Pediatr Surg Int (2014) 30:317–321
DOI 10.1007/s00383-014-3467-0
ORIGINAL ARTICLE
The evaluation of the validity of Alvarado, Eskelinen, Lintula
and Ohmann scoring systems in diagnosing acute appendicitis
in children
Arzu Sencan • Nail Aksoy • Melih Yıldız •
Özkan Okur • Yusuf Demircan • İrfan Karaca
Published online: 22 January 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose To show whether Alvarado, Eskelinen, Lintula
and Ohmann scoring systems have predictive values in
diagnosing acute appendicitis in children.
Methods Sixty patients with suspected acute appendicitis
were prospectively evaluated. Alvarado, Eskelinen, Lintula
and Ohmann scores were calculated separately for each
patient at the time of admission. The specificity, sensitivity,
positive and negative predictive values of the scores were
calculated. The predictive value of the scores was evalu-
ated with the receiver operating characteristic (ROC) curve
and the consistency among the scores by Kappa test.
Results Twenty of the patients were female (33.3 %). The
mean age of the patients was 9.9 years (3–16 years). Forty
two patients were operated and appendectomies were per-
formed with the diagnosis of acute appendicitis. The area
under the ROC curve showed that the scores had no pre-
dictive value in diagnosing acute appendicitis. Kappa test
showed that agreement between the scores was not good.
Conclusion The sensitivity and specificity of the four
scoring systems were not sufficient enough in diagnosing
acute appendicitis in our patient group. We concluded that
the most important factor affecting the decision for surgery
in suspected acute appendicitis is the surgeon’s experience
combined with physical findings of repeated clinical
examinations.
Keywords Acute appendicitis
Alvarado score

Eskelinen score
Lintula score
Ohmann score
Children
A. Sencan (&)
N. Aksoy
M. Yıldız
Ö. Okur

Y. Demircan
İ. Karaca
Department of Pediatric Surgery, Dr. Behçet Uz Children’s
Trianing Hospital, Izmir, Turkey
e-mail: arzusencan71@yahoo.com.tr
Introduction
Appendicitis is the most common surgical emergency in
childhood [1]. Despite advances in the diagnosis and sur-
gical treatment, diagnosing appendicitis still remains diffi-
cult. Acute appendicitis is one of the few surgical diagnosis
that is made clinically and decision to undergo surgery is
often given without certainty of the definitive diagnosis.
The delay in the diagnosis increases morbidity and mor-
tality, whereas false positive diagnosis of appendicitis leads
to unnecessary surgery. Due to diagnostic delays, perfora-
tion rates are reported as 17–33 % and negative laparotomy
rates between 3 and 54 % [2, 3]. Although radiological
imaging techniques and laboratory tests are helpful in the
diagnosis of appendicitis, several clinical diagnostic scores
have been developed to aid in the diagnosis of suspected
cases. Different results of these scoring systems have been
reported in the literature. Some studies showed that the
scoring systems reduced the negative appendectomy rate by
50 % [4, 5], while some others reported that the diagnostic
accuracy of the scores was low [6, 7].
To our knowledge, four different scoring systems have
not been compared all together in one study, so far.
Therefore, we designed this study to show whether Alva-
rado, Eskelinen, Lintula and Ohmann scoring systems are
useful or not in the diagnosis of acute appendicitis in
children with abdominal pain and also to evaluate the
consistency of these four scores among each other.
