Acute appendicitis, one of the most common surgical emergencies, presents a significant challenge in medical diagnosis and management. With a lifetime prevalence rate of approximately 8% [1]. The lifetime risk of developing acute appendicitis differs slightly between genders, standing at 8.6% for males and 6.7% for females [2]. Interestingly, the lifetime risk of undergoing an appendectomy is higher, reported at 12% for men and 25% for women. A notable issue in the treatment of appendicitis is, where surgery is performed which results in a normal histopathology specimen [3]. This highlights the diagnostic challenge acute appendicitis poses, even for experienced surgeons. Typically, the diagnosis of appendicitis relies on a combination of careful history taking, physical examination, investigations including lab

and radiological, and various scoring systems designed to assist in ambiguous cases. Among these, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score and the ALVARADO score stand out as recent developments in diagnostic scoring systems for acute appendicitis [4]. These systems have demonstrated higher sensitivity, specificity, and diagnostic accuracy. The Alvarado score, in particular, has been a time-tested tool with high sensitivity and specificity. However, it was initially developed for the Caucasian population and shows lower sensitivity and specificity in other ethnic groups. To address this gap, the RIPASA score was developed in Malaysia, tailored to provide more accurate diagnostics in populations where the Alvarado score might be less effective. The RIPASA score includes additional parameters such as age, gender, and duration of symptoms before presentation, which are not considered in the Alvarado score. [5] A comparative study between these two scoring systems in the diagnosis of acute appendicitis can provide valuable insights, especially in diverse populations. This study is particularly pertinent in the Indian context, where the effectiveness of the RIPASA scoring system's sensitivity and specificity is being evaluated. Patients in this study are assessed preoperatively using ultrasound (USG) and Contrast-Enhanced Computed Tomography (CECT) of the abdomen, and postoperatively through histopathological examination, allowing for a comprehensive comparison between the RIPASA and Alvarado scoring systems in the context of acute appendicitis diagnosis. The aim of this study was to examine the individual and combined predictive value of RIPASA over Alvarado score in the diagnosis of acute appendicitis.

This prospective study was conducted in the Department of General Surgery at Bhaskar Medical College and General Hospital, Yenkapally, Moinabad, Hyderabad over a period of 18 months. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in the vernacular language.

Inclusion Criteria

All patients with right iliac fossa pain are diagnosed with acute appendicitis before undergoing treatment.

Males and Females

Those admitted and treated at our hospital

Willing to participate in the study voluntarily.

Exclusion Criteria

Patients below the age of 15 years.

Pregnant women.

Patients with a right iliac fossa mass.

Patients previously treated conservatively for right iliac fossa mass now

presenting for interval appendectomy.

Patients with a history of urolithiasis and pelvic inflammatory disease.

This study included 100 patients with Acute Appendicitis over 18 months. A detailed history was obtained according to the protocol. Information regarding age, nature of symptoms, duration of symptoms, history of similar complaints, and other comorbidities was obtained. History of pain (onset, type, progression, aggravating, and relieving factors), fever (onset, duration, type), vomiting and nausea, and anorexia. Personal history (mainly alcohol addiction) was recorded. Clinical abdominal examination included inspection, palpation, percussion, and auscultation. The clinical scores of RIPASA and ALVARDO were calculated according to the history and physical examination. The relevant data are tabulated in the master chart. All patients underwent routine investigations such as CBP, RFTs, RBS, LFTs, Viral Serology (HBsAg, HCV, HIV), BT, CT, Blood grouping and Rh factor typing, CUE, ECG, and chest radiography. Ultrasonography of the abdomen and pelvis was performed routinely in all patients, and CECT of the Abdomen and Pelvis was performed in a few cases where scores showed low probability and results correlated with scores. All patients underwent appendicectomy after proper preoperative evaluation. Histopathological examination was performed postoperatively in all cases.

Statistical Analysis: Statistical analysis was performed using SPSS version 26.0. Data are presented using graphs and charts to illustrate frequencies and percentages. Sensitivity and specificity analyses were conducted to assess the diagnostic accuracy of the Alvarado and RIPASA scores in predicting acute appendicitis.

A total of 100 cases were included in the study based on the inclusion and exclusion criteria the sex distribution in acute appendicitis, showing that there are 62% males and 36% females. Table 1 categorizes age distribution in acute appendicitis and reveals that the age group of 21 - 30 years has the highest number of cases (40%), followed closely by the 31 - 40 years age group (25%) and the 16 - 20 years age group (24%). The > 40 years age group has the fewest cases, with only 11%.

