For healthcare professionals
Alvarado score calculator (MANTRELS)
The Alvarado score adds up eight symptoms, signs and blood test findings into a total from 0 to 10 for a patient with suspected acute appendicitis. The mnemonic MANTRELS lists the items. This calculator gives the total and its risk stratum. It is written for clinicians and is not a diagnosis.
Findings
For a patient with suspected acute appendicitis. Answer each item. Nothing you enter leaves this page.
What you will see
The Alvarado total from 0 to 10, the items that scored, and whether the total falls in the low (4 or less), intermediate (5 to 6) or high (7 to 10) stratum.
Educational only, not medical advice. Not a diagnosis and not a treatment decision.
Source
Alvarado A, Ann Emerg Med 1986 (the original score). Items, points and thresholds as printed in Table 1 of Al-Tarakji and colleagues, 2022 (open access); performance at the cut points of 5 and 7 from the systematic review by Ohle and colleagues, 2011 (open access). The tests check every point value and every stratum boundary.
Validated in
Built from a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis (Alvarado 1986). The 2011 systematic review pooled 42 validation studies from emergency departments and surgical wards in many countries, with separate analyses for men, women and children; studies of pregnant patients were excluded.
Limits
The score helps sort patients with suspected appendicitis; it is not a test for other causes of abdominal pain. Studies of pregnant patients were excluded from the 2011 review. In the 2011 review it over-predicted appendicitis in women across all strata and gave inconsistent results in children, and a high score was not specific enough on its own to proceed to surgery.
Alvarado score items and points
The items, with their points, are listed below in the order of the MANTRELS mnemonic (Al-Tarakji 2022) (Ohle 2011). Tenderness in the right lower quadrant and leukocytosis score 2 points each; the other six items score 1 point each.
| Letter | Item | Points |
|---|---|---|
| M | Migration of pain to the right iliac fossa | 1 |
| A | Anorexia | 1 |
| N | Nausea or vomiting | 1 |
| T | Tenderness in the right iliac fossa | 2 |
| R | Rebound tenderness | 1 |
| E | Elevated temperature (over 37.3 °C) | 1 |
| L | Leukocytosis (white cells over 10,000 per µL) | 2 |
| S | Shift to the left (neutrophils over 75%) | 1 |
| Total | 10 |
In the original study, the factors ranked by diagnostic weight were localized right lower quadrant tenderness, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea and vomiting, anorexia, and rebound pain (Alvarado 1986).
Risk strata
| Alvarado total | Stratum |
|---|---|
| 4 or less | Low probability of acute appendicitis |
| 5 to 6 | Intermediate probability |
| 7 to 10 | High probability |
These are the strata printed with the score in the source table, which lists the low stratum as 1 to 4 (Al-Tarakji 2022); a total of 0 is also below the cut point of 5. The 2011 systematic review used the same strata (Ohle 2011).
How well the score performs
A 2011 systematic review of 42 studies tested the score at two cut points (Ohle 2011):
- Cut point of 5, to rule out: pooled sensitivity was 99% overall, 96% in men, 99% in women and 99% in children. The authors called the score a useful rule-out tool at this cut point for all patient groups.
- Cut point of 7, to rule in: pooled specificity was 81% overall, 57% in men, 73% in women and 76% in children, which the authors judged too low to go straight to surgery in any group.
- Calibration: predicted and observed rates matched well in men. The score over-predicted appendicitis in women across all strata and in children in the intermediate and high strata.
The review also notes that further tests such as ultrasound or CT are recommended when the probability is in the intermediate range (Ohle 2011). Local pathways and current guidelines should guide imaging and referral.
Related tools
For other clinician scores on this site, see the qSOFA score calculator for suspected infection, the Glasgow Coma Scale calculator, the CURB-65 calculator for pneumonia and the Centor score calculator for a sore throat. For acute pancreatitis, see the Ranson criteria calculator.
Sources
- 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. PMID 3963537. Abstract (retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis; eight predictive factors). pubmed.ncbi.nlm.nih.gov/3963537/
- Al-Tarakji M, Zarour A, Singh R, et al. The role of Alvarado score in predicting acute appendicitis and its severity in correlation to histopathology: a retrospective study in a Qatar population. Cureus. 2022;14(7):e26902. doi:10.7759/cureus.26902. PMID 35983388. Open access (CC BY). Table 1 (Alvarado items, points, thresholds and risk strata). pmc.ncbi.nlm.nih.gov/articles/PMC9376215/
- 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. doi:10.1186/1741-7015-9-139. PMID 22204638. Open access (CC BY). Abstract and Results (42 studies; cut points of 5 and 7; calibration by risk stratum in men, women and children). pmc.ncbi.nlm.nih.gov/articles/PMC3299622/
Written and maintained by the uncovermyrisk.com editorial team. We do not have a medical reviewer; every claim links to its primary source above. Last reviewed: 2026-11-01. Spotted an error? See About.