Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

A Comparative Study of RIPASA and Alvarado

Scores for the Diagnosis of Acute Appendicitis in
Patients at University of Abuja Teaching Hospital,
Abuja: A Prospective Cohort Study
Dr. Chukwuemeka Emmanuel Onyedi; Stephen Ekundayo Garba; Dr. George OnuIllah
Department of Surgery, University of Abuja Teaching Hospital Gwagwalada, FCT, Abuja, Nigeria

Abstract:- accuracy of 66.7%, 57.1%, 93.9%, 14.8% and 65.8%

Introduction: The incidence of Acute appendicitis, a respectively. The negative appendectomy rate (NAR)
major cause of acute abdomen, in Africa is low but is based on clinical evaluation was 9.2%.
said to be progressively increasing. Accurate diagnosis of
acute appendicitis, amidst different clinical conditions Conclusion: The RIPASA scoring system outperforms
that mimic it, is challenging and fraught with pitfalls. the Alvarado scoring system as a diagnostic tool for
Clinical scoring systems, developed to aid prompt acute appendicitis. Surgery decisions can be influenced
diagnosis, prevent possible perforations with its by the RIPASA grading system, and this can help avoid
challenges and limit negative appendectomies, play a unnecessary procedures.
pivotal role in Sub-Saharan Africa where paucity of
funds abounds, and novel investigation modalities are Keywords: Acute Appendicitis, RIPASA Scores, Alvarado
lacking. The Alvarado scoring system, the first of such Scores, Diagnostic Accuracy, Negative Appendectomy,
aids, is reported to have varying diagnostic outcomes Sensitivity, Specificity.
alongside high perforation rates in sub-Saharan Africa
compared to other climes. Better diagnostic tools are still I. INTRODUCTION
being sought after, and a new scoring system, the Raja
Isteri Pengiran Anak Saleha Appendicitis (RIPASA), was Acute appendicitis is a frequently occurring surgical
compared with Alvarado to bridge this gap and solve this problem confronting young surgeons and emergency room
challenge at the University of Abuja Teaching Hospital physicians. It is a frequently occurring surgical condition
(UATH), Gwagwalada. that needs to be identified quickly to reduce morbidity and
prevent major sequelae1,2. With a prevalence in the general
Objective: To prospectively determine and compare the population ranging from 7 to 12 percent, it is one of the
diagnostic accuracy, specificity, and sensitivity of the most common conditions requiring abdominal surgery. 1,2.
RIPASA and Alvarado scoring systems in the diagnosis Despite being a common surgical concern, the diagnosis
of acute appendicitis. may still be problematic since it can mimic several different
acute abdominal conditions. Acute appendicitis, if untreated
Patients and Methods: A One-year prospective promptly or undiagnosed, could lead to a higher risk of
comparative cross-sectional study in which seventy-nine adverse outcomes, including death3. The statement made by
patients between 7-62 years of age, of both sexes, Sir William Osler that "medicine is a science of uncertainty
presenting with pain in the right lower abdominal and an art of probability" is exemplified in the diagnosis of
quadrant and suspected to have acute appendicitis were appendicitis 4.
enrolled. Each patient’s clinical details, alongside their
Alvarado and RIPASA scores, were obtained at It is not always simple to accurately identify
presentation and a decision for surgery was exclusively individuals who will benefit from active observation or
based on the clinical findings and the investigations. those who require immediate surgical intervention 5. Several
Only seventy-six patients had surgery based on clinical diagnostic tests for appendicitis have a lot of potential for
assessment and these patients were correlated with the use in clinical settings. It is still difficult to diagnose atypical
histologic diagnoses. Data collated was analyzed using appendicitis early enough to prevent needless surgery and
SPSS 25 and the diagnostic accuracy, sensitivity, lower healthcare costs as it mimics so many acute
specificity, positive predictive values (PPV), negative abdominal conditions 6,7. A surgeon's expertise and
predictive values (NPV) and negative appendectomy familiarity with comparable cases is largely required for the
rates (NAR) of the scoring systems were determined. accurate diagnosis of acute appendicitis. Using a clinical
grading system can help overcome the challenges associated
Results: The sensitivity, specificity, PPV, NPV and with diagnosing acute appendicitis and improve the
diagnostic accuracy of RIPASA was 97.1%, 71.4%, prognosis of affected individuals 8.
97.1%, 71.4% and 94.7% respectively while Alvarado
had sensitivity, specificity, PPV, NPV and diagnostic

