Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis
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 90 patients who underwent appendectomies and were documented as having “acute appendicitis” or “abdominal pain” in the operating theatre register from June 2014 to May 2018. 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 68 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.
Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, et al. Development of the RIPASA score:a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J. 2010;51(3):220-225.
Wani MM, Yousaf MN, Khan MA, Abdul B, Durrani M, Shafi M. Usefulness of the Alvarado scoring system with respect to age, sex and time of presentation, with regression analysis of individual parameters. Internet J Surg. 2007;11(2):562-569.
Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis:a prospective study. Ann R Coll Surg Engl. 1994;76(6):418-419.
Kanumba ES, Mabula JB, Rambai P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC Surg. 2011;11:4. doi: https://doi.org/10.1186/1471-2482-11-4.
Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, Tan LT, Daud FM, Tan C, Telisinghe PU, Ang SH. Evaluation of the RIPASA Score: a new scoring system for the diagnosis of acute appendicitis. Brueni Int Med J. 2010;6(1):17-26.
Gilmore OJ, Browett JP, Griffin PH, Ross IK, Brodribb AJ, Cooke TJ, et al. Appendicitis and mimicking conditions. Lancet. 1975;2(7932):421-424. doi: https://doi.org/10.1016/s0140-6736(75)90841-7.
Antel J, Rivera L, Landenberg B, Halm G, Fatava MA, Brown CVR. Clinical diagnostic pathway for acute appendicitis: prospective validation. JAM Coll Surg. 2006;203(6):849-856. doi: https://doi.org/10.1016/j.jamcollsurg.2006.08.012.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-565. doi: https://doi.org/10.1016/s0196-0644(86)80993-3.
Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. JR Soc Med. 1992;85(2):87-88.
N N, Mohammed A, Shanbhag V, Ashfaque K, S A P. A comparative study of RIPASA Score and Alvarado Score in the diagnosis of acute appendicitis. J Clin Diagn Res. 2014;8(11):NC03-NC05. doi: https://doi.org/10.7860/JCDR/2014/9055.5170.
Ünlüer EE, Urnal R, Eser U, Bilgin S, Hacıyanlı M, Oyar O, et al. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis. World J Emerg Med. 2016;7(2):124-129. doi: https://dx.doi.org/10.5847%2Fwjem.j.1920-8642.2016.02.007.
Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, et al. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singapore Med J. 2011;52(5):340-345.
Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: Computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004;141(7):537-546. doi: https://doi.org/10.7326/0003-4819-141-7-200410050-00011.
Andersson M, Andersson RE. The appendicitis inflammatory response score:a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg. 2008;32(8):1843-1849. doi: https://doi.org/10.1007/s00268-008-9649-y.
Von-Mühlen B, Franzon O, Beduschi M, Kruel N, Lupselo D. Air score assessment for acute appendicities. ABCD Arq Bras Cir Dig. 2015;28(3):171-173. doi: https://doi.org/10.1590/S0102-67202015000300006.
Malyar AA, Singh B, Dar HM, Ahmad MM, Bhat SB. A comparative study of appendicitis inflammatory response (AIR) score with Alvarado score in diagnosis of acute appendicitis. BMMR. 2015;18(3):72-76. doi: https://doi.org/10.5455/bmmr.180876.