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1 J Korean Surg Soc 2010;78: DOI: /jkss 원 저 급성충수돌기염진단시연령에따른 Alvarado Score 의진단적가치 이화여자대학교의학전문대학원외과학교실 오보영ㆍ김광호ㆍ이령아ㆍ정순섭 Diagnostic Efficacy of the Alvarado Score according to Age in Acute Appendicitis Bo-Young Oh, M.D., Kwang-Ho Kim, M.D., Ph.D., Ryung-Ah Lee, M.D., Ph.D., Soon Sup Chung, M.D., Ph.D. Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea Purpose: This study aims to assess the diagnostic efficacy of the Alvarado score and to determine cut-off values of Alvarado score according to age for deciding on the options for patients with suspected appendicitis. Methods: From October 2008 to January 2009, we prospectively reviewed 152 patients with suspected appendicitis. The patients were classified into adults and children groups. We then determined cut-off values of the Alvarado score by analyzing each score s sensitivity and specificity. Results: Of the 147 patients, 96 patients were adults and 51 were children. The mean Alvarado score for adults and children were 6.08±1.85, and 6.69±1.43 in appendicitis and 4.32±2.02, and 4.60±1.81 in non-appendicitis, respectively. In adults, the sensitivity of the Alvarado scores 7 or higher for appendicitis was 66.2%, and the specificity was 67.7%. And the sensitivity of the Alvarado scores 4 or lower for non-appendicitis was 58.1%, and the specificity was 81.5%. In children, the sensitivity of the Alvarado scores 7 or higher for appendicitis was 80.8%, and the specificity was 68.0%. And the sensitivity of the Alvarado scores 4 or lower for non-appendicitis was 52.0%, and the specificity was 92.3%. Conclusion: The cut-off values for Alvarado score were not different according to age of the patient. If the Alvarado score is 7 or higher, surgical management is recommended, and if the Alvarado score is 4 or lower, observation without CT or US is recommended. In equivocal appendicitis as defined by the Alvarado scores 5 to 6, adjunctive CT or US are recommended to confirm appendicitis. (J Korean Surg Soc 2010;78: ) Key Words: Acute appendicitis, Alvarado score, Age 중심단어 : 급성충수돌기염, Alvarado 점수, 연령 서 급성충수돌기염은응급복부수술을요하는가장흔한 책임저자 : 김광호, 서울시양천구목동 , 이화여자대학교의학전문대학원외과학교실 Tel: , Fax: eastgate@ewha.ac.kr 접수일 :2009 년 9 월 30 일, 게재승인일 :2009 년 11 월 12 일본논문은 2009 년도대한외과학회추계학술대회에서발표되었음. 론 질환중의하나로,(1,2) 급성복증을호소하는환자들에게있어서이에대한감별진단이필요하며 (3-5) 이를위해서는임상증상, 이학적소견, 염증상태를시사하는검사소견등을파악해야한다.(4,6) 그러나전형적인증상이나신체소견을보이지않는경우에는여전히진단에어려움이따르며,(1) 특히소아의경우비특이적증상으로인해성인에비해진단이늦어질수있다.(7,8) 이처럼진단이모호한경우에수술의지연으로인한천공및합병증의발생률이높아질수있고경우에따라불필요한수술이시행되기도한다.(1) 최근컴퓨터단층촬영술이나복부초음파등의영상진 100

