One of the many adages in medicine deals with surgeons diagnosing appendicitis. It says that “If you don’t remove a normal appendix now and then, you’re missing cases of appendicitis.” It’s very true. Appendicitis can be tricky to diagnose. History and physical findings don’t always comply with the normal textbook description, so surgeons use their clinical judgement and experience to decide which patient needs an appendectomy. On occasion, they operate on someone who had classic symptoms and physical exam, but turned out to have a normal appendix.
The comments stated above are fortunately “old school” medicine. When a surgeon is asked to consult on a patient with possible appendicitis, an abdominal CT scan has been done, and it quite accurately (94%-99% sensitive, 94%-97% specific) shows appendicitis. The surgeon just needs to know where to make his incision.
There still exist, though, clinicians who overthink, over-analyze, and over-complicate diagnosing certain disorders. Appendicitis is one of those disorders that people have gone to great lengths to intellectualize when CT scanning has simplified the diagnosis. What I’m referring to are called clinical scoring systems. To my way of thinking, these are templates that attempt to “dumb down” clinical decision-making and take away the art of medicine manifested by diagnostic acumen. Before CT scanning, appendicitis was a diagnosis you used your medical intuition to diagnose.
Clinical scoring systems were developed to improve diagnostic accuracy and use weighted numbers to value each criterion. Values are given for demographics, lab findings, signs, and symptoms. If the total equals or exceeds a predetermined value, the diagnosis is correct.
For appendicitis, two scales exist—the Alvarado and the RIPASA. Examples of criteria are elevated white blood cell count (2 points), negative urinalysis (1), certain physical exam findings like RLQ tenderness (1 point), “guarding (2),” rebound pain (1), loss of appetite (1), and migration of the pain (1), among others. If the total equals or exceeds 7.5, appendicitis is probable. An experienced surgeon worth his salt has these criteria ingrained in his memory bank and doesn’t need a checklist to diagnose appendicitis. It comes naturally.
These scales are ok, but no surgeon I knew would have ever used a scale like this in a public manner—maybe in his head, but not out in the open. If he wasn’t already knowledgeable about appendicitis, he should take another year of training. These scales are an academic exercise that would help students remember all the diagnostic criteria. For the practicing surgeon, however, these criteria are the basis of natural decision-making.
Reference: Pyzocha N. Clinical Scoring System for Adults with Acute Appendicitis Am Fam Phys. 2026 June;112(6):595-596.
