European Journal of Cardiovascular Medicine

Acute appendicitis is still a clinical diagnosis. Abdominal pain being the most common symptom. In the classic presentation, the patient describes the pain as beginning in the peri-umbilical or epigastric region and then migrating to right iliac fossa. This is associated with fever, anorexia, nausea, and vomiting.

The clinical presentation of Acute Appendicitis varies widely owing to variable degree of involvement by inflammatory process, different positions of appendix and varying age of the patient. The inconsistent clinical presentation often leads to misdiagnoses of acute appendicitis in 1 out of 5 cases and negative appendicectomy rates in the range of 15 – 20%. Adding to this the “CLASSIC” symptomatology only occurs in 50-60% of cases making the diagnosis difficult. Difficulties in diagnosis especially arise in very young, elderly patients and females of reproductive age because they are more likely to have an atypical presentation, and many other conditions may mimic Acute Appendicitis in these patients.

Acute appendicitis is the most common non traumatic surgical acute abdominal pain. Acute Appendicitis is a frequent reason for emergency hospital admission and appendectomy is one of the most common emergency Procedure Performed in contemporary medicine. The lifetime risk of developing appendicitis is 8.6% for males and 6.7% for females, with the highest incidence in the second and third decades. 1-3

Acute appendicitis is one of the most common reasons for emergency laparotomy. The lifetime risk of having an appendectomy is 12% for men and 23% for women. 1-3 One side there is fear of perforation due to delay in diagnosis leading to prolonged hospital stay and increased morbidity and mortality, on the other is a high negative appendectomy rate of 15% to 20% for the total population and as high as 22% in females of reproductive age. 1

This is also a cause for concern with significantly longer hospital stay, high fatality rate, higher rate of infectious complications and unnecessary hospital expenses.1 One should both decrease the rate of perforation and the negative appendectomy rate by increasing the diagnostic accuracy.

Hence, having understood the importance for early and right diagnosis, and having understood that clinical evaluation provides the best and most accurate diagnostic modality for appendicitis, many clinical scoring systems have been developed over the years. 4

Abdominal ultrasonography is an imaging modality for acute appendicitis first popularized by PUYLAERT, 1986.5 Graded compression sonography with adjuvant use of a posterior manual compression technique seems to be useful for detecting the vermiform appendix and for diagnosing acute appendicitis having a sensitivity and specificity of 0.86 and 0.81 respectively.

Many scoring systems for the diagnosis of acute appendicitis have been tried. The Modified Alvarado Score is a combination of Clinical Evaluation & Laboratory which is an easy, simple and cheap diagnostic tool for supporting the diagnosis of Acute Appendicitis. Tzanaki’s score is another scoring is a combination of Clinical Evaluation, Laboratory and Ultrasound.

Despite extraordinary advances in modern diagnostic techniques the accurate diagnosis of acute appendicitis still remains an enigmatic challenge. Ultra-sound is Easily Available, Portable, Repeatable, Non-Invasive method. Hence now USG in experienced hands is recognised to improve diagnostic accuracy. 6

In the present study, Modified Alvarado scoring system (MASS) and Tzanaki’s scoring systems are compared among the patients admitted in the District Hospital, Dharwad, Karnataka, India, to find out the Validity of scoring systems and which scoring system is more relevant and applicable, in order to aid early diagnosis of acute appendicitis.

Material and Methods: This Observational study was conducted Among Participants are those patients presenting to Department of General Surgery, District Hospital, Dharwad between January 2021 to April 2022 with suspected clinically as AA and underwent surgery for the same were included in the study with ≥18 years of age fulfilling Inclusion criteria and Exclusion criteria between January 2021 to April 2022.

The Modified Alvarado score and Tzanaki’s score were calculated from the collected data. Histology results from the removed appendices were followed up. The negative appendicectomy rate was then calculated. Prior to start of the study institutional ethical committee approval was taken.

Patients admitted as IN PATIENT at Department of General Surgery, District Hospital, Dharwad between January 2021 to April 2022 with suspected clinically as AA and underwent surgery for the same were included in the study

Sample Size: A sample size of 100 Patients fulfilling inclusion and exclusion criteria undergoing Open/Lap appendicectomy in Department of General Surgery, District Hospital, Dharwad.

