European Journal of Cardiovascular Medicine

Acute appendicitis is the most common surgical emergency in both accidents and emergency departments. It is one of the most common causes of acute abdominal pain in both adults and children with lifetime risks of 8.6% in men and 6.7% in women.[1,2] The incidence ranges from 1.5 to 1.9 per 1000 people, and it is more common in men than in women.[2] Appendectomy is the most frequently performed emergency operation, but appendicitis can resemble other acute abdominal conditions that cause right iliac fossa pain.[3] Abdominal pain is the most common clinical presentation of appendicitis. On examination, patients often exhibit anorexia, nausea, vomiting, and tenderness or shielding rigidity in the right iliac fossa.[4] The classical history of peri- umbilical pain that later shifts to the right iliac fossa is present in only 50% of cases. In 70% of the cases, the clinical presentation is typical, making the diagnosis straightforward. A negative appendectomy rate ranging from 10% to 44% has been considered acceptable by various authors to minimize the incidence of perforation and associated morbidity and mortality.[5]

Various diagnostic modalities including radiological, laparoscopic, and laboratory methods have been reported to affect the rate of negative appendectomies. Recognising the importance of early and accurate diagnosis, numerous clinical scoring systems have been developed to aid clinicians. These systems have significantly improved the accuracy of diagnosis and the timeliness of management. Despite the prevalence of appendicitis, its diagnosis remains challenging and relies primarily on clinical evaluation, supplemented by laboratory tests such as an elevated white blood cell count.[3-5]

An immediate and accurate diagnosis, primarily based on clinical assessment and laboratory results, is crucial for reducing complications and mortality rates. The challenging nature of diagnosing appendicitis and the fear of missing an inflamed appendix can lead to negative appendectomies. To mitigate these ambiguities, many scoring systems have been developed.[4]

The present study aimed to compare the efficacy of the Alvarado and Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scores in diagnosing acute appendicitis.

This prospective, comparative study was conducted in the Department of Surgery at tertiary care hospital. A total of 300 patients clinically diagnosed with acute appendicitis were included. Informed consent was obtained from all the participants.

Inclusion criteria

Patients with pain in the right iliac fossa and those aged < 40 and > 40 years were included.

Exclusion criteria

Patients with a diagnosed appendicular lump, patients presenting with a right iliac fossa mass, previously diagnosed cases of acute appendicitis, immunocompromised patients, patients who had already undergone appendectomy, and pregnant females were excluded.

Methodology

A detailed clinical history and thorough clinical examination were conducted by the attending surgeon. Relevant investigations, such as haemoglobin, leukocyte count, urine albumin, sugar, and microscopic examinations were performed in all cases. The final diagnosis of acute appendicitis was based on clinical evaluation and laboratory investigation reports. The laboratory staff were blinded to the clinical findings, decisions, and outcomes. Patients were scored using both the Alvarado and RIPASA scoring systems, with scores documented in the proforma.

The Alvarado score includes 8 parameters, while the RIPASA score includes 18 parameters, with scores ranging from 0.5-2 for RIPASA and 1-2 for Alvarado. A score of 7 was considered a high probability of acute appendicitis in the Alvarado scoring system, and 7.5 in a RIPASA probability for acute appendicitis. The decision to perform appendectomy was based solely on the surgeon’s clinical judgment, taking into account all clinical, laboratory, and radiological findings.

Of the 300 participants, 59.7% were male and 40.3% were female. Additionally, 70% were under 40 years old, whereas 30% were over 40 years old. Symptom duration analysis revealed that 75.4% of participants presented with symptoms lasting less than 48 h, whereas 24.6% of participants had symptoms persisting for more than 48 h. Histopathology results indicated that 91.2% of cases were histopathologically confirmed as positive for appendicitis, whereas 8.8% of cases were histopathologically negative. The diagnostic cutoff values for the scoring systems were established as 7.5 for the RIPASA score and 7 for the Alvarado score. In terms of the Alvarado scoring system, 68% of the participants had a score >7, whereas 32% had a score

< 7. For the RIPASA scoring system, 88% of the participants had a score >7.5, while 12% had a score < 7.5 [Table 1].

The diagnostic values of the Alvarado Scoring System are presented in Table 2. For scores greater than 7, there were 186 true positives and 8 false positives, totalling 194 cases. For scores less than 7, there were 80 true negatives and 11 false negatives, for a total of 91 cases. Overall, the Alvarado scoring system had 266 positive and 19 negative cases out of the 285 total cases.

The diagnostic values of the RIPASA scoring system are shown in Table 3. For scores greater than 7.5, there were 246 true positives and 5 false positives, totalling 251 cases. For scores less than 7.5, there were 11 true negatives and 23 false negatives, totalling to 34 cases. Overall, the RIPASA scoring system had 257 positive and 28 negative cases out of the 285 total cases.

