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Alvarado score (MANTRELS): the eight items and how they add up

The Alvarado score adds points for eight findings in suspected appendicitis, remembered by the letters MANTRELS: Migration of pain to the right lower quadrant (1), Anorexia (1), Nausea or vomiting (1), Tenderness in the right lower quadrant (2), Rebound pain (1), Elevated temperature of 37.3 °C or more (1), Leukocytosis, a white cell count over 10,000/µL (2), and Shift to the left, neutrophils over 75% (1). The maximum is 10. Migration, right-lower-quadrant tenderness and a white count of 10,001 give 1 + 2 + 2 = 5.

This page doesn't give a cutoff. Magent's calculator also returns a score band, but this page explains how the total is built, not what a total means or what to do with it.

Not a medical device. Not a diagnosis or dosing recommendation.

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What is the Alvarado score?

The Alvarado score is a points score for suspected acute appendicitis published by Alfredo Alvarado in Annals of Emergency Medicine in 1986. It's also called the MANTRELS score, after the first letters of its eight items, or the Alvarado appendicitis score.

The 1986 abstract describes the method: "Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability," and the author "devised a practical diagnostic score" from eight predictive factors.

This page explains each item and how the total adds up. It doesn't say what a given total means, and the score doesn't diagnose appendicitis.

The Alvarado formula

Alvarado = migration
         + anorexia
         + nausea_vomiting
         + 2 × rlq_tenderness
         + rebound
         + (temperature_c >= 37.3 ? 1 : 0)
         + 2 × (wbc_ul > 10000 ? 1 : 0)
         + (neutrophil_percent > 75 ? 1 : 0)

Exact expression the calculator uses:

Alvarado (MANTRELS) = migration + anorexia + nausea_vomiting + 2*rlq_tenderness + rebound + (temperature_c >= 37.3) + 2*(wbc_ul > 10000) + (neutrophil_percent > 75); max 10; bands 0-4 / 5-6 / 7-10

Each yes/no item counts 1 when true, except right-lower-quadrant tenderness, which counts 2. Maximum: 10.

The MANTRELS items

LetterItemInputPoints
MMigration of pain to the right lower quadrantmigration (true/false)1
AAnorexiaanorexia (true/false)1
NNausea or vomitingnausea_vomiting (true/false)1
TTenderness in the right lower quadrantrlq_tenderness (true/false)2
RRebound painrebound (true/false)1
EElevated temperature, 37.3 °C or moretemperature_c (30.0–45.0)1
LLeukocytosis, white cell count over 10,000/µLwbc_ul or wbc_k_ul2
SShift to the left, neutrophils over 75%neutrophil_percent (0–100)1

How to calculate the Alvarado score

  1. Score the five yes/no findings. Migration, anorexia, nausea or vomiting and rebound pain score 1 each. Right-lower-quadrant tenderness scores 2.
  2. Temperature. 37.3 °C or higher scores 1. 37.2 scores 0.
  3. White cell count. Over 10,000 cells/µL scores 2. Exactly 10,000 scores 0; 10,001 scores 2.
  4. Neutrophils. Over 75% scores 1. Exactly 75.0 scores 0; 75.1 scores 1.
  5. Add everything. The total is 0 to 10.

Units for the white cell count

Magent's calculator takes the white cell count in either of two forms:

  • wbc_ul: cells per µL (the same as cells/mm³), for example 12000.
  • wbc_k_ul: thousands per µL (the same as 10⁹/L), for example 12.

A value in 10⁹/L is converted to cells/µL, so 12 × 10⁹/L is 12,000/µL. The item scores when the converted value is over 10,000.

What the calculator returns

Magent's calculator returns the total, the maximum of 10, the white cell count it used in cells/µL, the temperature and neutrophil percent it used, and a score band. This page doesn't interpret the band.

Worked examples

These use Magent's own expected values for the calculator. In each, unlisted yes/no items are "no", temperature is 37.0 °C, the white cell count is 8,000/µL and neutrophils are 60%, unless stated.

Example 1: nothing present

  1. Five yes/no items: all no → 0.
  2. Temperature 37.0 → 0; white cells 8,000 → 0; neutrophils 60 → 0.
  3. Alvarado = 0 (of 10).

