Which One is Better? Comparison of the Acute Inflammatory Response, Raja Isteri Pengiran Anak Saleha Appendicitis and Alvarado Scoring Systems

Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study

Background

Acute appendicitis is a complex diagnosis that often requires both clinical and radiological evaluation. Significant variations in diagnostic approaches are evident among clinicians and healthcare institutions. While certain guidelines advocate for risk stratification based on clinical characteristics, others emphasize the importance of pre-operative imaging. This study seeks to explore the accuracy of the Alvarado Score and abdominal ultrasound (AUS) in diagnosing acute appendicitis.

Methods

Suspected cases of appendicitis admitted to Al-Thora Hospital in Ibb, Yemen, from Jan 2021 to July 2022 were evaluated. The demographics, clinical, and laboratory data were collected and analyzed. This study assessed Alvarado scores (calculated based on clinical evaluation and laboratory data) and pre-operative AUS findings, correlating them with post-operative and histopathology findings. The Alvarado scores and AUS sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were assessed using the ROC curve.

Results

Out of 1021 cases of acute abdomen, 171 patients were suspected of appendicitis. Using AUS along with the Alvarado score, appendicitis was presumed in 137 patients who underwent appendectomy. 130 (94.9%) patients had positive intraoperative and histopathology findings while 7 (5.1%) had negative findings. The Alvarado Score had a sensitivity and specificity of 94.62% and 87.80% at cutoffs of 6, respectively [Area under the curve (AUC): 0.985; 95% confidence interval (CI), 0.954 to 0.998; p < 0.0001]. Abdominal US showed a sensitivity of 98.46% and specificity of 82.93% (AUC:0.907; 95% CI, 0.853 to 0.946; p < 0.0001).

Conclusion

Alvarado's score and AUS exhibited high sensitivity and specificity in diagnosing acute appendicitis. The substantial accuracy and efficacy of both the Alvarado score and AUS support their utilization as primary investigative tools in resource-limited settings. This approach can help avoid unnecessary appendectomies and minimize the financial burden on patients.

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis

BACKGROUND

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system.

METHODS

This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index.

RESULTS

A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis.

CONCLUSION

Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis

The Alvarado score (AS) has not been widely used for diagnosing acute appendicitis although it has shown to be a good predictor for diagnosing appendicitis. The aim was to perform a systematic review of the available literature and synthesize the evidence.

Methods

A systematic review was performed as per the PRISMA guidelines using search engines like Ovid, PubMed, and Google Scholar with predefined, strict inclusion and exclusion criteria. The quality assessment of included studies was performed using the QUADAS 2 tool. Summary statistics were performed for all variables. A linear regression model was performed between dependent and independent variables using STATA software. Heterogeneity testing showed significant heterogeneity within the included studies; hence, a forest plot with pooled estimates could not be constructed, and therefore a meta-regression was performed.

Results

Seventeen full-text articles met inclusion and exclusion criteria. Ten of which were identified as low-risk studies. Five studies were included in final data pooling with total patients being 2239 and mean age of 31.9 years. (1) Linear regression demonstrated an association between 'histological appendicitis' and 'AS 7-0' with patients receiving intervention, with a significant P value of less than 0.005. (2) Meta-regression demonstrated a positive coefficient (0.298), a positive Z score of 2.20 with a significant P value of 0.028 for patients with 'high AS' who received interventions that were significantly proven to be 'histologically appendicitis', indicating a cause-and-effect relationship.

Conclusion

High AS (7 and above) is a significant predictor of acute appendicitis. The authors recommend further prospective randomized clinical trials to establish a cause-and-effect relationship.

Comparison of Alvarado score, appendicitis inflammatory response score (AIR) and Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score in predicting acute appendicitis

Introduction

Acute Appendicitis is the most common surgical emergency encountered in emergency departments. To prevent the rate of negative appendectomies, different systems i.e. Alvarado score and Appendicitis Inflammatory Response Score (AIR) scores were used, but their diagnostic accuracy in Asian population is questionable. Raja Isteri Pengiran Anak Saleha (RIPASA) score has showed promising results in the recent literature. The purpose of this study is to compare the efficacy of Alvarado, AIR and RIPASA scores in the diagnosis of acute appendicitis.

Methods

Alvarado, AIR and RIPASA scores were prospectively applied to 132 included patients that were admitted with provisional diagnosis of acute appendicitis and then their surgery was performed in General Surgery Unit, Hayatabad Medical Complex Peshawar, Pakistan from 1st January 2022 to 31st July 2022. Final diagnosis was confirmed by histopathology report and scores were correlated with final report. Cut off value of score >7, >5 and >7.5 were set for Alvarado, AIR and RIPASA score, respectively according to previous literature. Statistics analysis was done for all 3 scoring systems on SPSS version 23.

