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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 671-674

Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scores in diagnosis of patients with acute appendicitis


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Tala General Hospital, Menoufia, Egypt

Date of Submission15-Jul-2019
Date of Decision09-Sep-2019
Date of Acceptance14-Sep-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Mohamed M Elsayad
Tala, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_219_19

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  Abstract 


Objective
The aim was to compare between Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) and Alvarado scoring systems in the diagnosis of acute appendicitis.
Background
Acute appendicitis is one of the most common surgical emergencies. The RIPASA and Alvarado scores are new diagnostic scoring systems developed for the diagnosis of acute appendicitis.
Patients and methods
A cross-sectional study was carried out on 186 patients complaining of acute abdominal pain during the 8-month period in the Department of Surgery, Menoufia University and Tala Control Hospital. Histopathological reports of the cases were collected and compared with the scores. Full history was taken, and routine investigation was done.
Results
There was poor agreement between Alvarado and RIPASA scoring systems in the diagnosis of appendicitis. The agreement in appendicitis was 43%. Moreover, RIPSA score diagnosis and histopathological diagnosis were not significantly different among the studied patients. However, there was a significant difference between RIPSA score and histopathological diagnosis in the diagnosis of appendicitis among patients. Regarding accuracy of diagnosis, RIPSA score had a sensitive level (94%) higher than Alvarado score (54%) in diagnosis of appendicitis, whereas Alvarado score had specificity level (62%) higher than RIPSA score (10%).
Conclusion
The difference in the diagnostic accuracy between Alvarado and RIPASA scoring system is significant, indicating that the RIPASA score is a much better diagnostic tool for the diagnosis of acute appendicitis.

Keywords: abdominal pain, acute appendicitis, Alvarado scoring, diagnosis, Raja Isteri Pengiran Anak Saleha appendicitis scoring


How to cite this article:
Amar MS, Abd Hallem MS, Elsayad MM. Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scores in diagnosis of patients with acute appendicitis. Menoufia Med J 2020;33:671-4

How to cite this URL:
Amar MS, Abd Hallem MS, Elsayad MM. Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scores in diagnosis of patients with acute appendicitis. Menoufia Med J [serial online] 2020 [cited 2020 Jul 14];33:671-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/671/287760




  Introduction Top


Acute appendicitis is a common cause of acute abdominal pain in the world. Appendectomy is one of the most frequently performed surgical procedures[1]. Acute appendicitis is one of the most common surgical emergencies. Different techniques have been devised to assist unequivocal cases in attempts to decrease negative appendectomy rates[2]. A number of scoring systems have been used for aiding in early diagnosis of acute appendicitis and its prompt management, of which Alvarado score is the most popular[3]. The open approach to appendectomy was originally initiated by McBurney, and laparoscopic appendectomy has been performed using minimally invasive approach. Perforated appendicitis occurs in 20–30% of patients with acute appendicitis. This condition is associated with significant risk of postoperative complications such as wound infection and intra-abdominal abscesses[4]. Despite being a common problem, it remains a difficult diagnosis to establish, particularly among the young, the elderly, and females at reproductive age, where a host of other genitourinary and gynecological inflammatory conditions can present with signs and symptoms that are similar to those of acute appendicitis. A delay in performing an appendectomy to improve its diagnostic accuracy increases the risk of appendicular perforation and sepsis, which in turn increases morbidity and mortality[5]. The opposite is also true, where with reduced diagnostic accuracy, the negative or unnecessary appendectomy rate is increased, and this is generally reported to be ∼20–40%. Several authors have considered higher negative appendectomy rates acceptable to minimize the incidence of perforation. Diagnostic accuracy can be further improved through the use of ultrasonography or computed tomography imaging. However, such routine practice may inflate the cost of health care substantially[6]. The aim of this study was to compare between Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) and Alvarado scores in diagnosis of acute appendicitis patients to evaluate the accuracy of diagnosis.


  Patients and Methods Top


A cross-sectional study was carried out on 186 patients complaining of acute abdominal pain during an 8-month period in the Department of Surgery, Menoufia University and Tala Central Hospital. Histopathological reports of the cases were collected and compared with the scores. Inclusion criteria were patients complaining of acute abdominal pain between 4 and 40 years of age, who were scored per Alvarado and RIPASA scoring systems.

Ethical consideration

The study was approved by the ethical committee of Menoufia Faculty of Medicine, and an informed consent was obtained from all patients before the study was commenced.

