Original Article

Journal of International Medical Research

2015, Vol. 43(3) 341–349
Comparison of multislice ! The Author(s) 2015
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DOI: 10.1177/0300060514564475
clinical scores for diagnosing imr.sagepub.com

acute appendicitis
Wen Liu1, Jin Wei Qiang1 and Rong Xun Sun2

Abstract
Objective: To compare Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado
scores with multislice computed tomography (MSCT) for diagnosing acute appendicitis (AA).
Methods: This retrospective study included patients with abdominal pain who had undergone
MSCT, and whose medical notes included RIPASA and Alvarado score parameters. MSCT was
compared with RIPASA and Alvarado scores for diagnosing AA.
Results: Of 297 patients included, sensitivity, specificity and accuracy for diagnosing AA were
95.2%, 73.6% and 87.2% for RIPASA score (cutoff value 7.5) and 63.1%, 80.9% and 69.7% for
Alvarado score (cutoff value 7). Sensitivity, specificity and accuracy of MSCT for diagnosing AA
were 98.9%, 96.4% and 98.0%, respectively. In terms of accuracy, statistically significant differences
were observed between RIPASA and Alvarado scores, and between MSCTand RIPASA scores. The
mean RIPASA score was significantly different in the simple AA group (9.7  2.2) compared with
other AA groups (10.5  1.7). No statistically significant difference was observed in RIPASA score
between nonperforated and perforated AA. MSCT sensitivity, specificity and accuracy for
diagnosing simple AA were 94.1%, 96.4% and 95.8%, respectively; for differentiating perforated and
nonperforated AA, scores were 90.2%, 95.2% and 94.1%, respectively.
Conclusion: MSCT is the optimum diagnostic tool for AA, followed by RIPASA score and
Alvarado score, particularly in diagnosing simple and perforated AA.

Keywords
Acute appendicitis, tomography, X-ray computed, Alvarado score, RIPASA score

Date received: 21 August 2014; accepted: 14 November 2014

1
Department of Radiology, Jinshan Hospital, Fudan
University, Shanghai, China
Introduction 2
Department of General Surgery, Jinshan Hospital, Fudan
University, Shanghai, China
Acute appendicitis (AA) is the most
common surgical abdominal emergency, Corresponding author:
Dr Jin Wei Qiang, Department of Radiology, Jinshan
occurring in 7–12% of the general popula- Hospital of Fudan University, 1508 Longhang Rd, Jinshan
tion;1 its diagnosis is usually based on District, Shanghai 201508, China.
clinical manifestations and laboratory tests. Email: [email protected]

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342 Journal of International Medical Research 43(3)

An atypical type of AA accounts for MSCT examination) and all parameters

approximately 30% of cases,2,3 however, required to calculate RIPASA and
and some other diseases resemble its clinical Alvarado scores. The exclusion criteria
manifestations.4–8 Thus, the correct – and comprised children (<18 years old), preg-
differential – diagnosis of AA is of great nant female patients and patients who were
importance in informing the choice of clin- allergic to iodinated contrast material. Cases
ical treatment. of AA with appendectomy performed >24 h
The Alvarado scoring system, which is following MSCT examination were also
based on specific findings observed in AA, excluded, to reduce the bias of AA stages.
was developed to aid AA diagnosis and has For the diagnosis of AA, MSCT images, and
been shown to have good diagnostic valid- RIPASA and Alvarado scores, were evalu-
ity.9–11 The Alvarado score is widely used in ated retrospectively from complete medical
the diagnosis of AA due to its convenience, notes.
economy and avoidance of radiation expos- The study was approved by the
ure, although studies have reported poor Institutional Review Board affiliated to
diagnostic accuracy for AA when used in Jinshan Hospital, Fudan University,
women, children and the elderly.12,13 Shanghai, China (approval No. 2008-34).
A new scoring system was therefore devel- Since this was a retrospective cohort study,
oped, the Raja Isteri Pengiran Anak informed consent was not required.
Saleha Appendicitis (RIPASA) score,14,15
which produced higher sensitivity and
specificity than the Alvarado score. The
MSCT scan and image interpretation
value of RIPASA for discriminating differ- Abdominal scans were performed using a
ent stages of AA, however, has not been 64-slice Somatom Sensation 64 MSCT scan-
investigated. Computed tomography (CT), ner (Siemens, Erlangen, Germany). Lower
particularly multislice (MS)CT, is widely abdomen scans extended from the superior
performed and important in the diag- border of the third lumbar to the pubic
nosis and differential diagnosis of AA symphysis, and whole abdomen scans
because of its higher accuracy than extended from the diaphragmatic dome to
ultrasonography.16,17 the pubic symphysis. Unenhanced scans and
In the present retrospective cohort study, contrast-enhanced scans were performed,
medical records from patients with abdom- and CT scanning parameters were as fol-
inal pain were retrieved and MSCT scan lows: tube voltage, 120 kV; tube current,
results, and RIPASA and Alvarado scores 200 mA; collimation, 0.6 mm; reconstruc-
were analysed to compare their value in tion slice thickness, 1.0 mm; reconstruction
diagnosing AA. interval, 0.5 mm; pitch, 1. Patients suspected
of colonic tumour, or ureteral or pelvic
Patients and methods lesions, received 1500 ml of water (as nega-
tive contrast material), orally at 0.5, 1 and
Study population and clinical data 1.5 h prior to scanning, to improve the
This retrospective cohort study included quality of image acquisition. Patients sus-
patients treated for abdominal pain between pected of requiring urgent surgery did not
June 2009 and June 2012 at Jinshan receive oral contrast material, to avoid
Hospital, Fudan University, Shanghai, delaying treatment. Patients who underwent
China. enhanced CT were administered 1–1.5 ml/kg
The inclusion criteria comprised patients UltravistÕ 370 (370 mgIodine/ml, Bayer
with complete medical records (including Schering Pharma, Guangzhou, China),
Liu et al. 343

