Alvarado’s Criteria for Diagnosis of Children’s Acute Apendicitis

Acute abdomen in children is a condition that causes great distress to parents, and appendicitis is its most common cause, being more frequent at school age. This pathology is the cause of numerous visits to public and private hospitals around the world, and brings several complications. It is important that the health team is aware of the possibility of appendicitis in children, due to its high incidence and difficulty in establishing its diagnosis, because the symptoms are nonspecific and there are different clinical presentations. Objective: to explain the importance of the Alvarado criterion for the diagnosis of acute childhood appendicitis. Methodology: This is an integrative bibliographic review, in articles published in the PubMed, Virtual Health Library and Google Scholar databases. For the search for data, the descriptors “Acute abdomen”, “Appendicitis”, “Children” and the keyword “Alvarado score” were used. Data were collected in December 2020. Results: 16 articles were selected as the final sample for analysis of the review, six in English, nine in Portuguese and one in Spanish. Conclusion: Through this review it can be concluded that the use of the Alvarado Score for the diagnosis of acute appendicitis in children is useful and effective, avoiding the use of imaging tests in patients with a score above 7 on this scale.


Introduction
Acute appendicitis is the most common cause of surgical abdomen in children, being a pathological process of inflammatory origin that occurs in any age group, from the newborn to the elderly, being more common in school age. This pathology is the cause of numerous visits in public and private hospitals in the world, and also promotes several complications. This condition was already reported in ancient Egypt, and was discussed in the middle of the Western European Renaissance, when the Cecal Appendix was discovered as an anatomical entity (Arredondo, 2014).
Although it is common in childhood and adolescence, the disease is also prevalent in young adults (19 to 44 years), especially in males (Lima et al., 2016). The overall prevalence rate of the disease is approximately 7% and the peak incidence varies according to the gender and age group of children and adolescents, being 10-14 years in females and between 15-19 years in males (Lima et al., 2016).
In a historical context it is worth saying that the first surgical removal of the appendix was performed by Amayand in 1735, with James Parkinson being the first in the English language to scientifically describe the pathology of appendicitis (Arredondo, 2014). He described in detail, in 1812, the fatal case of one of his patients, a 5-year-old boy, who he had observed for some time, with health problems, but made no particular complaint until two days before his death, when he suddenly began vomiting and great prostration. The abdomen became very turgid and sore when pressed, the face pale and the wrist almost imperceptible. The death, preceded by extreme restlessness and delirium, occurred within 24 hours (Pearn and Gardner-Thorpe, 2001). Pearn and Gardner-Thorpe (2001) explain that Parkinson's performed the autopsy of the boy in the case cited, and described his findings saying there was a slight adhering between the peritoneum covering the viscera and the wall of the abdomen, where the viscera, regardless of inflammation of its peritoneal covering, appeared in a perfectly healthy state, except for the vermiform appendix of the cecum. Also, according to the authors, Parkinson (1812) reported that no sick appearance was seen near the cecum, however, about an inch of its extremity was considerably enlarged and thickened, its internal surface ulcerated and a small opening of ulceration was found at the beginning of the sick part, around the central part of the appendix, through which it appeared as a thin fluid, dark-colored and highly fetid had vased into the abdominal cavity. When opening