All cases were subjected to the following: complete history, including personal, present, and past, and family history such as age, relative, consanguinity, blood transfusion per year, and drug history. Clinical examination comprised local, including cardiovascular system, central nervous system, abdominal, and chest examination. Signs and symptoms and duration of symptoms (hours) of patients with appendicitis were obtained. Diagnosis of appendicitis was done by RIPSA scoring and Alvarado scoring and histopathological diagnosis was according to Chong et al.[7]

Statistical analysis

Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS v. 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using descriptive, for example, percentage, mean, and SD, and analytical, which included χ2 test, Z-test, Student's t-test, and receiver operating characteristic (ROC) curve. A value of P less than 0.05 was considered statistically significant.


  Results Top


Results showed that 59.7% of patients with acute appendicitis had age less than 40 years. More than half (51.1%) of patients were males. Regarding acute appendicitis symptoms, nausea and vomiting were the most symptoms presented (82.8%) among the studied patients, and 65.6% of the patient had duration of symptoms less than 48 h. Moreover, right iliac fossa (RIF) tenderness and guarding were the most common signs of acute appendicitis presented among studied patients (84.9% each), followed by rebound tenderness (75.8%). Regarding investigations, 55.9% had raised white blood cells (WBCs) and 50.5% had negative urine analysis [Table 1]. The current study shows that regarding Raja Isteri Pengiran Anak Saleha Appendicitis (RIPSA) scoring, 49.5% of patients with acute appendicitis had confirmed appendicitis (≥12) and 43% had high probability of appendicitis (7.5–11.5), followed by 5.9% with low probability of appendicitis (5–7), and 1.6% with appendicitis unlikely (<5). Regarding Alvarado scoring among patients with acute appendicitis, 47.3% of patients had probable appendicitis (6–9) and 34.4% had not sure (<5), followed by 18.3% had compatible (5–6). However, there were no patients who had confirmed appendicitis (>9) [Table 2]. Additionally, the current study shows that there was poor agreement between Alvarado and RIPASA scoring systems in the diagnosis of appendicitis. The agreement in appendicitis was 43% and 3.2% in not appendicitis. Moreover, there was no significant difference between RIPSA score diagnosis and histopathological diagnosis among patients with acute appendicitis. However, there was a significant difference between RIPSA score and histopathological diagnosis in the diagnosis of appendicitis among patients with acute appendicitis [Table 3]. Moreover, RIPSA score had sensitive level (94%) higher than Alvarado score (54%) in diagnosis of appendicitis, whereas Alvarado score had specificity level (62%) higher than RIPSA score (10%). There was no significant difference between both scores regarding positive and negative predicted values and the diagnostic accuracy of appendicitis [Figure 1] and [Table 4]).
Table 1: The data in patients with acute appendicitis

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Table 2: Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scoring among acute appendicitis patients

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Table 3: Degree of agreement between Raja Isteri Pengiran Anak Saleha appendicitis score and Alvarado score in diagnosis of appendicitis in patients

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Figure 1: Receiver operating characteristic curve of Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scores for predicting appendicitis.

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Table 4: Accuracy of diagnosis for Raja Isteri Pengiran Anak Saleha appendicitis score versus Alvarado score compared to histopathological diagnosis in patients

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  Discussion Top


In our study, there was poor agreement between Alvarado and RIPASA scoring systems in diagnosis of appendicitis. The agreement in appendicitis was 43%, and 3.2% in not appendicitis[8]. There were no significant differences between the mean values of Alvarado or RIPSA scores regarding positive and negative cases as diagnosed by histopathology in the studied patients[4]. Moreover, there was no significant difference between RIPSA score diagnosis and histopathological diagnosis among patients. On the contrary, there was a significant difference between RIPSA score and histopathological result in the diagnosis of appendicitis among the studied patients. In addition, RIPSA score had sensitive level (94%) higher than Alvarado score (54%) in the diagnosis of appendicitis, whereas Alvarado score had specificity level (62%) higher than RIPSA score (10%). There was no significant difference between both scores regarding positive and negative predicted values and the diagnostic accuracy of appendicitis[9]. In our study, the sensitivity and specificity levels of the RIPASA scoring system were 94 and 10%, respectively. The positive predictive value and negative predictive value of RIPASA score were 58 and 57%, respectively. In our study, the sensitivity and specificity of Alvarado scoring system were 54 and 62%, respectively. The positive and negative predictive values of RIPASA score were 65 and 51%, respectively. Moreover, in our study, RIPSA score had sensitive level higher than Alvarado score in the diagnosis of appendicitis[10]. In a similar study done by Nanjundaiah et al.[6] at optimal cutoff threshold of greater than 7.5, the sensitivity and specificity of the RIPASA scoring system were 96.2 and 90.5%, respectively. The positive predictive and negative predictive value of RIPASA score were 98.9 and 73.1%, respectively. In a study done by Chong et al.[7] at the optimal cutoff threshold score of 7.5 derived from the ROC, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the RIPASA score were 98.0, 81.3, 85.3, 97.45, and 91.8%, respectively. The difference in the diagnostic accuracy between Alvarado and RIPASA scoring systems was reported by Nanjundaiah et al.[6], which showed a difference of 33.93%. However, P value was significant in both studies indicating the RIPASA score was a much better diagnostic tool for the diagnosis of acute appendicitis[11].

