|Year : 2021 | Volume
| Issue : 3 | Page : 425-429
Effectivity of raja isteri pengiran anak saleha appendicitis scoring system for diagnosing acute appendicitis
D Suhas, Darshana Tote
Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India
|Date of Submission||12-Jul-2021|
|Date of Decision||12-Aug-2021|
|Date of Acceptance||30-Aug-2021|
|Date of Web Publication||12-Mar-2022|
Dr. D Suhas
# 7, Jawaharlal Street, Seshadripuram, Bengaluru - 560 020, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Acute appendicitis is a very common cause of acute abdomen, particularly associated with the young and middle age groups. Its diagnosis and management are primarily based on the clinical signs and symptoms. Many scoring systems have been made collaborating the signs and symptoms but do not cater to all population. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system is a relatively newer clinical scoring system, which has been used worldwide with good efficacy in the quick diagnosis of acute appendicitis. Methods: Research was done on 50 patients whose signs and symptoms were clinically suggestive of acute appendicitis. The patients were evaluated using RIPASA scores primarily on admission and were operated on the basis of the surgeon's decision. The scores were compared with the histopathological analysis, and efficacy was analyzed. Results: The sensitivity of the RIPASA score was 94.11%, specificity was 93.75%, positive predictive value was 96.96%, the negative predictive value of RIPASA score was 88.23%, and the diagnostic accuracy of RIPASA score was 94%. Conclusion: RIPASA scoring system is a simple and effective scoring system, which can be used in a bedside manner for an accurate diagnosis of appendicitis.
Keywords: Acute abdomen, clinical scoring system, Raja Isteri Pengiran Anak Saleha Appendicitis
|How to cite this article:|
Suhas D, Tote D. Effectivity of raja isteri pengiran anak saleha appendicitis scoring system for diagnosing acute appendicitis. J Datta Meghe Inst Med Sci Univ 2021;16:425-9
| Background|| |
The outward manifestation of in a suspected case of acute appendicitis, when a patient presents with acute abdomen can be confused with other severe abdominal emergencies due to its similarity in presentation. Due to the associated surrounding structures, the clinical presentations of the appendix show varied presentations. Atypical signs and symptoms are commonly encountered in the extremes of age.
The related mortality has been found to be between 0.2% and 0.8% more due to the complications associated with it. Delay in diagnosis and subsequent treatment can increase the mortality rate to 20%.
Acute appendicitis is diagnosed with a combination of clinical and imaging modalities. Despite the advances in imaging modalities, diagnosis of acute appendicitis is difficult due to its varied presentations. Clinical diagnosis is purported to be accurate in about 50% of cases, depending entirely on the clinical acumen of the examiner and his experience. The related mortality has been found to be between 0.2% and 0.8% more due to the complications associated with it. Delay in diagnosis and subsequent treatment can increase the mortality rate to 20%.
Acute appendicitis could be managed conservatively, but adopting the surgical method of management remains the most common, considering the complications arising out of it. When associated with extremes of age group, pregnancy and other gynecological disorders in the presence of genitourinary disorders masking its presence, makes the diagnosis of acute appendicitis difficult. However, the delay in diagnosing acute appendicitis sharply increases the morbidity and mortality of the patient. The mortality rate of acute appendicitis is associated in the range of <0.1% in noncomplicated cases, a mortality rate of 0.6% when associated with gangrene, and 5% when associated with perforation.
Numerous clinical scoring systems have been devised over the years as high burden associated with the early and accurate diagnosis and with the knowledge that good clinical acuity in combination with the results of accurate diagnostic facilities helps in improving the accuracy of diagnosis. The reliable scoring system had to have high sensitivity, specificity, and diagnostic accuracy and that which could be universally applied. In this attempt, multiple studies were conducted globally to compare various scoring systems [Graph 1].
There was a need to develop a scoring system which caters to the Asian and Middle Eastern population as well, since many of the scores which were developed by Western researchers were proved to be efficacious, mainly in the Western population. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) clinical scoring system was developed comprising 15 parameters, designed by Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam with a view to diagnose acute appendicitis in varied population.
The current study was conducted on the population in Central India to find out the validity and relevance of the RIPASA in diagnosing acute appendicitis.
Aims and objective
To assess the effectiveness of the RIPASA score in the early diagnosis of acute appendicitis.
To study the outcome of the RIPASA scoring system with respect to sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy.
| Methods|| |
Study design: Prospective observational study
This was a prospective observational study done at rural hospital in Central India over a period of 2 years. This study was conducted following the approval of the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, in 2018. Those patients who presented to hospital in Central India with pain in the right iliac fossa were evaluated and taken up for surgery were included in this study. Patients who were lesser than 13 years, pregnant females and patients with perforation peritonitis were excluded from the study. The sample size was kept as 50 after consultation with statistician.
