Manterals sign
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Manteral sign clinical medicine meningism spine
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https://pmc.ncbi.nlm.nih.gov/articles/PMC12553477
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"Manteral sign" OR "Manterel sign" neurology clinical examination
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"Manteral" sign orthopedic spine lumbar OR cervical clinical
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"Manteral sign" meningitis OR meningism clinical eponym
After thorough searching across medical textbooks, PubMed literature, and the web, I cannot find any clinical sign specifically called "Manteral's sign" in authoritative medical sources. Here is my honest assessment:
Manteral's Sign - Not Found in Standard References
"Manteral's sign" does not appear in any of the major medical textbooks in the library (Harrison's, Goldman-Cecil, Tintinalli's, Neuroanatomy through Clinical Cases, etc.), nor in any indexed PubMed literature or standard neurology/clinical examination references.
Possible explanations:
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Spelling variant - You may be thinking of a similarly named sign. Common eponymous signs in the context of meningeal irritation include:
- Kernig's sign - Hip flexed 90°, pain/resistance on knee extension; suggests meningeal irritation (sensitivity 5-27%, specificity 90-95%)
- Brudzinski's sign - Passive neck flexion causes involuntary hip and knee flexion
- Nuchal rigidity - Resistance to passive neck flexion; the most classic sign of meningism
- Amoss's / Tripod sign - Patient props up on arms when sitting; seen in pediatric meningism
- Jamil's sign (2022) - Assessing neck stiffness in lateral decubitus position
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Regional/uncommon eponym - Some clinical signs are described in regional textbooks or non-English literature and are not widely indexed. If you encountered this in a specific textbook or lecture, the source context would help.
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Possible misspelling - Could you be referring to "Monro's sign," "Marburg's sign," or another sign? Please double-check the spelling or the source where you came across this.
If you can provide more context - such as the specialty, clinical setting (neurology, orthopedics, pediatrics), or the source (textbook name, lecture), I can search more precisely. I would rather acknowledge uncertainty than give you inaccurate information about a clinical sign.
Manterals score
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"Manterals score" OR "Manteral score" clinical medicine
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Got everything needed. Here is the full answer:
MANTRELS Score (Alvarado Score)
"Manterals score" is the MANTRELS score, which is the same as the Alvarado Score - a 10-point clinical prediction tool developed by Dr. Alfredo Alvarado in 1986 for the early bedside diagnosis of acute appendicitis. MANTRELS is simply the mnemonic that spells out its eight components.
The MANTRELS Mnemonic
| Letter | Feature | Points |
|---|---|---|
| M | Migration of pain to RLQ (right lower quadrant) | 1 |
| A | Anorexia | 1 |
| N | Nausea / Vomiting | 1 |
| T | Tenderness in RLQ | 2 |
| R | Rebound tenderness | 1 |
| E | Elevated temperature (fever) | 1 |
| L | Leukocytosis (WBC > 10,000/mm³) | 2 |
| S | Shift of WBC to the left | 1 |
| Total | 10 |
Score Interpretation
| Score | Interpretation | Action |
|---|---|---|
| 1 - 4 | Low probability of appendicitis | Observe; unlikely appendicitis |
| 5 - 6 | Suggestive of appendicitis | Surgeon evaluation or imaging |
| 7 - 8 | Probable appendicitis | Surgical consultation |
| 9 - 10 | Very likely appendicitis | Surgical intervention likely needed |
- A score ≥ 7 raises probability of appendicitis significantly (LR = 3.1)
- A score ≤ 4 substantially reduces probability (LR = 0.1)
Key Points
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Consists of 3 symptoms (M, A, N) + 3 signs (T, R, E) + 2 lab values (L, S)
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Tenderness in RLQ and leukocytosis each carry 2 points (higher weight)
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It is fast, simple, non-invasive, and repeatable - useful even in peripheral hospitals without advanced imaging
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Limitation in females: Lower diagnostic accuracy due to gynecological mimics (e.g., ovarian cyst, PID); additional imaging (USS/CT) is recommended alongside the score in women
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Does not replace clinical judgment - the experienced clinician's impression remains the most important factor
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Sleisenger and Fordtran's Gastrointestinal and Liver Disease, Table 11.4
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Tintinalli's Emergency Medicine, Scoring Systems section
Management of acute appendicites
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acute appendicitis management guidelines 2024 2025
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"acute appendicitis"[MeSH Terms] AND "appendectomy"[MeSH Terms]
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Excellent - I now have comprehensive, detailed content from multiple surgical textbooks. Here is the full answer:
Management of Acute Appendicitis
1. Initial Resuscitation and Antibiotics
Once the diagnosis is confirmed, all patients should be started on:
- IV crystalloid fluids for resuscitation (if needed)
- Broad-spectrum IV antibiotics covering gram-negative organisms and anaerobes
The most common organisms involved are E. coli, B. fragilis, and K. pneumoniae.
