Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children

Validation of the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system for the diagnosis of acute appendicitis among Ethiopian patients: a multi-institutional observational study

BACKGROUND

Acute appendicitis is the most common surgical emergency in Ethiopian clinical practice. Although a multitude of scoring systems have been used in clinical practice, none have been universally validated. The purpose of this study was to validate the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system in the Ethiopian context.

METHODS

A total of 315 consecutive patients who presented with a presumptive diagnosis of acute appendicitis and were planned to undergo appendectomy were studied. All the studied patients had diagnostic sonography and underwent the RIPASA scoring system. The sensitivity, specificity, positive predictive value, and negative predictive value of RIPASA and ultrasound results with intraoperative gross examinations.

RESULTS

The mean age of the participants was 27.4 ± 11.5 years, with a male-to-female ratio of 1.6:1. The concordance between ultrasound and RIPASA for the diagnosis of acute appendicitis was 93.6%. The sensitivity, specificity, positive predictive value, and negative predictive value of RIPASA were 96.2%, 30.8%, 93.9%, and 42.1%, respectively. Similarly, the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound were 95.3%, 27.8%, 95.6%, and 26.3%, respectively. White cell count and RIPASA scores were weakly correlated with intraoperative stages of acute appendicitis, r(313) = 0.18, p = 0.001, and r(313) = 0.129, p = 0.022, respectively. The rate of a negative appendectomy was 6%.

CONCLUSION

RIPASA and ultrasound had equivalent performance in the diagnosis of acute appendicitis. In both cases, the rate of negative appendectomy was low enough to validate RIPASA for clinical practice in low-income institutions where sonographic diagnosis by a conventionally trained radiologist is not available.

Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study

OBJECTIVE

The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED).

METHODS

A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED.

RESULTS

Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases.

CONCLUSIONS

The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.