Alvarado's Criteria for Diagnosis of Children's Acute Apendicitis
International Journal for Innovation Education and Research Vol.10 No.10 (2022), pg. 170 the appendix, hardened objects were found impacted on the part that was between the opening and the part of the appendix.
Still, appendicitis is of great importance and all health team should be aware of the possibility of appendicitis in children, due to its high incidence and difficulty in establishing its diagnosis, due to the symptoms being nonspecific and having different clinical presentations (Peyvasteh et al., 2017).
There is a major problem when appendicitis affects preschool children and neonates. In these smaller ranges, patients may present more atypical symptoms, being confused with gastroenteritis, and may evolve rapidly to more severe complications such as perforation, abscesses and necrosis (Song et al., 2018). It is commonly known that in children under five years of age the incidence of appendicitis is usually lower, however, its clinical diagnosis is much more complicated (Arredondo, 2014), this is partly explained by the anatomical characteristics that these children present, such as short momentum, disabling the effective blockade of intraperitoneal infectious processes evolving faster to septic conditions (Song et al., 2018).
The time of diagnosis in preschool patients and neonates in hospital services is of paramount importance, but there are still some barriers in the process of diagnosing the disease, such as difficulty in communicating and skills of professionals on physical examination when faced with an acute abdomen in children, as well as in the identification of symptoms of the condition. Therefore, it is necessary to have the knowledge of the main abdominal disorders in children, with their specific presentations, diagnoses, and treatments with minimally invasive actions with the lowest possible costs (Song et al., 2018).
In this case, the test of choice to better assist in the diagnosis of Acute Appendicitis is contrast computed tomography, as it presents high sensitivity and specificity (Do Nascimento et al., 2018). However, it is notorious that its use presents a high cost to the public health system and may provide the child with a high amount of radiation, causing harmful effects to different cells.
As a result of the difficulty, whether due to financial resources in the public health system, or by the inability of the hospital service, to easily provide imaging tests and in order to facilitate the identification of inflammatory abdomen by physical examination, different classification scales were created for the diagnosis of acute appendicitis (Do Nascimento et al., 2018;Peyvasteh et al., 2017).
In 1986, Dr. Alfredo Alvarado observed more frequent signs and symptoms for the diagnosis of Acute Appendicitis, and from then on developed, through studies, his own scale (Adorno et al., 2016). Several studies (Adorno et al., 2016;Do Nascimento et al., 2018;Peyvasteh et al., 2017) show the association between the Alvarado Score scoring criterion and the diagnostic confirmation of Acute Appendicitis. In the study by Do Nascimento et al. (2018) The Alvarado score proved to be a good method for diagnostic screening in Acute Appendicitis, using as a cutoff point score greater than or equal to six that were associated with a higher probability of diagnostic confirmation to histopathology.
Thus, the social relevance of this research is justified by the fact that acute appendicitis represents the most common surgical condition in the world, with a high incidence mainly in the school age group, between 10 and 20 years of age. Diagnosis should be made based on the clinical evaluation of the patient and is an emerging condition in children, but its timely and early diagnosis remains a problem (Song et al., 2018).
In view of the above, this review aimed to determine the importance of the Alvarado criterion for the diagnosis

Alvarado's Criteria for Diagnosis of Children's Acute Apendicitis
International Journal for Innovation Education and Research Vol.10 No.10 (2022), pg. 171 of acute infantile appendicitis.

Methodology
The study was developed through an integrative bibliographic review, with the collection of data in published articles, searched through the PubMed databases, Virtual Health Library and Google Scholar. The inclusion criteria for this review were articles with free text available in full, in Portuguese, Spanish and/or English without limitation of publication date, that is, the studies published throughout the period allowed by the selected databases, because the purpose was to cover as many articles as possible. The repetitions and documents that did not meet the research objective were excluded from the sample, remaining only once.
For the selection of articles, a consultation was made to the Descriptors in Health Science (DeCS), and the following descriptors were identified, selected and used in Portuguese: "Acute abdomen", "Appendicitis" and "Children". With the interest in analyzing a comprehensive production about publications related to the theme of this review and in order to expand the sample of analysis, the keyword "Alvarado Score" was also used as a search strategy, having as its guide axis the inclusion and exclusion criteria, previously established to maintain coherence in the search for articles and avoid possible vieses. These terms were crossed from the Boolean AND or OR operators.
In December 2020, therefore, searches were performed using the descriptors and the keyword in the databases selected in this review.
After a pre-selection of the articles resulting from these searches, readings of the titles and abstracts of the total sample were made, applying the inclusion and exclusion criteria.
After doing this process, 16 articles were selected as the final sample of review analysis. From the material obtained, a thorough reading of its contents was carried out in order to deepen the knowledge on the subject and achieve the proposed objective.
The articles selected for review were organized by means of an instrument, not validated, elaborated by the authors, containing: title, year of publication, category and focus of the study with the objective of summing up, extracting and analyzing the data.

