Discussion:
Acute Appendicitis is a major surgical emergency and is one of the most
often admitted cases to the surgical ward. Due to its increased
incidence, a ED doctor need to be at its best to correctly diagnose a
case of acute appendicitis, but being the best is not enough in high
capacity ED department in a major tertiary care hospital of the
region.7 Timely intervention is needed to circumvent
any risk of perforation, peritonitis and sepsis. To operate or not to
operate is conundrum forever facing a surgeon. Appendicectomy may not be
necessary in all cases of acute appendicitis as several publications
show that some inflamed appendix may resolve spontaneously and others
can be treated with antibiotics alone.8,9 And in case
of negative appendectomy the patient undergoes unnecessary
surgery.10 As a diagnostic help modalities such as
Ultrasound and CT scan can be employed to help in the diagnostic
process.9,11,13 Ultrasound being operator dependent
have a low threshold of sensitivity and
specificity.9,12 And Computer Tomography Scan has a
high specificity 84% but exposes the patient to ionization radiation
and incurs high cost.13 Both ultrasound and CT scan
are not ideal modalities in the diagnostic process especially in
emergency setting as in case of acute appendicitis and are mostly
expensive or woefully unavailable in developing nations or with region
with limited development.9 The Alvarado scoring system
was introduced to help in diagnosing of acute appendicitis by set
criterion, and it worked like a charm, reducing the number of negative
appendectomies drastically.14 First introduced in
1986, Alvarado scoring system quickly gained popularity among the
surgical circles and became a handy tool to have a final or a
prospective say in the management plan of the patient, but this scoring
system also had a high false positive specially in females of child
bearing age, and a further modification was later on added in the form
of modified Alvarado score in 1994, in which shift to the left of
neutrophils was excluded15, this further improved
sensitivity and decreased the false positive percentage; but the
reported sensitivity and specificity of these scoring system were
remained low.16 While these scoring systems came of
use all around the world, over time in surgical centers of Asia, it was
seen that Alvarado as well as modified Alvarado were deficient for the
purpose of accurately diagnosing acute appendicitis with decreased
sensitivity and specificity.17,18 In 2010, it was
reported by Department of Surgery, Raja Isteri Pengiran Anak Saleha
(RIPAS) Hospital, Brunei Darussalam in a retrospective analysis a new
scoring system that could cater better to differentiate ethnic
population with different diet.18 So was introduced
RIPASA scoring system for Asian population with better sensitivity and
specificity for detection of acute appendicitis was 96.2% and 85.7%
respectively when compared with RIPASA. This must be kept in mind that
RIPASA scoring system has been adopted and tested now in multiple
centers around Pakistan and had shown promising
results19. In Kohat, Butt et al has shown that RIPASA
Score had sensitivity of 96.7%, specificity 93.0%, diagnostic accuracy
was 95.1%.3 And our study showed the same profile
sensitivity and specificity, PPV, NPV, FP rate and FN rates was reported
by Butt et al .
Secondarily the age groups distributions showed interesting results for
a practicing surgeon to consider as high risk group being the adolescent
to early twenties namely of Age 15-30, were 87
(61.7%).20 This probably reinforces the fact that
nonconforming and variable and unsafe dietary practices which are the
hallmark of this age group most probably contributes to the increased
incidence of acute appendicitis in the said segment of the
population.20,21 Similarly it is also noted that most
of the false positives arose from females in child bearing age group or
married, with normal appendix22, and their complains
having another primary cause (extra-appendiceal pathology) namely
ruptured ovarian cyst, ovarian torsion, ectopic
pregnancy23. It was further noted that the false
positives, patients in whom the diagnosis for acute appendicitis was
missed was in age group of 40–55 and mostly female and diabetic, adding
another perspective to the issue of a multiple differentials to be
excluded and females pose a difficult problem therein and always needs
to be considered carefully and investigated fully in context of this
latest evidence.24,25 Over all our sensitivity of
RIPASA Score at a cut-off value of 7.5 was sensitivity of 85.2%,
specificity 95.6%, diagnostic accuracy 94%, PPV 82.1% and NPV was
96.4% respectively. Greatly reinforcing the confidence of this scoring
system.