Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis

doi:10.5847/wjem.j.1920-8642.2017.04.005

Abstract

Abstract:

BACKGROUND: Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%-10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population.

METHODS: This study included 180 patients who underwent appendectomies and were documented as having "acute appendicitis" or "abdominal pain" in the operating theatre logbook (unit B) from November 2014 to March 2016. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software.

RESULTS: A total of 136 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems.

CONCLUSION: Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14 clinical parameters that can be obtained from a good patient history, clinical examination and laboratory investigations. The RIPASA scoring system is more accurate and specific than the modified Alvarado scoring system for Kuwait population.

Key words: Acute appendicitis, Modified Alvarado score, RIPASA score

Abdullah Shuaib, Ali Shuaib, Zainab Fakhra, Bader Marafi, Khalid Alsharaf, Abdullah Behbehani. Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis[J]. World Journal of Emergency Medicine, 2017, 8(4): 276-280.

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References 16

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Parameters	Score
Migratory right iliac fossa pain	1.0
Anorexia	1.0
Nausea and vomiting	1.0
Right iliac fossa tenderness	2.0
Rebound tenderness	1.0
Fever	1.0
Leucocytosis	2.0
Shift to the left neutrophils	1.0
Total score	10.0

Parameters	Score
Migratory right iliac fossa pain	1.0
Anorexia	1.0
Nausea and vomiting	1.0
Right iliac fossa tenderness	2.0
Rebound tenderness	1.0
Fever	1.0
Leucocytosis	2.0
Total score	9.0

Parameters	Score
Female	0.5
Male	1.0
Age<39.9 years	1.0
Age>40.0 years	0.5
Right iliac fossa (RIF) pain	0.5
Migration of pain to RIF	0.5
Anorexia	1.0
Nausea and vomiting	1.0
Duration of symptoms<48 hours	1.0
Duration of symptoms>48 hours	0.5
RIF tenderness	1.0
Guarding	2.0
Rebound tenderness	1.0
Rovsing's sign	2.0
Fever	1.0
Raised WBC	1.0
Negative urine analysis	1.0
Total score	16.5

Variables	Results
Mean age (years)	26.8±13.2
Gender
Male	72 (52.9)
Female	64 (47.1)
Procedure (appendectomy)
Laparoscopic	117 (85)
Open	19 (14)
Diagnostics
Abdominal ultrasonography	44 (32.4)
Computed tomography	35 (25.7)
Histopathology
Early acute appendicitis	10 (7.4)
Active suppurative appendicitis	88 (64)
Acute necrotising appendicitis	5 (3.7)
Gangrenous/perforated appendicitis	8 (5.9)
Negative appendectomy rate	25 (18.4)
Clinical parameters
Right iliac fossa pain	135 (99.3)
Nausea and vomiting	111 (81)
Anorexia	79 (58.1)
Fever	53 (39.0)

Variables	Modified Alvarado≥7 (95%CI)	RIPASA≥7.5 (95%CI)	P value
Sensitivity	83.8% (74.3%-89.1%)	94.5% (88.1%-97.7%)	<0.001
Specificity	56.0% (35.2%-74.9%)	88.0% (67.6%-96.8%)	<0.001
PPV	89.4% (81.4%-94.2%)	97.2% (91.4%-92.2%)
NPV	42.4% (25.9%-60.6%)	78.5% (58.5%-90.0%)	<0.001
Diagnostic accuracy	77.94%	93.38%	<0.001
Negative appendectomy rate	10.7%	2.2%	=0.048