The present study was comparable with the study done by Chong et al.[7]. When the ROC curve was observed, the area under the curve was high for both RIPASA and Alvarado scoring, but it was higher for RIPASA scoring system. The area under the curve (AUC) was significant for Alvarado and RIPASA scoring systems. In a study done by Nanjundaiah et al.[6], it was found that the difference in the diagnostic accuracy was 13.4%, which was significant between two scoring systems, which equates to 30 (13.4%) patients with acute appendicitis who were misdiagnosed using the Alvarado score compared with the RIPASA score. A study done by Chong et al.[7] found that diagnostic accuracy for the RIPASA score was 0.9183 (91.83%), which is greater than that for the Alvarado score, which was 0.8651 (86.51%). The difference in the area (shaded) under the curve of 0.0532 (5.32%) was significant between the two scoring systems, which equates to 30 (15.6%) patients with acute appendicitis who were misdiagnosed using the Alvarado score compared with the RIPASA score. The results are very close to this study[12].


  Conclusion Top


The difference in the diagnostic accuracy between Alvarado and RIPASA scoring system is significant, indicating that the RIPASA score is a much better diagnostic tool for the diagnosis of acute appendicitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386 :78–87.  Back to cited text no. 1
    
2.
Riddell R, Jain D. Lewin, Weinstein and Riddell's Gastrointestinal Pathology and its Clinical Implications. Philadelphia, Pennsylvania, and Baltimore, Maryland, New York City, USA: Lippincott Williams & Wilkins; 2014. 58.  Back to cited text no. 2
    
3.
Lang ER. Emergence of Medicine from the 'Dark Ages'. Bloomington, India: Xlibris Corporation; 2018. 6–11.  Back to cited text no. 3
    
4.
Dai L, Shuai J. Laparoscopic versus open appendectomy in adults and children: a meta-analysis of randomized controlled trials. United Eur Gastroenterol J 2017; 5 :542–553.  Back to cited text no. 4
    
5.
Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg 2014; 101 :9–22.  Back to cited text no. 5
    
6.
Nanjundaiah N, Mohammed A, Shanbhag V, Ashfaque K, Priya SA. A comparative study of RIPASA score and ALVARADO score in the diagnosis of acute appendicitis. J Clin Diagn Res 2014; 8 :03.  Back to cited text no. 6
    
7.
Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010; 51 :220.  Back to cited text no. 7
    
8.
Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11 :34.  Back to cited text no. 8
    
9.
Chavan S, Bhatnagar S, Bendre M, Sinha N. Comparative study of Alvarado score and RIPASA score in the diagnosis of acute appendicitis. Int Surg J 2018; 5 :1330–1334.  Back to cited text no. 9
    
10.
Singla A, Singla S, Singh M, Singla D. A comparison between modified Alvarado score and RIPASA score in the diagnosis of acute appendicitis. Updates Surg 2016; 68 :351–355.  Back to cited text no. 10
    
11.
Pasumarthi V, Madhu CP. A comparative study of RIPASA score and ALVARADO score in diagnosis of acute appendicitis. Int Surg J 2018; 5 :796–801.  Back to cited text no. 11
    
12.
Desalphine M, Bagga PK, Gupta PK, Kataria AS. A comparative study of RIPASA score and ALVARADO score in the diagnosis of acute appendicitis. J Clin Diagn Res 2014; 8 :11.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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