|Year : 2015 | Volume
| Issue : 6 | Page : 744-749
Evaluation of Raja Isteri Pengiran Anak Saleha Appendicitis score: A new appendicitis scoring system
Sarang Rathod1, Iqbal Ali1, Arjinder Pal Singh Bawa2, Gurjit Singh1, Siddharth Mishra1, Mackson Nongmaithem1
1 Department of Surgery, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Community Medicine, Army Medical College of Medical Sciences, New Delhi, India
|Date of Web Publication||19-Nov-2015|
Department of Surgery, Dr. D. Y. Patil Medical College, Pimpri - 411 018, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Acute appendicitis is the most common cause of an acute abdomen requiring surgery, the clinical presentation is typical in 50% of the cases, but the decision to explore the patient can sometimes be challenging. The diagnosis is based on history, clinical examination, and few laboratory investigations. To help the surgeon make diagnosis with certainty and reduce negative laparotomy rate, a number of clinical scoring systems are in vogue. The present study was undertaken to evaluate the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score in the diagnosis of acute appendicitis. Materials and Methods: A prospective study was undertaken among 100 cases presenting with signs and symptoms suggestive of acute appendicitis. Validity of RIPASA score as a diagnostic test for appendicitis was established by calculating its sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) along with 95% confidence intervals (CIs), using intraoperative diagnosis confirmed by histopathology as gold standard. Results: RIPASA had sensitivity of 82.61% (95% CI 72.02, 89.76) and specificity of 88.89% (95% CI 67.2, 96.9). It had a PPV of 96.61% (95% CI 88.46, 99.07), NPV of 57.14% (95% CI 39.07, 73.49), and a diagnostic accuracy rate of 83.91% (95% CI 74.78, 90.17). Conclusion: The RIPASA score is a simple scoring system with a reasonable sensitivity and specificity for the diagnosis of acute appendicitis.
Keywords: Acute appendicitis, Raja Isteri Pengiran Anak Saleha Appendicitis score, validity
|How to cite this article:|
Rathod S, Ali I, Bawa AP, Singh G, Mishra S, Nongmaithem M. Evaluation of Raja Isteri Pengiran Anak Saleha Appendicitis score: A new appendicitis scoring system. Med J DY Patil Univ 2015;8:744-9
|How to cite this URL:|
Rathod S, Ali I, Bawa AP, Singh G, Mishra S, Nongmaithem M. Evaluation of Raja Isteri Pengiran Anak Saleha Appendicitis score: A new appendicitis scoring system. Med J DY Patil Univ [serial online] 2015 [cited 2020 Nov 28];8:744-9. Available from: https://www.mjdrdypu.org/text.asp?2015/8/6/744/169914
| Introduction|| |
Acute appendicitis is the most common cause of an acute abdomen requiring surgery, with a lifetime risk of about 7%.  The clinical presentation is typical in 50% of the cases, but the decision to explore the patient can sometimes be challenging and tests the clinical acumen of the surgeon, particularly in young, elderly, and females of reproductive age group.  The diagnosis and management of acute abdominal pain remains one of the last bastions of clinical medicine, which remains to be conquered. There is no common situation where clinical feature, accurate diagnosis, and immediate decision are of utmost importance.  The diagnosis is based on history, clinical examination, and few laboratory investigations. In addition, a negative appendicectomy rate of 20-40% has been documented, and many surgeons would accept a rate of 30% as inevitable. 
Mostly in other fields, an initial tentative or even differential diagnosis is not necessarily harmful, we can wait until it is confirmed or refuted by clinical progress of the case, but in acute appendicitis, however, a treatment delay of even hours may result in a stormy course. It should be stressed of course that the physical signs of acute appendicitis are not specific, but merely those produced by the local peritoneal irritation in the right iliac fossa (RIF), the most common cause of which is acute appendicitis. Timely intervention of acute appendicitis among the young, elderly, and females of the reproductive age group is essential to avoid complications. 
To help the surgeon make diagnosis with certainty and reduce negative laparotomy rate, a number of clinical scoring systems are in vogue. The modified Alvarado score is the one which is most commonly used nowadays. However, its low sensitivity and specificity has demanded score with greater accuracy; moreover, this score was developed in Western countries, with different diet and environmental factors.