- Study duration: September 2018–August 2020
- Sample size calculation
ƞ = (Zɑ/2) 2. p (1 − p)/d2
where Zɑ/2 is the level of significance at 5%, i.e., 95% confidence interval = 1.96
p = proportion of number of cases of acute appendicitis, 6.3%–0.063
d = desired error of margin = 7% = 0.007
ƞ = 1.962 × 0.063 × (1 − 0.063)/0.072
Thus, the sample size was set to 50 in accordance with Chaudhari YP, Jawale PG. Prevalence of appendicitis at surgery inpatient department of a tertiary care hospital: a descriptive study. Int Med J 2015;2(11):768-0.
The patients were explained about the study and the risks and consequences of the operative procedure. After obtaining their informed written consent, the demographic data such as age and sex were collected along with any history of comorbidities. The patients, after being subjected to a thorough clinical examination and laboratory tests, were later decided to undergo the operative procedure. Patients were then taken up for surgical intervention based finally on the decision of the treating surgeon. Postoperatively, the specimens were sent for histopathological analysis. Later, the reports were correlated with the score obtained from the RIPASA score and further subjected to statistical analysis [Table 1], [Table 2], [Table 3].
|Table 1: Raja Isteri Pengiran Anak Saleha Appendicitis score based on clinical presentation|
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|Table 2: Results of Raja Isteri Pengiran Anak Saleha Appendicitis scoring system|
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|Table 3: Results of Raja Isteri Pengiran Anak Saleha Appendicitis score of the current study in comparison with other studies|
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Data collected were gathered, and a master chart was organized. Data were sectioned, and disseminated and discrete tables were made with graphical representations on Microsoft excel worksheet (Microsoft, USA). Patients admitted under the surgery department or to the Emergency Department with the following criteria were screened for the study. The final decision to operate was based on the operating surgeon and not on the scoring systems.
Statistical analysis was performed with IBM Statistical Package for the Social Sciences (Statistics for Windows, Version 24.0. Armonk, NY, USA: IBM Corp.).
| Results|| |
In the present study, a total of 50 patients were included, and RIPASA scores were applied preoperatively. The score consisted of 14 parameters. In our study, it was found that a total of 33 males and 17 females were studied, which constituted 66% and 34% of the study, respectively. Thirty-five patients who constituted 70% of the population, were in the age group which belonged to <39 years category.
All the 50 patients who constituted 100% of the population had presented with pain in the right iliac fossa. About 72% of patients gave the history of nausea and 70% of patients gave the history of vomiting. When evaluating the signs of a patient suspected of acute appendicitis, it was found that all 50 patients who constituted 100% of the population had tenderness in the right iliac fossa, while 72% of the population had rebound tenderness. While evaluating the laboratory parameters, 72% population had raised white blood cell (WBC) counts and 76% of the population had a negative urinalysis.
Results of Raja Isteri Pengiran Anak Saleha Appendicitis score in correlation with histopathological examination
The 50 patients were subjected to operative procedure, and postoperatively, the samples were sent for histopathological examination. The results of the histopathological examination were compared with the preoperative score determined by the RIPASA scoring system.
In this study, it was found that 64% of the patients had a score >7.5 and had a positive histopathology. Thirty percent of patients had a score <7.5 and had a negative histopathology. On the assessment of the results of the RIPASA score, it was found that there were 32 true positive patients (64%) having a score between 7.5 and 11.5 (high probability). Fifteen patients (30%) who were true negatives belonged to low probability range, having a score between 5 and 7. One patient (2%) who was false positive belonged to the high probability range having a score between 7.5 and 11.5. Two patients (4%) who were false negative, belonged to the low probability range having a score between 5 and 7.
The sensitivity of RIPASA score was 94.11%, specificity was 93.75%, positive predictive value was 96.96%, negative predictive value of RIPASA score was 88.23%, and the diagnostic accuracy of RIPASA score was 94%.
| Discussion|| |
Acute appendicitis is a commonly seen surgical emergency. Although the procedure of appendectomy is simple, the complications associated with the condition make it challenging to diagnose and treat. Initially, the signs and symptoms in a patient combined with good clinical experience gave way to decide whether the patient would undergo appendectomy or be conserved. Over the years, as technology improved, diagnostic modalities such as ultrasonography and computed tomography were used to clinch the diagnosis.
Many scoring systems such as Samuel, Tzanakis, Ohmann, Eskelinen, Fenyo, Lindberg, and the logistic score of Kharbanda et al. were devised over the years to improvise on the efficiency in detecting acute appendicitis in a quick and effective bedside manner.
As many scoring systems were used, which showed inadequacies in application across a larger population with the difference in age, sex, race, ethnicity, etc., the results could not be reciprocated in different population. An overall perspective about the requirements of various population was considered and a novel scoring system was devised by Chong CF et al. in Brunei in 2011. This scoring system was well with similar results being reciprocated worldwide. This study is done with a view to evaluate the efficacy of the RIPASA scoring system.
On analyzing the presentation according to individual parameters in the RIPASA score, it was found in our study that males constituted 66% and females constituted 34% of the study, respectively. This was similar to the results obtained by Chong et al. in Brunei and it was found that there was a preponderance toward the males over females in the incidence of acute appendicitis seen in a ratio of 1.4:1. In a study done by Naik et al., it was observed that there was a male preponderance with 68.23% of males and 31.77% of females.
