Background: Acute appendicitis remains a leading cause of emergency abdominal surgery. The Alvarado Scoring System (ASS) is a well-established clinical tool, yet its performance in specific geographic and demographic contexts—such as the hilly regions of Northern India—requires validation. This study evaluated the diagnostic accuracy of the Alvarado score in a tertiary care setting in Himachal Pradesh.

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Methods: A prospective observational study was conducted from May 2021 to April 2022. Eighty-four patients (age ≥12 years) with suspected appendicitis were enrolled. Alvarado scores were calculated at admission. All patients underwent appendectomy, and histopathological examination (HPE) served as the gold standard. Diagnostic metrics were calculated at a cut-off of ≥7.

Results: Histopathology confirmed acute appendicitis in 79 out of 84 patients (94.05%). At a   cut-off of ≥7, the sensitivity was 86.08% (95% CI: 76.0–92.7%) and specificity was 60.00% (95% CI: 14.7–94.7%). The positive predictive value (PPV) was exceptionally high at 97.14%, while the negative predictive value (NPV) was 21.43%. The overall diagnostic accuracy was 84.52%, with an area under the ROC curve (AUC) of 0.89.

Conclusion: The Alvarado score is a robust “rule-in” tool in high-prevalence settings but lacks the sensitivity to “rule out” the disease when scores are low. In hilly terrains where imaging is often delayed, a score ≥7 justifies surgical intervention, whereas lower scores necessitate vigilant serial clinical observation.