The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) is a new scoring system, which has been developed for a better diagnosis of acute appendicitis; this score includes 14 clinical parameters, which have higher sensitivity, specificity, and diagnostic accuracy than Alvarado scoring, especially in the Asian population.  It was developed in the Department of Surgery at Raja Isteri Pengiran Anak Saleha Hospital, Brunei Darussalam, in 2008. 
The present study was undertaken to validate the RIPASA score as a tool for diagnosis of acute appendicitis in our hospital setting.
| Materials and Methods|| |
A prospective study was undertaken among 100 cases who presented with signs and symptoms suggestive of acute appendicitis at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, between July 2012 and September 2014.
Institutional Ethical Committee approval was taken. Besides, informed consent was obtained from each participant in the study.
Patients with RIF pain were included and patients with any form of nonRIF pain such as lower abdominal pain or right upper quadrant pain and those who had undergone other emergency laparotomy where appendicectomy was also performed as a part of the procedure were excluded. The following information was recorded from patients who met our inclusion criteria:
- Pain in RIF
- Migration of pain from umbilicus to RIF
- Nausea and vomiting
- Duration of symptoms
- RIF tenderness
- Rovsing's sign
- Rebound tenderness.
The following investigations were also carried out:
- Complete hemogram including total white blood cell count.
- Urinalysis (urine routine microscopy).
After the clinical examination and the above investigations, RIPASA scoring was done [Table 1].
Scoring was performed every 2 hourly until a decision was made for continuing conservative line of management or appendicectomy. For the patients with a score of 5-7, they were observed and decision was made whether to be treated conservatively or appendicectomy to be done. Patients who were managed conservatively and discharged were reviewed in the surgical outpatient department after 1 week. All patients with a true negative RIPASA score status were contacted by telephone within a month to confirm whether they had been re-admitted and had undergone emergency appendicectomy at another hospital at later date. Diagnosis of all patients undergoing appendicectomy was confirmed by histopathological examination of the appendicular specimen.
Validity of RIPASA score as a diagnostic test for appendicitis was established by calculating its sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) along with 95% confidence interval (CI), using operative diagnosis confirmed by histopathology as gold standard. The cut-off value for RIPASA score was determined by receiver operating characteristic (ROC) curve. ANOVA was applied to explore whether there was any significant age difference in RIPASA scores.
| Results|| |
The age distribution in the study sample varied from <20 years to more than 40 years of age. Majority of cases (38%) were between 21 and 30 years of age [Table 2].
Out of 100 patients included in the study, majority of patients in the study group were males (59%).
Distribution of RIPASA scores at the time of admission is given in [Table 3].
Totally, 87 out of 100 patients were subjected for emergency appendicectomy. Out of these 87 cases who underwent surgery, 71.26% cases were confirmed as acute appendicitis on histopathology, 8.05% were found with perforated appendicitis, and 20.69% were normal on histopathology [Table 4].
|Table 4: Histopathological fi nding wise distribution of cases in the study group|
Click here to view
In our study, the optimal cut-off threshold score derived from ROC analysis was 7.25. This cut-off yielded sensitivity of 82.61% (95% CI 72.02, 89.76); specificity of 88.89% (95% CI 67.2, 96.9); PPV of 96.61% (88.46, 99.07); and NPV of 57.14% (95% CI 39.07, 73.49). It had a diagnostic accuracy of 83.91% (95% CI 74.78, 90.17) [Table 5].
|Table 5: Validity of RIPASA score using histopathology confi rmed appendicitis as gold standard|
Click here to view
True positives in the study group had mean age of 28.84 years with standard deviation of 10.49, false positives in the study group had mean age of 39.00 years with standard deviation of 5.66, true negatives had 31.75 as mean age in years and standard deviation of 8.53 and false negatives had 35.58 as mean age in years and 13.19 as standard deviation [Table 6].
With a total of 52 male patients, 35 were true positives and out of 35 female patients, 22 were true positives [Table 7].
| Discussion|| |
Acute appendicitis is one of the most common surgical emergencies encountered, especially by junior doctors during on-call duties with emergency appendicectomy making up 10% of all emergency abdominal surgeries. , The evaluation is mainly based on history and clinical findings, which is an important parameter in reaching a diagnosis of acute appendicitis. 
Despite this, making a quick and accurate diagnosis of acute appendicitis can be difficult.