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Whether or not to perform surgery is the actual, core An effective scoring system for the diagnosis of acute
clinical decision in diagnosing a patient with probable appendicitis strikes a balance between a more limited
appendicitis 4. There are many clinical grading systems approach, which aims to lower the risk of needless surgery,
available to facilitate the diagnosis of acute appendicitis. and early operative intervention, which seeks to prevent
The purpose of all the previously stated scores has been to perforation3,14,15. Moreover, physicians must ponder the
improve the diagnosis accuracy by simply assigning accuracy, delay-to-surgery, and radiation risks of using
numerical values to specific signs and symptoms. The use of computed tomography (CT) imaging, as well as the
clinical rating charts can help healthcare providers in reliability of laboratory results and clinical scoring systems.
improving decision-making, patient management, and It is often known that even with its widespread incidence,
identification of suspected appendicitis 2. Moreover, several diagnosing acute appendicitis remains difficult for medical
lines of evidence suggest that the integrated use of clinical professionals., suggesting the need for novel advances to
scoring systems and diagnostics images correctly identifies improve patients’ management 3,14,15.
cases of acute appendicitis 2,3,9. Most appendicitis scores have been shown to be quick
and inexpensive diagnostic tests. Nonetheless, variations in
The Alvarado score, developed in 1986 by Alvarado, diagnostic precision have been noted when applying the
who processed appendectomy patient data retrospectively, is ratings to different patient populations and healthcare
one of the most well-known grading systems. It includes environments. The purpose of this study was to compare the
eight diagnostic criteria such as historical data, physical diagnostic accuracy of Alvarado and RIPASA to see which
examination, and laboratory values 7,10,11. Another scoring can give us a better option in our setting. The ideal course of
system is the Raja Isteri Pengiran Anak Saleha Appendicitis action is to treat every instance of appendicitis as soon as
(RIPASA)5 score, which is a rather recently developedeasy- possible without requiring needless surgical procedures 4.
to-apply scoring system that has been proposed to have a An ideal scoring system would work as a tool that speeds up
significantly higher sensitivity, specificity, and diagnostic and increases the accuracy of decision-making, and at the
accuracy than other scoring systems in some other climes. same time reduces the need for potentially harmful and
Several parameters missing from the Alvarado score is expensive imaging 16.
included in the e RIPASA score, such as age, gender, and the
duration of symptoms before presentation 5. It has been II. THEORETICAL FRAMEWORK
demonstrated that these factors impact the Alvarado scoring
system's sensitivity and specificity in the diagnosis of acute Acute appendicitis is a common surgical complication
appendicitis10. that needs to be identified quickly to reduce morbidity and
prevent major complications5,10. It is not always
These scoring systems were developed to lower the straightforward to correctly identify those who will benefit
risk of a negative appendectomy while also assisting in the from active observation and those who require urgent
early detection and timely treatment of acute appendicitis. surgery 5. Quite a few scoring systems have been developed
An appendicitis preoperative diagnosis that is treated with to assist decision-making in questionable cases, including
surgery and yields a normal histology specimen is referred the Eskelinen, Ohmann, Alvarado, Raja Isteri Pengiran Anak
to as a negative appendicectomy 8,12. Generally, most Saleha Appendicitis (RIPASA) and a few others10. These
scoring systems make use of clinical history, physical scoring systems are easy to apply in a range of clinical
examination, and laboratory findings 2,13. These scoring settings and make use of routine clinical and laboratory data.
systems work well in many different clinical contexts and This study is assessing two of the scoring systems, the
are easy to apply. However, if the scores were applied to Alvarado and the RIPASA at UATH, Gwagwalada, Abuja,
different populations and clinical contexts, disparities in Nigeria.
sensitivities and specificities were noted, generally
performing poorly when used outside the population in A. Alvarado
which they were originally created5. Furthermore, their Alvarado score
usefulness may be hampered by regional variations in the
prevalence and clinical pattern of the differential diagnosis
of acute abdominal discomfort 5

for a score of 7 or 8, and "extremely probable" for a score of

Table 1 uses eight predictive factors of diagnostic value 9 or 10, which indicates the need for surgical intervention
5,14
in acute appendicitis and allots each factor a value of 1 or 2 .
based on their diagnostic weight 4. Elevated temperature
>37.3°C, rebound tenderness, migration of pain to the right One of the bottlenecks of the use of the Alvarado score
lower quadrant (RLQ), anorexia, nausea, vomiting, and is that young children must identify factors like migratory
leukocyte left shift all receive a score of 1. Leucocytosis that pain, nausea, and anorexia in their history—variables that
is more than 10,000 and RLQ tenderness receive a score of are relatively difficult for them to recognize3,14,17. It is also
2. Based on the overall score, the chance of appendicitis and believed that the Alvarado score is deficient in several areas,
specific management advice are provided5. It is advised to including age, gender, and length of symptoms, all of which
observe or examine the patient repeatedly if the patient have been demonstrated to be important in the diagnosis of
receives a score of 5 or 6. Appendicitis is considered "likely" acute appendicitis 3,14,17.