Results and Discussion
16 articles were selected as a data source for the present scientific study, six in English, nine in Portuguese and one in Spanish. The results of the publications selected in this review are described in Table 1. As Cerruti (1942) explains, acute inflammation of the appendix causes lesions, which are simple at first, but which become progressively more severe in a few hours, providing different anatomopathological classifications, which correspond to the succession of stages of organ inflammation. Thus, are described by the author: The initial lesion (primaerdefetke) is located in a crypt or deep fold of the mucosa of the appendix. Through this erosion there is invasion of the organ wall by an inflammatory process that extends, in the form of a wedge,

Alvarado's Criteria for Diagnosis of Children's Acute Apendicitis
International Journal for Innovation Education and Research Vol.10 No.10 (2022), pg. 177 more in the muscular and serum layer than properly in the mucosa and submucosa. Such microscopic alteration corresponds macroscopically to a hyperemiated or even normal-looking appendix. This is catarrhal appendicitis. With the progress of the process there is generalization of inflammation with involvement of other crypts and the various tunics of the appendix which, entirely infiltrated by an exudate of neutrophil polynuclear, constitutes the picture of phlegm appendicitis. [...] In earlier phases appear complicated forms of acute appendicitis. There is, then, purulent fluidification with abscesses forming on the wall of the appendix that can be opened in its light or through serous and, at the expense of very small perforations, largely contaminate the phemonium. It's the suppuration appendicitis drilled. Finally, in certain cases there is edema and inflammation of the mesoappendix, thrombosis of the appendicular artery, which being terminal causes gangrene of the appendix to a variable extent. It is gangrenous appendicitis with organ perforation. This is the most serious modality of appendicitis [...] (Cerruti, 1942, p. 8-9).
Thus, with regard to histopathological description, a reference is the classification cited by Fisher et al. (2005), in degree of evolution, such as: catarrhal phase (grade 1); phlegmonous phase (grade 2); suputive phase (grade 3) and gangrenous phase (grade 4). The macroscopic description of the appendix can be performed according to the criteria described in the study by Souza-Rodrigues et al. (2014), to the following grades: 1) appendix without perforation and minimal modifications; 2) appendix without perforation and the presence of gangrene suppuration or necrosis; 3) appendix with perforation and peritonitis or abscess at the site; and 4) appendix with perforation and diffuse peritonitis. Borges et al. (2003) say that appendicitis affects the male sex more, at a ratio of 3:2, with a higher incidence in family members. As the researchers explain, Aneiros et al. (2019), age makes a difference in the diagnosis in cases of acute appendicitis, because it is verified that, due to its presentation being rare in children under 5 years of age, it is often misdiagnosed, which increases its morbidity. In the study of these authors, although their clinical presentation varies between infants and preschoolers, the researchers did not observe statistically significant differences in the proportion of perforated appendages or in postoperative complications.
It is medical knowledge that the diagnosis of acute appendicitis is clinical. A good anamnesis and an adequate physical examination may be resolutive for early discovery. However, the use of tools such as imaging exams is increasingly common in ready-to-care services in Brazil. In this sense, radiological examination has a limited role, while ultrasonography (US) has the advantage of being a noninvasive procedure, that there is no exposure of the patient to radiation, however, it does not provide a well-defined image, especially in obese patients and when the intestinal loops are distended in addition to requiring an examiner with skill and experience (Adorno et al., 2016).
Incorrect diagnosis is more common in children and the elderly, and its late diagnosis is not very uncommon, due to atypical presentation in the disease with 40% of children misdiagnosed, so it presents as a challenge to professionals. Late-term appendicitis represents severe pathological progressions related to systemic complications, longer hospitalization time, increased morbidities and/or mortality, representing higher costs to the public health system, and loss of life, thus on the health services (Iamarino et al., 2017).
In addition, the use of clinical study through anamnesis and physical examination has been abandoned by professionals, either by insecurity or unpreparedness. With this, there is an excessive increase in the use of

