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Alvarado Score Calculator (Appendicitis)

Likelihood of acute appendicitis with the Alvarado (MANTRELS) score — migration of pain, anorexia, nausea, RLQ tenderness, rebound, fever, leukocytosis, neutrophil shift — with imaging and surgical guidance.

Migration of pain to the right lower quadrant (1)

Anorexia or ketones in urine (1)

Nausea or vomiting (1)

Tenderness in the right lower quadrant (2)

Rebound pain (1)

Elevated temperature ≥ 37.3 °C (1)

Leukocytosis > 10 ×10⁹/L (2)

Shift to the left — neutrophils > 75% (1)

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How it works

Migration 1 + Anorexia 1 + Nausea/vomiting 1 + Tenderness RLQ 2 + Rebound 1 + Elevated temperature 1 + Leukocytosis 2 + Shift to left 1 (MANTRELS, max 10); ≤ 3 low, 4–6 intermediate, ≥ 7 high

The Alvarado score, remembered by the mnemonic MANTRELS, structures the classic clinical picture of appendicitis: pain that starts centrally and migrates to the right iliac fossa, loss of appetite, nausea, focal tenderness with rebound, low-grade fever and a neutrophil-predominant leukocytosis. Its best use is as a rule-out tool — scores below 5 make appendicitis very unlikely and can spare CT radiation, particularly in children. High scores are less reliable, especially in women of reproductive age, where gynaecological causes mimic appendicitis, so most centres image intermediate and high scorers before surgery. The paediatric appendicitis score (PAS) and the adult appendicitis score are refinements for specific populations.

Worked example

Migration, anorexia, RLQ tenderness, rebound, temperature 37.8 and WBC 13 with 82% neutrophils: 1 + 1 + 2 + 1 + 1 + 2 + 1 = 9 — high probability; surgical review.

Frequently asked questions

Should a high score go straight to theatre?

In men with a classic picture some surgeons operate without imaging; most guidelines still recommend ultrasound or CT to reduce negative appendicectomy rates, which are highest in young women.

Is the score valid in children?

It performs reasonably, but the Paediatric Appendicitis Score (which adds cough/percussion/hopping tenderness) was designed for children and is preferred.

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Clinical decision tool for education and for use by trained clinicians alongside judgement — not a diagnosis and not a substitute for medical assessment. Scores validated in specific populations may not apply to every patient.