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Table 1: Alvarado Scoring System

THE ALVARADO SCORING SYSTEM SCORE
SYMPTOMS Migratory RIF Pain 1
Anorexia 1
Nausea/ Vomiting 1
SIGNS Tenderness RLQ 2
Rebound Tenderness RLQ 1
Elevation of Temperature >37.3ºC 1
LABORATORY Leucocytosis > 10 X 10 9/L 2
Neutrophilic shift to the left >75% 1
TOTAL 10

 Interpretation Alvarado Score at 312 patients who had appendicectomies performed at the
 Score 1- 4:Acute appendicitis is very unlikely; keep for Department of Surgery at the Raja Isteri Pengiran Anak
observations. Saleha (RIPAS) hospital in Brunei Darussalem between
 Score 5-6:Acuteappendicitis is probable; admit the October 2006 and May 200819. The researchers, who were
patient for close observations andrescoring. dissatisfied with the diagnostic accuracy, low sensitivity, and
 Score 7-8:Acute appendicitis is likely; operate. specificity levels of the Alvarado scoring system (as well as
 Score 9-10:Acute appendicitis definite; operate the Modified Alvarado scoring system) when applied to
immediately. Asian, Middle Eastern, and Oriental populations, developed
RIPASA to get a better diagnostic aid for acute appendicitis
12,19
Numerous academic institutions have researched the .
Alvarado scoring system, with differing results 3,14,18.
In addition to fourteen predefined generalized criteria,
B. Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) the RIPASA score also includes one extra parameter unique
Score to the Asian population, to which individual scores are
One of the newest scoring methods is called RIPASA assigned according to their diagnostic weight. With a
(Table 2), and it is based on six factors around the clinical thorough history, a physical examination, and two quick
and personal characteristics of the patient that are not blood tests, these criteria can be quickly and simply
included in the Alvarado score: age, gender, duration of determined in any population. These are the scores and
symptoms, guarding, Rovsing's sign, and negative parameters referred to in
urinalysis3. The RIPASA score was created by looking back
Table Error! No text of specified style in document.:.

Table Error! No text of specified style in document.: The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score12,19
The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score Score
PATIENTS Female 0.5
Male 1.0
Age < 39.9 years 1.0
Age > 40 years 0.5
SYMPTOMS RIF pain 0.5
Pain migration to RIF 0.5
Anorexia 1.0
Nausea & Vomiting 1.0
Duration of symptoms < 48 hrs. 1.0
Duration of symptoms > 48 hrs 0.5
SIGNS RIF tenderness 1.0
Guarding 2.0
Rebound tenderness. 1.0
Rovsing’s sign 2.0
Fever > 37° C < 39° C 1.0
INVESTIGATIONS Raised WBC 1.0
Negative urine analysis 1.0
ADDITIONAL SCORE Foreign national resident in the country 1.0
TOTAL 17.5

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Total Score is achieved by adding all the scores for
each category together. If it stays high, prepare the patient for appendectomy.

An additional score is added for patients who are Abdominal ultra sonography should be performed in
foreign nationals resident in the country (FNRIC). female patients to rule out gynaecological reasons for RIF
discomfort.
 Management Guidelines Based on the Total Score: • > 12 = Definite acute appendicitis; refer to surgeon
• < 5 = Probability of acute appendicitis is unlikely. on-call for admission and appendectomy

Monitor patients in accident and emergency (A&E) Despite having numerous criteria, the RIPASA scoring
and repeat scoring afterwards 1–2 hrs. system is equally user-friendly andis believed to have
superior diagnostic accuracy than the Alvarado and most
If there is a dropping score, discharge. If there is an other score systems when applied among Asians.3,19.
increasing score, treat according to score level.
 Acute appendicitis diagnosis cut-off points for scoring
• 5–7.0 = Low probability of acute appendicitis. systems:
Different cut-offs were used in each study to generate
Observe in accident and emergency and repeat scoring the diagnostic parameters for RIPASA and Alvarado scores.
system after 1–2 hrs. Most of the research employed the standard cut-offs for
Alvarado and RIPASA scores, which are 7.0 and 7.5,
Or perform an abdominal ultrasound to rule out acute respectively. As a result, if a patient's score was higher than
appendicitis. these cut-off points, they were diagnosed with acute
appendicitis.
Patients may require admission for observations,
discuss with the surgeon on-call16. C. Two by Two (2x2) Contingency Table
A 2x2 contingency table can be used to demonstrate
• 7.5–11.0 = Probability of acute appendicitis is high. the diagnostic power of both the Alvarado and RIPASA
scores for negative appendectomy rate (NAR) using
Refer patient to surgeon on-call for admission and histology report as the gold standard
repeat score in 1–2 hrs. time.
Table 1.

Table 1: A 2x2 Contingency Table for Alvarado Scoring System

Alvarado Score Histology Appendicitis Present Histology Appendicitis Absent Total
≥7 True Positives (TP) False Positives (FP) TP + FP
<7 False Negatives (FN) True Negatives (TN) FN + TN
Total TP + FN FP + TN Total

 Interpretation:  False Negatives (FN): Patients with appendicitis who

 True Positives (TP): Patients with appendicitis who scored <7 but histology confirmed it.
scored ≥7 and had it confirmed by histology.  True Negatives (TN): Patients without appendicitis who
 False Positives (FP): Patients without appendicitis who scored <7 and histology confirmed it.
scored ≥7 but histology showed no inflammation.

