• Shehryar Noor Accident and Emergency Department, Khyber Teaching Hospital
  • Abdul Wahab Surgical B Unit, Lady Reading Hospital Peshawar
  • Gulsharif Afridi Surgical D Unit, Lady Reading Hospital Peshawar
  • Kaleem Ullah Surgical A Unit, Khyber Teaching Hospital Peshawar.


Background: The clinical diagnosis of acute appendicitis remains difficult despite the use of different scoring systems. A high rate of negative appendectomies is no longer acceptable. This study was aimed to compare RIPASA score and Alvarado score in Pakistani population for the diagnosis of acute appendicitis using histopathology as a gold standard. Methods: This cross-sectional prospective study was carried out from January to September 2018 in the Accident and Emergency Department and Department of Surgery, Khyber Teaching Hospital, Peshawar. Patients clinically suspected as acute appendicitis aided by routine ultrasound were included in the study. RIPASA and Alvarado scoring was done in all patients. After appendectomies, specimen was sent for histopathological examination. A score of 7.5 was considered as optimal cutoff threshold for RIPASA and 7 for Alvarado score. Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracies of both scores were calculated. Results: A total of 300 patients were included in the study. The mean age of patients was 28±10.0 years and there were 176 males. Sensitivity, Specificity of RIPASA score and Alvarado score was found to be 98.52% and 90%, and 68.15% and 80% respectively. Positive Predictive Value and NPV of RIPASA score was 98.88% and 97.67% as compared to 96.84% and 21.82% for Alvarado score. Diagnostic accuracy of RIPASA and Alvarado score was 97.67% and 69.33% respectively. Conclusion: RIPASA scoring system is a more accurate, sensitive and specific indicator of diagnosing acute appendicitis as compared to Alvarado scoring systemKeywords: RIPASA; Alvarado; Acute Appendicitis

Author Biographies

Shehryar Noor, Accident and Emergency Department, Khyber Teaching Hospital

Consultant surgery and Incharge Accident and Emergency Department Khyber Teaching Hospital Peshawar.03005844137House No. 129, Street 5, Askari 6, Nasir Bagh road Peshawar.

Abdul Wahab, Surgical B Unit, Lady Reading Hospital Peshawar

Assistant Professor Surgical B UnitLady reading hospital Peshawar03459050066House No. 187, Street 5, Sector J2, Phase 2 Hayatabad Peshawar

Gulsharif Afridi, Surgical D Unit, Lady Reading Hospital Peshawar

Assistant Professor Surgical D UnitLady Reading Hospital Peshawar.03005959004New TMO Hostel Room No. B 13 Lady reading hospital Peshawar

Kaleem Ullah, Surgical A Unit, Khyber Teaching Hospital Peshawar.

Registrar Surgical A wardKhyber teaching Hospital Peshawar.03459451961Room No. 58 New doctors hostel KTH Peshawar.


Stephens PL, Mazzucco JJ. Comparison of ultrasound and the Alvarado score for the diagnosis of acute appendicitis. Conn Med 1999;63(3):137–40.

Cuschieri A. The small intestine and vermiform appendix; In: Cuscheri A, Giles GR, Mossa AR, editors. Essential surgical practice. 3rd ed. London: Butter worth Heinman, 1995; p.1325–8

Regar MK, Choudhary GS, Nogia C, Pipal DK, Agrawal A, Srivastava H. Comparison of Alvarado and RIPASA scoring systems in diagnosis of acute appendicitis and correlation with intraoperative and histopathological findings. Int Surg J 2017;4(5):1755–61.

Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15(5):557–64.

Cantrell JR, Stafford ES. The diminishing mortality from appendicitis. Ann Surg 1955;141(6):749–58.

Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are no longer acceptable. Am J Surg 1997;174(6):723–7.

Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, 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.

Subramani B, Kalaichelvan L, Selvam G, Madhavan L. Comparison between RIPASA and alvarado scoring in diagnosing acute appendicitis. J Evid Based Med Health 2017;4(11):624–7.

Williams GR. Presidential address: A history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983;197(5):495–506.

Kumar V, Cotran RS, Robbins SL. Appendix. In: Robbin’s Basic Pathology. 5th ed. London: WB Saunders, 1992; p.520.

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

Chan I, Bicknell SG, Graham M. Utility and diagnostic accuracy of sonography in detecting appendicitis in a community hospital. AJR Am J Roentgenol 2005;184(6):1809–12.

Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg 2005;201(6):933–9.

Ozao-Choy J, Kim U, Vieux U, Menes TS. Incidental findings on computed tomography scans for acute appendicitis: prevalance, costs and outcome. Am Surg 2011;77(11):1502–9.

Dey S, Mohanta PK, Baruah AK, Kharga B, Bhutia KL, Singh VK. Alvarado scoring in acute appendicitis—a clinico-pathological correlation. Indian J Surg 2010;72(4):290–3.

Khan I, ur Rehman A. Application of Alvarado scoring in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17(3):41–4.

Alnjadat I, Abdallah B. Alvarado versus RIPASA score in diagnosing acute appendicitis. Rawal Med J 2013;38(2):147–51.

Butt MQ, Chatha SS, Ghumman AQ, Farooq M. RIPASA score: a new diagnostic score for diagnosis of acute appendicitis. J Coll Physicians Surg Pak 2014;24(12):894–7.

Chavan S, Bhatnagar S, Bendre M, Sinha N. Comparative study of alvarado score and RIPASA score in the diagnosis of acute appendicitis. Int Surg J 2018;5(4):1330–4.



Most read articles by the same author(s)