Reducing negative appendectomies: a prospective comparative study of the RIPASA and Alvarado scoring systems in the emergency setting in an Indian population cohort

Arijit Roy; Saurav Majumdar; Lita Bag; Divyajyoti Panigrahi; Naru Gali Reddy; Manthan Ghosh; Samsunnehar; Akshita Khare

doi:10.18203/2320-6012.ijrms20262615

Authors

Arijit Roy Department of Surgery, KPC Medical College and Hospital Kolkata, India
Saurav Majumdar Department of Surgery, KPC Medical College and Hospital Kolkata, India
Lita Bag Department of Surgery, KPC Medical College and Hospital Kolkata, India
Divyajyoti Panigrahi Department of Surgery, KPC Medical College and Hospital Kolkata, India
Naru Gali Reddy Department of Surgery, KPC Medical College and Hospital Kolkata, India
Manthan Ghosh Department of Surgery, KPC Medical College and Hospital Kolkata, India
Samsunnehar Department of Surgery, KPC Medical College and Hospital Kolkata, India
Akshita Khare Department of Surgery, KPC Medical College and Hospital Kolkata, India

DOI:

https://doi.org/10.18203/2320-6012.ijrms20262615

Keywords:

RIPASA score, Negative appendectomy, Emergency surgery, Diagnostic accuracy, Acute appendicitis, Alvarado score

Abstract

Background: Acute appendicitis is the most common surgical emergency worldwide, with a reported lifetime prevalence of approximately 7–12%. Clinical scoring systems offer a rapid, cost-effective adjunct to diagnosis, yet conventional tools such as the Alvarado score exhibit suboptimal sensitivity, particularly in Asian populations. The RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) score, incorporating six additional parameters including age, sex duration of symptoms, was developed specifically to address this limitation.

Methods: A prospective observational comparative study was conducted in the Surgery Department of KPC Medical College and Hospital, Kolkata, India, from December 2022 to June 2024 (18 months). Fifty-one adult patients (aged ≥12 years) presenting with right iliac fossa pain were prospectively enrolled. Both the Alvarado and RIPASA scores were applied at presentation. Definitive diagnosis was established by histopathological examination (HPE) of appendectomy specimens or clinical follow-up. Diagnostic performance metrics sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) overall accuracy were calculated using standard 2×2 contingency tables. Statistical significance was assessed by chi-square test and z-test (SPSS v27).

Results: RIPASA demonstrated superior sensitivity (83.3% vs 66.7%), specificity (80.0% vs 66.7%), NPV (66.7% vs 45.5%) accuracy (82.35% vs 66.66%) compared to Alvarado. The chi-square statistic for RIPASA was 18.60 (p<0.0001) versus 4.80 (p=0.029) for Alvarado. The potential negative appendectomy rate with the RIPASA cut-off was 66.7% lower than with the Alvarado system.

Conclusions: The RIPASA score is a superior clinical diagnostic tool for acute appendicitis in the emergency setting, particularly in Asian populations. Its adoption in Indian emergency departments has the potential to significantly reduce negative appendectomy rates, associated morbidity healthcare costs.

References

GBD Appendicitis Collaborators. Trends and levels of the global, regional national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021. Lancet Gastroenterol Hepatol. 2024;9(9):796–812.

Ferris M, Quan S, Kaplan BS. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg. 2017;266(2):237–41.

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910–25.

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557–64.

Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado score for acute appendicitis in adults. Saudi Med J. 2004;25(9):1229–31.

Chong CF, Thien A, Mackie AJ. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singapore Med J. 2011;52(5):340–5.

Favara G, Maugeri A, Barchitta M. Comparison of RIPASA and Alvarado scores for risk assessment of acute appendicitis: a systematic review and meta-analysis. PLoS One. 2022;17(9):275427.

Frountzas M, Stergios K, Kopsini D. Alvarado or RIPASA score for diagnosis of acute appendicitis. A meta-analysis of randomised trials. Int J Surg. 2018;56:307–14.

Butt MQ, Chatha SS, Ghumman AQ, Farooq M. RIPASA score: a new diagnostic score for diagnosis of acute appendicitis. J Coll Physicians Surg Pak. 2014;24(12):894–7.

Singla A, Singla S, Singh M, Singla D. A comparison between modified Alvarado score and RIPASA score in the diagnosis of acute appendicitis. Updates Surg. 2016;68:351–5.

Banepali N, Koirala K, Mukhiya R, Sthapit RR. A comparative study of RIPASA score and modified Alvarado score in acute appendicitis in Nepalese population. Nepalese Med J. 2019;2(2):224–8.

Suresh P, Janardhanan R, Paul D. A comparative study of RIPASA and Alvarado score for the diagnosis of acute appendicitis. Int Surg J. 2020;7(12):4006–10.

Heiranizadeh N. Alvarado or RIPASA. Which one do you use to diagnose acute appendicitis. A cross-sectional study. Health Sci Rep. 2023;6(1):1078.