Example 2: right-lower-quadrant tenderness alone

  1. Tenderness → 2.
  2. Alvarado = 2.

Example 3: temperature at the line

  1. Temperature 37.3 → 1.
  2. Alvarado = 1. At 37.2, the same case scores 0.

Example 4: white cell count at the line

  1. White cells 10,000 → 0.
  2. White cells 10,001 → 2.

Example 5: migration, tenderness and a white count of 10,001

  1. Migration → 1.
  2. Tenderness → 2.
  3. White cells 10,001 → 2.
  4. Alvarado = 5.

Example 6: four symptoms plus a high white count

  1. Migration → 1; anorexia → 1; nausea or vomiting → 1.
  2. Tenderness → 2.
  3. White cells 10,001 → 2.
  4. Alvarado = 7.

Alvarado reference values

These are Magent's expected values for the calculator (temperature 37.0 °C, white cells 8,000/µL and neutrophils 60% unless stated otherwise). No findings scores 0. Migration, anorexia, nausea or vomiting and rebound each score 1, and right-lower-quadrant tenderness scores 2. Temperature 37.2 °C scores 0 and 37.3 °C scores 1. White cells of 10,000/µL score 0 and 10,001/µL score 2. Neutrophils of 75% score 0 and 75.1% score 1. Migration, anorexia and tenderness score 4; migration, tenderness and white cells of 10,001/µL score 5; and migration, anorexia, nausea or vomiting, tenderness and white cells of 10,001/µL score 7.

History of the Alvarado score

The score comes from Alfredo Alvarado, A practical score for the early diagnosis of acute appendicitis, Annals of Emergency Medicine, 1986 (volume 15, issue 5, pages 557–564).

The abstract describes "a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis." It reports that "Eight predictive factors were found to be useful," and ranks them by diagnostic weight: "localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain." The two highest-weighted factors, tenderness and leukocytosis, are the two that score 2 points.

The abstract lists the factors but doesn't state the point values or the temperature, white cell and neutrophil lines. Those come from Magent's record for the calculator.

When it's used

The 1986 study looked at patients in hospital with abdominal pain suggestive of acute appendicitis. Magent's record notes that the findings are assigned by the caller; the calculator doesn't examine the abdomen.

Where it's used

The original study was a retrospective study of hospitalized patients.

Who uses it

The abstract presents the score as something "that may help in interpreting the confusing picture of acute appendicitis."

Limits of the calculation

  • It adds eight items. It doesn't examine the abdomen and doesn't diagnose appendicitis.
  • It's the Alvarado 1986 (MANTRELS) score. It isn't RIPASA and isn't the pediatric Appendicitis Score.
  • The temperature, white cell and neutrophil lines are fixed: 37.3 °C or more, over 10,000/µL, over 75%.
  • The calculator returns a score band alongside the total. This page doesn't give a cutoff or say what any total means.

Clinical decisions belong to a qualified clinician who knows the patient.

  • Centor and McIsaac scores are another findings-based points score, for sore throat rather than abdominal pain. Magent's record describes them as four caller-assigned pharyngitis findings, with an age adjustment in the McIsaac edition.

Glossary

  • Right lower quadrant (RLQ): the lower right part of the abdomen.
  • Migration of pain: pain that starts in one place and moves to the right lower quadrant.
  • Rebound pain: pain when pressure on the abdomen is released.
  • Leukocytosis: a raised white blood cell count.
  • Shift to the left: a higher share of neutrophils among white blood cells.
  • Anorexia: loss of appetite (here, not the eating disorder).

Common mistakes

  • Giving tenderness 1 point. Right-lower-quadrant tenderness and leukocytosis each score 2.
  • Scoring a white count of exactly 10,000. It has to be over 10,000.
  • Scoring neutrophils of exactly 75%. It has to be over 75.
  • Entering the white count in the wrong unit. 12 (thousands/µL) and 12,000 (cells/µL) are the same count; use the matching input.
  • Confusing Alvarado with RIPASA or the pediatric Appendicitis Score. They're separate scores.

Source

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564. DOI: 10.1016/S0196-0644(86)80993-3

Frequently asked questions

How do you calculate the Alvarado score?

Add 1 each for migration of pain, anorexia, nausea or vomiting, rebound pain, temperature 37.3 °C or more and neutrophils over 75%, and 2 each for right-lower-quadrant tenderness and a white count over 10,000/µL. The maximum is 10.

What does MANTRELS stand for?

Migration, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound, Elevated temperature, Leukocytosis, Shift to the left.

What Alvarado score means appendicitis?

This page doesn't give a cutoff. It shows how the total is built.

Which items score 2 points?

Right-lower-quadrant tenderness and leukocytosis (white count over 10,000/µL).

Is the Alvarado score the same as the pediatric Appendicitis Score?

No. Magent's record lists the pediatric Appendicitis Score and RIPASA as separate scores.

Who created the Alvarado score?

Alfredo Alvarado, in a 1986 paper in Annals of Emergency Medicine.