intravenously (i.v.) at a rate of 3 ml/s. Table 1. Alvarado appendicitis scoring system.9

Scanning commenced 60 s following the
Assessment item Score
initiation of i.v. injection.
The appendix was reconstructed using Pain migration to RIF 1
multiplanar reformation and curved planar Anorexia 1
reformation techniques. CT findings were Nausea and vomiting 1
evaluated as follows: maximum appendiceal RIF tenderness 2
diameter; maximum appendiceal wall thick- Rebound tenderness 1
ness; maximum depth of the intraluminal Fever  37.3 C 1
appendiceal fluid; defect in enhancing Raised WCC 2
Shift of WCC to left 1
appendiceal wall; periappendiceal inflam-
Total score 10
mation; phlegmon or abscess; extraluminal
air; intraluminal and/or extraluminal Guidelines for management according to total score:
appendicolith. <4,probability of acute appendicitis (AA) unlikely; 4–7,
Simple AA was diagnosed when max- AA suspected; >7, definite AA.
RIF, right iliac fossa; WCC, white cell count.
imum depth of the intraluminal appendiceal
fluid was >2.6 mm.18,19 Phlegmonous AA
was diagnosed when appendiceal diameter
was >6 mm with associated periappendiceal
inflammation.1,20,21 Perforated AA was Table 2. Raja Isteri Pengiran Anak Saleha
diagnosed when appendiceal diameter was Appendicitis (RIPASA) appendicitis scoring
>6 mm with at least one of five specific CT system.14
signs: defect in enhancing appendiceal wall,
Assessment item Score
phlegmon or abscess, extraluminal air,
extraluminal appendicolith.22,23 Images Female sex 0.5
were evaluated separately by two radiolo- Male sex 1.0
gists (J.W.Q., W.L.) with > 8 years’ experi- Age 40 years 1.0
ence, who were blinded to the clinical score Age >40 years 0.5
results during the image evaluation period, RIF pain 0.5
Migration of RLQ pain 0.5
and who reached consensus following dis-
Anorexia 1.0
cussion when disagreement occurred. Mean
Nausea and vomiting 1.0
values were calculated for the two sets of Duration of symptoms <48 h 1.0
measurement data obtained by the two Duration of symptoms >48 h 0.5
radiologists. RIF tenderness 1.0
RIF guarding þ 2.0
Rebound tenderness 1.0
Alvarado and RIPASA score Rovsing’s sign þ 2.0
For all cases, Alvarado and RIPASA scores Fever >37 C – <39 C 1.0
were derived and calculated from complete Raised WCC 1.0
medical notes separately by two surgeons Negative urinalysis 1.0
Total score
(R.X.S., Y.Z.), each with >10 years’ experi-
ence, based on criteria listed in Tables 1 Guidelines for management according to total score: <5,
and 2. 9,14,15 The two surgeons were blinded probability of acute appendicitis (AA) is unlikely; 5–7.0, low
to the CT diagnostic results during the score probability of AA; 7.5–12.0, probability of AA is high; >12,
definite AA.
evaluation period, and in the case of dis-
Negative urinalysis, absence of blood, neutrophils or
agreement, consensus was reached following bacteria; RIF, right iliac fossa; RLQ, right lower quadrant;
discussion. WCC, white cell count.
344 Journal of International Medical Research 43(3)