The RIPASA score is simple and easy to use as a quantitative scoring system and most of the included 14 clinical parameters are easily obtained from a good clinical history and examination. This also includes urinalysis, which can be easily performed. Hence, a score can be obtained quickly, and a rapid diagnosis can be made without having to wait for the full investigations. 
Radiological investigations such as computed tomography (CT) scan have been reported to have high sensitivity (94%) and specificity (95%) for diagnosing acute appendicitis. 
It is now a common practice in major centers to perform a CT scan in all patients suspected of having acute appendicitis. 
However, such practice can be very costly and stretch an already overburdened national healthcare system. Furthermore, arrangement for CT scan may delay emergency appendicectomy.
Recent reports have suggested that the indiscriminate use of CT scan may lead to the detection of early low-grade appendicitis and these patients may then be subjected to unnecessary appendicectomy, in a condition that would otherwise have resolved spontaneously with antibiotics therapy. 
Several scoring systems such as the Alvarado and the modified Alvarado scoring system had been introduced since 1986 to help with clinical decision-making process in achieving an accurate diagnosis of acute appendicitis in the fastest and cheapest way. ,
Such scoring systems also provide guidelines to help junior doctors to select patients for either emergency appendicectomy or conservative management with further radiological investigations, if required. ,
Despite good sensitivity and specificity when applied to a Western population, both these scoring systems have been shown to achieve low sensitivity and specificity, ranging from 50% to 59% and 23% to 94%, respectively, when applied to Middle Eastern, Asian, or Oriental populations. ,,
The Alvarado score has more emphasis on tenderness in RIF, which has given a higher score than that of rebound tenderness, whereas rebound tenderness is a clinical parameter, which is more important in reaching a diagnosis of acute appendicitis as RIF tenderness can be present as a different pathological condition.
Because of the poor sensitivity and specificity of both the Alvarado and the modified Alvarado scoring systems, the RIPASA score was developed, which was more applicable to our Asian population, given the nature of diet and high prevalence of parasitic infestation. 
This prospective evaluation of RIPASA score in our study had a PPV of 96.61% (score >7.25) and an NPV of 57.14% (score <7.25). The results clearly outperformed both the Alvarado and the modified Alvarado scores. ,,
Recently, a new scoring system called, "appendicitis inflammatory response score" was introduced by Andersson and Andersson in 2008. This scoring system had a sensitivity of only 96% and a specificity of 73% for a cut-off threshold set at >4 or a sensitivity of 37% and specificity of 99% if the cut-off threshold was set at >8. 
In this score, CRP has been given more emphasis, but as it is an acute phase protein, it can also be raised in other conditions and this investigation is time-consuming and time is of essence considering the morbidity and mortality in acute appendicitis. In addition, the parameter of rebound tenderness is completely based on subjective analysis, so as to divide it into light, medium, and strong may create a difference in final score and achieving the diagnosis.
Using this appendicitis inflammatory response score, 73% of the nonappendicitis patients (true negative and false positive) were classified to the low probability group whereas 67% of patients with advanced appendicitis (true positive and false negative) were classified to the high probability group with a high accuracy, in comparison with 96.61% and 57.14%, respectively, for the RIPASA score in our study.
Using the RIPASA score, the predicted negative appendicectomy rate was 17.39%, which is a 2.01% reduction from the observed rate of 19.4%. 
The sensitivity and specificity of the RIPASA score in our study were 82.61% and 88.89%, respectively, whereas in a retrospective study done by other investigators, the sensitivity and specificity of Alvarado and modified Alvarado score was less and similar to the sensitivity and specificity of that of a CT scan. ,, By application of the RIPASA score, the number of costly CT scans that are to be performed to exclude acute appendicitis could be reduced.
The number of patients in our study had males more than females, which is similar to a study done by Canavosso et al. in which the incidence of acute appendicitis was more in males than in females. 
In our study, the PPV of RIPASA score was 96.61%, whereas a study done by Singh et al.  found PPV of 83.79%, which suggests that the RIPASA score is superior to Alvarado score.
The RIPASA score is simple and easy to use as a quantitative scoring system and as shown in Appendix, most of these 14 clinical parameters are easily obtained from a good clinical history and examination. This also includes a urinalysis, which can be easily performed on the spot. Hence, a score can be obtained quickly and a rapid diagnosis can be made without having to wait for the full investigations to be available. 