D. Calculating Diagnostic Measures:

Table 2: Diagnostic Measure Formulae

VARIABLE CALCULATION
Sensitivity (TP / (TP + FN)) * 100%. This shows the test's ability to correctly identify true cases of
appendicitis (≥7 score).
Specificity (TN / (FP + TN)) * 100%. This shows the test's ability to correctly identify true cases of non-
appendicitis (<7 score).
Positive Predictive Value (PPV) (TP / (TP + FP)) * 100%. This is the proportion of true positives among all the cases that the
test identified as positive.
Negative Predictive Value (TN / TN + FN)) * 100. The proportion of true negatives among all the cases that the test
(NPV) identified as negative.
Accuracy Rate [(True Positives + True Negatives) / Total] * 100%

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Negative Appendectomy Rate (FP / (TP + FP)) * 100%. This indicates the percentage of unnecessary surgeries among
(NAR) patients scoring ≥7.

With the help of 2 × 2 table, the sensitivity, specificity,

positive predictive value, negative predictive value, and B. Secondary Question:
diagnostic accuracy can be calculated individually, and then Can the use of the RIPASA score influence surgical
compared with each other decision-making and potentially reduce negative
appendectomies at UATH?
Table 220–23. Histological examinations that reveal
transmural neutrophil infiltration in the appendix are
typically used to diagnose acute appendicitis 16. VI. RESEARCH HYPOTHESIS
Histopathological diagnosis is considered the final arbiter.
TheAlvarado scores and RIPASA scoresgenerated are A. Primary Hypothesis
compared to the histopathology report in this study.
 Null Hypothesis (H0):
III. STATEMENT OF THE PROBLEM There is no statistically significant difference in the
diagnostic accuracy (sensitivity, specificity, positive
The ability to correctly separate right iliac fossa pain predictive value, and negative predictive value) between the
caused by appendicitis from other abdominal pains that RIPASA and Alvarado scoring systems for diagnosing acute
mimic it is a problem young surgeons and emergency room appendicitis in patients at UATH.
physicians often face. Avoiding negative appendicectomies,
with their associated morbidity, death, and higher medical  Alternative Hypothesis (H1):
expensesis essential to good surgical practice. The There is a statistically significant difference in the
harrowing sequelae resulting from a missed diagnosis of diagnostic accuracy of the RIPASA and Alvarado scoring
acute appendicitis is an unacceptable disaster5,14,17. To systems for diagnosing acute appendicitis in patients at
address this issue, surgeons require a strong grading system UATH, but the direction of the difference is unknown.
with a high level of diagnostic precision.
B. Secondary Hypothesis:
IV. JUSTIFICATION  Ho: The use of the RIPASA scoring system does not
significantly influence surgical decision-making for
Comparing the RIPASA and Alvarado scoring systems suspected acute appendicitis at UATH compared to the
for the diagnosis of acute appendicitis in our context is a Alvarado scoring system.
relatively new area of research4,7,9,15. There is an ongoing  H1: The use of the RIPASA scoring system influences
quest for a cost-effective, efficient, easy-to-use, and reliable surgical decision-making at UATH, leading to a
diagnostic aid that will minimize overt dependency on high reduction in the proportion of negative appendectomies
radiology investigations for accurate diagnoses of common compared to the Alvarado scoring system.
surgical problems like acute appendicitis in our setting- sub-
Saharan Africa. Patients' productivity and quality of life will VII. PURPOSE OF STUDY
be greatly impacted by understanding and contrasting the
diagnostic profiles of RIPASA and Alvarado. The diagnostic This study sets out to investigate the diagnostic profiles
accuracy of RIPASA and Alvarado scores in patients with of Alvarado and RIPASA in patients with suspected acute
acute appendicitis has not yet been studied at our hospital. appendicitis at UATH, Gwagwalada Abuja.
That is why this research is being done.Hence, we
prospectively compared Alvarado and RIPASA scores by VIII. SIGNIFICANCE OF THE STUDY
applying them to the patients attending our hospital with
right iliac fossa pain with suspected acute appendicitis The results from this study will reveal which of these
during the period July 2016 and June 2017 and cross two is a better diagnostic scoring system in patients with
examined them with the histologic diagnoses. These formed suspected acute appendicitis in our setting and so aid young
the base of our research. surgeons in the accurate diagnosis of acute appendicitis, as
well as effect reductions in missed diagnoses, and negative
V. RESEARCH QUESTIONS appendectomies.
A. Primary Question: IX. AIMS AND OBJECTIVES
Does the RIPASA scoring system demonstrate superior
diagnostic accuracy compared to the Alvarado scoring A. Aim
system for identifying acute appendicitis in patients To compare and evaluate the diagnostic profiles of
presenting to UATH, as measured by sensitivity, specificity, RIPASA and Alvarado Scores in co-relation to
and positive and negative predictive values? histopathology report for the diagnosis of acute appendicitis.