Statistical analyses sensitivity and specificity between MSCT

Data are presented as mean  SD, n inci- and RIPASA scores for diagnosing AA were
dence or %. Statistical analyses were per- analysed using 2-test. A P value < 0.05 was
formed using StataÕ statistical software, considered statistically significant. Cohen’s
release 7.0 (StataCorp LP, College Station,  coefficient was used to test inter-rater
TX, USA). Based on cutoff values of 7.5 for agreement and a -value > 0.75 was con-
RIPASA and 7.0 for Alvarado scores,9,14,15 sidered good.
the sensitivity, specificity, and accuracy were
calculated for diagnosing AA. Differences in
the accuracy of RIPASA compared with
Results
Alvarado scores in diagnosing AA were A total of 297 patients with abdominal pain
assessed using 2-test. Differences in the were enrolled in this retrospective cohort
accuracy of RIPASA score for diagnosing study (male, 158 cases; female, 139 cases; age
simple AA versus other types of AA, simple range, 19–87 years; mean age, 47.9  17.6
AA versus phlegmonous AA, and perfo- years). All cases were confirmed by path-
rated AA versus nonperforated AA were ology results and/or surgery. A total of 187
analysed using Student’s t-test. Sensitivity, cases were confirmed as appendicitis, and
specificity and accuracy of MSCT for diag- the range of diseases represented by this
nosing simple AA and differentiating perfo- patient cohort are shown in Table 3. All
rated from nonperforated AA were patients included in this study underwent
calculated. Differences in accuracy, MSCT scan prior to surgery.

Table 3. Distribution of disease, confirmed by pathology results and/or surgery, in 297 patients aged 19–87
years with abdominal pain.

Incidence
Disease n ¼ 297 RIPASA score Alvarado score

Simple AA 34 9.7  2.2 5.5  1.9

Phlegmonous AA 112 10.4  1.7 6.4  2.0
Perforated AA 41 10.6  1.5 6.7  1.8
Negative finding 10 7.2  2.3 6.0  1.8
Crohn’s disease 2 6.5  0.7 5.5  0.7
Gastrointestinal perforation 3 7.8  1.6 7.0  1.0
Inflammation of caecum and/or ascending colon 9 7.3  1.2 6.8  1.4
Adhesive ileus 5 6.3  0.8 4.0  1.6
Intussusception 2 5.8  0.4 4.5  0.7
Volvulus 4 6.4  1.1 5.5  1.3
Right ureter tumour 3 5.8  0.3 5.0  1.0
Right ureter calculus 8 6.2  1.1 6.3  1.5
Right accessory tumour 12 5.7  0.8 4.8  1.6
Right pelvic endometrioma 2 5.8  0.4 4.0  1.4
Uterine myoma 3 5.7  0.3 4.3  1.2
Appendiceal tumour 3 5.6  0.8 3.7  1.2
Gastrointestinal tumour 44 5.9  1.0 5.0  1.7

Data presented as n incidence or mean  SD.

RIPASA, Raja Isteri Pengiran Anak Saleha Appendicitis.
AA, acute appendicitis.
Liu et al. 345

Lower abdomen MSCT scans were per- diagnostic accuracy for AA (2 ¼ 26.93,
formed in 194 cases and whole abdomen P < 0.001).
MSCT scans were performed in 103 cases. The sensitivity, specificity and accuracy
Unenhanced scans were performed in 90 of MSCT for diagnosing AA were 98.9%
cases of phlegmonous appendicitis, and (185/187), 96.4% (106/110) and 98.0% (291/
unenhanced and contrast-enhanced scans 297), respectively. There were significant
were performed in the remaining 207 cases. differences between MSCT and RIPASA
Interobserver agreement between the two scores in terms of diagnostic accuracy
radiologists who evaluated CT images was (2 ¼ 25.13, P < 0.001), sensitivity (2 ¼
very strong, with a -value, 0.96. 4.59, P ¼ 0.03), and specificity (2 ¼ 22.28,
Interobserver agreement between the two P < 0.001) for AA. (Figure 1). A statistically
surgeons who evaluated the Alvarado and significant difference was found between the
RIPASA scores was less strong, but still mean RIPASA score for the simple AA
good, with a -value of 0.76. group (9.7  2.2) compared with the other
The sensitivity, specificity and accuracy types of AA grouped together (10.5  1.7;
values for diagnosing AA were 95.2% (178/ t ¼ 2.32, P ¼ 0.02). The mean RIPASA
187), 73.6% (81/110) and 87.2% (259/297) score in the phlegmonous AA group
for RIPASA score (cutoff value 7.5) and (10.4  1.7) was significantly different from
63.1% (118/187), 80.9% (89/110) and 69.7% the simple AA group (t ¼ 2.16, P ¼ 0.03).
(207/297) for Alvarado score (cutoff value No statistically significant difference was
7), respectively. There was a statistically found in RIPASA score between the non-
significant difference between RIPASA perforated and perforated AA groups
score and Alvarado score in terms of (t ¼ 0.84, P ¼ 0.40). Diagnosis of simple