2 Bo-Young Oh, et al:diagnostic Efficacy of the Alvarado Score according to Age in Acute Appendicitis 101 단방법의발전으로급성충수돌기염의진단율이높아지고있으나 (4,9) 이의무분별한사용으로인한시간및비용의낭비, 또는판독자의기술적차이로인해급성충수염이의심되는모든환자에게이를적용하는데무리가따를수있다.(1,6) 이러한측면에서불필요한영상진단방법의사용을최소화하기위한여러임상점수제가사용되어왔으며이중가장대표적인것이 Alvarado score이다.(3,4) Alvarado score는환자들의임상증상, 혈액검사소견등을수치화하여점수로표시한것으로,(8) 1986년그의보고에따르면 7 10점은수술을, 5 6점은관찰및추가검사를, 0 4점은귀가조치를추천하였으며,(10) 이는현재까지도간단하고유용한진단수단의하나로이용되고있다.(2) 이에저자들은성인과소아에서급성충수돌기염을진단함에있어 Alvarado score의진단적가치를비교분석하고, 점수에따른추가검사및수술시행의적용기준을정하고자하였다. 방 본연구는 2008년 10월부터 2009년 1월까지이화여자대학교목동병원응급실및외과외래를통해급성충수돌기염의심하에진료의뢰된환자 152명을대상으로전향적으로진행되었다. 이들중타병원으로전원된환자 4명및자의퇴원한환자 1명은연구대상에서제외되었으며대상환자를연령에따라분류하여만 18세이하를소아, 만 19세이상을성인으로구분하여결과를분석하였다. 모든대상환자에게 Alvarado score를적용하여점수화한후에컴퓨터단층촬영술또는복부초음파를시행하여수 Table 1. Alvarado scoring system Features Score Symptoms Migration of pain 1 Anorexia 1 Nausea/vomiting 1 Signs Tenderness in the right lower abdomen 2 Rebound tenderness 1 Elevated temperature ( 37.3 o C) 1 Laboratory test Leukocytosis* 2 Neutrophilic shift to the left 1 Total score 10 *2 5 yrs: >14,500, 6 11 yrs: >13,500, 12 yrs: >10,000; 2 5 yrs: >55.2%, 6 11 yrs: >59.3%, 12 yrs: >75.2%. 법 술여부를결정하였으며, 수술을시행한경우각결과를조직병리결과와비교분석하였다. 또한 Alvarado score에따른민감도, 특이도, 양성예측도, 음성예측도, 위양성도, 위음성도을비교하여 Alvarado score의 cut-off value를정하고자하였다. Alvarado score는임상양상및검사실소견을토대로점수화하는것으로이동통증 1점, 식욕부진 1점, 오심또는구토 1점, 우하복부압통 2점, 반발통 1점, 발열 1점, 백혈구증가 2점, 호중구증가 1점을부여하여총 10점으로구성되어있으며, 이중백혈구증가및호중구증가를평가하기 위한정상범위는본원의기준을따랐으며연령에따라정상범위를달리분류하였다 (Table 1). 통계학적분석은 SPSS version 17.0을이용하여 student s t-test와 ANOVA test를통해분석하였으며, P값이 0.05 이하일경우를유의하다고판정하였다. Table 2. Result of Alvarado score according to the pathologic findings Pathology 결 Number (%) Mean score Number (%) Mean score Suppurative 39 (60.0) 6.08± (80.8) 6.48±1.33 Gangrenous 21 (32.3) 6.38± (7.7) 7.50±0.50 Perforated 5 (7.7) 6.60± (11.5) 8.67±0.47 Total 65 (100.0) 6.22± (100.0) 6.81±1.41 P-value 과 1) 수술소견에따른환자분포 총 147명의환자중성인이 96명 ( 남자 41명, 여자 55명 ), 소아가 51명 ( 남자 30명, 여자 21명 ) 이었으며이들의평균연령은각각 37.58±13.00세 (19 79세), 10.37±4.35세 (2 18세) 였다. 대상환자들중충수돌기절제술을시행받은환자는총 94명으로성인이 66명, 소아가 28명이었고, 이중성인은 65 명 (67.71%), 소아는 26명 (50.98%) 이급성충수돌기염으로확인되었으며음성충수절제술의비율은성인이 1.52%, 소아가 7.14% 였다. 수술을시행하지않고추적관찰한환자들중추후에급성충수돌기염으로재진단받은경우는한경우도없었다. 수술후조직병리결과에따라급성충수돌기염의정도를

