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The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score is a new diagnostic scoring system for the diagnosis of acute appendicitis and has been shown to have significantly higher sensitivity, specificity and diagnostic accuracy than that reported for the Alvarado or Modified Alvarado scores.

The RIPASA score is more extensive than the Alvarado score. It includes parameters such as age, gender and duration of symptoms prior to presentation, which have been shown to affect the sensitivity and specificity of the Alvarado and Modified Alvarado scores. The RIPASA score consists of 14 fixed generalised parameters, with an additional parameter that is specific to our local population. We prospectively compared the RIPASA score (6) with the Alvarado score by applying both scores to patients who presented to our Department of General surgery with right iliac fossa (RIF) pain and who were suspected of acute appendicitis.


The present study consists of 250 patients of age group 15 to 60 years diagnosed with acute appendicitis between July 2017 TO August 2018 in Government Vellore medical college.

The Study was conducted in Department of Surgery in Government Vellore medical college, Vellore from JULY 2017 TO AUGUST 2018. Ethical committee clearance was taken for the study. This is a prospective study of all patients coming to our institution in the Department of Surgery [7] with complaints of right iliac fossa abdominal pain. The basic aim is to compare the Alvarado Score and RIPASA Score in their efficacy to diagnose acute appendicitis so that the diagnostic criteria can be improved, and we can reduce the unwanted operations and expensive imaging studies

Type of the Study [7]

Cross--Sectional study.

Statistical Analysis

The collected data were tabulated and statistically analyzed using SPSS program (Statistical Package for Social Science) version 24. Qualitative data were represented as frequencies and relative percentages. Chi square test ([chi square]) and Fisher exact was used to calculate difference between qualitative variables as indicated. Quantitative data were expressed as mean [+ or -] SD (Standard deviation) for parametric and median and range for non-parametric data. The significance level for all above mentioned statistical tests was done P-value [less than or equal to] 0.05 indicates significant, p <0.001 indicates highly significant difference while, P>0.05 indicates non-significant difference.

Interpretation of Alvarado Score [4]

Score Interpretation

* 1-4 Very unlikely, keep under observation.

* 5-6 Acute appendicitis may be, for regular observation.

* 7-8 Acute appendicitis is probable, operate.

* 9-10 Acute appendicitis definite, operate.


* The study period was 12 months with total 250 patients were involved. Total 250 patients of age range 15 to 60 years of age. Peak age group was 15 to 25 years of age (45%). Least affected age group was above 45 years of age.

* Males are predominantly affected with M: F ratio 1.9: 1.

* Most common presentation was found Pain in abdomen in 97.5% of patients followed by Nausea and Vomiting in 88% and Right Iliac Fossa Tenderness [9] in 86% of the patients. Majority of patients (58%) presenting after 48 hours of the onset of symptoms to the hospital.

* WBC counts were found to be raised (>10, 000/[mm.sup.3]) in 56% of the patients.

* In 94% of the patients Urine culture and sensitivity was found positive.

* Almost 90% of the patients were diagnosed positive for acute appendicitis on Ultrasonography. In Histopathology, 95% of the patients tested positive for acute appendicitis.

* Emergency Appendicectomy were performed in about 193 (96.5%) patients and 190 (95%) patients confirmed Histology for acute appendicitis.

* Mean Hospital stay was 3.05 days.

* Wound infection was found in 2.5% of the patients, 2% having Wound Gaping and 2% had Postoperative adhesions.

* Most of the patients (65%) were discharged within 4 days of admission.

* Regarding Alvarado Score and RIPASA Score, out of 250 patients 135(54%) patients had Alvarado Score <7 and 115 (46%) had score >=7

* And 4 (1.5%) Patients had RIPASA Score <5,

* 52 (6%) patients have scores between 5-7,

* 166 (66.5%) patients had scores between 7.5-11.5,

* 69 (27.6%) patients had scores >=12.


The present study included clinically suspected 250 cases of appendicitis, with age group of patients taken from 15 to 60 years of age. There were 165 males and 85 females in the study.

All the patients clinically suspected to have acute appendicitis were scored according to both the scoring systems and were taken up for surgery.

Histopathology was considered the gold standard for the confirmation of the diagnosis. The histopathologically inflamed appendix was classified acute appendicitis. The histopathologically normal appendix was put under no appendicitis group. The symptoms such as RIF pain was present in 243 patients (97.5%) in the study group. anorexia was present in 195 patients (78%), nausea and vomiting were present in 220 patients (73%), fever was present in 165 patients (66%) and presenting with duration of symptoms less than 48 hours were 105(42%). Of all the symptoms RIF pain, Pain migration, nausea and vomiting and duration of symptoms came out to be statistically significant (with p value 0.032, 0.048, 0.016 and 0.042 respectively) but RIF pain and nausea and vomiting came out to be highly significant (with p value 0.032 and 0.016 respectively) Signs such as RIF tenderness was present in 190 cases (p value 0.016), guarding was present in 85 (p value 0.226), rebound tenderness was present in 75 (p value 0.461) and Rovsing's sign was present in 80 (p value 0.134). Out of all the clinical signs, RIF tenderness was found to be statistically significant. Alvarado score when applied in all patients clinically suspected to have appendicitis, had 115 cases (46%) with a score of [greater than or equal to] 7 and 135 cases (54%) with a score of <7. On analysing with respect to the histopathology, the sensitivity and specificity of the scoring system in the present study came out to be 70% and 20% respectively. The positive and negative predictive values were 94.32% and 3.38% respectively. Accuracy was 74% with 8 false positive cases and 57 false negative cases. Khan et al applied the Alvarado scoring system in Asian population and achieved a sensitivity and specificity of 59% and 23% respectively, with a positive predictive value of 83.3% with negative appendicectomy rate of 15.6%. RIPASA score when applied in all the patients clinically suspected of having appendicitis, had 235 patients (94%) in [greater than or equal to] 7.5 group and 15 patients (6%) in < 7.5 score group. When analysed with respect to histopathology the sensitivity of the scoring system in the present study came to be 98.42%, specificity of 90%, positive and negative predictive values of 99.46% and 75% respectively

* On comparing both the scoring systems in the present study, RIPASA score has been found to be more sensitive (98.42%) as compared to Alvarado score (73.7%).