Table 1: Age-wise distribution of cases included in the study

Table 2 presents the distribution of cases based on the RIPASA age score, a diagnostic tool for acute appendicitis. It shows that a significant majority of the cases, totaling 91% have a RIPASA age score above 40 years and 9% of cases are below 39.9 years. The RIPASA sex score is used in the diagnostic evaluation of acute appendicitis. It shows that 64% registered RIPASA sex score of 1.0 (males) and 36% showed a score of 0.5 (females). The RIF (Right Iliac Fossa) pain distribution indicates that in the majority of cases, 77% had RIF pain, while 23% of the cases did not report experiencing this pain.

Table 2: RIPASA score distribution in the cases of the study

Table 3 shows the distribution of Migratory Pain Scores. In this study population, 71% had migratory pain according to RIPASA Score whereas the same was 47% with respect to ALVARADO Score.

Table 3: Migratory Pain Score Distribution

Table 4 shows the distribution of anorexia and nausea/vomiting. RIPASA: 54% of patients scored 0 (no anorexia), and 46% scored 1 (anorexia present). Alvarado: 53% of patients scored 0 (no anorexia), and 47% scored 1 (anorexia present). RIPASA: 54% of patients scored 0 (no nausea/vomiting), and 46% scored 1 (nausea/vomiting present). Alvarado: 54% of patients scored 0 (no nausea/vomiting), and 46% scored 1 (nausea/vomiting present). The distribution of both anorexia and nausea/vomiting is very similar between the RIPASA and Alvarado scoring systems. This suggests that both systems comparably assess these symptoms.

Table 4: Anorexia, Nausea, and vomiting distribution of the cases

Table 5 shows the distribution of scores for Right Iliac Fossa (RIF) tenderness, rebound tenderness, and fever.  There was a difference in RIF tenderness scored between the two systems. RIPASA uses a 0-2 scale but assigns no score of 2, while Alvarado assigns no score of 1 but uses both 0 and 2. Both systems show a similar distribution for rebound tenderness, with slightly more patients lacking this sign. While both systems show an even split for fever, Alvarado reports a higher proportion of patients with fever (61%) compared to RIPASA (51%).

Table 5: Distribution of various scores in the patients of the study

Table 6 shows the distribution of patients categorized as having high, low, possible, or unlikely probability of acute appendicitis, based on their RIPASA and Alvarado scores. The RIPASA score classifies a larger number of patients (70%) as having a high probability of appendicitis compared to the Alvarado score (59%). The Alvarado score includes a "Possibly" category, which accounts for (13%) patients. RIPASA doesn't have an equivalent category.

Table 6: Analysis and distribution of the score

In this study Ultrasound of the abdomen and pelvis findings showed 9mm of inflamed appendix in the majority of cases i.e. 28% and 14mm of inflamed appendix in 1% of cases. All the cases in this study underwent appendicectomy out of which 95% were biopsy-proven appendicitis, and 5% had negative appendicectomy in biopsy. Out of the total number of cases, 95% of case Histopathology reported appendicitis and 5% reported normal.

Table 8: USG Abdomen and pelvis distribution

In this study, the RIPASA scoring system demonstrated a sensitivity of 59.5% (95% CI: 41.12 - 53.12) and a specificity of 97.32% (95% CI: 92.1 - 97.41). The Positive Predictive Value (PPV) was estimated at 91.82% (95% CI: 80.73 - 93.53), and the Negative Predictive Value (NPV) was 69.12% (95% CI: 61.22 - 77.71). The overall diagnostic accuracy of the RIPASA score was 75% (95% CI: 67.3 - 79.54). In this study, the sensitivity was 59.2% with a 95% confidence interval of (34.13, 58.23), and the specificity was 88.91% with a 95% confidence interval of (81.04, 93.2). The Positive Predictive Value (PPV) was estimated at 79.91% with a 95% confidence interval of (68.41, 87.82). The Negative Predictive Value (NPV) was 66.43% with a 95% confidence interval of (58.95, 72.23). The diagnostic accuracy of the Alvarado Score was 70.12% with a 95% confidence interval of (64.1, 76.4). The sensitivity of both RIPASA and Alvarado are comparable, but there seems to be a definite upgrade in specificity, positive predictive value, and a certain amount in diagnostic accuracy as well in RIPASA scoring over Alvarado.