Figure 1. Flow diagram showing multislice computed tomography (MSCT) and Raja Isteri Pengiran Anak
Saleha Appendicitis (RIPASA) score diagnostic accuracy in patients with or without acute appendicitis (AA).
CT (þ), case diagnosed as AA by MSCT; CT (): AA ruled out by MSCT.
346 Journal of International Medical Research 43(3)

AA using MSCT revealed sensitivity, speci- (RIPASA), and 63.1%, 80.9% and 69.7%
ficity and accuracy values of 94.1% (32/34), (Alvarado), respectively, for diagnosing AA.
96.4% (106/110) and 95.8% (138/144), The RIPASA score had a significantly
respectively. Use of MSCT for the differen- higher diagnostic accuracy compared with
tial diagnosis of perforated versus nonper- Alvarado score in the current study, and
forated AA revealed sensitivity, specificity concurred with the results of previous
and accuracy values of 90.2% (37/41), reports,14,15 in which the diagnostic value
95.2% (139/146) and 94.1% (176/187), of RIPASA score was higher than that for
respectively. Representative CT scan the Alvarado score for diagnosing AA. The
images are shown in Figures 2–4. RIPASA score contains parameters such as
age and sex, which could increase the accur-
acy compared with Alvarado score, and the
Discussion RIPASA score also contains more param-
In the current study of adults with abdom- eters that could aid with the differential
inal pain, cutoff values of 7.5 for the diagnosis of AA. All 14 parameters of the
RIPASA score and 7 for the Alvarado RIPASA score are easily obtained from
score yielded sensitivity, specificity and good clinical histories, examinations and
accuracy of 95.2%, 73.6% and 87.2% investigations, and RIPASA score is easy
to implement without additional costs.

Figure 2. Representative multislice computed Figure 3. Representative multislice computed

tomography (MSCT) scan image showing phlegmo- tomography (MSCT) scan image showing simple
nous acute appendicitis (AA). In this case, Alvarado acute appendicitis (AA). In this case, Alvarado score
score was 3 and Raja Isteri Pengiran Anak Saleha was 2 and Raja Isteri Pengiran Anak Saleha
Appendicitis (RIPASA) score was 10. The appendix Appendicitis (RIPASA) score was 6.5. The appendix
was reconstructed using the multiplanar reforma- was reconstructed using the multiplanar reforma-
tion technique; arrow indicates the appendix tion technique; arrow indicates the appendix
(diameter, 11.6 mm) with periappendiceal inflam- (diameter, 8.5 mm) without findings of periappendi-
mation; appendicolith and fluid seen in appendiceal ceal inflammation; fluid seen in appendiceal lumen
lumen; CT findings met the diagnostic criterion of (diameter, 3.1 mm); computed tomography findings
phlegmonous AA. met the diagnostic criterion of simple AA.
Liu et al. 347