* RIPASA score is also more specific (90%) as compared to Alvarado score (80%).

* Positive and negative predictive values of RIPASA came out to 99.46% and 75% as compared to Alvarado having 94.32% and 3.38%. Accuracy of the RIPASA score was 97% as compared to the Alvarado score having accuracy of 74%. In a prospective study by Chon CF et al, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the RIPASA score were 98%, 81.3%, 85.3%, 97.4% and 91.8% respectively when compared to Alvarado score with sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of 68.3%, 87.9%, 86.3%, 71.4% and 86.5% respectively.


Both Alvarado and RIPASA scoring systems have significant differences when Non-Parametric Pearson Chi Square Test was applied with a p value of <0.05; correlation between the Alvarado Pi and RIPASA Score rho= 0.538 and p value <0.05; significant difference was found with positive agreement between the two scores. From the above parameters we conclude that RIPASA Score is a better Scoring system in diagnosing cases of acute appendicitis [4] as compared to the Alvarado score [5].


[1] Chong CF, Adi MI, Thien A, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010;51(3):220-5.

[2] Livingston EH, Woodward WA, Sarosi GA, et al. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 2007;245(6):886-92.

[3] Chong CF, Thien A, Mackie AJA, et al. Evaluation of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Brunei Int Med J 2010;6(1):17-26.

[4] Pal KM, Khan A. Appendicitis: a continuing challenge. J Pak Med Assoc 1998;48(7):189-92.

[5] Khan I, Ur Rehman A. Application of alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17(3):41-4.

[6] Wani MM, Yousaf MN, Khan MA, et al. Usefulness of the Alvarado scoring system with respect to age, sex and time of presentation, with regression analysis of individual parameters. Internet J Surg 2007;11(2):1-5.

[7] Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15(5):55764.

[8] Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 2008;32(8):1843-9.

[9] Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado Score for acute appendicitis in adults. Saudi Med J 2004;25(9):1229-31.

Loganathan Devarajan (1), Ramesh A (2), Gayathri S (3)

(1) Associate Professor, Department of General Surgery, Government Vellore Medical College, Vellore, Tamilnadu, India.

(2) Assistant Professor, Department of General Surgery, Government Vellore Medical College, Vellore, Tamilnadu, India.

(3) Junior Resident, Department of General Surgery, Government Vellore Medical College, Vellore, Tamilnadu, India.

'Financial or Other Competing Interest': None.

Submission 25-02-2019, Peer Review 04-04-2019, Acceptance 11-04-2019, Published 13-05-2019.

Corresponding Author: Dr. Loganathan Devarajan, Associate Professor, Department of General Surgery, Government Vellore Medical College, Vellore, Tamilnadu, India.

DOI: 10.14260/jemds/2019/349
Table 1. Age Group

AGE Groups No. of Patients in
Particular Age Group

15-25                           115 (45%)
26-35                           65 (26.5%)
36-45                           45 (18.5%)
46-60                           25 (10%)

Table 2. Male: Female Ratio

         Number   Percentage

Male     165      66%
Female   85       34%

Out of 250 patients 165 are Males and 85 are Females.

Alvarado Score

Characteristics                                   Score

M-Migration Of Pain To The Right Lower quadrant   1
A-Anorexia                                        1
N-Nausea                                          1
T-Tenderness in The Right Lower Quadrant          2
R-Rebound Tenderness                              1
E-Elevated Temperature                            1
L-Leucocytosis                                    2
S-Shift of WBC To the Left                        1
Total                                             10

Minimal total score is 2, Maximum total score is 17.5.

Parameter Score

Male                    1.0
Female                  0.5
<39                     1.0
>40                     0.5
RIF Pain                0.5
Migration of RLQ Pain   0.5
Anorexia                1.0
Nausea and Vomiting     1.0
Duration of Symptoms
<48 hrs.                1.0
>48 hrs.                0.5
RIF Tenderness          1.0
RIF Guarding            2.0
Rebound Tenderness      1.0
Rovsing's Sign          2.0
Fever                   1.0
Raised WBC              1.0
Negative Urinalysis     1.0
Foreign NRIC            1.0

Signs and Symptoms

Signs and Symptoms

Pain in Abdomen       243   97.5%
Nausea and Vomiting   220   88%
Anorexia              195   78%
Fever                 165   66%
RIF Tenderness        190   86%
Rebound Tenderness    75    30%
Guarding              85    34%
Rovsing Sign          80    32%

Post-Operative Histopathology of Appendix

Histopathology   No. of Patients

Positive (+ve)   237
Negative (-ve)   13

Treatment Modality

Treatment Modality         No. of Patients

Emergency Appendicectomy   241
Exploratory Laparotomy     9

Comparison Between the RIPASA and Alvarado Scoring
Systems with Respect to Different Variables

Variables                   RIPASA> 7.5   Alvarado >7.0   p Value

Sensitivity                 98.42%        73.7%           <0.0001
Specificity                 90%           80%             <0.0001
Positive Predictive Value   99.46%        94.32%          <0.0001
Negative Predictive Value   75%           3.38%           <0.0001
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Article Details
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Title Annotation:Original Research Article
Author:Devarajan, Loganathan; Ramesh, A.; Gayathri, S.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Geographic Code:9INDI
Date:May 13, 2019

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