Table 1: Demographic details

Table 2: Diagnostic value of Alvarado scoring system

Table 3: Diagnostic value of RIPASA scoring system

Acute appendicitis poses a significant challenge to surgeons because its diagnosis relies heavily on clinical assessments. While CT scans of the abdomen and pelvis with contrast are widely used for confirmation because of their impressive sensitivity (94%) and specificity (95%), reliance on clinical examination persists, particularly in peripheral centres without access to CT scans.[1] This reliance often leads to higher misdiagnosis rates, resulting in negative appendectomies ranging from 15% to 30%. Although the Alvarado score is effective in Western populations, its diagnostic utility is limited in Asian populations. In response, the RIPASA score offers a promising alternative, with 14 fixed variables tailored to unique population parameters.[6,7]

In our study, we observed that the RIPASA score emerged as a superior diagnostic tool for predicting acute appendicitis than the Alvarado score. Histopathology confirmed appendicitis in a significant proportion of the cases (91.2%). In the Alvarado scoring system, 68% of the participants scored above 7, whereas 32% scored below 7. In the RIPASA scoring system, 88% of the participants scored above 7.5, and 12% scored below 7.5.

Aslam et al. observed that 94 cases had an RIPASA score of 7 or higher, while 31 cases had an Alvarado score exceeding 7. Of these cases, 93 had a positive histopathology report, while 7 turned out to be normal. The sensitivity of the RIPASA score was 95.69%, significantly higher than that of the Alvarado score (32.25%). The specificity of the RIPASA score was 33.33%, lower than that of the Alvarado score (85.71%). They concluded that the RIPASA score outperforms the Alvarado score in diagnosing acute appendicitis.[8]

Similarly, a recent study by Onyedi et al. (2024) found that the RIPASA scoring system outperformed the Alvarado score in the diagnosis of acute appendicitis. The RIPASA score demonstrated a sensitivity of 97.1% and a diagnostic accuracy of 94.7%, whereas the Alvarado score showed a sensitivity of 66.7% and a diagnostic accuracy of 65.8%.[9] Moreover, Regar et al. revealed that the RIPASA score is a more valuable tool for diagnosing acute appendicitis than the Alvarado score, with 93% accuracy, 94.74% sensitivity, and 60% specificity. Despite the availability of sophisticated investigations like CT, the RIPASA score helps reduce treatment costs and minimizes the negative appendectomy rate.[3]

Additionally, Heiranizadeh et al. (2023) demonstrated that the RIPASA scoring system had a higher sensitivity, PPV, NPV, and accuracy than the Alvarado score. The sensitivity and specificity of the RIPASA score were 86.6% and 66.7%, respectively, while those of the Alvarado score were 67.1% and 72.2%, respectively. The diagnostic accuracy was 83% for the RIPASA score, significantly higher than the 68% observed for the Alvarado score.[10] Furthermore, Zeb et al., Sanjive et al., Koroth et al., Tekyol et al., and Banepali et al. presented diverse ranges of sensitivity, specificity, positive predictive value, and negative predictive value for both the RIPASA and Alvarado scoring systems. These studies suggest that The RIPASA score outperforms the Alvarado score as a more effective diagnostic tool for acute appendicitis.[1,11-14] The RIPASA score is a superior scoring system for categorising patients with suspected appendicitis. Its implementation may potentially reduce the need for diagnostic imaging and decrease the negative appendectomy rates.

Limitation

Acute appendicitis diagnosis was based on the clinical evaluation of the consultant on duty, which might have led to a potential subjective bias. When calculating the scoring system by surgical residents, a potential source of subjective bias arises when the resident’s expertise gives a score to abdominal exploration signs. We evaluated only those patients with abdominal pain who were referred for general surgery.

Despite its limitations, this study is the only prospective investigation conducted in our region, indicating a new era for further exploration of this crucial topic. This lays the groundwork for future studies aimed at uncovering robust associations and evaluating the efficacy of scoring systems in diagnosing one of the most prevalent surgical issues.

In conclusion, our study highlights a male predominance and a higher prevalence of acute appendicitis among individuals under 40 years of age. Most participants presented with symptoms lasting less than 48 h. The RIPASA and Alvarado scoring systems exhibited promising diagnostic values, with RIPASA demonstrating slightly higher sensitivity. These results emphasise the potential of scoring systems to facilitate accurate diagnosis of acute appendicitis.

Source of Support: Nil,

Conflict of Interest: None declared

Acknowledgments:

The authors would like to thank all of the study participants and the administration of Department of Surgery, Government Erode Medical College and Hospital, Perundurai, Tamilnadu, India  for granting permission to carry out the research work.

Ethical statement:

The study was approved by the institutional human ethics committee, Government Erode Medical College and Hospital, Perundurai. Informed written consent was obtained from all the study participants and only those participants willing to sign the informed consent were included in the study. The risks and benefits involved in the study and the voluntary nature of participation were explained to the participants before obtaining consent. The confidentiality of the study participants was maintained.

Authors’ contributions:

Dr K.P.Senthan Amudhan- conceptualization, data curation, investigation, methodology, project administration, visualization, writing—original draft, writing—review and editing; Dr P.Prasanth -conceptualization, methodology, writing—original draft, writing—review and editing; Dr T.Mahalingam - conceptualization, visualization, supervision, writing—original draft. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.

DATA AVAILABILITY:

All datasets generated or analyzed during this study are included in the manuscript.

INFORMED CONSENT:

Written informed consent was obtained from the participants before enrolling in the study.

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