Nigam’s scoring system for acute appendicitis with high accuracy surpassing Alvarado scoring system


  • Vinod Kumar Nigam Department of General and Minimal Invasive Surgery, Max Hospital Gurugram, Haryana, India
  • Siddarth Nigam Department of General and Minimal Invasive Surgery, Max Hospital Gurugram, Haryana, India



Accuracy, Acute appendicitis, Alvarado scoring system, Complications, Diagnosis, Negative appendectomy, NSS


Background: Acute appendicitis is one of the most common surgical emergencies. Delay in the treatment of acute appendicitis can result in complications, may be lethal. That’s why the early diagnosis and quick treatment is essential. The diagnosis of acute appendicitis is still a clinical one. Alvarado scoring system is the commonest scoring system but it has many lacunae. Nigam’s scoring system (NSS) is invented to deal with drawbacks of Alvarado scoring system and improve accuracy.

Methods: NSS has 17 scoring points. This scoring system can be divided into three parts, 6 and below 6, 7 to 10, and 11 and above. This study includes 36 patients of acute abdomen during a period of 8 years from Jan 2012 to Jan 2020. The diagnosis of acute appendicitis by NSS was compared with the ultrasonography findings, operation findings, and histopathological results.

Results: Out of 36 patients 2 patients scored 6 and below, 3 patients scored 7 to 10 and 31 patients scored 11 and above. Accuracy of NSS resulted in 100%. No negative appendicectomy was recorded.

Conclusions: NSS has better accuracy than Alvarado scoring system in diagnosing acute appendicitis. NSS is an easy, economical, simple, accurate, fast and dependable scoring system. NSS is best suited for small hospitals which lack advance investigative techniques such as ultrasound, CT scan and MRI.



Owen TD, William H, Stiff G, Jenkinson LR, Rees BI. Evaluation of Alvarado scoring in acute appendicitis. JR Soc Med. 1992;85:87-8.

Mardan MA, Mufti TS, Khattak IV. Role of ultrasound in acute appendicitis. J Ayub Med Coll Abottabad. 2007;19:72-8.

Singh KP, Gupta S, Parga P. Application of Alvarado scoring system in the diagnosis of acute appendicitis. JK Sci. 2008;10:84-6.

Paulson E. Clinical Practice: Suspected Appendicitis. NEJM. 2003;248:236-42.

Kanumba ES, Mabula JB, Ramabu. Modified Alvarado scoring system as a diagnostic tool for acute appendicitis at Bufando Medical Centre. Moonza, Tanzoma. BMC surg. 2011;11:4.

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emergency Med. 1986;15(5):557-64.

Douglas CD. Randomized controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ. 200;321(7206):919-22.

Andersson M, Andersson RE. The Appendicitis inflammatory response score, a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Emergency. 2008;32(8):1843-9.

Adi MIW, Thien A, Suyol A, Mackie AJ, Astin S, Tripathi S et al. Development of the RIPASA score a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J. 2010;51(3):220-5.

Chan MY, MG BL. The Alvarado score in acute appendicitis. Ann Academy Med Sing. 2001;30(5):510-2.

Memon ZA, Sami W. Acute appendicitis. Diagnostic accuracy of Alvarado scoring system. Asian J Sur. 2013;36(4):144-9.

Alvarado A. Improved Alvarado score (MANTRELS) for the early diagnosis of Acute Appendicitis. Int J Surg Res Practice. Alvarado Int J Surg Res Pract. 2019;6:098:1-6.

Ohle R, O’ Reilly F, Dinitrov BD. The Alvarado score for predicting acute appendicitis. A systematic review. BMC Med. 2011;9:139.

Rajshekhar J, Uday MM, Naveen N. Modified Alvarado score and its Application in the Diagnosis of Acute Appendicitis. IJCMR. 2013;3(5):1398-400.

Abbas ARM, Safaa AM, Ashwag HAQ, El Syed AA, Al Shigiti NA. Accuracy of Alvarado Scoring System and Selective Computed Tomogarphy in Diagnosis of Suspected Cases of Acute Appendicitis. J Clin Res Rep. 2020;1(2):1-11.

Lumley JSP. Acute appendicitis The Acute Abdomen. Hamilton Bailey Physical signs, Butter Worth-Heineman. 18th Editions International Editors.. 1997;304.

Lowry SF, Hong J. Appendicitis and appendicial absess. Mastery Surg. 2007;5(2):1430.

Alvarado A. How to improve the clinical diagnosis of acute appendicitis in resource limited settings. World J Emrg Surg. 2016;26:11-6.

Alvarado A. Clinical Approach in the Diagnosis of Acute Appendicitis. Intech Open. 2018.

Takada T, Inokuchi R, Kim H, Sasavi S, Terada K, Yokota H et al. Is “pain before vomiting” useful? Diagnostic performance of the classic patient history item in acute appendicitis. Am J Emrg Med. 2021;41:84-9.

Craig S. Appendicitis Clinical Presentation. Drug and Disease. Emergency Med. 2018.

Robert SL. Murphy’s Triad. BMJ. 1971;1(5745):401-2.

Rajshekhar J, Uday MM, Naveen N. Modified Alvarado score and its Application in the Diagnosis of Acute Appendicitis. IJCMR. 2013;3(5):1398-400.

Teacher I, Landa B, Cohen M. Scoring system to and in diagnosis of appendicitis. Am Surg. 1983;198:753-9.

Queshi H, Burud L. Modified Alvarado scoring system in the diagnosis of acute Appendicitis. J Young Mid Rcs. 2014;1(2):1-6.

Kozar RA, Roslyn JJ. The Appendix. Principles of Surgery. Mc Graw Hill. 7th Edn. 1999;1383-93.

Hoffman J, Rasmussen OO. Aids in the diagnosis of acute appendicitis. Br J Surg. 1989; 76: 774-779.

Velanovich V, Savata R. Balancing the normal appendectomy rate with the perforated appendicitis rate: implication for quality assurance. Am Surg. 1992;58:26-9.

Petrosyan M, Estrada J, Chan S, Somers S, Yacoule WN. CT scan in patient with suspected appendicitis. Clinical implications for the acute care surgeon. Eur Surg Res. 2008;40:211-9.

Santos DA, Manunga JJr, Hohman D, Avik E, Taylor EW. How often does computed tomography change the management of Acute Appendicitis? Am Surg. 2009;75(10):918-21.

Evans SRT. Appendicitis 2006. Ann Surg. 2006;244(5):661-2.

Williams NS, O’ Connell PR, Mc Caskie AW. Bailey and Love’s. Short Practice of Surg. 2018;27(2):1303.

Yalmanchili N, Mortala VR, Medasani R, Gade RKR. Study of modified Alvarado score and ultrasound imaging with post-operative histopathology in diagnosis of acute appendicitis. IJSS. 2021;5(4):91-6.

Connor TJ, Garcha IS, Ramshaw BJ. Diagnostic laparoscopy for suspected appendicitis. Am Surg. 1955;61:187-92.






Original Research Articles