Antibiotic options:
| Regimen | Class |
|---|---|
| Piperacillin-tazobactam | Extended-spectrum (first-line) |
| Ampicillin-sulbactam | Beta-lactam/inhibitor |
| Imipenem-cilastatin | Carbapenem |
| Ceftriaxone + metronidazole | Narrow-spectrum alternative |
| Cefoxitin | Narrow-spectrum alternative |
Studies show no difference in outcomes between extended-spectrum and narrow-spectrum antibiotics for uncomplicated appendicitis - narrow-spectrum agents are preferred given rising antibiotic resistance. For uncomplicated appendicitis treated with appendectomy, antibiotics need not be continued postoperatively.
2. Timing of Surgery
- Uncomplicated appendicitis is no longer considered an absolute surgical emergency
- Surgery delayed up to 24 hours from hospital presentation carries no significantly higher risk of progression to complicated appendicitis (WSES Jerusalem Guidelines 2020)
- Delay to hospital day 2 shows similar outcomes (NSQIP data)
- Delay to hospital day 3 is associated with increased 30-day mortality and major complications - this should be avoided
3. Uncomplicated Appendicitis - Two Treatment Paths
A. Surgical Management (Standard of Care)
Laparoscopic appendectomy is the preferred approach where expertise and equipment are available.
Advantages of laparoscopic over open:
- Lower surgical site infection (SSI) rate
- Shorter hospital stay
- Faster return to normal activity
- Less postoperative pain
- (Caveat: slightly higher intra-abdominal abscess rate than open)
Open appendectomy via McBurney's point incision remains an important alternative where laparoscopy is unavailable or contraindicated. Robotic and single-incision approaches are also now available.
B. Non-Operative Management (NOM) with Antibiotics Alone
NOM has emerged as a viable alternative for carefully selected patients:
Key trial evidence:
- APPAC trial (Finland, n=530): 72.7% of antibiotic-treated patients did not need appendectomy at 1 year; however, 39.1% eventually required appendectomy by 7-year follow-up
- CODA trial (USA, n=1,552): Antibiotics not inferior to appendectomy for 30-day health status, but 29% required appendectomy by 90 days (41% if appendicolith present, 25% without)
- 5-year recurrence rate approaches 50% in both children and adults treated with antibiotics alone
- Complications were less likely with antibiotics vs. surgery
Criteria for selecting NOM candidates:
- No appendicolith on imaging
- Small appendix diameter
- CRP < 60 g/L
- WBC < 12,000/mm³
- Age < 60 years
Antibiotic regimen for NOM: IV ertapenem x 3 days, then oral levofloxacin + metronidazole x 7 days (total 10 days)
Bottom line: Appendectomy retains higher treatment efficacy. NOM is an acceptable shared-decision alternative for uncomplicated appendicitis in low-risk patients, or where surgery is high-risk or contraindicated.
4. Complicated Appendicitis
Perforated Appendicitis
- Requires urgent surgical intervention - cannot be managed nonoperatively
- IV antibiotics continued postoperatively for a duration based on clinical severity
- Higher temperature and WBC count indicate perforation/abscess
Periappendiceal Abscess or Phlegmon
- Current evidence supports non-operative management first: IV antibiotics (transitioned to oral) + percutaneous drainage if feasible
- Immediate appendectomy in this setting is associated with higher morbidity
- Nonsurgical treatment failure rate is only ~7.6%
- Routine interval appendectomy is NOT recommended - recurrence risk is low (7.4%)
- Colonoscopy or repeat CT is recommended after successful NOM due to risk of underlying malignancy (~1.2%) or significant benign disease, especially in patients >40 years
5. Special Populations
| Population | Consideration |
|---|---|
| Pregnant women | MRI preferred for imaging; laparoscopic appendectomy is safe; short in-hospital delay with repeat USS acceptable if equivocal findings |
| Children | Surgery within 24 hours; USS first-line imaging to avoid radiation; pediatric surgery consulted before CT where possible |
| Elderly | Higher perforation risk at presentation; if suspected malignancy, conservative open appendectomy preferred |
6. Post-Appendectomy Follow-Up
After successful NOM for abscess/phlegmon, follow-up imaging (CT) or colonoscopy is recommended to exclude:
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Colonic malignancy
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Inflammatory bowel disease
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Other significant underlying pathology
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Current Surgical Therapy 14e, pp. 325-328
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Mulholland and Greenfield's Surgery 7e, pp. 457-459
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Sleisenger and Fordtran's Gastrointestinal and Liver Disease, Table 11.4
The 2025 WSES Jerusalem Guidelines provide the most current international consensus on diagnosis and treatment of acute appendicitis.
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