Inclusion Criteria:

• Age ≥18 years of age
• Participants with clinical diagnosis of Acute Appendicitis
• Patients undergoing Open as well as Lap Appendicectomy
• Patient with scores below the cut off values (for MASS and Tzanaki’s score) based on Clinical Assessment and Judgement
• Patient willing to participate and give consent for the study

Exclusion Criteria:

• Age <18 years of age
• Patient with alternative diagnosis during surgery with or without an inflamed appendix
• Patients with Appendicular Mass, Appendicular Abscess, Appendicular Perforation, Generalized Peritonitis
• Patient not willing to participate and did not give consent for the study
• Patient with blunt trauma abdomen
• Patient with recurrent appendicitis
• Patient not fit for surgery
• Patient with right lower abdomen pathology other than appendix

• All cases had undergone thorough history and detailed clinical examination at the time of admission as part of routine management.
• Total and differential leucocyte count was measured using an auto-analyser
• As USG is technician dependent, only those patients who underwent abdominal USG by Consultant Radiologist were included in the study to exclude observer bias.
• He is blinded to the results of physical examination and blood report of the patients.
• Well established ultrasonographic criteria were applied to discriminate an acutely inflamed appendix from a normal one.
• Both Modified Alvarado Score and Tzanaki’s score are done for all the patients at the time of admission and prior to surgery
• Even the patients with scores below the cut off values were subjected to surgery based on clinical assessment and judgment.
• Patients were either subjected to emergency laparotomy/ Open or Lap appendicectomy at the time of admission or after few hours of conservative management.
• Emergency appendicectomy was done by Open/Lap method under spinal or general anaesthesia in all cases
• Final diagnosis to be confirmed by Histopathological Examination of the specimen by the pathologist.
• Data was analysed to compare the efficacy of both scoring systems in diagnosing Acute appendicitis
• Sonographic Criterias For Appendicitis

• Noncompressible appendix of size > 6 mm AP diameter,
• Hyperechoic thickened appendix wall > 2 mm—target sign.
• Prescence of Appendicolith.
• Interruption of submucosal continuity.
• Peri-appendicular fluid.

• Data Collection Technique And Tools

• Every Patient Included in This Study Will Be Counselled and Consent Taken.
• Detailed History Taking, Clinical Examination Will Be Done to Satisfy Inclusion and Exclusion Criteria.
• Patients Will Be Scored According to Modified Alvarado Score as Well as Tzanaki’s Score at The Time of Admission And Prior To Surgery.
• USG will Be Done Using 5mhz Linear Transducer.
• Total and differential leucocyte count was measured using an auto-analyser
• The Final Diagnosis Will Be Confirmed by Histopathological Examination of The Specimen by Pathologist.
• After Thorough Clinical Examination, Radiological Examination and Laboratory Investigations Modified Alvarado Score and Tzanaki’s Score Will Be Calculated.
• MODIFIED ALVARADO SCORE:

Total Score: 9

Patient with Score 6 Or >6 Will Undergo Appendicectomy and Histopathology Results Will Be Analysed.

• TZANAKI’S SCORE:

Total Score: 15

Patient with Score >8 Will Undergo Appendicectomy and Histopathology Sample Will Be Analysed.

Statistical Analysis:

After collection of Data, entire data will be statistically analysed using Statistical Package for Social Sciences (SPSS Ver 22.0, IBM Corporation; NY, USA) for MS Windows with Descriptive statistics including Frequency, Percentage, Mean and Standard Deviation. The agreement between MAS and Tzanaki’s scoring system was calculated by using Kappa statistics. Sensitivity, Specificity, PPV, NPV, Accuracy and other related findings were calculated. P-values less than 0.05 will be considered to be statistically significant. (5% level of Statistical significance)

The mean age of patients was 25.69 years with a standard deviation of 7.58 years. Of the 100 patients studied, 64% were male and 36% were female.

The mean age of male patients was 25.17 years with a standard deviation of 7.18 years. And the mean age of female patients was 26.61 years with a standard deviation of 8.28 years.