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
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proformas were implemented. The diagnosis of acute
B. Objectives: appendicitis was based on the report of the histopathological
report.
 Primary Objectives.
To find out how different the RIPASA and Alvarado XIV. RESEARCH PROTOCOL
scores are in terms of sensitivity, specificity, positive
predictive value, and negative predictive value when it A clinical suspicion of acute appendicitis was a
comes to identifying acute appendicitis in patients at UATH. requirement for patient admission and surgical treatments.
Based on clinical signs and symptoms, consultants from the
 Secondary Objective Department of Surgery at UATH made the clinical diagnosis
To determine if the RIPASA score can influence of acute appendicitis. Patients who were thought to have
surgical decisions better than the Alvarado score. acute appendicitis underwent a thorough assessment that
included clinical information, ultrasonography, and
X. RESEARCH DESIGN investigation. Care was provided to the patients not
according to their RIPASA and Alvarado scores, but rather
This research was a prospective study. according to the results of the clinical assessment and the
investigative report. On a proforma, however, the Alvarado
XI. DESCRIPTION OF THE STUDY AREA: and RIPASA scores of every patient suspected of having
appendicitis were noted. Age, gender, height, weight, length
This study was conducted at the University of Abuja of hospital stays, previous medical history, results from
Teaching Hospital's surgery department in Gwagwalada, operations or follow-up care, and results from lab and
Abuja, Nigeria. The hospital can accommodate five hundred imaging tests were all documented along with other patient
beds and acts as a referral centre for medical facilities run by data.
the Federal Capital Territory Administration as well as the
states that border it—Kogi, Niger, Nasarawa, Kaduna, A diagnosis of appendicitis was given macroscopically
Benue, and Plateau states24. during the operation (purulent formations, and oedematous-
necrotic changes on the appendix wall). The results were
XII. POPULATION OF THE STUDY confirmed with histopathological findings 5. We compared
prospectively the RIPASA and Alvarado scoring systems by
All patients who gave their consent and presented to applying them to the seventy-six patients enrolled. A score
UATH between July 2016 and June 2017 with a diagnosis of of 7.5 was the optimal cut-off threshold for RIPASA and
probable acute appendicitis were included in this study. seven for the Alvarado scoring system for this study.
Patients who did not give their consent, those who had an Intraoperative findings were noted, and each specimen
acute abdomen from another reason (such as trauma, bowel obtained was preserved in 10% formalin solution and sent to
blockage, etc.), and any instances of appendicitis or the histopathologist for histological diagnosis. The histology
appendectomies that were unintentional were not included. reports were subsequently retrieved and correlated with the
findings obtained. Sensitivity, specificity, positive predictive
XIII. SAMPLE AND SAMPLING PROCEDURE value (PPV) and negative predictive (NPV) for RIPASA &
Alvarado system were calculated using a 2 x 2 possibility
All patients undergoing appendectomies in the table. Even though all the patients had concurrent RIPASA
Department of Surgery, University of Abuja Teaching and Alvarado scores, these patients were assessed and
Hospital, Gwagwalada, Abuja, Nigeria, over a period of one operated on based on the clinical findings of the surgeons as
year and who consented to participate in the study. Patients well as some extra imaging. Histological results related to
with complicated appendicitis were excluded from the study. how well the scoring systems performed.
Patients who satisfied the requirements for inclusion were
sequentially added to the trial. They were evaluated on XV. RESEARCH INSTRUMENT
admission using the Alvarado and RIPASA scores as well as
clinical evaluation to determine whether they had acute The researcher created a questionnaire that was
appendicitis or not.All patients underwent appendectomy employed as the research tool in this investigation. The
according to the hospital protocol. The judgement to operate proforma was used to collect data on patients who came to
was the prerogative of the surgeon or surgical resident based UATH, Abuja with a suspected case of acute appendicitis. A
on total clinical assessment and not the Alvarado and pre-tested, coded questionnaire was used to gather data, and
RIPASA scores. SPSS statistical software version 25 was used for the
analysis.
Surgical residents collected the basic data for the
construction of the score during the initial examination at XVI. DATA ANALYSIS
the emergency department. The collected data included
clinical findings (tenderness in RLQ, guarding in RLQ, and Data collection utilized a proforma and Microsoft
body temperature), and symptoms (pain in RLQ, migration Excel. IBM SPSS version 25 was used to analyze
of pain, vomiting, and anorexia), as well as laboratory test categorical variables with frequencies and percentages,
results. The Alvarado and RIPASA scoring system while continuous variables were summarized using means
and standard deviations. Results were presented in tables,

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and line graphs. Statistical tests, including chi-square and t- (46.8%) and forty-two (42) females (53.2%) were assessed
tests, were used to compare variables between study groups. as having acute appendicitis during this study period giving
Significance was determined at p<0.05. The sample size a male–female ratio of 1:1.14. These patients cut across the
calculation was based on a significance level of 0.05. We diverse ethnic groups in Nigeria. Fifty-five (70%) were
needed a sample of at least 43 patients to achieve 80% Christians and 24 (30%) were Muslims. The ages of the
power. Cross tables were prepared for sensitivity, specificity, patients range from 7-62 years. The majority were between
positive predictive value (PPV), negative predictive value the 2nd to the fourth decade of life. The peak, however, was
(NPV), and the diagnostic accuracy values of the scoring in the third decade of life (39.2%). The mean age is 27.1266
systems. years with a standard deviation of +/- 10.8620. Many of
these patients were students (46.8%), civil servants (17.7%),
businessmen (10.1%), artisans (10.1%) and health workers
(6.3%). However, only seventy-six were analyzed as three
patients were excluded on clinical grounds of not having
XVII. RESULTS acute appendicitis and therefore no histological report was
available for analysis. The different histological pattern is
Seventy-nine patients were recruited initially into the presented in
study group during this period. Thirty-seven (37) males
Table .