Materials and methods
Sixty patients who admitted to the pediatric surgery
emergency department of our hospital with complaint of
abdominal pain between February 2011 and August 2011,
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and who were hospitalized with suspected acute appendi- Table 1 Diagnostic performance parameters
citis were prospectively evaluated. Patients with a history Sensitivity (%) Specificity (%) PPV (%) NPV (%)
of previous surgery and those with acute abdominal trauma
were excluded. The study was approved by the Ethics Alvarado 76.19 38.89 74.42 41.18
Committee of our institution. The parents of the patients Eskelinen 73.81 50 77.5 45
were informed about the study and their approval was Lintula 16.67 66.67 53.85 25.53
obtained at the time of hospitalization. The history, clinical Ohmann 21.43 88.89 81.82 32.65
examination results, basic laboratory data (white blood PPV positive predictive value, NPV negative predictive value
cell; WBC) and routine radiologic imaging results
(abdominal ultrasonography; USG, plain abdominal gra-
Table 2 The Kappa statistics comparing the agreements between the
phy) were recorded on the previously prepared data sheets scores
at the time of admission. Alvarado, Eskelinen, Lintula and
Ohmann scores, described previously in the literature, were Kappa Eskelinen Lintula Ohmann
calculated separately for each patient. Physical examina- Alvarado 0.416* 0.144*** 0.111***
tions and the operations were performed by three experi- Eskelinen 0.131*** 0.202**
enced pediatric surgeons. An Alvarado score of 7 or greater Lintula 0.064***
[8], an Eskelinen score of 57 or greater [9], a Lintula score
* \0.6 moderate, ** \0.4 fair, *** \0.2 poor
of 21 or greater [10] and an Ohmann score of 12 or greater
[11] are indicative of appendicitis. The decision for surgery
was based on overall clinical judgement, together with the abdominal pain. No preoperative or postoperative compli-
laboratory findings and radiologic imaging results. Physical cations occured in neither of the patients. They were dis-
examination was repeated every 2 h for suspected cases. charged from the hospital on an average of 2 days
The scoring systems played no role on the decision to postoperatively.
operate in neither of the patients. Operations were per- For 60 patients, the sensitivity of Alvarado score was
formed by open surgical technique in all patients. Ampi- 76.19 %, the specificity was 38.89 %, the PPV was
cillin-Sulbactam was prescribed postoperatively. The 74.42 % and the NPV was 41.18 %. The sensitivity of
diagnosis of acute appendicitis was made by the intraop- Eskelinen score was 73.81 %, the specificity was 50 %, the
erative macroscopic appearance of the appendix; edema- PPV was 77.5 % and the NPV was 45 %. The sensitivity of
tous and hyperemic appendix was diagnosed as acute Lintula score was 16.67 %, the specificity was 66.7 %, the
appendicitis; and additional fibrinous appearance was PPV was 53.85 % and the NPV was 25.53 %. The sensi-
diagnosed as phlegmonous appendicitis. Intraoperative tivity of Ohmann score was 21.43 %, the specificity was
diagnosis was confirmed by histopathological examination. 88.89 %, the PPV was 81.82 % and the NPV was 32.65 %
Statistical analyses were performed with SPSS 13 for (Table 1). Kappa test showed that agreement between the
Windows Package Programme. The sensitivity, specificity, scores was not good (Table 2).
positive and negative predictive values (PPV, NPV) of The area under the ROC curve was 0.576 (95 % CI
each of the four scores were calculated separately. The 0.40–0.74) for Alvarado score (Fig. 1), 0.565 (95 % CI
receiver operating characteristic (ROC) curve was used to 0.39–0.73) for Eskelinen score (Fig. 2), 0.553 (95 %
evaluate the predictive value of the scores. The consistency CI 0.37–0.73) for Lintula score (Fig. 3) and 0.590 (95 %
among the scores was evaluated by Kappa test. CI 0.42–0.75) for Ohmann score (Fig. 4). As a result, these
findings showed that the scores had no predictive value in
diagnosing acute appendicitis.
Results

Twenty of the patients were female (33.3 %) and 40 were Discussion

male (66.7 %). The mean age of the patients was 9.9 years
(3–16 years). Forty two patients were operated and
appendectomies were performed with the diagnosis of
acute appendicitis. The intraoperative diagnosis was cor-
related with histopathological examination. No negative
laparotomy was performed among the operated patients.
