Alvarado Score in Diagnosis of Acute Appendicitis. (May 1997). Annual Meeting of
Association of Surgeons of Great Britain and Ireland Bournmouth, ENGLAND.
2. Bengezi O A and Al-Fallouji M: Modified Alvarado Score in Diagnosis of Acute Appendicitis. Association of Surgeons of
Great Britain and Ireland. British Journal of Surgery May 1997; vol. 84, supplement 1: 30.
3. O. Bengezi and M. Al-Fallouji. In Postgraduate Surgery, The Candidate's Guide. By M. Al-Fallouji, 2nd Ed. Oxford:
Butterworth- Heinemann; 1998. Pages 388-9.
4. Salam IM, Al-Fallouji MA, El Ashaal, et al: Early patient discharge following appendicectomy: safety and feasibility. Journal
of the Royal College of Surgeons of Edinburgh Oct 1995; 40(5): 300-302
5. ACUTE APPENDICITIS: AN OVERVIEW. H.S. Saidi, BSc. (Anat), MBChB and J.A. Adwok, MMed (Surg), FRCSEd, Professor,
Department of Surgery, College of Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya East African
Medical Journal Vol. 77 No. 3 March 2000
6. Fente, B.G. Echem, R.C. Prospective Evaluation of The Bengezi and Al-Fallouji Modified Alvarado Score for Presumptive
Accurate Diagnosis of Acute Appendicitis in University Of Port Harcourt Teaching Hospital, Port Harcourt. Niger J Med.
2009 Oct-Dec;18(4):398-401. CONCLUSION: The Bengezi and Al-Fallouji modified Alvarado score is a simple, safe and
cost effective aid in diagnosis of acute appendicitis and decreases NAR. [PubMed - indexed for MEDLINE]
7. MODIFIED ALVARADO SCORING SYSTEM IN THE DIAGNOSIS OF ACUTE APPENDICITIS Talukder DB, Siddiq AKMZ. JAFMC
(June) 2009; Vol 5, No 1:18-20
8. Fast-track Packages in Colorectal Surgery: An Examination and Development of the Evidence Supporting Their Use. A
thesis submitted for the degree of DOCTOR OF MEDICINE (M.D.) by Catherine Jane Walter at The University of Hull. 2008
9. Haider Kamran, Danish Naveed, Shawana Asad, Muhammad Hameed, Umar Khan. EVALUATION OF MODIFIED ALVARADO
SCORE FOR FREQUENCY OF NEGATIVE APPENDICECTOMIES . J Ayub Med Coll Abbottabad 2010;22(4)