Table 5: Correlating the histologic diagnosis with clinical scores (Alvarado vs RIPASA)
Histologic Diagnosis Alvarado Alvarado Score RIPASA RIPASA Total
Score <7 ≥7 <7.5 ≥7.5
Acute Appendicitis 12 8 1 19 20
Acute Recurrent Appendicitis 8 13 1 20 21
Acute Gangrenous Appendicitis 1 7 0 8 8
Perforated Appendicitis 0 18 0 18 18
Schistosoma Appendicitis 2 0 0 2 2
Non-Appendicitis 4 3 5 2 7
TOTAL 27 49 7 69 76

A 2x2 table demonstrating the diagnostic power of

Alvarado scores using histology as the gold standard is
shown in
Table , and
Table ,
Table 7 Similar parameters for the RIPASA scores are Table . The diagnostic profiles were compared in Table
likewise presented in 10.

Table 6: Alvarado Patient Score Sheet

Alvarado Score Histology (Appendicitis Present) Histology (Appendicitis Absent) Total
≥7 True Positives (TP) 46 False Positives (FP) 3 49
<7 False Negatives (FN) 23 True Negatives (TN) 4 27
Total 69 7 76

Table 7: Alvarado Diagnostic Profile

Parameter Alvarado Scores in %
Sensitivity 66.67
Specificity 57.14
Positive Predictive Value (PPV) 93.88
Negative Predictive Value (NPV) 14.8
Diagnostic Accuracy 65.79

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Table 8: RIPASA Patient Score Sheet

Histology – Histology –
RIPASA Score Total
Appendicitis Present Appendicitis Absent
≥7.5 True Positives (TP) 67 False Positives (FP) 2 69
<7.5 False Negatives (FN) 2 True Negatives (TN) 5 7
Total TP + FN 69 FP + TN 7 76

Table 9: RIPASA Diagnostic Profile

Parameter RIPASA Scores in %
Sensitivity 97.10
Specificity 71.43
Positive Predictive Value (PPV) 97.10
Negative Predictive Value (NPV) 71.43
Diagnostic Accuracy 94.74

Table 10: Comparison of the Diagnostic Profiles of Alvarado and RIPASA

Variables Score in % (95% CI)
RIPASA ALVARADO p-value
Sensitivity 97.10 66.67 < 0.01
Specificity 71.43 57.14 < 0.01
PPV 97.10 93.88
NPV 71.43 14.81 < 0.01
Diagnostic Accuracy 94.74 65.79 < 0.01
Negative Appendectomy Rate 2.90 6.52 < 0.01

Using the Independent Samples t-test, the difference

between RIPASA and Alvarado was significant at a p-value Using Table 10 above to evaluate this hypothesis, there
of p = 0.013 is a statistically significant difference in the diagnostic
accuracy (sensitivity, specificity, positive predictive value,
Clinical assessment picked 76 patients as having and negative predictive value) between the RIPASA and
positive appendicitis but only 69 were histologically Alvarado scoring systems for diagnosing acute appendicitis
confirmed leaving a false positive rate of (76-69=7/76) in patients at UATH. Using the Independent Samples t-test,
meaning a 9.2% rate of NAR. the comparison between RIPASA and Alvarado was
significant at a p-value of p = 0.013. The above hypothesis
Alvarado score picked 49 patients with scores =>7 but is, therefore, rejected. The alternative hypothesis is upheld.
only 46 of the patients were histologically confirmed leaving
NAR of 3/49 (6.12%) 2) Ho: The use of the RIPASA scoring system does
not significantly influence surgical decision-making for
RIPASA picked 69 patients with scores =>7.5 out of suspected acute appendicitis at UATH compared to the
which 67 were histologically confirmed with a negative Alvarado scoring system.
appendectomy rate of 2/69 (2.90%)
Referring to Table 10 for the testing of this hypothesis,
XVIII. HYPOTHESIS TESTING the diagnostic accuracies of RIPASA and Alvarado are
significantly different (Diagnostic Accuracy of RIPASA at
1) Ho: There is no statistically significant difference in 94.74 % compared to the diagnostic accuracy of 65.79% for
the diagnostic accuracy (sensitivity, specificity, positive Alvarado score with a p = value of <0.01. At this level, the
predictive value, and negative predictive value) between the RIPASA scoring system can significantly influence surgical
RIPASA and Alvarado scoring systems for diagnosing acute decision-making for suspected acute appendicitis at UATH
appendicitis in patients at UATH. compared to the Alvarado scoring system. Therefore, the

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ISSN No:-2456-2165
null hypothesis that says, “The use of the RIPASA scoring score is superior to the Alvarado score within the context of
system does not significantly influence surgical decision- this study. This objective has been met.
making for suspected acute appendicitis at UATH compared
to the Alvarado scoring system” is rejected and the B. Secondary Objective
alternative hypothesis is hereby accepted. To determine if the RIPASA score can influence
surgical decisions better than the Alvarado score. This study
XIX. SUMMARY OF THE FINDINGS (FINDINGS has met this objective to prove within the context of this
BASED ON THE FORMULATED HYPOTHESES research that RIPASA can positively influence surgical
TESTING) decision-making with a diagnostic power of > 95%.

