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Level of Accuracy in the Diagnosis of Acute Appendicitis: Comparative Analysis Between the Scale of Alvarado, RIPASA and New Proposal

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Level of Accuracy in the Diagnosis of Acute Appendicitis: Comparative Analysis Between the Scale of Alvarado, RIPASA and New Proposal Cirujano ORIGINAL ARTICLE General July-September 2019 Vol. 41, no. 3 / p. 144-156 ORIGINAL ARTICLES Level of accuracy in the diagnosis of acute ARTÍCULOS ORIGINALES appendicitis: comparative analysis between the scale of Alvarado, RIPASA and new proposal Escala de mayor precisión para el diagnóstico de apendicitis aguda: análisis comparativo entre la escala de Alvarado, RIPASA y nueva propuesta Juan Hernández-Orduña* Keywords: Acute appendicitis, ABSTRACT RESUMEN Alvarado scale, RIPASA scale. Objective: To compare the Alvarado scale, RIPASA, and Objetivo: Comparar la escala de Alvarado, RIPASA, y a new proposal the most accurate in the early diagnosis of una nueva propuesta para conocer cuál es más exacta Palabras clave: acute appendicitis. Setting: Atizapán General Hospital, en el diagnóstico temprano de apendicitis aguda. Sede: Apendicitis aguda, ISEM. Design: Prospective, cross-sectional, comparative, Hospital General de Atizapán, ISEM. Diseño: Estudio escala Alvarado, and observational study. Statistical analysis: measures of prospectivo, transversal, comparativo y observacional. RIPASA. central tendency, analysis of diagnostic tests (sensitivity, Análisis estadístico: Medidas de tendencia central, specificity, predictive values), and ROC curve. Patients análisis para pruebas diagnósticas (sensibilidad, espe- and methods: At the General Hospital of Atizapán (Period: cificidad, valores predictivos) y curva ROC.Pacientes y November 2016-October 2017) the 182 patients studied métodos: Se estudiaron 182 pacientes que ingresaron al came to the emergency room with an abdominal pain Servicio de Urgencias del Hospital General de Atizapán syndrome suggestive of acute appendicitis. Simultaneously, en un periodo de noviembre de 2016 a octubre de 2017, Alvarado scale, RIPASA, and a new scale were applied. con síndrome doloroso abdominal sugestivo de apendi- General epidemiological, clinical, and surgical findings citis aguda; se les realizaron estudios de laboratorio y were noted correlating them with the histopathology of gabinete, aplicando en forma simultánea las escalas de the appendix as well as post-operative evaluation and Alvarado, RIPASA y una nueva escala. Se observaron ha- complication rate. Results: Taking into account the high llazgos epidemiológicos generales, clínicos y quirúrgicos scores of each scale applied to patients, the sensitivity of y se les correlacionó con el resultado de histopatología Alvarado was 81% with a positive predictive value of 70%, del apéndice así como con la evolución postquirúrgica that of RIPASA was 88% with a positive predictive value y la tasa de complicaciones. Resultados: Tomando las 92% and the scale proposed had a sensitivity of 91% with a puntuaciones altas de cada escala aplicadas en los positive predictive value of 98%. The area under the ROC pacientes se obtuvo que la sensibilidad de Alvarado fue curve of the scale of Alvarado was 0.83, that of RIPASA de 81% con valor predictivo positivo de 70%; RIPASA was 0.85, and the area of the new proposed scale was 0.92. 88% con valor predictivo positivo de 92% y en la nueva Conclusions: The three scales showed good sensitivity in escala propuesta la sensibilidad fue de 91% con valor the diagnosis of acute appendicitis. However the proposed predictivo positivo de 98%. El área bajo la curva ROC * M Sc in Education. new scale is more exact in the diagnosis, with a much de la escala de Alvarado fue de 0.83, RIPASA fue de Department of General Surgery, Atizapán higher positive predictive index, favoring not only less 0.85, y la escala propuesta de 0.92. Conclusiones: Las General Hospital, white laparotomies but even an earlier and timely diagnosis tres escalas mostraron buena sensibilidad para el diag- Instituto de Salud del with a lower rate of advanced phases and complications. nóstico de apendicitis aguda. Sin embargo, la escala Estado de México. propuesta presenta mayor exactitud diagnóstica con un índice predictivo positivo muy superior, lo que favorece Received: 28/02/2018 no sólo la disminución de laparotomías blancas, sino un Accepted: 07/12/2018 www.medigraphic.org.mxdiagnóstico más temprano y oportuno con menor tasa de fases avanzadas y complicaciones. How to cite: Hernández‑Orduña J. Level of accuracy in the diagnosis of acute appendicitis: comparative analysis between the scale of Alvarado, RIPASA and new proposal. Cir Gen. 2019; 41(3): 144‑156. Cirujano General 2019; 41 (3): 144-156 www.medigraphic.com/cirujanogeneral Hernández-Orduña J. Level of accuracy in the diagnosis of acute appendicitis 145 INTRODUCTION age, gender, and specific clinical conditions, have been published.9 cute appendicitis (AA) is the most This has led to numerous investigations to Afrequent cause of acute abdominal pain: identify clinical, laboratory, and radiological it represents 47.8% of surgical admissions in findings with greater diagnostic certainty for emergency services.1 In Mexico, according to