Of the 100 patients studied, 54% (n = 54) patients were having M. Alvarado score below 6, Amongst them, 57.81% were male patients and 47.22% were female patients. 46% (n = 46) patients were having M. Alvarado score 6 or above 6, Amongst them, 42.19% were male patients and 52.78% were female patients.

Of the 100 patients studied, 18 (18%) patients were having Tzanaki’s score 8 or below 8, Amongst them, 10 were male patients and 8 were female patients. 82 (82%) patients were having Tzanaki’s score above 8, Amongst them, 54 were male patients and 28 were female patients.

Of the 100 patients studied, 6% (n= 6) patients were found to be negative for HPR and 94% (n= 94) patients were found to be positive for HPR amongst which 3 were male and 3 were female.

Of the 100 patients studied, mean value for male patients in M. Alvarado score was 5.02 whereas, mean value for male patients in Tzanaki’s score was 10.78 and mean value for female patients in M. Alvarado score was 5.47 whereas, mean value for female patients in Tzanaki’s score was 10.53.

TABLE 1: Agreement Between Hpr Findings And M. Alvarado Score

Of the 100 patients studied, 54% (n = 54) patients were having M. Alvarado score below 6 and 46% (n = 46) patients were having M. Alvarado score 6 or above 6. In those patients with score below 6, HPR findings were negative in 8% (n = 4) of the patients and in those patients with score 6 or above 6, HPR findings were negative in 4.54% (n = 2) of the patients.

TABLE 2: Agreement Between Hpr Findings and Tzanaki’s Score

Of the 100 patients studied, 18 (18%) patients were having Tzanaki’s score 8 or below 8 and 82 (82%) patients were having Tzanaki’s score above 8. In those patients with score 8 or below 8, HPR findings were negative in 6% (n = 1) of the patients and in those patients with score above 8, HPR findings were negative in 6% (n = 5) of the patients.

TABLE 3: Agreement Between M. Alvarado Score and Tzanaki’s Score

*p<0.05

Of the 100 patients studied, 18 (18%) patients were having Tzanaki’s score 8 or below 8 and 82 (82%) patients were having Tzanaki’s score above 8. Whereas, 54% (n = 54) patients were having M. Alvarado score below 6 and 46% (n = 46) patients were having M. Alvarado score 6 or above 6. In those 100 patients, 15 patients were having score below the cut off values for MASS & Tzanaki’s score and were operated based on Clinical Assessment and Judgement.

TABLE 4: Status Of M Rlq, N/V, A, F In M. Alvarado Score

Of the 100 patients studied, most common symptom in MASS was RLQ tenderness (100%, n=100) followed by Nausea/Vomiting, RT, Leucocytosis, Fever, Migration to RLQ And Anorexia respectively.

Of the 100 patients studied, USG report was Positive for 78% of the patients and Negative for 22% of the patients.

TABLE 5: Comparison Of Status Of Rlq T, R.T., And Wbc Between M. Alvarado Score And Tzanaki’s Score

*p<0.05

Of the 100 patients studied, most common symptom in MASS & Tzanaki’s score was RLQ tenderness followed by RT. Leucocytosis observed in 46% of the patients in MASS whereas, 29% of the patients in Tzanaki’s Score.

TABLE 6: Sensitivity, Specificity of M. Alvarado Score as Compared to Hpr with Cut Off Values

Area Under Curve Analysis

The sensitivity & specificity of Modified Alvarado Score was 47.87% & 66.67% with a positive predictive value of 95.74% & negative predictive value of 75.5%. The diagnostic accuracy of M. Alvarado score was 49%.

TABLE 7: Sensitivity, Specificity of M. Alvarado Score as Compared to Hpr with Cut Off Values In %

The sensitivity & specificity of Modified Alvarado Score was 47.87% & 66.67% with a positive predictive value of 95.74% & negative predictive value of 75.5%. The diagnostic accuracy of M. Alvarado score was 49%.

TABLE 8: Sensitivity, Specificity Of Tzanaki’s Score As Compared To Hpr With Cut Off Values

Area Under Curve Analysis

The sensitivity and specificity of Tzanaki’s score was 87.23% and 16.67% respectively with a positive predictive value of 94.25% and negative predictive value of 76.9%. The diagnostic accuracy of Tzanaki’s score was 83%.

