Alvarado Score Calculator
Alvarado score for appendicitis from eight symptoms, signs, and laboratory items.
What it does
The Alvarado score, also called the MANTRELS score, is a clinical score for suspected acute appendicitis. It combines symptoms, physical signs, and two laboratory findings.
The eight items are migration of pain to the right lower quadrant, anorexia, nausea or vomiting, right lower quadrant tenderness, rebound tenderness, elevated temperature, leukocytosis, and a left shift. Tenderness and leukocytosis carry 2 points each, so the maximum is 10.
The score is most useful for risk stratification, not for confirming or excluding appendicitis. Imaging, pregnancy status, age, and the full clinical picture can change the decision even when the score is typical.
The defaults describe a patient with pain migration, anorexia, right lower quadrant tenderness, rebound, elevated temperature, and leukocytosis. Nausea and left shift are absent, so the score is 8 and falls in the probable band.
How to use
- Ask about pain migration, anorexia, and nausea or vomiting.
- Examine for right lower quadrant tenderness and rebound tenderness.
- Check temperature and use 37.3 C (99.1 F) or higher as the temperature threshold.
- Enter the white blood cell count category and whether a left shift is present.
- Press Calculate to see the total score and probability band.
- Use imaging and surgical consultation for decisions, especially in children, pregnancy, and older adults.
Formula
- Pain migration
- 1 point for migration to the right lower quadrant.
- Anorexia
- 1 point.
- Nausea or vomiting
- 1 point.
- RLQ tenderness
- 2 points.
- Rebound tenderness
- 1 point.
- Temperature
- 1 point at 37.3 C (99.1 F) or higher.
- Leukocytosis
- 2 points above 10 x 10^9/L.
- Left shift
- 1 point for 75 percent or more neutrophils or bands above 5 percent.
Add 1 point for each of the six single-point items and 2 points each for right lower quadrant tenderness and leukocytosis. The total runs from 0 to 10. The temperature threshold is 37.3 C or 99.1 F. Leukocytosis means more than 10 x 10^9/L, and left shift means 75 percent or more neutrophils or bands above 5 percent.
Worked example
Example: pain migration, tenderness, rebound, fever, and leukocytosis
Defaults: pain migration Yes, anorexia Yes, nausea No, RLQ tenderness Yes, rebound Yes, elevated temperature Yes, leukocytosis Yes, left shift No.
- Pain migration 1 plus anorexia 1 gives 2 points.
- Nausea or vomiting is absent: 0 points.
- RLQ tenderness gives 2 points, raising the total to 4.
- Rebound 1 plus elevated temperature 1 gives 2 more, for 6.
- Leukocytosis gives 2 points, for a total of 8.
- Left shift is absent: 0 points.
- The score is in the probable band (7 to 8), so the tool suggests surgical consultation and imaging.
Reference table
| Item | Points |
|---|---|
| Pain migrated to the right lower quadrant | 1 |
| Anorexia | 1 |
| Nausea or vomiting | 1 |
| Right lower quadrant tenderness | 2 |
| Rebound tenderness | 1 |
| Elevated temperature (37.3 C or 99.1 F or higher) | 1 |
| Leukocytosis (above 10 x 10^9/L) | 2 |
| Left shift (75 percent or more neutrophils or bands above 5 percent) | 1 |
Limits
- The score cannot confirm or exclude appendicitis.
- It performs less well in children, pregnant patients, and older adults.
- Pelvic inflammatory disease, urinary tract infection, and other conditions can mimic appendicitis.
- Imaging and surgical judgment remain central to the decision.
Common mistakes
- Counting right lower quadrant tenderness as 1 point instead of 2.
- Counting leukocytosis as 1 point instead of 2.
- Using a temperature below 37.3 C (99.1 F) as positive.
- Treating a low score as proof that appendicitis is absent.
- Skipping imaging or surgical review because the score fits a typical band.
Try it yourself
Quick checks. Answers sit tucked under each question.
A patient has none of the eight items. What is the Alvarado score?
0 of 10, which is in the low probability band (0 to 4).
A patient has pain migration, anorexia, nausea, and RLQ tenderness only. What is the score?
5 of 10. The first three items give 3 points and tenderness gives 2, so the score is in the possible band (5 to 6).
A patient has all eight items. What is the score?
10 of 10, which is in the very probable band (9 to 10).
Questions
What is a normal Alvarado score?
There is no normal value. The score is grouped from low probability at 0 to 4 up to very probable at 9 to 10.
What does the Alvarado score of 7 mean?
A score of 7 is in the probable band (7 to 8). It supports further evaluation with imaging and surgical consultation.
Can the Alvarado score rule out appendicitis?
No. A low score is reassuring but does not exclude the diagnosis. Clinical reassessment and imaging may still be needed.
Why are tenderness and leukocytosis worth 2 points?
They were the strongest predictors in the original score. The weighting gives them more influence than the other six items.
Is the Alvarado score used in children?
It can be used, but performance is lower and pediatric appendicitis requires a dedicated assessment pathway.
Does the score replace a CT scan or ultrasound?
No. Imaging is often needed to confirm the diagnosis, especially when the score is intermediate or the clinical picture is unclear.
Sources
- Alvarado score, StatPearls table
- Alvarado score validation in appendicitis
- Alvarado original description