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1. Comparison of diagnostic accuracy of
appendicitis inflammatory response and adult
appendicitis scoring system in diagnosing
acute appendicitis taking surgical findings as
gold standard

2. Introduction

3. Acute appendicitis is one of the common surgical
Emergencies in the world and has a lifetime risk of 7-8%
(Chen et al., 2012).
The clinical presentation is typical only in 50% of the cases.
Particularly among the children, elderly and females of
reproductive age, diagnosis can be challenging due to
overlapping symptoms with other abdominal conditions , also
it is eminently clinical, being supplemented with laboratory
findings and imaging modalities. Only 20-33% of cases
present typical findings (Mohamed & Bhat, 2009)

4. Management of patients with equivocal diagnosis is also
controversial (Singh et al., 2017).
The treatment of choice remains surgical in both complicated and
uncomplicated patients. Hence, over diagnosis can lead to an
increase in unnecessary surgeries, resultant morbidity and
drainage of resources in a resource-improvised setting (Flum &
Koepsell, 2002).
Recent studies have shown the negative appendectomy rate as
high as 17.2% (Joshi et al., 2015).

5. Chae MS et al., conducted a study in 2017 in which the negative
appendectomy rate was 20.8% (Chae et al., 2017). Sammalkorpi HE et
al., studied histologically confirmed reduced negative appendectomy rate
from 18.2-8.7% (Sammalkorpi et al., 2017).
Statistics show that one out of five appendicitis is misdiagnosed. An
effective scoring system can be an excellent guiding tool for deciding on
managing patients with acute appendicitis (Sammalkorpi et al., 2017). In
emergency cases, the concept of scoring along with the clinical
examination can increase the accuracy of diagnosis. The most widely
used and researched rating system is the Alvarado score (Brigand et al.,
2009)

6. However, its sensitivity and specificity are only
appropriate for ruling out appendicitis cases—not
for deciding which patients need surgery (Ohle et
al., 2011; Chong et al., 2011; Walczak et al., 2015;
Nanjundaiah et al., 2014). Clinical scores alone
seem sensitive enough to identify low-risk patients
in patients with suspected AA, obviating the
necessity for imaging and counterproductive
surgical exploration (such as diagnostic
laparoscopy (Di Saverio et al., 2020). Madasi V
concluded that the Alvarado score was surpassed
invalidity and reliability by the newly designed
AIR score (Madasi, 2016)

7. Karki O Band Hazra NK found that AIR scoring
performed well and was more accurate than the
Alvarado scoring system, with high specificity and
high NPV preventing negative appendectomies
(Karki & Hazra, 2019). Pogorelic Zet al., found that
the AIR score can detect acute appendicitis with a
high level of sensitivity and specificity(Pogorelic et
al., 2021).

8. In the recent guideline of World Society of
Emergency Surgeons ( WSES )
recommendations regarding the clinical
scoring systems for acute appendicitis are
remarkable . It is stated that clinical scoring
systems , on their own , can be used to
exclude acute appendicitis and decrease
negative laparotomy rates .

9. Currently Appendicitis Inflammatory
Response Score ( AIR ) and Adult
Appendicitis Score ( AAS ) are the best
clinically performing scoring systems . As a
result , based on strong evidence the use of
these two systems are recommended . Both
scoring systems are developed based on
clinical findings and laboratory parameters .
The aim of this study is to validate both
systems as well as to compare the efficiency
of both systems on excluding negative
appendectomies.

10. Rationale

11. The findings of this research will help healthcare
professionals make more precise and informed
diagnostic decisions.
If these scoring systems demonstrate high
diagnostic accuracy, they could be valuable tools
in distinguishing appendicitis from other
conditions, leading to prompt and appropriate
clinical management.

12. Moreover, all the existing scoring system has been
crafted for the western population. Therefore, studies
are needed to validate the scoring system of the
Pakistan population.
Ultimately, the rationale for this study is to contribute
to improved patient care, reduce unnecessary surgical
interventions, the importance of the study is cost
effective and to reduce negative appendectomy which
is high (20-30%) by evaluating the accuracy of these
scoring criteria we can screen high risk cases.

13. Literature
review

14. authors Count
ry of
study
Sample size Results conclusion
OB Karki, NK
Hazra (2021)
Nepa
l
The study
included 217
patients
The results analyzed showed
sensitivity of Appendicitis
Inflammatory Response score
(96.91%) The positive and negative
predictive values was 79.70% and
72.20% for AIR score.
Appendicitis Inflammatory
Response (AIR) scoring
perfumed well and more
accurate than the other
scoring system with high
specificity and NPV
preventing negative
appendectomies
M Reena et al
(2023)
India The study
included
100 patients
It was found that the AIR score had more
sensitivity (92.55%),followedby the AAS
(84.04%)score for diagnosing acute
appendicitis. The specificity of AAS and
AIR was (83.33%)and (66.67%)score.AIR
score had more NPV(36.40%)as
compared to AAS (25%). The diagnostic
accuracy of AIR (91%) was higher than
AAS score 84%.
Appendicitis Inflammatory
Response (AIR) score and
AAS can be used for better
diagnosis of acute
appendicitis in emergency
patients and to reduce threat
of negative appendectomy.