There is a statistically significant difference in the XXII. DISCUSSION OF THE FINDINGS

diagnostic accuracy of the RIPASA and Alvarado scoring
systems for diagnosing acute appendicitis in patients at About 40% of emergency surgical procedures
UATH. performed in most hospitals globally are for acute
appendicitis, which is a common cause of acute abdomen
11,25
The use of the RIPASA scoring system significantly . Its lifetime risk is 6.7% for women and 8.6% for males,
influences surgical decision-making for suspected acute with an incidence of 1.17 per 100028,24,26. The estimated
appendicitis at UATH. lifetime incidence of appendicitis, however, is 7% 26. In
Northern Nigeria, the incidence of acute appendicitis is 2.6
The ability of the RIPASA scoring system to pick those per 100,000 per annum 27. Edino et al reported 142 cases
positive for appendicitis as positive is very high (97.10%) over a 5-year period in Kano (1997-2002) i.e. 28 cases
compared to the sensitivity of Alvarado (66.67%). yearly 11. Ahmed et al reported 382 cases of clinical
suspected appendicitis over a 10-year period in Zaria. (2001-
XX. ANSWERING THE RESEARCH QUESTIONS 2010) 28 compared to 79 cases seen in our centre within a
12-month period (July 2016- June 2017).
A. Primary Question:
Does the RIPASA scoring system demonstrate superior The clinical diagnosis of appendicitis can be vague and
diagnostic accuracy compared to the Alvarado scoring full of pitfalls because of the lack of constant
system for identifying acute appendicitis in patients pathognomonic clinical features. Several scoring systems
presenting to UATH, as measured by sensitivity, specificity, have been developed to help in the accurate diagnosis of this
and positive and negative predictive values? condition to minimize the high rate of negative
appendectomies. Many have used Alvarado scoring systems
Answer: Yes, the RIPASA scoring system to diagnose this condition, but it is not perfect hence the
demonstrates superior diagnostic accuracy compared to the search for better scoring systems. Following the
Alvarado scoring system for identifying acute appendicitis development of the Alvarado scoring system, the RIPASA
in patients presenting to UATH, as measured by sensitivity, scoring system was developed; however, its diagnostic
specificity, and positive and negative predictive values. The efficacy has not been evaluated in our setting.
diagnostic accuracy of RIPASA is 94.74 % compared to the
diagnostic accuracy of 65.79% for the Alvarado score is Identifying patients who require immediate surgery and
significant with a p-value of <0.01. avoiding the needless risks and expenses of surgery for
patients who do not have appendicitis are the two main
B. Secondary Question: objectives of an optimal grading system 16. This study
Can the use of the RIPASA score influence surgical compared the diagnostic characteristics of RIPASA and
decision-making and potentially reduce negative Alvarado scores using prospectively gathered data on our
appendectomies at UATH? patients. The purpose of the scoring systems is to facilitate
early identification, reduce the number of unfavourable
Answer: Yes, with the RIPASA ability to pick a appendectomies, and avoid appendicitis complications
positive case of acute appendicitis standing at 94.74 %, as across all age groups and genders. The search for the most
compared to 65.79% of Alvarado; therefore, the RIPASA effective acute appendicitis scoring system in resource-poor
scoring system can influence surgical decision-making and sub-Saharan Africa continues.28.
potentially reduce negative appendectomies.
In this study, RIPASA has a sensitivity of 97.1%,
XXI. DETERMINING THE RESEARCH OBJECTIVES specificity of 71.4%, PPV of 97.1%, NPV of 71.4% and
diagnostic accuracy of 94.7% compared to Alvarado’s
A. Primary Objectives sensitivity of 66.7%, specificity of 57.1%, PPV of 93.9%,
To find out how different the RIPASA and Alvarado NPV of 14.8% and diagnostic accuracy of 65.8%. This
scores are in terms of sensitivity, specificity, positive shows that RIPASA supersedes Alvarado in diagnosing
predictive value, and negative predictive value when it acute appendicitis here in UATH, Gwagwalada.
comes to identifying acute appendicitis in patients at UATH.
The sensitivity, specificity, PPV, NPV and diagnostic Chong et al had reported similar findings in their
accuracy profiles are displayed in Table 10. The RIPASA prospective study in Brunei Darussalam, that RIPASA had a
diagnostic accuracy, sensitivity, specificity, PPV, NPV of

