Appendicitis inflammatory response score: a novel scoring system for acute appendicitis

Abstract

INTRODUCTIONReginald Fitz from Boston first identified inflammation of the appendix as a cause of right lower quadrant pain. He coined the term appendicitis and recommended early surgery intervention. Robert Lawson performed first appendectomy in England.1 Now 130 years later, acute appendicitis still remains one of the most common abdominal emergency, demanding surgery. Mortality rate has improved since advent of antibiotics in 1940. No perfect diagnostic evaluation tool exists to detect appendicitis if symptoms are ambiguous. If symptoms are vague diagnostic process takes longer, thus delaying surgery increasing the possibility of complications. On the other hand, hasty operation without accurate diagnosis will lead to negative appendectomy, increasing the morbidity and cost of treatment. 2,3Even with the advent of modern diagnostic tools, misdiagnosis of appendicitis has remained more or less constant. The percentage of misdiagnosis is higher among women than men. Diagnostic approaches include symptomatology, physical examinations, laboratory findings and imaging modalities like ultrasonography and computerized tomography (CT) of abdomen. Although the advent of ultrasound has improved the diagnosis of ABSTRACT Background: Acute appendicitis is one of the most common surgical emergencies encountered by doctors on call with emergency appendicectomy being a very common outcome of emergency laparotomies. There's been a marked decline in mortality over the past 50 years, but the rates of perforation and negative laparotomy have not changed much as they're influenced by factors untouched by technological advances. Methods: A prospective comparative study to compare appendicitis inflammatory response score (AIR) and Alvarado scoring systems in evaluating suspected cases of acute appendicitis. 100 patients presenting with pain in the right lower quadrant of abdomen at the surgical clinics at Basaveshwar Teaching and General Hospital, Kalaburagi, Karnataka, India, who after clinical examination and relevant investigations were provisionally diagnosed to have acute appendicitis and warranted surgery for the same were evaluated using the scoring systems -Alvarado Score and Appendicitis Inflammatory Response Score. The scores were tallied and compared with final histopathology report. The study was conducted for a period of one and a half year. Results:The results revealed that AIR (at score >4) demonstrated a higher sensitivity and specificity compared to Alvarado score (89.9 versus 78.6%) and (63.6 versus 54.5) respectively. Alvarado showed a slightly better sensitivity at score>8 (21.3 versus 12.3%). Conclusions: The Appendicitis Inflammatory Response Score outperformed the Alvarado score. It holds promise to be incorporated into the clinician's daily inventory in efficiently diagnosing Appendicitis.

Comparison between AIR score and Alvarado score in cases of non-perforated and perforated acute appendicitis

“…Patil S et al, study reported maximum number of patients were present in score range of 5-8, with 56 patients being grouped by Alvarado score and 73 patients grouped by AIR score. 22 It was observed in the present study that AIR diagnosed 85 patients as acute appendicitis (at score >4) of which 5 were false positive cases. AIR score ruled out acute appendicitis (at score <4) in 15 individuals of which 10 were false negative ones.…”

“…AIR could diagnose 11 cases of acute appendicitis (at score >8) with no false positive cases. 22 In our study, Alvarado score diagnosed 77 patients as acute appendicitis (at score >4) of which 7 were false positive cases. Alvarado score ruled out acute appendicitis (at score <4) in 23 individuals of which 20 were false negative ones.…”

“…23 Patil S et al, study reported sensitivity of AIR of 89.9% (at score >4), Both AIR and Alvarado (at score >8) demonstrated specificity of 12.3% and 21.3% respectively and specificity of Alvarado (at score >4) at 54.5%. 22 Sudhir S et al, study reported cases of phlegmonous appendicitis, for scores >4, Alvarado score has high sensitivity (97.06) compared to AIR score (78.43).…”

“…Patil S et al, found histopathology which was the gold reported 89 cases as acute appendicitis and 11 cases as chronic appendicitis. 22 Gopalam PR et al, cross sectional prospective study reported 116 cases of 300 (38.7%) were diagnosed pathologically as appendicitis, with 88 cases as phlegmonous appendicitis and 28 as cases of advanced appendicitis. In the remaining 184 cases which were negative pathologically for appendicitis, other alternate causes of diagnosis were found in 116 cases.…”

“…Alvarado score (at score >8) correctly diagnosed in 19 individuals with zero false positive cases. 22 Gopalam PR et al, cross sectional prospective study reported 146 out of 300 cases were placed under low risk category by scoring less than 5 points, with 16 cases of Phlegmonous appendicitis and 2 cases of advanced appendicitis. In the cases scored by Alvarado scoring, 102 cases were of lower risk category with 21 phlegmonous and 6 cases of advanced appendicitis.…”