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.