Acute appendicitis is a common surgical condition that, if not diagnosed early, can lead to complications such as perforation, abscess formation, peritonitis, and even death. Early diagnosis is challenging due to non-classical presentations, prompting the development of scoring

systems like RIPASA and Alvarado to aid clinical decision-making. These systems help determine the need for surgery when patients present with suspected appendicitis. This study evaluated the diagnostic accuracy of these scores, focusing on their sensitivity, specificity, and predictive values in different populations. The highest incidence of acute appendicitis was observed in the 21–30-year age group (40%), consistent with Das et al. [6], who reported 35% in the same age group. This confirms that younger adults are most commonly affected. Male predominance was noted (64%), aligning with Nanjundiah et al. [7] (61.6%) and Ravi et al. [8] (64.5%), further supporting the higher prevalence of appendicitis in males.

Histopathological examination (HPE), ultrasound (USG), and contrast-enhanced CT (CECT) were used to validate the scoring systems. For the RIPASA score, no significant differences were found across HPE (p = 0.22), USG (p = 0.46), and CECT (p = 0.72), consistent with Viswanath [9]. In contrast, the Alvarado score showed significant differences (HPE: p = 0.005, USG: p = 0.03, CECT: p = 0.02), indicating its variability in diagnostic accuracy. Histopathological findings revealed diverse appendicitis types. Ravi et al. [8] reported 40% suppurative, 25% catarrhal, 20% perforated, and 15% normal appendices. Reddy et al. [10] found 90% confirmed appendicitis cases, with 10% negative cases showing reactive lymphoid hyperplasia. Park et al. [11] reported a 15% negative appendectomy rate, attributed to late presentation or misdiagnosis.

The sensitivity and specificity of the Alvarado score ranged from 53–88% and 75–80%, respectively [12, 13], similar to findings by Nanjundiah et al. [7]. Walczak et al. [14] in a similar study reported 91% sensitivity and 81% specificity, while Ohle et al. [15] reported 82% sensitivity and 81% specificity. However, these studies were conducted in Western populations, whereas our study and Nanjundiah et al. [7] focused on Indian populations, explaining the variability in results. Viswanath [9] compared the Alvarado score with HPE, revealing 63% positive Alvarado results (60% true positives, 3% false positives) and 37% negative results (32% false negatives, 5% true negatives). This highlights the Alvarado score’s high false-negative rate (32%) in this population, despite its low false-positive rate (3%). In our study, 95% of cases were confirmed as appendicitis by HPE, while 5% were normal. The RIPASA score demonstrated higher sensitivity, positive predictive value (PPV), and negative predictive value (NPV) compared to Alvarado. The RIPASA score’s statistical significance (p = 0.000) was supported by a larger area under the receiver operating characteristic (ROC) curve (0.77 vs. 0.67 for Alvarado). Viswanath [9] suggested that the Alvarado score is less sensitive in Asian populations, whereas the RIPASA score performs better.

Reddy et al. [10] reported 90% sensitivity and 72% specificity for RIPASA, with a PPV of 89% and NPV of 30%. Kumar et al. [16] found 84.2% sensitivity, 100% specificity, and 100% PPV for RIPASA. Rathod et al. [17] reported 82.6% specificity and 66.7% sensitivity, while Sammalkorpi et al. [18] noted poor sensitivity (59.6%) and diagnostic accuracy (63.3%) for Alvarado. Reyes-García et al. [19] also reported poor Alvarado performance in non-European populations, with an 18.3% negative appendectomy rate. Noor et al. [13] found RIPASA had higher sensitivity (98.5% vs. 68.1%) and specificity (90% vs. 80%) than Alvarado, with better NPV (87.10% vs. 21.82%) and PPV (98.88% vs. 96.84%). In our study, RIPASA showed 59.5% sensitivity, 97.32% specificity, 91.82% PPV, 69.12% NPV, and 75% diagnostic accuracy, outperforming Alvarado (59.2% sensitivity, 88.91% specificity, 71.99% PPV, 66.43% NPV, and 70.12% accuracy).

In conclusion, the RIPASA score demonstrates higher sensitivity, specificity, PPV, and overall diagnostic accuracy compared to the Alvarado score, particularly in Asian populations. Its statistical significance and reliability make it a preferred tool for diagnosing appendicitis, reducing misdiagnosis and unnecessary surgeries. These findings underscore the importance of adopting the RIPASA score in clinical settings for timely and accurate diagnosis.

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