specific parameters, and in many other dis-

eases (including inflammation of the caecum
and/or ascending colon, gastrointestinal per-
foration, and right ureter calculus), a few
abnormal parameters that are included in the
RIPASA score often develop.
The diagnostic value of the RIPASA
score has been documented as being higher
than the Alvarado score for AA,14,15 how-
ever no study has reported the diagnostic
value of the RIPASA score for different
types of AA. In the current study, the
RIPASA score for the simple AA group
was significantly lower than for other types
of AA grouped together, indicating that the
Figure 4. Representative multislice computed diagnostic value of this score for simple AA
tomography (MSCT) scan image showing perforated was lower than for other types of AA
acute appendicitis (AA). In this case, the Alvarado grouped together, based on the guidelines
score was 7 and Raja Isteri Pengiran Anak Saleha for management according to RIPASA total
Appendicitis (RIPASA) score was 10.5. The score. This may be explained by the fact that
appendix was reconstructed using the multiplanar simple AA had more atypical presentations
reformation technique; the long arrow indicates
than other types of AA grouped together in
markedly enhanced and swelling appendix (diameter,
the current study and, therefore, RIPASA
12.8 mm); the short arrow indicates defect in
enhancing appendiceal wall located in the distal score could not effectively address the prob-
appendix; periappendiceal abscess with rim lem of differentially diagnosing simple AA.
enhancement was observed; computed tomog- Comparable with published reports,18,19
raphy findings met the diagnostic criterion of the sensitivity, specificity and accuracy of
perforated AA. MSCT for diagnosing simple AA were
94.1%, 96.4% and 95.8%, respectively,
indicating that MSCT is an important pro-
Compared with the Alvarado score, there- cedure for the diagnosis of simple AA.
fore, the RIPASA score may be more Clinical management options for perfo-
appropriate for the diagnosis of AA. rated AA are reported to be different from
Computed tomography is thought to be those for nonperforated AA.22–24 The rou-
important in the diagnosis and differential tine treatment of choice for perforated AA is
diagnosis of AA,3,16,17 however, no studies to administration of antibiotics and/or drain-
date directly compare the RIPASA score age, with or without appendectomy 6–12
with CT in the diagnosis of AA. In the weeks following antibiotic treatment. In
current study, the sensitivity, specificity and patients with nonperforated AA, prompt
accuracy of MSCT were significantly higher appendectomy is recommended to reduce
than those of the RIPASA score for diagnos- the risk of complications. Thus, differentiat-
ing AA. There were statistically significant ing perforated from nonperforated AA can
differences in diagnostic accuracy, sensitivity be critically important in order to select the
and specificity between MSCT and RIPASA correct therapeutic approach. To date, no
score, indicating that MSCT is an important study has reported the value of the RIPASA
supplement to RIPASA score. This may be score for differentiating perforated from
because the RIPASA score lacks highly nonperforated AA, however. In the current
348 Journal of International Medical Research 43(3)

study, there was no statistically significant

difference in the RIPASA score between the Funding
nonperforated and perforated AA groups. This study was supported by the Science and
However, use of MSCT for differentiating Technology Commission of the Jinshan District
perforated from nonperforated AA revealed of Shanghai (Grant No. 2010-3-18).
a sensitivity, specificity and accuracy of
90.2%, 95.2% and 94.1% respectively, Acknowledgement
which were similar values to those reported The authors thank Dr Yong Zhang for collecting
previously.22,23 These results indicate that the clinical histories as part of his routine duties.
MSCT is superior compared with the
RIPASA score in the differential diagnosis
of perforated versus nonperforated AA. References
The current study is limited by the fact 1. Chalazonitis AN, Tzovara I, Sammouti E,
that it is a retrospective cohort study, how- et al. CT in appendicitis. Diagn Interv Radiol
ever, sample cases with complete medical 2008; 14: 19–25.
notes are presented, which improves the 2. Pinto Leite N, Pereira JM, Cunha R, et al.
CT evaluation of appendicitis and its com-
accuracy of the results, and provides evi-
plications: imaging techniques and key
dence that may guide the choice of clinical
diagnostic findings. Am J Roentgenol 2005;
pathway in the diagnosis of abdominal pain. 185: 406–417.
Cases of AA with appendectomy performed 3. Ebell MH. Diagnosis of appendicitis: part II.
>24 h following MSCT examination were Laboratory and imaging tests. Am Fam
excluded, which may have biased the MSCT Physician 2008; 77: 1153–1155.
results, however, this was done to avoid 4. Yu J, Fulcher AS, Turner MA, et al. Helical
inaccurate reporting of the stages of AA, CT evaluation of acute right lower quadrant
since some nonperforated AA may rapidly pain: part I, common mimics of appendicitis.
progress to perforated AA after 24 h.23 Am J Roentgenol 2005; 184: 1136–1142.
In conclusion, the current study suggests 5. Hoeffel C, Crema MD, Belkacem A, et al.
that MSCT is the optimum diagnostic tool Multi-detector row CT: spectrum of diseases
involving the ileocecal area. Radiographics
for AA compared with RIPASA and
2006; 26: 1373–1390.
Alvarado scores, particularly in cases of 6. van Breda Vriesman AC and Puylaert JB.
simple and perforated AA. The study also Mimics of appendicitis: alternative nonsur-
showed that the RIPASA score may be a gical diagnoses with sonography and CT.
superior diagnostic scoring system com- Am J Roentgenol 2006; 186: 1103–1112.
pared with the Alvarado score for AA, 7. Pooler BD, Lawrence EM and Pickhardt PJ.
which is important in hospitals where Alternative diagnoses to suspected appendi-
MSCT scans are not readily available. A citis at CT. Radiology 2012; 265: 733–742.
prospective study of MSCT versus the 8. Purysko AS, Remer EM, Filho HM, et al.
RIPASA score should be conducted, to Beyond appendicitis: common and uncom-
further confirm the superiority of MSCT mon gastrointestinal causes of right lower
over RIPASA in terms of sensitivity, speci- quadrant abdominal pain at multidetector
CT. Radiographics 2011; 31: 927–947.
ficity and accuracy in the diagnosis and
9. Alvarado A. A practical score for the early
differential diagnosis of AA. diagnosis of acute appendicitis. Ann Emerg
Med 1986; 15: 557–564.
10. Khan I and ur Rehman A. Application of
Declaration of conflicting interest
Alvarado scoring system in diagnosis of
The authors declare that there are no conflicts of acute appendicitis. J Ayub Med Coll
interest. Abbottabad 2005; 17: 41–44.
Liu et al. 349