Results

Of 132 patients, there were n = 79(59.8%) males and n = 53(40.2%) females. Mean age was 24 years (SD ± 11.6) with youngest patient of 9 years and oldest one was 70 years old. Negative Appendectomy rate was 8.3%(n = 11). RIPASA score was superior to AIR and Alvarado score in Sensitivity, NLR, Accuracy and Area under the Curve. AIR score performed better in specificity, NPV, PLR compared to RIPASA and Alvarado score.

Conclusion

RIPASA score is an overall better scoring system in diagnosing acute appendicitis in compared to Alvarado and AIR score.

Diagnostic Accuracy Rates of Appendicitis Scoring Systems for the Stratified Age Groups

BACKGROUND

Many scoring systems have been developed for acute appendicitis, which is the most common emergent disorder in surgical practice. Considering the physiological changes and chronic diseases occurring with advancing age, an applied scoring system may not produce the same score in similar patients in all age groups.

OBJECTIVES

We aimed to compare the predictive values of scoring systems in different age groups.

METHODS

In this prospective study, the patients operated on in our clinic with a prediagnosis of acute appendicitis between March 2020 and March 2021 were included. We divided them into three age groups as 18-45 years (group 1), 46-65 years (group 2), and >65 years (group 3). We compared the scores of the nine acute appendicitis scoring systems most commonly used in the literature for these age groups.

RESULTS

A total of 203 patients were included in our study. The Alvarado scoring system yielded the most accurate results for group 1, whereas the Fenyo-Linberg scoring system was the most accurate system for group 2 and the Eskelinen scoring system for group 3.

CONCLUSION

Age should be considered as a major parameter during the selection of the scoring system to be applied for patients with prediagnosis of acute appendicitis. Our study revealed the Alvarado and the Fenyo-Lindberg scoring systems as the most accurate systems for the differential diagnosis of appendicitis in the 18-45 and 46-65 years age groups, respectively. Although we found the Eskelinen scoring system as the most accurate one in the >65 years age group, the confidence intervals indicated that it may not be appropriate for use alone in this group.

Comparison of RIPASA and ALVARADO scores for risk assessment of acute appendicitis: A systematic review and meta-analysis

Background

In the last decades, several clinical scores have been developed and currently used to improve the diagnosis and risk management of patients with suspected acute appendicitis (AA). However, some of them exhibited different values of sensitivity and specificity. We conducted a systematic review and metanalysis of epidemiological studies, which compared RIPASA and Alvarado scores for the diagnosis of AA.

Methods

This systematic review was conducted using PubMed and Web of Science databases. Selected studies had to compare RIPASA and Alvarado scores on patients with suspected AA and reported diagnostic parameters. Summary estimates of sensitivity and specificity were calculated by the Hierarchical Summary Receiver Operating Curve (HSROC) using STATA 17 (STATA Corp, College Station, TX) and MetaDiSc (version 1.4) software.

Results

We included a total of 33 articles, reporting data from 35 studies. For the Alvarado score, the Hierarchical Summary Receiver Operating Curve (HSROC) model produced a summary sensitivity of 0.72 (95%CI = 0.66–0.77), and a summary specificity of 0.77 (95%CI = 0.70–0.82). For the RIPASA score, the HSROC model produced a summary sensitivity of 0.95 (95%CI = 0.92–0.97), and a summary specificity of 0.71 (95%CI = 0.60–0.80).

Conclusion

RIPASA score has higher sensitivity, but low specificity compared to Alvarado score. Since these scoring systems showed different sensitivity and specificity parameters, it is still necessary to develop novel scores for the risk assessment of patients with suspected AA.

RIPASA versus Alvarado score in the assessment of suspected appendicitis in children: a prospective study

Background

Diagnosis of acute appendicitis remains a problem in children with right lower quadrant pain.

Challenging diagnosis and fears of missing an inflamed appendix may lead to a negative appendectomy. Many scoring systems have been developed to reduce ambiguities in the diagnosis of appendicitis. Alvarado is one of the most commonly used scoring methods in pediatric patients. The RIPASA score is considered to be a better diagnostic scoring method in adults compared to Alvarado. The present study aims to compare RIPASA and Alvarado scoring systems in determining the possibility of acute appendicitis in children with right lower quadrant pain.

This study included 179 consecutive pediatric patients who were referred to pediatric surgery with suspicion of acute appendicitis. The cut-off value was >7.5 for the RIPASA score vs. ≥7 for the Alvarado score. The possibility of appendicitis was divided into three groups for the Alvarado score and four groups for the RIPASA score.

Results

In this study, 158 of 179 patients were operated on. In 140 of the operated patients, the diagnosis of appendicitis was confirmed by histopathology. The negative appendectomy rate was 11.4%. Specificity and negative predictive value of RIPASA score were higher than those of Alvarado (p<0.001). No difference was found between the two scores concerning sensitivity, positive predictive value, and the area under the receiver operator characteristics curve (p>0.05).