The data collected include the patients' demographics (age and gender), the presenting symptoms (RIF pain, the migration of pain to the RIF, nausea and vomiting, anorexia, and the duration of symptoms), clinical signs (RIF tenderness, guarding, rebound tenderness, Rovsing's sign, and fever), and laboratory investigations (elevated white cell count and negative urinalysis). The inclusion of these 14 parameters was agreed upon by a panel of general surgeons at RIPAS Hospital. These 14 parameters formed the basis of the new appendicitis scoring system. The probability of each parameter was calculated and scores of 0.5, 1.0, or 2.0 points were allocated to each parameter based on its probability, with extra weightage provided to two clinical signs: Guarding and Rovsing's signs. 
Our study suggests that RIPASA score can be considered a superior score than the commonly used Alvarado score in terms of higher sensitivity and specificity in diagnosing acute appendicitis, similarly a study done by Alnjadat and Abdallah concluded that both the RIPASA and Alvarado scoring systems could significantly lower negative appendicectomy rate; however, RIPASA could identify a significant proportion of patients who could be otherwise missed by Alvarado score. 
The RIPASA score was specifically developed for our Asian population, the 14 fixed clinical parameters are common to all the worldwide population and hence the RIPASA score can be applied in any country. The additional parameter of foreign NR can be included to the score in countries where there is a large foreign work-force who have to pay for any healthcare treatment.
| Conclusion|| |
The RIPASA score is a simple scoring system with high sensitivity and specificity for the diagnosis of acute appendicitis. The 14 clinical parameters are all present in a good clinical history and examination and can be easily and quickly applied. Therefore, a decision on the management can be made early. Although the RIPASA score was developed for the local population of Brunei, we believe that it should be applicable to other regions. Further studies can confirm this impression.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ohle R, O'Reilly F, O'Brien K, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: A systemic review. Biomed Cent Med 2011;9:1-13.
Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, et al
. Evaluation of the RIPASA score: A new scoring system for the diagnosis of acute appendicitis. Brunei Int Med J 2010;6:17-26.
Fitz RH. Perforating inflammation of the vermiform appendix: With special reference to its early diagnosis and treatment. Trans Assoc Am Physician 1886;1:107.
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;11:562-9.
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;52:340-5.
Kumar V, Cotran RS, Robbins SL, Appendix. In: Robbin's Basic Pathology. London: WB Saunders; 1992. p. 520.
Pal KM, Khan A. Appendicitis: A continuing challenge. J Pak Med Assoc 1998;48:189-92.
Ergul E, Ucar AE, Ozgun YM, Korukluoglu B, Kusdemir A. Family history of acute appendicitis. J Pak Med Assoc 2008;58:635-7.
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;141:537-46.
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: 1843-9.
Livingston EH, Woodward WA, Sarosi GA, Haley RW. Disconnect between incidence of nonperforated and perforated appendicitis: Implications for pathophysiology and management. Ann Surg 2007;245:886-92.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64.
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;76:418-9.
Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado score for acute appendicits in adults. Saudi Med J 2004;25:1229-31.
Khan I, ur Rehman A. Application of Alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17:41-4.
Jang SO, Kim BS, Moon DJ. Application of Alvarado score in patients with suspected appendicitis. Korean J Gastroenterol 2008;52:27-31.
Smith DE, Kirchmer NA, Stewart DR. Use of the barium enema in the diagnosis of acute appendicitis and its complications. Am J Surg 1979;138:829-34.
Memon ZA, Irfan S, Fatima K, Iqbal MS, Sami W. Acute appendicitis: Diagnostic accuracy of Alvarado scoring system. Asian J Surg 2013;36:144-9.
Bramhachari S, Jajee AB. Alvarado score: A valuable clinical too for diagnosis of acute appendicitis - A retrospective study. J Med Allied Sci 2013;3:63-6.
Canavosso L, Carena P, Carbonell JM, Monjo L, Palas Zuñiga C, Sánchez M, et al.
Right iliac fossa pain and Alvarado score. Cir Esp 2008;83:247-51.
Singh K, Gupta S, Pargal P. Application of Alvarado scoring system in diagnosis of acute appendicitis. JK Sci 2008;10:84-6.
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;51:220-5.
Alnjadat I, Abdallah B. Alvarado versus RIPASA score in diagnosing acute appendicitis. RMJ 2013;38:147-51.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]