3 102 J Korean Surg Soc. Vol. 78, No. 2 화농성, 괴저성, 천공성으로분류하였으며, 각단계에따른평균 Alvarado score를비교한결과충수염이심할수록 Alvarado score가높아지는경향을보였는데소아에서는통계학적으로유의하였으나성인에서는유의하지않았다 (Table 2). 2) 컴퓨터단층촬영술및복부초음파결과 급성충수돌기염을진단하기위해모든환자가컴퓨터단층촬영술또는복부초음파를시행하였는데성인의경우 87명이컴퓨터단층촬영술을시행하였고나머지 9명이복부초음파를시행하였다. 이중 62명이급성충수돌기염소견을보였으며수술결과위양성은없었고위음성은 3명있었다. 소아의경우에는 32명이컴퓨터단층촬영술을, 19 명이복부초음파를시행하였으며, 이중 27명이급성충수돌기염소견을보였고위양성 2명, 위음성 1명이었다. Table 3. Findings of CT or US negative group Normal 13 8 Lymphadenopathy 0 9 Diverticulitis 7 4 Enterocolitis 5 0 Pelvic inflammatory disease 4 0 Peritonitis 1 0 Ovarian cyst 1 1 Pancreatitis 1 0 Acute pyelonephritis 1 0 Inflammatory bowel disease 1 0 Intussusception 0 1 Ganglioneuroma 0 1 Total 컴퓨터단층촬영술과복부초음파검사에서충수돌기가정상이었던경우는성인이 34명, 소아가 24명이었으며, 이중성인 13명, 소아 8명은특이소견이관찰되지않았으나나머지환자들은급성충수돌기염외에다른질환을동반하고있었다. 대표적질환으로성인에서는게실염이 7명으로가장많았으며소아에서는장간막림프절염이 9명으로가장많았다 (Table 3). 3) Alvarado score의진단적가치모든환자들의초진시에 Alvarado score를측정하였으며 score에따른환자분포는 Table 4와같았다. 이들의평균 Alvarado score는성인이 5.56±2.13점, 소아가 5.74±1.95점이었으며, 이중충수돌기염환자의평균 Alvarado score는성인과소아가각각 6.22±1.88점, 6.81±1.41점이었고비충수돌기염환자의경우에는각각 4.19±1.97점, 4.58±1.78점으로성인과소아양군에서모두통계학적으로유의한차이를보였다 (Fig. 1, 2). 급성충수돌기염의진단을위한 cut-off value를구하기위해 Alvarado score에따른민감도와특이도, 양성예측도, 음성예측도, 위양성도, 위음성도를구하였다 (Table 5). 성인의경우 Alvarado score가 8점이상일때의민감도는 26.2%, 특이도는 96.8% 였으며, 7점이상일때의민감도와특이도는각각 55.4%, 83.9% 였고, 6점이상일때는각각 66.2%, 67.7% 로 Alvarado score가 7점이상일때가충수돌기염을양성으로평가하기에가장적절한것으로평가되었다. 소아의경우 8점이상일때의민감도와특이도가각각 34.6%, 88.0% 였고, 7점이상일때는각각 61.5%, 88.0%, 6점이상일때는 Table 4. Alvarado scores of patients Score Appendicitis Non-appendicitis Total Appendicitis Non-appendicitis Total Total

4 Bo-Young Oh, et al:diagnostic Efficacy of the Alvarado Score according to Age in Acute Appendicitis 103 Fig. 1. Frequency according to Alvarado score in adults. Fig. 2. Frequency according to Alvarado score in children. Table 5. Statistical value according to Alvarado score Sensitivity (%) Specificity (%) PPV* (%) NPV (%) FP (%) FN (%) AS AS AS AS AS AS AS AS *PPV = positive predictive value; NPV = negative predictive value; FP = false positive; FN = false negative; AS = Alvarado score. 각각 80.8%, 68.0% 로소아의경우에서도역시 Alvarado score 가 7점이상일때가충수염을진단하기에가장적절하였다. 또한비충수돌기염을평가하기위한분석결과, 성인에서 Alvarado score가 4점이하일때의민감도가 67.7%, 특이도가 81.5% 였고, 3점이하일때는민감도 35.5%, 특이도 92.3% 였으며, 2점이하일때는각각 16.1%, 93.8% 로 4점이하일때가가장적절한것으로평가되었다. 소아의경우에는민감도와특이도가 4점이하일때각각 64.0%, 92.3%, 3점이하일때 28.0%, 100.0%, 2점이하일때 16.0%, 100.0% 로성인과마찬가지로 4점이하일때가비충수돌기염을평가하기에가장적절하였다. 고찰 급성충수돌기염은급성복증의가장흔한원인중의하나로 (1,3) 남성에서약 9%, 여성에서약 7% 의발생률을보 인다.(4) 이에대한치료가지연될경우충수돌기천공으로이어질수있어정확하고신속한진단이요구되나, 33% 까지보고되고있는비특이적증상 (11) 으로인해여전히진단에어려움이따른다.(6) 현재사용되고있는진단방법으로는환자의문진및신체검사, 검사소견등을바탕으로진단하는것이가장기본적이며,(3,6) 컴퓨터단층촬영술이나복부초음파, 자기공명영상등과같은영상진단방법을이용할수도있고진단적복강경술을시행하기도한다.(12) 이러한방법들중컴퓨터단층촬영술이나복부초음파와같은영상진단방법은가장보편적으로사용되고있는것으로 (11) 이의발달로급성충수돌기염의진단율이매우높아지고있으며,(13,14) 음성충수절제술의비율도낮아졌다는연구결과들이보고되고있다.(15,16) 컴퓨터단층촬영술의진단율에대한일부연구에따르면 Lee 등 (2) 은민감도 90%, 특이도 97%, 양성예측도 99%, 음성예측도 78%, 정확도 92% 로보고하였으며, Rhea 등 (17) 은민감도 99%, 특