Eighteen patients were conservatively followed up and
discharged from the hospital when their abdominal pain
subsided. These patients were evaluated as nonspecific
The average lifetime risk of appendicitis is 7 % [12].
Despite advances in the diagnosis and treatment tech-
niques, appendicitis still remains a challenging surgical
emergency with significant morbidity and mortality. The
delay in the diagnosis and the treatment of the condition
can lead to complications [13]. Radiologic imaging tech-
niques and various laboratory studies have diagnostic aid,
thus increasing the cost with additional radiation risk.

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Pediatr Surg Int (2014) 30:317–321
Fig. 1 ROC curve for the Alvarado scoring system: 0.576 (95 % CI
0.40–0.74)
Fig. 2 ROC curve for the Eskelinen scoring system: 0.565 (95 % CI
0.39–0.73)
Therefore, searches for helpful diagnostic tools for acute
appendicitis have been going on. For this purpose, a group
of authors have developed scoring systems based on clin-
ical findings and routine laboratory studies. In this study,
we aimed to assess the validity of the four previously
defined scoring systems on our patient group who were
being evaluated for abdominal pain suggestive of acute
appendicitis, and to investigate the consistency of the four
scores among each other.
Only a small number of patients who present with
abdominal pain require surgical intervention. In this pres-
ent study, the number of patients who did not undergo
surgery is much less compared to the total number of
patients. This may be explained by the fact that all the
319
Fig. 3 ROC curve for the Lintula scoring system: 0.553 (95 % CI
0.37–0.73)
Fig. 4 ROC curve for the Ohmann scoring system: 0.590 (95 % CI
0.42–0.75)
patients who presented with abdominal pain were exam-
ined by the pediatricians first and only the cases with
suspected appendicitis were referred to pediatric surgery
department. In our study, Alvarado score had the highest
sensitivity (76.19 %). However, the specificity and the
NPV of the same score was low (specificity 38.89 %, NPV
41.18 %). In the original article by Alvarado [8], while the
sensitivity and the NPV of the score were similar to our
results, the specificity (81 %) and the PPV (92 %) were
much higher. Different results about the performance of
this scoring system have been published in the literature.
Some authors concluded that Alvarado score was helpful in
the diagnosis of acute appendicitis [14, 15], while some
others reported that the scoring system was not sufficient in
the diagnosis of acute appendicitis [7, 16]. Limpawatt-
anosiri et al. [14] in a prospective study assessing the
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accuracy of Alvarado score in predicting acute appendicitis
with 1,000 patients, reported the sensitivity of the score as
87.41 %, specificity as 74.39 %, PPV as 83.7 % and they
concluded that Alvarado score is a helpful tool for the
admission criteria of acute appendicitis. Shera et al. [17]
reported that Alvarado score was reliable in the early
preoperative diagnosis of acute appendicitis. They reported
that PPV of the score was 93.1 % and it was helpful in
reducing the incidence of negative appendicectomy rate.
On contrary, subsequent prospective studies concluded that
this score alone was inadequate as a diagnostic test [18,
19]. Schneider et al. [16] evaluated appendicitis scoring
systems using a prospective pediatric cohort and concluded
that Alvarado score did not provide sufficient PPV to be
used in clinical practice as the sole method for determi-
nation of the need for surgery. This is similar to the result
of our current study. These disputes in the literature may be
due to the differences in the number of patients, patient
characteristics and the experience of the examining phy-
sicians. In our study, the Alvarado score had the highest
specificity and the sensitivity when compared with the
other scores. However, the score alone was not useful
enough to support the diagnosis of acute appendicitis.