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
91.8%, 98.0%, 81.3%, 85.3% and 97.4% respectively The sensitivity, specificity, and diagnostic accuracy of
compared to Alvarado which had a diagnostic accuracy, RIPASA (97.1%, 71.4% and 94.7% respectively)
sensitivity, specificity, PPV, NPV of 86.5%, 68.3%, 87.9%, significantly outweigh that of Alvarado’s (66.7%, 57.1% and
86.3%, 71.4% respectively 19. Nanjundaiah N et al reported 65.8% respectively). The low negative appendectomy rate
similarly in their prospective study at Kasturba Medical (NAR) of RIPASA makes it a good scoring system to be
College Hospital, Mangalore-Karnataka, India 29. RIPASA included in our armamentarium of management of suspected
had sensitivity, specificity, PPV and NPV of 96.2%, 90.5%, cases of acute appendicitis. It is easy to apply. Its addition to
98.9% and 73.1% respectively. These were higher and better our arsenal could improve the delivery of healthcare in sub-
compared to the sensitivity, specificity, PPV and NPV of the Saharan Africa's resource-poor environments. Within the
Alvarado scoring system which were 58.9%, 85.7%, 97.3% context of this study, the RIPASA scoring system is a more
and 19.1% respectively 29. convenient, accurate, and efficient scoring system for our
population than the Alvarado scoring system. The RIPASA
Erdem H et al 5 had in their study in Turkey compared score, easily determined byfactors from good clinical
the diagnostic accuracy of 4 scoring systems (Alvarado, history, physical examination, and two simple blood assays,
Eskelinen, Ohhmann and RIPASA) in the diagnoses of acute is a helpful tool for diagnosing acute appendicitis. Thus, an
appendicitis among 113 patients. They discovered that operating surgeon can make a quick decision when he sees a
though RIPASA had a higher sensitivity of 100% compared patient with right iliac fossa pain by determining the
to Alvarado’s 82%, their diagnostic accuracy was similar i.e. RIPASA score. A patient with a RIPASA score > 7.5 is to be
77% for RIPASA and 80% for Alvarad. Butt et al in their operated on, while patients with a RIPASA score < 7.0 can
study of 267 patients at the Combined Military Hospital, either be observed in the unit’s day ward or discharged with
Kohat, discovered that RIPASA had a sensitivity of 96.7%, an early clinic review appointment. Unnecessary and
specificity of 93.0%, diagnostic accuracy of 95.1%, PPV of expensive radiological investigations can be avoided by
94.8% and NPV of 95.54% and so proposed similarly that using RIPASA score and thus reducing health care
RIPASA score at a cut-off total score of 7.5 was a useful tool expenditure 21.
in diagnosing acute appendicitis 17.
XXIV. RECOMMENDATIONS
Kurane et al in their study of Modified Alvarado in
sixty patients in Belgaum, Karnataka, India reported As of right now, the RIPASA score outperforms the
sensitivity, specificity, PPV, NPV and diagnostic accuracy of Alvarado score for acute appendicitis diagnostic scoring; in
78.26%, 83.78%, 75.00%, 86.11% and 81.00% respectively our study,the RIPASA score achieved significantly higher
23
. These values increased significantly with the use of sensitivity and diagnostic accuracy. By gathering a thorough
Ultrasonography to 88.8%, 96.5%, 94.11%, 93.33% and medical history, doing a clinical examination, and
93.61% respectively. Hence, they advocate the use of conducting investigations, we can obtain information about
Ultrasonography along with clinical scores, especially seventeen fixed parameters of the RIPASA score. Using the
Alvarado, for all patients. 23. RIPASA score can also help prevent costly imaging studies
and unwanted admissions. As a diagnostic aid, it can help
The negative appendectomy rate (NAR) of 9.2% young surgeons and emergency physicians. The present
picked clinicallyin this study is better than the 14.1% study validates that the RIPASA scoring system performs
reported in Kano, Northwestern Nigeria by Edino et al. 11. It better than the Alvarado scores. We recommend the
is, however, similar to 10.9% that was reported at Ile-Ife, inclusion of RIPASA in our armamentarium of management
Southwestern Nigeria by Ademola et al. 25. Khan et al had of patients with suspected appendicitis in our setting.
similarly reported a NAR of 15.62% while appraising
Alvarado scores alone in Pakistan. Kanumba et al in XXV. FINANCIAL IMPLICATION AND FUNDING
Mwanza, Tanzania reported 33.1%. Larger rates have been
reported and NAR of 15- 34% is generally acceptable by The researcher funded the study without additional
most surgeons 23,30. costs to participating patients, who only paid the standard
surgical fees.
Tai-Hsun Huang et al reported a NAR of 5.1% in their
series by making use of a CT scan in addition to the patient’s XXVI. LIMITATION
clinical features in diagnosing acute appendicitis in Taiwan.
31
. A negative appendectomy rate of 9.2% in our study This is a single centre-based study in Abuja, north-
suggests that applying both Alvarado and RIPASA will central Nigeria. A prospectivemulti-centre study will go a
reduce cases of needless surgeries, while providing prompt, long way in further establishing the gains in using RIPASA
affordable and effective health care in resource-poor settings scores for the diagnosis of acute appendicitis.
like ours. Dependence on expensive imaging techniques
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