15. authors Country
of study
Sample size Results conclusion
H
Mohamed
et al (2022)
United
kingdo
m
The study
included 73
patients
It was found that the core relation
between AIR score and historical
record was highly significant the
sensitivity of AIR ware 77.97%
specificity was 85.71%
The AIR score had
high specificity,
sensitivity, positive
predictive value, and
a lower rate of false
positive.
A Manne et
al (2021)
Swede
n
The study
included 2893
patients
The AIR scoring is highly performing n
detecting complicated appendicitis
Complicated appendicitis is unlikely at AIR
score <4 points NPV 99%,
Appendicitis is likely at AIR score >8
points, especially in young patients PPV
96%,
The AIR score has
high sensitivity for
complicated
appendicitis AIR
SCORE is a valid
decision support
when perform in
both sexes

16. Author
s
Country
of study
Sampl
e size
Results conclusion
T
Tahira
et al
(2022)
Pakista
n
384
were
includ
ed in
the
study
AIR score
Sensitivity
(72.6%),
Specificity
(94.2%), and
accuracy was
75.5%. Right iliac
fossa pain was
76.8%, pain
migration to right
iliac fossa was
63.5%, anorexia
was 90.9%.
Higher sensitivity
and specificity of the
Appendicitis
inflammatory
response score was
found to outperform
the histological
findings in
appendicitis.

17. Objective

18. To compare diagnostic accuracy of appendicitis
inflammatory response and adult appendicitis
scoring system in diagnosing acute appendicitis
taking surgical findings as gold standard.

19. OPERATIONAL
DEFINITION

20. Suspected patients of Appendicitis: Patients
having pain in right iliac fossa (RIF) within 7
days along with vomiting and nausea that
will be assessed on history, told by parents
or attendants , they will be include in study
if they have Alvarado score is ≥7,

21. Diagnostic accuracy: It will be calculated as

DIAGNOSTIC ACCURACY OF AIR (Annexure – DIAGNOSTIC ACCURACY OF AAS
True positive
It will be labeled positive if
AIR is > 8 and surgical
findings are also positive
It will be labeled positive if AAS
score is > 14 and surgical
findings are also positive
True negative
It will be labeled if AIR ≤8
and surgical findings are is
negative
It will be labeled if AAS is ≤ 14
and surgical findings are
negative
False positive
It will be labeled if AIR is > 8
and report of surgical
findings are negative
It will be labeled if AAS > 14 and
surgical findings are negative
False negative
(FN)
It will be labeled if AIR is ≤ 8
and surgical findings are
positive
It will be labeled if AAS ≤ 14 and
surgical findings are positive

22. DIAGNOSTIC ACCURACY WILL BE CALCULATED AS
Sensitivity = TP/TP+FN x 100
Specificity = TN/FP+TN x 100
Positive predictive value = TP/TP+FP x 100
Negative predictive value = TN/FN+TN x 100
Diagnostic accuracy = (TP +TN) / (TP+FP +FN
+TN) x 100

23. Material &
methodology

24. Study design: Validation cross sectional study
Setting: Study will be conducted in the four
Departments of General Surgery, Quaid e Azam
medical collage and Bahawalpur Victoria
Hospital, Bahawalpur, Pakistan.
Duration: 9 months

25. Sample size calculation:
A total of 109 suspected cases will be taken, the
sample size is calculated by using frequency of
(High probability of Appendicitis by AIR score as
97.75%, sensitivity of AIR as 92.55%, 5% margin
of error and 95% confidence level. (Meena et al.,
2023)

26. The following formula and procedure were
used:

27. Inclusion criteria:
• All clinically suspected patients of acute appendicitis
in the Emergency Department
• AVARDO scale ≥ 7
• Ages of 18 to 60 years.
• Either gender
Exclusive criteria:
• All the pregnant women,
• Patients who are not fit for surgery,
• Patients with appendicular perforation or abscess,
appendicular mass.

28. Data collection procedure:
After approval from research ethics committee and
taking informed consent, all data will be taken. Their
demographic details will be taken like name, age,
gender, duration of pain. They will be considered
suspected on the basis of Alvarado scale. All patients
will be scored using the AAS and AIR scoring systems.
AIR score will be inclusive of vomiting, pain in the
Right Lower Quadrant (RLQ), abdominal guarding,
raised temperature, WBC, serum CRP, and segmented
neutrophils. AAS will be employed to evaluate pain in
RLQ, abdominal guarding, WBC, neutrophils
proportion, and CRP levels.

29.  operative decision will be made, and the patients will
undergo an emergency appendectomy.
 Resected appendix specimens will be sent for
histopathology examination.
 Postoperative histopathological reports will be
collected and compared with the preoperative
diagnosis.
 The calculated scores will be considered positive if
they show the probability of appendicitis.
 comparisons will be made with the gold standard
histopathological diagnosis.
 Based on the data collected, sensitivity and specificity
will be calculated for each scoring system separately.
 The receiver operator curve will be plotted for further
analysis.

30. Data analysis:
• All data will be entered and analyzed using SPSS
version 26.
• Mean and SD will be calculated for quantitative
data. Frequency (%) will be used for categorical
data.
• 2 x2 table will be made to calculate diagnostic
accuracy for AIR and AAS like, sensitivity,
specificity, PPV, NPV and overall diagnostic
accuracy taking surgical findings as gold
standard.
• ROC will also be calculated to optimum cut of
value. Diagnostic accuracy will be calculated
using open epi software and ROC will be done on
SPSS.

31. QUESTIONNAIRE
 Case No.: Date:
 Registration No.:
 Name:
 Address: _____________________________
 Contact:
 Age: years
 Sex: □Male □ Female
 Weight _____________kg Height _______________cm
 BMI __________________________________

32. QUESTIONNAIRE
Duration of pain: _______________________
Baseline Alvarado Score: _____________ (7-8 / 9-10)
Appendicitis Inflammatory Response score ____________
Adult Appendicitis Scoring System___________________
Diagnosis of Acute appendicitis
on histopathology Positive Negative
on Appendicitis Inflammatory Response score Positive Negative
on Adult Appendicitis Scoring System Positive Negative

33. Annexure -1:
Alvarado score
Appendicitis inflammatory response score (AIR)

34. Adult appendicitis score (AAS)

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