Alvarado's Criteria for Diagnosis of Children's Acute Apendicitis
International Journal for Innovation Education and Research Vol.10 No.10 (2022), pg. 178 radiological examination in pediatric hospitals. The use of computed tomography (CT) already represents 21% to 49% of cases. According to a study conducted by Kharbandaet et al. (2017), the potential for CT use is problematic, due to risks with radiation, by induction of malignancy, especially in young women. Thus, it is consensus to limit its use.
One option is the use of the Alvarado scale for the diagnosis of acute appendicitis. Symptomate and laboratory parameters with different scores are included in this scale; migratory pain in the right iliac fossa (1), nausea and/or vomiting (1), fever (1), anorexia (1), right lower quadrant wall defense (QID) (2), decompression pain (1), Leukocytosis >10,000 (2) and left deviation (1). It is observed that each characteristic is worth one (1) point, except leukocytosis and wall defense in QID, which are worth two (2), thus totaling 10 points (Adorno et al., 2016).
In relation to the Alvarado score, Adorno et al. (2016) explain that those who have a score greater than or equal to 7 have indication for surgical treatment; when between 5 and 6, the probability of acute appendicitis is high, therefore, simple imaging tests such as USG or CT are indicated to confirm the diagnosis; if the score is less than 4, the probability of appendicitis is low. It is noteworthy that inflammation of the appendix rarely presents a score lower than 4.
According to Depinet et al. (2016), although the accuracy of clinical factors for the diagnosis of appendicitis is reported in 70% to 87%, the use of diagnostic images, including CT, has become widespread. Despite the current recommendation of ultrasound as the preferred test for diagnosis of appendicitis imaging, and the small increased lifetime risk of malignancy associated with ionizing radiation, CT is still commonly used in some areas for imaging diagnosis in these cases. Borges et al. (2003) used a sample of 81 children and adolescents, with the cut-off point of >5. The results of their study demonstrated that the Alvarado score is a procedure that is not invasive, simple, fast and reproducible, and with a minimum score of 5 points, is presented as a high-value instrument in the screening of children and adolescents with suspected diagnosis of acute appendicitis.
Similarly, the study conducted by Cunha et al. (2018) also evaluated the efficacy of the Alvarado score in an emergency hospital in the city of Fortaleza, concluding that its use in health services emerges as an accessible and effective tool to optimize the approach of patients with a condition suggestive of appendicitis. In addition, the Alvarado score may also suggest the degree of inflammation of the appendix. The authors also recall that the faster the therapeutic definition of acute appendicitis, the lower the chance of necrosis or abscess formation in the appendix and the shorter the length of hospital stay in the postoperative period. In the study conducted by Iamarino et al. (2017), the most frequently diagnosed symptom was migratory pain, found in 96% of patients who had uncomplicated appendicitis and in 93% of those with complication appendicitis. Among the complications, which are due to the evolution of the acute inflammatory process, the authors mention: suppuration, perforation with or without hemorrhage and gangrene of the appendix.
Decompression pain was the second most common symptom of the study by Iamarino et al. (2017), presented by 80% of patients without complications, and by 93% of patients with complications. Then, nausea and vomiting were presented by 73% of patients without complications, and by 83% of those with complications.
Regarding fever, 44% of patients without complications had this symptom, while 72% of those who had complications also had fever. It is noteworthy that the authors did not evaluate the other symptoms of the Alvarado Score, bringing only the results already mentioned.
In another study, conducted by Peyvasteh et al. (2017), the most common symptom was wall defense in QID, found in 91.4% of patients. Then came leukocytosis, demonstrated by 89.3% of patients. The symptomatology of nausea and vomiting was the third most frequent, with 84.3% of them presenting these symptoms. Anorexia was found in 73.6% of patients, and fever was the least frequent, being verified in 49.3% of the patients evaluated by the authors. However, as in the study by Iamarino et al. (2014), these authors also did not evaluate the other symptoms of the Alvarado Score. found of the symptoms presented by the patients, but some agreements were found, and the symptoms of nausea and vomiting, pain to decompression and leukocytosis as the most frequently found, while migratory pain in the right iliac fossa and the left deviation to the leukogram would be the least common.

Conclusion
Through the data presented here, it can be concluded that the use of the Alvarado Score for the diagnosis of acute appendicitis in children is useful and effective, avoiding the use of imaging tests in patients with a score above 7.
Therefore, in case of acute abdomen in children, imaging should not be performed without need, since when the Alvarado score is equal to or above 7 it is already indicative of surgery, therefore, such tests are unnecessary.
If confirmation is still desirable, especially when in children under 5 years of age, where the diagnosis is less accurate, the examination of choice should be US, and no tests such as radiography and CT are indicated for children's exposure to ionizing radiation.