Conclusion

The RIPASA scoring system can be used as an alternative to the Alvarado scoring system in the management of patients with right lower quadrant pain in emergency services and pediatric outpatient clinics. With the use of the RIPASA score, more patients with a low likelihood of appendicitis can be detected and further contributed to the reduction of the negative appendectomy rate.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

Diagnostic accuracy of Alvarado, RIPASA and Tzanakis scoring system in acute appendicitis: A prospective observational study

Our prospective observational study, enrolling 167 patients undergoing emergency appendicectomy, served to evaluate the Alvarado, Tzanakis and RIPASA diagnostic scores. The latter was found to be a better scoring system because of its higher diagnostic accuracy. At centres with limited expertise in ultrasonography, RIPASA outperforms the Tzanakis score. Although easy to use, the Alvarado score was useful only to 'rule in' cases with AA with significant accuracy but at the cost of low sensitivity. It cannot be effectively used in triaging.

Preoperatively predicting the pathological types of acute appendicitis using machine learning based on peripheral blood biomarkers and clinical features: a retrospective study

Background

This study aimed to establish machine learning models for preoperative prediction of the pathological types of acute appendicitis.

Methods

Based on histopathology, 136 patients with acute appendicitis were included and divided into three types: acute simple appendicitis (SA, n=8), acute purulent appendicitis (PA, n=104), and acute gangrenous or perforated appendicitis (GPA, n=24). Patients with SA/PA and PA/GPA were divided into training (70%) and testing (30%) sets. Statistically significant features (P<0.05) for pathology prediction were selected by univariate analysis. According to clinical and laboratory data, machine learning logistic regression (LR) models were built. Area under receiver operating characteristic curve (AUC) was used for model assessment.

Results

Nausea and vomiting, abdominal pain time, neutrophils (NE), CD4⁺ T cell, helper T cell, B lymphocyte, natural killer (NK) cell counts, and CD4⁺/CD8⁺ ratio were selected features for the SA/PA group (P<0.05). Nausea and vomiting, abdominal pain time, the highest temperature, CD8⁺ T cell, procalcitonin (PCT), and C-reactive protein (CRP) were selected features for the PA/GPA group (P<0.05). By using LR models, the blood markers can distinguish SA and PA (training AUC =0.904, testing AUC =0.910). To introduce additional clinical features, the AUC for the testing set increased to 0.926. In the PA/GPA prediction model, AUC with blood biomarkers was 0.834 for the training and 0.821 for the testing set. Combining with clinical features, the AUC for the testing set increased to 0.854.

Conclusions

Peripheral blood biomarkers can predict the pathological type of SA from PA and GPA. Introducing clinical symptoms could further improve the prediction performance.

Validation of the Appendicitis Inflammatory Response (AIR) Score

Background

Patients with suspicion of appendicitis present with a wide range of severity. Score-based risk stratification can optimise the management of these patients. This prospective study validates the Appendicitis Inflammatory Response (AIR) score in patients with suspicion of appendicitis.

Method

Consecutive patients over the age of five with suspicion of appendicitis presenting at 25 Swedish hospital’s emergency departments were prospectively included. The diagnostic properties of the AIR score are estimated.

Results

Some 3878 patients were included, 821 with uncomplicated and 724 with complicated appendicitis, 1986 with non-specific abdominal pain and 347 with other diagnoses. The score performed better in detecting complicated appendicitis (ROC area 0.89 (95% confidence interval (CI) 0.88–0.90) versus 0.83 (CI 0.82–0.84) for any appendicitis, p < 0.001), in patients below age 15 years and in patients with >47 h duration of symptoms (ROC area 0.93, CI 0.90–0.95 for complicated and 0.87, CI 0.84–0.90 for any appendicitis in both categories). Complicated appendicitis is unlikely at AIR score <4 points (Negative Predictive Value 99%, CI 98–100%). Appendicitis is likely at AIR score >8 points, especially in young patients (positive predictive value (PPV) 96%, CI 90–100%) and men (PPV 89%, CI 84–93%).

Conclusions

The AIR score has high sensitivity for complicated appendicitis and identifies subgroups with low probability of complicated appendicitis or high probability of appendicitis. The discriminating capacity is high in children and patients with long duration of symptoms. It performs equally well in both sexes. This verifies the AIR score as a valid decision support.

Trial registration number

https://clinicaltrials.gov/ct2/show/NCT00971438

[Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]

The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.

Predictive value of scoring systems for the diagnosis of acute appendicitis in emergency department patients: Is there an accurate one?

Background:

Acute appendicitis is one of the challenging surgical conditions presented in the emergency departments. Clinical scoring systems were developed to reduce the negative appendectomy rate and also to avoid unnecessary diagnostic evaluation.