5 104 J Korean Surg Soc. Vol. 78, No. 2 이도 95% 라고보고하였다. 복부초음파에대해서 Zielke 등 (18) 은민감도 86%, 특이도 96% 라고하였고, Douglas 등 (12) 은민감도 94.7%, 특이도 88.9% 라고하였다. 본연구에서도컴퓨터단층촬영술및복부초음파의민감도와특이도는각각성인에서 95.4%, 100%, 소아에서는 96.2%, 92.0% 로높은진단율을보였다. 하지만이러한높은진단율에도불구하고이의무분별한사용에대한부정적인의견도제기되고있다.(19) 환자의비용부담및재원기간의증가와검사자의능력에따른진단율의차이가발생할수있으며, 컴퓨터단층촬영술의경우방사선노출이나조영제사용에따른부작용의위험이있을수있다.(1,6) 또한수술전컴퓨터단층촬영술의시행이임상소견에의한진단보다정확도가높지않았으며,(20,21) 음성충수절제술비율을낮추지못했다는연구결과가보고되기도하였다.(22,23) 이러한점에서급성충수돌기염이의심되는모든환자에게컴퓨터단층촬영술이나복부초음파를시행하는것은비효율적이며, 환자의임상증상을토대로하여급성충수돌기염의여부를판단하기어려운경우에선택적으로추가적인영상진단방법을시행하는것이적절할것이다. 이를위해환자의임상증상을객관화하기위한여러임상점수제가도입되어사용되고있으며 (4,11) Alvarado score가가장대표적인점수제로 (24) 이는쉽고빠르며, 경제적인동시에비침습적인방법이다. Alvarado(10) 는대상환자들의임상증상과검사소견을점수화하여세군으로분류하였으며, 급성충수돌기염이강하게의심되는 7 10점인경우즉각적인수술을하도록하였고, 급성충수돌기염의가능성이떨어진다고판단한 0 4점인경우는추가검사없이귀가조치하도록하였다. 또한점수만으로는판단이애매한 5 6점인경우에는급성충수돌기염을진단하기위한추가검사를시행할것을권고하였다. 이후이와관련된연구들이진행되었으며 Macklin 등 (24) 은 Alvarado와같은점수인 7점을 cut-off value로정하고이때의민감도와특이도를 76.3%, 78.8% 로보고하였다. 또한 Jang 등 (1) 은 Alvarado의결과와달리 6점이상인경우를 cut-off value로정하여이때의민감도와특이도를 88.3%, 94.5% 라고하였고, Sun 등 (4) 도 6점이상일때의민감도와특이도를 72.8%, 61.6%, 양성예측도와음성예측도를각각 71.7% 와 72.8% 로보고하였다. 이러한기존의연구들은주로성인을대상으로한것으로소아에대한연구는아직까지미미한상태이다.(24) 이에저자들은연구를진행함에있어대상환자를성인과소아로구분하여각각의결과를비교 하였다. 본연구에서는 Alvarado의연구결과와같이급성충수돌기염을진단하기에가장적절한 cut-off value로 7점을정하였으며이는성인과소아에서동일한결과를보였다. 이때의민감도와특이도는성인에서 55.4%, 83.9% 였고소아에서는 61.5%, 88.0% 였다. 또한비충수돌기염을판단하기에가장적절한 cut-off value도성인과소아에서모두 4점이었으며이때의민감도와특이도는각각성인에서 67.7%, 81.5%, 소아에서 64.0%, 92.3% 였다. 조직학적으로충수돌기염이확인된경우 Alvarado score 에따른염증의정도를평가하기위한연구가진행되었으며, Lee 등 (2) 에의하면점수가높을수록충수돌기의염증이심해지는결과를보였다고하였다. 본연구에서도이와유사한결과를보였으나성인의경우통계학적으로유의하지는않았다. Alvarado score가컴퓨터단층촬영술이나복부초음파에비해진단율이떨어지기는하지만급성복증환자의초진시에활용하기에효과적이며, 음성충수절제술의비율도크게높지않아약 7%,(25) 8.7%,(6) 11.5%(1) 등의연구결과가보고되고있다. 본연구결과에서도 Alvarado score만이용했을경우예상되는음성충수절제술의비율은성인에서 16.1%, 소아에서 12.0% 로일반적으로용인되는 12 15%(2,4) 를크게벗어나지는않았다. 결 급성충수돌기염을진단함에있어 Alvarado score는성인과소아모두에서이용가능하며적절한처치를결정하기위한 cut-off value는연령에따른차이를보이지않았다. Alvarado score가 7 10점인경우는수술을시행하고, 0 4 점인경우는추가검사없이외래추적관찰을하며, 5 6점으로진단이어려운경우에는컴퓨터단층촬영술이나복부초음파와같은추가검사를시행할필요가있을것으로사료된다. 또한소아의경우 score와염증의정도는비례하는것으로분석되므로신속한처치가필요할것으로생각한다. 론 REFERENCES 1) Jang SO, Kim BS, Moon DJ. Application of Alvarado score in patients with suspected appendicitis. Korean J Gastroenterol 2008;52:27-31.