Lintula, the other scoring system that we tested in our
current study, did not have enough diagnostic value in
acute appendicitis, either. There is no consensus about the
results of Lintula score in the literature. Lintula reported
the sensitivity of the score as 87 % and specificity as 98 %
on adult patients, emphasizing that it would be helpful for
general surgeons [20]. He stated that the score alone was
not helpful enough to diagnose acute appendicitis in
pediatric age group [10]. In another randomized controlled
trial where they evaluated whether diagnosis using Lintula
score might improve clinical outcomes for children with
suspected appendicitis, Lintula concluded that the score
reduced the unnecessary appendicectomy rate in children
[21]. Yoldas et al. [22] reported that Lintula score was a
useful method to diagnose acute appendicitis with a sta-
tistically significant predictive accuracy. In our study,
Lintula scoring system had the lowest sensitivity rate of
16 % and the minimum area under the ROC curve (0.553).
This result may be due to the fact that some variables in
this score, such as intensity of pain and relocation of pain,
may not be well described by the children.
In this current study, Ohmann and Eskelinen scores were
not found to be reliable enough for the diagnosis of acute
appendicitis, either. Ohmann, in a multicentric prospective
study including 1,484 patients from eight departments,
concluded that Ohmann score could not be recommended
as a standard tool for diagnostic decision making in acute
appendicitis [11]. In a study validating the diagnostic value
of Eskelinen scoring system, the sensitivity, specificity,
PPV and NPV of the score were reported as 79, 85, 65 and
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Pediatr Surg Int (2014) 30:317–321
91 %, respectively. ROC analysis revealed an area index of
0.91. They concluded that the Eskelinen score might give
acceptable clinical results only after calibration of the
cutoff value [23]. Kiyak et al. [24] evaluated the Ohmann
and Eskelinen scores for the diagnosis of appendicitis in
adult patients and they reported that there were significant
differences in positive and negative appendectomies for
women, but no difference for men. Another study showed
that Ohmann scoring system was helpful in the diagnosis of
acute appendicitis [25].
As a result, this current study showed that the four
scoring systems, used either alone or together, were not
predictive in diagnosing acute appendicitis. The area under
the ROC curve was 0.576 for Alvarado score, 0.565 for
Eskelinen score, 0.553 for Lintula score and 0.59 for Oh-
mann score. These values showed that the scoring systems
had no diagnostic value. Besides, the degree of agreement
between the scores was not good. The sensitivity of one
score was high, while it was low in another score. Same
results were also found for the specificity of the scores.
Clinical scoring systems developed for the diagnosis of
acute appendicitis may have advantages because they are
non-invasive and cost-effective. However, the results may
differ depending on the patient population, age, time of
admission to hospital, subjective evaluation of the symp-
toms and the experience of the physician. The course of
acute abdominal pain shows variations, especially in the
pediatric age group. We think that the biggest confusion
about the diagnostic scores in the literature arises from
these factors. Some variables of the scores such as location,
duration and migration of pain, and right lower quadrant
tenderness may not be well described by young children or
their evaluation may be subjective. For example; the
parameter of ‘severe pain’ in Lintula score may differ
depending on the patient and the examining physician.
There are some limitations to our study. First, the total
number of patients is small. Second, the parameter values
were calculated according to the findings at the time of
admission. Repeated physical examinations in later hours
might give different results. There were no negative
appendectomies or perforations due to a delay in the
diagnosis in our current study. Repeated physical exami-
nation of the patient who is being evaluated for suspected
acute appendicitis, following the patient for at least 6–8 h
and the experience of the surgeon play an important role in
giving decision for surgery. Ultrasonography and routine
laboratory tests are also additional tools helping the sur-
geon decide for surgery. We also took the ultrasonography
and laboratory findings into consideration when deciding
for surgery, but the exact decision was based on the find-
ings of our repeated clinical examinations.
In conclusion, the sensitivity and specificity of the four
scoring systems were not sufficient enough in diagnosing
Pediatr Surg Int (2014) 30:317–321
acute appendicitis in our patient group. Therefore, we think
that the most important factor affecting the decision for
surgery in suspected acute appendicitis is the surgeon’s
experience combined with physical findings of repeated
clinical examinations.
Conflict of interest The authors declare that they have no conflict
of interest.
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