TABLE 9: Sensitivity, Specificity Of Tzanaki’s Score As Compared To Hpr With Cut Off Values In %

The sensitivity and specificity of Tzanaki’s score was 87.23% and 16.67% respectively with a positive predictive value of 94.25% and negative predictive value of 76.9%. The diagnostic accuracy of Tzanaki’s score was 83%.

From the time the Concept of Clinical Scoring Systems has been introduced, multiple studies have been done in search of the most sensitive, specific and diagnostically Accurate Clinical Score to aid in the diagnosis of Acute Appendicitis. Since its introduction in 1986, Alvarado is one of the most well-known and studied scores for ACUTE APPENDICITIS. 7 Its modification MASS has been equally in common use. As this is the most popular and commonly used scoring system, we planned to compare the newer scoring system (Tzanaki’s scoring system) with it, and study its efficacy in terms of Sensitivity, Specificity and Diagnostic Accuracy among other factors.

TABLE 10: Comparison Of Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of Mass of Patients of The Present Study with Other Studies

The Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of Modified Alvarado score was 47.87%, 66.67%, 95.74% and 75.5% with diagnostic Accuracy

of 49%.

TABLE 11: Comparison Of Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of Tzanaki’s Score of Patients of The Present Study with Other Studies

The Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of Tzanaki’s score of was 87.27%, 16.67%, 94.25% and 76.9% with diagnostic Accuracy of

83%.

TABLE 11: Comparison Of Negative Appendicectomy Rate Of Patients Of The Present Study With Other Studies

The negative appendicectomy rate is 6% in present study which lowest compared to the other studies.

There was a slight male preponderance with 64 patients being males and 36 patients being females (Male: Female = 1.8:1)

The mean age of patients was 25.69 years with a standard deviation of 7.58 years. The mean age of male patients was 25.17 years with a standard deviation of 7.18 years. And the mean age of female patients was 26.61 years with a standard deviation of 8.28 years. 94% of patients has histologically proven Appendicitis. Overall negative appendicectomy rate was 6%

The sensitivity & specificity of Modified Alvarado Score was 47.87% & 66.67% with a positive predictive value of 95.74% & negative predictive value of 75.5%.

Tzanaki’s et al has reported the sensitivity and specificity of 95.4% and 97.4%. Results of our study were comparable with that. The sensitivity and specificity of Tzanaki’s score in our study was 87.23% and 16.67% respectively with a positive predictive value of 94.25% and negative predictive value of 76.9%. The low specificity of Tzanaki’s score in our study was likely to be due to low sensitivity rate of USG which can be improved by experienced sonologists and newer advanced USG machines. The diagnostic accuracy of M. Alvarado score was 49% and that of Tzanaki’s score was 83%.

A negative appendectomy rate of 15-20% has been reported in the literature and many surgeons advocate early surgical intervention for the treatment of acute appendicitis to avoid perforation, accepting a negative appendectomy rate of about 15-20%. Overall negative appendectomy rate in our study was 6% which is Lowest compared to various studies reported in the literature.

Negative appendectomy rate among females (8.33%) was higher than in males (4.69%). The discrepancy is due to high chances of alternate diagnosis in females of reproductive age group.

The present study compares M. Alvarado scoring and Tzanaki’s scoring in the effective diagnosis of Acute Appendicitis. Tzanaki’s score was superior in terms of Sensitivity, Positive Predictive Values, Negative Predictive Values & Diagnostic Accuracy. So, this study substantiates the use of Tzanaki’s scoring as a useful tool in the effective diagnosis of Acute Appendicitis to supplement the clinical decision and to reducing the morbidity and mortality of AA.

Tzanaki’s scoring system can be used as an effective modality in the establishment of accuracy in diagnosis of acute appendicitis. There is increased Sensitivity, PPV & Diagnostic Accuracy in Tzanaki’s scoring when compared to Modified Alvarado score. Tzanaki’s score is an effective modality to establish the accurate diagnosis of AA and helps in reducing complications, morbidity, mortality of Appendicitis & negative Appendicectomy rate.

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