6 Bo-Young Oh, et al:diagnostic Efficacy of the Alvarado Score according to Age in Acute Appendicitis 105 2) Lee SM, Chang IT, Kim BG, Cha SJ, Kim YS, Pak JS. The efficacy of the Alvarado score in the diagnosis of acute appendicitis. J Korean Soc Coloproctol 2008;24:1-6. 3) Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 2008;32: ) Sun JS, Noh HW, Min YG, Lee JH, Kim JK, Park KJ, et al. Receiver operating characteristic analysis of the diagnostic performance of a computed tomographic examination and the Alvarado score for diagnosing acute appendicitis: emphasis on age and sex of the patients. J Comput Assist Tomogr 2008; 32: ) Petrosyan M, Estrada J, Chan S, Somers S, Yacoub WN, Kelso RL, et al. CT scan in patients with suspected appendicitis: clinical implications for the acute care surgeon. Eur Surg Res 2008;40: ) McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007; 25: ) Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring systems using a prospective pediatric cohort. Ann Emerg Med 2007;49: ) Yang ES, Yoon SK, Kim EY, Rho YI, Park SK, Park YB, et al. Usefulness of a Alvarado scoring system for the diagnosis of acute appendicitis in children. Korean J Pediatr Gastroenterol Nutr 2004;7:1-7. 9) Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med 2003;10: ) Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15: ) Yildirim E, Karagulle E, Kirbas I, Turk E, Hasdogan B, Teksam M, et al. Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis. Diagn Interv Radiol 2008;14: ) Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321: ) Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med 2003;348: ) Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004;141: ) Stroman DL, Bayouth CV, Kuhn JA, Westmoreland M, Jones RC, Fisher TL, et al. The role of computed tomography in the diagnosis of acute appendicitis. Am J Surg 1999;178: ) Brandt MM, Wahl WL. Liberal use of CT scanning helps to diagnose appendicitis in adults. Am Surg 2003;69: ) Rhea JT, Halpern EF, Ptak T, Lawrason JN, Sacknoff R, Novelline RA. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR Am J Roentgenol 2005;184: ) Zielke A, Sitter H, Rampp T, Bohrer T, Rothmund M. Clinical decision-making, ultrasonography, and scores for evaluation of suspected acute appendicitis. World J Surg 2001;25: ) Martin AE, Vollman D, Adler B, Caniano DA. CT scans may not reduce the negative appendectomy rate in children. J Pediatr Surg 2004;39: ) Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD. A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003;4: ) Smink DS, Finkelstein JA, Garcia Pena BM, Shannon MW, Taylor GA, Fishman SJ. Diagnosis of acute appendicitis in children using a clinical practice guideline. J Pediatr Surg 2004;39: ) Poh AC, Lin M, Teh HS, Tan AG. The role of computed tomography in clinically-suspected but equivocal acute appendicitis. Singapore Med J 2004;45: ) Vadeboncoeur TF, Heister RR, Behling CA, Guss DA. Impact of helical computed tomography on the rate of negative appendicitis. Am J Emerg Med 2006;24: ) Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl 1997;79: ) van den Broek WT, Bijnen BB, Rijbroek B, Gouma DJ. Scoring and diagnostic laparoscopy for suspected appendicitis. Eur J Surg 2002;168:

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Jkss hwp 급성복증을보이는감염성요막관기형 Infected Urachal Remnants with Symtoms of the Acute Abdomen: The Differential Diagnosis & Proper Management Jan Dy Lee, M.D., Chee Young Lim, M.D. 1, Hyoung Il Kim, M.D. 1, Chul Woon Chung,