Tick what is present
Symptoms
Signs
Blood tests
The score
| Item (MANTRELS) | Points |
|---|---|
| Migration of pain to the right iliac fossa | 1 |
| Anorexia | 1 |
| Nausea or vomiting | 1 |
| Tenderness in the right iliac fossa | 2 |
| Rebound tenderness | 1 |
| Elevated temperature, 37.3 °C or more | 1 |
| Leucocytosis, white cells above 10 × 109/L | 2 |
| Shift to the left, neutrophils above 75% | 1 |
| Total | 10 |
| Score | Meaning |
|---|---|
| 1–4 | Appendicitis unlikely |
| 5–6 | Equivocal: observe, repeat, image |
| 7–8 | Probable |
| 9–10 | Very probable |
A worked example
A 19-year-old man with 18 hours of pain
The pain started around the umbilicus and moved to the right iliac fossa (1). He has not eaten (1) and vomited once (1). He is tender (2) with rebound (1) in the right iliac fossa, and his temperature is 37.8 °C (1). White cells are 14.2 (2) with 84% neutrophils (1). Alvarado 10 / 10: appendicitis very probable. He goes to a surgical review, and in a young man with a classic story many surgeons proceed to laparoscopy.
Where the Alvarado score falls short
It was built in 1986 on adults, mostly men. It is good at ruling appendicitis out (a score below 5 makes it unlikely) but poor at ruling it in, especially in women, where gynaecological causes score highly too. The 2020 WSES Jerusalem guidelines prefer the Appendicitis Inflammatory Response (AIR) score or the Adult Appendicitis Score for adults, and advise against using any score alone to decide on an operation. Use it to structure your thinking, then examine the patient again.
Common exam questions
What sign is “migration”? Visceral pain from the inflamed appendix is felt at the umbilicus (midgut, T10). When the inflammation reaches the parietal peritoneum the pain becomes sharp and localised to McBurney’s point. That shift is the most specific symptom of appendicitis.
Why a pregnancy test? Ectopic pregnancy can produce every item on this list. Every woman of child-bearing age with right iliac fossa pain needs a urine or serum β-hCG, whatever her score.
References
- Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557–64.
- Ohle R, et al. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139.
- Di Saverio S, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020;15:27.
Educational use
This calculator is a teaching aid. It does not replace clinical judgement, senior advice or your local guidelines.