11. Shrivastava UK, Gupta A and Sharma D. computed tomography criteria including
Evaluation of the Alvarado score in the ‘‘maximum depth of intraluminal appendi-
diagnosis of acute appendicitis. Trop ceal fluid greater than 2.6 mm’’. J Comput
Gastroenterol 2004; 25: 184–186. Assist Tomogr 2009; 33: 383–389.
12. Dey S, Mohanta PK, Baruah AK, et al. 19. Moteki T, Ohya N and Horikoshi H.
Alvarado scoring in acute appendicitis-a Evaluation of the maximum depth of intra-
clinicopathological correlation. Indian J luminal appendiceal fluid to diagnose
Surg 2010; 72: 290–293. appendicitis with a 64-detector row CT
13. Ohle R, O’Reilly F, O’Brien KK, et al. The scanner. J Comput Assist Tomogr 2011; 35:
Alvarado score for predicting acute appen- 703–710.
dicitis: a systematic review. BMC Med 2011; 20. Raman SS, Lu DS, Kadell BM, et al.
9: 139. Accuracy of nonfocused helical CT for the
14. Chong CF, Adi MI, Thien A, et al. diagnosis of acute appendicitis: a 5-year
Development of the RIPASA score: a new review. AJR Am J Roentgenol 2002; 178:
appendicitis scoring system for the diagnosis 1319–1325.
of acute appendicitis. Singapore Med J 2010; 21. Ege G, Akman H, Sahin A, et al. Diagnostic
51: 220–225. value of unenhanced helical CT in adult
15. Chong CF, Thien A, Mackie AJ, et al. patients with suspected acute appendicitis.
Comparison of RIPASA and Alvarado Br J Radiol 2002; 75: 721–725.
scores for the diagnosis of acute appendicitis. 22. Horrow MM, White DS and Horrow JC.
Singapore Med J 2011; 52: 340–345. Differentiation of perforated from nonper-
16. Wang SY, Fang JF, Liao CH, et al. forated appendicitis at CT. Radiology 2003;
Prospective study of computed tomography 227: 46–51.
in patients with suspected acute appendicitis 23. Tsuboi M, Takase K, Kaneda I, et al.
and low Alvarado score. Am J Emerg Med Perforated and nonperforated appendicitis:
2012; 30: 1597–1601. defect in enhancing appendiceal wall–depic-
17. van Randen A, Laméris W, van Es HW, tion with multi-detector row CT. Radiology
et al. A comparison of the accuracy of 2008; 246: 142–147.
ultrasound and computed tomography in 24. Iqbal CW, Knott EM, Mortellaro VE, et al.
common diagnoses causing acute abdominal Interval appendectomy after perforated
pain. Eur Radiol 2011; 21: 1535–1545. appendicitis: what are the operative risks and
18. Moteki T, Ohya N and Horikoshi H. luminal patency rates? J Surg Res 2012; 177:
Prospective examination of patients sus- 127–130.
pected of having appendicitis using new