AA and the development of clinical scoring figures of the National Institute of Statistics, systems to guide the physician to the correct Geography and Informatics (Instituto Nacional diagnosis, to reduce delay and decreased de Estadística Geografía e Informatica, INEGI), rates of negative appendectomies. However, in 2008, 60,668 cases of acute appendicitis the diagnostic scales (Alvarado and Modified were admitted in all institutions of the Alvarado) have a sensitivity and specificity of country’s health services. In the United States, less than 90%, which still leads to delayed between 250,000 and 280,000 new cases diagnosis and early treatment, with an impact are documented every year, with a mortality on morbidity and mortality rates, and increased of 0.0002% and a morbidity of 3% when costs. The RIPASA scale (named after its diagnosis and timely treatment are carried origin in the Raja Isteri Pengiran Anak Saleha out.2,3 The probability of presenting AA is one Hospital, in the north of the island of Borneo, in five at birth, one in 35 at age 50 and younger in Southeast Asia), increases its sensitivity. than one in 100 at age 70. One in 15 people However, surgeries continue to be carried out will develop an acute appendicular picture in patients complicated by long evolution, at some point in their lives. The literature even of weeks’ length, having been managed reports that the overall risk of appendicitis is with multiple treatments for diverse diagnoses 8.6% for men and 6.7% for women in all age which modify the condition, leading to serious groups.4,5 Some authors have mentioned that complications, and putting patients and the the population most affected is between 25 entire medical staff, from the outpatient clinic, and 35 years of age.6,7 Others mention that the emergency room, and even the surgical the disease occurs at all stages, but is more team, in medical‑legal danger. frequent in the second and third decades of Since its inception, the diagnosis of acute life, in average around 22 years.2 A general appendicitis is clinical, with a characteristic parallelism is known between the amount symptomatic evolution even in atypical cases. of lymphoid tissue in the appendix and the We already know its symptomatic variants frequency of acute appendicitis, the peak of and its anatomical variants, so early surgical which occurs in mid‑adolescence. management should not be delayed in a patient The diagnosis of acute appendicitis is with symptoms of abdominal pain characteristic primarily clinical; however, it is difficult of acute appendicitis. in the initial stages of the process because On the other hand, there is sometimes findings can be confusing, especially at the no laboratory or imagery support in some extremes of life and in patients who consume first ‑contact medical facilities, mistakenly steroids, pain relievers or antibiotics, those prescribing medical treatment for a different immunosuppressed or during pregnancy. diagnosis, altering the evolution of the Although the symptomatic background may condition, and leading to complications that vary, cardinal symptoms are generally present. can be catastrophic. Some authors are in favor of carrying out As Dr. Weber recently mentioned: “it is imaging procedures to all patients with a clinical unfortunate that, based on fashions in other suspicion ofwww.medigraphic.org.mx appendicitis,8 others prefer that countries, less and less physicians are seen this be carried out only in doubtful cases, and to carry out a thorough history or palpate a few assure that diagnostic images are not the abdomen, basing their diagnosis only useful.9 Multiple reports have been published. on laboratory or “routine” imaging. It is Articles regarding the efficiency of various condemnable to belittle clinical intuition, based imaging modalities for the diagnosis of acute on knowledge and experience, not taking appendicitis depending on variables such as into account its usefulness, cost, risk and the Cirujano General 2019; 41 (3): 144-156 www.medigraphic.com/cirujanogeneral 146 Hernández-Orduña J. Level of accuracy in the diagnosis of acute appendicitis Table 1: Alvarado diagnostic scale for acute appendicitis. Parameter Observations Score Signs Migration of pain 1 Anorexia and/or urinary ketone bodies 1 Nausea and vomiting 1 Symptoms Pain in Right Iliac Fossa (RIF) 2 Rebound pain 1 Fever 1 Laboratory Leukocytosis (+ 10,000) 2 Left shift (neutrophils > 75%) 1 According to the score, management is suggested: If the score is from 1 to 4, there is a very low probability of appendicitis. With 5 and 6 points, the patient presents with probable appendicitis and will require serial clinical and laboratory evaluations, as well as some imaging studies (US, TAC). A score greater than 7 as a “unique strategy” to decide which patient requires surgery. Source: Alvarado, 1986.11 benefit they can provide to the specific case, Leukocytosis, and neutrophil Shift to the left and not making a rational and proportionate (Table 1). use of diagnostic methods”.10 Perhaps we should resume and reinforce specific skills, The RIPASA Scale competences, and know‑how to carry out a good semiology of acute abdomen at the In 2010, a scale was developed at the RIPAS universities.
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