Objectives:

The primary aim was to compare the clinical adequacy of the Alvarado, Acute Inflammatory Response, and the Raja Isteri Pengiran Anak Saleha Appendicitis scores in patients with right lower quadrant pain for the diagnosis of acute appendicitis.

Methods:

This was a prospective and observational study. All patients over the age of 18 years who presented with a complaint of right lower quadrant pain were enrolled. The Alvarado, Acute Inflammatory Response, and Raja Isteri Pengiran Anak Saleha Appendicitis scoring systems were compared. The patients were either admitted or followed-up as out-patient. Face-to-face or telephone follow-up visits were arranged for the patients who did not have surgery and who were not admitted.

Results:

232 patients were included and 14 patients were excluded from the study. Of the 218 patients, 114 patients underwent surgery. Of the 114 patients, 107 patients were pathologically diagnosed with acute appendicitis. It was determined that Raja Isteri Pengiran Anak Saleha Appendicitis score was the most valuable score with 0.88 accuracy, followed by Acute Inflammatory Response (area under the curve = 0.79) and Alvarado (area under the curve = 0.71) scores.

Conclusion:

The accuracy of Raja Isteri Pengiran Anak Saleha Appendicitis scoring system was higher for the diagnosis of acute appendicitis than the other scores. The cut-off of the Raja Isteri Pengiran Anak Saleha Appendicitis score from a 7.5-point threshold provides a practical, non-invasive, rapid diagnostic method that increases acute appendicitis discriminative power in patients presenting with right lower quadrant pain.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

Comparison of Raja Isteri Pengiran Anak Saleha Appendicitis and modified Alvarado scoring systems in the diagnosis of acute appendicitis

BACKGROUND

The diagnosis of acute appendicitis (AA) is mainly dependent on clinical evaluation. There are several scoring systems developed for an accurate and early diagnosis of AA. Modified Alvarado score is one of the most common systems. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was developed in 2010. The aim of this study is to evaluate and compare the accuracy of modified Alvarado and RIPASA scoring systems for the diagnosis of AA.

METHODS

A total of 100 cases with the clinical diagnosis of AA were included in the study. All the cases were treated surgically. For all cases, modified Alvarado and RIPASA scores were calculated and recorded. According to the calculated cut-off values, sensitivity, specificity, negative and positive predictive values and total accuracy were calculated for each scoring systems.

RESULTS

According to the receiver operating characteristic curve. the optimal score of modified Alvarado score for AA was found to be 5.5 with a sensitivity of 88% and specificity of 69%. According to the receiver operating characteristic curve, the optimal score of RIPASA score for AA was found to be 8.75 with a sensitivity of 94% and specificity of 88%. With the cut-off value of 8.75, total accuracy of RIPASA scoring was found to be 85.2%. Although there is no significant difference in negative appendicectomy rate, both sensitivity and the specificity of the RIPASA were found to be significantly higher than the modified Alvarado.

CONCLUSION

According to the current study, RIPASA scoring system was found to be superior to modified Alvarado in the prediction of cases with AA.

Can RIPASA Scoring System Predict the Pathological Stage of Acute Appendicitis?

Introduction

Being one of the scoring systems used in the diagnosis of acute appendicitis, the RIPASA score can be used easily with a high diagnostic accuracy.

Objective

To evaluate the possible relationship between RIPASA scores and the histopathological examination results of appendectomy materials.

Materials and Methods

This study retrospectively reviews 242 patients who were operated in our clinic between January 2016 and January 2018 with a prediagnosis of acute appendicitis, and the RIPASA scores calculated in the preoperative period were compared to the histopathological examination results of the appendectomy specimens.

Results

The patients consisted of 124 (51.2%) females and 118 (48.8%) males. The ages of the patients ranged from 15 to 81 years. The patients were divided into 3 groups based on their RIPASA scores as low-score (4-7), intermediate-score (7.5-11.5), and high-score (12 and over) groups. There were 20 (52.6%) catarrhal-stage appendicitis cases and 17 (44.7%) normal appendixes in the low-score group; there were 70 (83.3%) catarrhal-stage appendicitis cases, 9 (10.7%) suppurative-stage appendicitis cases, 4 (4.8%) gangrenous-stage appendicitis cases, and 1 (1.2%) perforated appendicitis case in the intermediate-score group. In the high-score group, there were 53 (44.2%) suppurative-stage appendicitis cases, 51 (42.5%) gangrenous-stage appendicitis cases, 11 (9.2%) perforated appendicitis cases, and 5 (4.2%) catarrhal-stage appendicitis cases. A strong positive correlation was found between the RIPASA scores of the patients and the pathological stage of appendicitis (r=0.889; p<0.001).

Conclusion

The RIPASA scoring system can make a correct and prompt diagnosis of acute appendicitis including its possible pathological stage without any need for a computed tomography.