Alvarado score (MANTRELS)
Clinical score for suspected acute appendicitis
Sources last checked: 2026-10-13
Alvarado score (MANTRELS)
Clinical score for suspected acute appendicitis
WSES 2020: a score below 5 is sensitive enough to exclude appendicitis (sensitivity ≈ 99 %).
Good at ruling out (cut-off 5) but not specific enough to rule in appendicitis in adults; it overpredicts in women. Derived retrospectively in 305 patients. The 37.3 °C temperature threshold is low compared with other definitions of fever.
Interpretation
| 0–4 — low risk | WSES 2020: a score below 5 is sensitive enough to exclude appendicitis (sensitivity ≈ 99 %). |
|---|---|
| 5–6 — intermediate | Intermediate-risk stratum: the score alone neither confirms nor excludes appendicitis. |
| 7–8 — high risk | High-risk stratum. WSES 2020 advises against using the Alvarado score alone to confirm appendicitis in adults — the AIR score or imaging adds specificity. |
| 9–10 — very high risk | WSES 2020: in patients younger than 40 with strong signs, pre-operative cross-sectional imaging may be omitted before diagnostic ± therapeutic laparoscopy. |
What is the Alvarado score (MANTRELS)?
The Alvarado score (mnemonic MANTRELS) assigns up to 10 points to eight symptoms, signs and laboratory findings of acute appendicitis. Alfredo Alvarado published it in 1986 based on a retrospective analysis of 305 patients. It is widely used but, according to WSES 2020, is better for ruling out than for confirming appendicitis.
When to use it
- Suspected appendicitis in the emergency department when CRP is not available.
- Ruling out appendicitis in low-risk patients (score < 5).
- Comparison with the AIR score in teaching and audits.
When not to use it
- To confirm appendicitis in adults — WSES advises against it.
- Pregnant women, in whom WBC and nausea are physiologically altered.
- As the sole basis for discharging elderly or immunosuppressed patients.
How it is calculated
| Criterion | Points |
|---|---|
| Migration of pain to the right iliac fossa | +1 |
| Anorexia (or acetone in urine) | +1 |
| Nausea or vomiting | +1 |
| Tenderness in the right iliac fossa | +2 |
| Rebound pain | +1 |
| Elevated temperature (≥ 37.3 °C) | +1 |
| Leukocytosis (WBC > 10 × 10⁹/L) | +2 |
| Shift to the left (neutrophils > 75 %) | +1 |
Clinical pearls and limitations
- Good at ruling out (cut-off 5) but not specific enough to rule in appendicitis in adults; it overpredicts in women. Derived retrospectively in 305 patients. The 37.3 °C temperature threshold is low compared with other definitions of fever.
- Right iliac fossa tenderness and leukocytosis score 2 points each; all other items 1.
- MANTRELS: Migration, Anorexia, Nausea/vomiting, Tenderness RIF, Rebound, Elevated temperature, Leukocytosis, Shift to the left.
- A systematic review (Ohle 2011) found it well calibrated in men, inconsistent in children and overpredicting in women; the cut-off of 7 performed poorly for ruling in.
- WSES 2020: a cut-off below 5 has about 99 % sensitivity for excluding appendicitis.
Frequently asked questions
What Alvarado score is high?
7–10 points places the patient in the high-risk stratum; 9–10 is the very-high-risk range referenced by WSES.
What does MANTRELS stand for?
Migration of pain, Anorexia, Nausea/vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature, Leukocytosis, Shift of WBC to the left.
Alvarado or AIR score?
WSES 2020 recommends AIR (or the Adult Appendicitis Score) for adults; Alvarado is acceptable to rule out but not to rule in.
Evidence and guidelines
- Primary source: Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15(5):557-564.
- Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139.
- Di Saverio S et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020;15:27 (statements 1.2–1.10).
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