Age distribution of the patients in this study saw a characteristic division where 35 patients, which constituted 70% of the population were in the age group which belonged to <39 years category. While those who were >40 years constituted 30% of population. Similarly, Chong et al. noted that 84.3% of the patients belonged to the <39 years category, while 15.7% belonged >40 years category. Studies done by Karan et al. showed similar results with 79.2% of patients in <39 years of age and 20.8% of the patients in >40 years of age group.
While evaluating the symptoms with which the patients presented within this study, it was noted that 100% of the population had presented with pain in the right iliac fossa, 54% of the patients gave a history of migration of pain, 72% of patients had anorexia, 70% of patients gave a history of nausea and vomiting and 88% of patients had developed a fever.
Similarly, it was noted by Chong et al. that patients commonly presented with pain right iliac fossa, history of migration of pain, nausea, and vomiting. Studies done by Karan et al. showed similar results with 100% of the population presenting with pain in the right iliac fossa, 44.8% of the patients with a history of migration of pain, 86.45% of patients with anorexia, 74% of patients with a history of nausea and vomiting and 63.54% of patients had developed a fever. Abdelrhman et al. in their study observed that 100% of the population had presented with pain in the right iliac fossa, 91% of the patients gave a history of migration of pain, 86% of patients had anorexia, 81% of patients gave a history of nausea and vomiting and 63% of patients had developed fever.
This score includes the duration of symptoms and, in our study, 70% of the population presented with the duration of symptoms which was <48 h, while 30% of the population presented with the duration of symptoms which was more than 48 h.
In another study done by Singh et al., it was found that that 76% of patients presented with the duration of symptoms <48 h and 24% of patients presented with the duration of symptoms >48 h.
In our study, it was found that 100% of the population had tenderness in the right iliac fossa, 66% of the patients had guarding of right iliac fossa, 72% of the population had rebound tenderness, while 56% of the population had a positive Rovsing's sign.
Similarly, Singh et al. in their study found that 100% of the population had tenderness in the right iliac fossa, 100% of the patients had guarding of right iliac fossa, 51% of the population had rebound tenderness, while 60% of the population had a positive Rovsing's sign. The study done by Singla et al. reported similar findings where 98% of the population had tenderness in the right iliac fossa, 34% of the patients had guarding of right iliac fossa, 28% of the population had rebound tenderness, while 34% of the population had a positive Rovsing's sign.
The RIPASA score included laboratory parameters such as raised WBC counts and negative urinalysis. In this study, it was seen that 72% population had raised WBC counts and 76% of the population had a negative urinalysis. Similarly, in the study done by Singla et al., it was seen that 52% population had raised WBC counts and 47% of the population had a negative urinalysis.
In the current study, out of 33 patients who had a score >7.5, 32 patients' histopathological examination revealed acute appendicitis. One patient who had a score >7.5 did not have appendicitis on histopathological examination (false positive). Out of 17 patients who had a score <7.5, 2 patients showed appendicitis on histopathological examination and 15 patients did not show appendicitis on histopathological examination. The negative appendicectomy calculated when using the RIPASA score was found to be 2% for this study.
A cutoff of 7.5 was arrived at by Chong et al. in the ROC analysis done in his original study. Thus, the decision to operate or conserve was based on this cutoff value. Those patients who had score >7.5 on presentations were considered for surgery and those who had scores <7.5 were conserved.
Hence after categorizing as per the cutoff level, it was seen in the present study that 64% of the patients with histopathology positivity had a score >7.5. This was comparable with the study done by Karan et al. who demonstrated that 92.7% of patients had a histopathology positivity and also had a score >7.5. This was similar to studies done by Naik et al. who showed 78.8% of patients had histopathology positivity and a score >7.5.
The present study showed that 2% of the patients with histopathology negativity had a score >7.5. This was comparable with the study done by Karan et al. and Naik et al. who showed 1.04% and 4.70% of patients, respectively, had histopathology negativity and a score >7.5.
The present study showed that 4% of the patients with histopathology positivity had a score <7.5. Studies done by Karan et al. and Naik et al. showed 2.08% and 7.05% of patients respectively had histopathology negativity and a score >7.5, which was comparable.
Similar studies have been conducted in various population, thus supporting the efficacy of the RIPASA score in detecting acute appendicitis.,,
| Conclusion|| |
With a view to reduce unwanted surgeries, various scores have been devised over the few decades, with the Alvarado score and the Modified Alvarado scores leading the path. The RIPASA score is fairly a new score which was devised with the aim of encompassing the Asian and middle eastern population in the diagnosis of acute appendicitis. The RIPASA score is extensive involving, the history of the patient, clinical and laboratory parameters.
The parameters used in the RIPASA score are simple which uses the history, physical examination, and the simple and easily available laboratory parameters. This gives an added advantage of the usage of this score at the bedside for a quick evaluation. The RIPASA scoring system is simple, effective, and has an accuracy which is high in diagnosing acute appendicitis.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]