Accuracy Score on Raja Isteri Pengiran Anak Saleha ( RIPASA ) and Pediatric Appendicitis ( PAS ) for Diagnosing Acute Appendicitis in Children

Introduction. Acute appendicitis is the most common case of acute abdomen. Diagnosis of acute appendicitis is still difficult and is one of the problems in the surgical field. The Clinical Scoring System (CSS) has been developed to help doctors classify risk categories. PAS has been widely evaluated in the pediatric population. In another study it was found that RIPASA had better sensitivity, specificity, and accuracy than PAS in pediatric patients. Methods. This study is a cross sectional study to assess the level of concordance between RIPASA and PAS scores in diagnosing acute appendicitis, with the gold standard of Histopathological examination. Samples were taken by consecutive method, in 30 patients aged <18 years for 1 year. Results. This study had an average age of 10.10 ± 3.745 years. Histopathologically early acute appendicitis 3.3%, acute suppurative appendicitis as much as 20%, acute gangrenous appendicitis 73.3% and others 3.3%. Using a cut-off point value of 9.5 for RIPASA and 7 for PAS, the sensitivity, Specificity, Accuracy of 82.75%, 100%, 80% for RIPASA, and 75.8%, 100%, 73.3% for PAS. Conclusion. The RIPASA score on the cut-off treshold 9.5 has better sensitivity and accuracy than PAS in diagnosing acute appendicitis in pediatric patients and can be used as CSS to assist in making decisions regarding the diagnosis of acute appendicitis in children. Keyword: acute appendicitis, pediatric, surgery, accuracy.


Introduction
Acute appendicitis is the most common case of acute abdomen, 1% of all surgical cases, very rare in infants, the incidence increases with age, with a peak at the age of 10-30 years, the ratio of males compared to females in adolescents is 3:2 and to 1:1 after the age of 25 years. 1 Acute appendicitis is one of the most common surgical emergencies in emergency departments with an incidence of 1.5-1.9 per 1000 population. 2 In children, this incidence is reported to increase at an average rate of 0.5 cases / 100.000 population / year, with a lifetime cumulative incidence of 9.0%. 3 More than 80% of patients undergoing emergency appendectomy are under 40 years of age and more than half are included in the age group of children. 4 The diagnosis of acute appendicitis is still difficult and is one of the problems in the field of surgery, negative appendectomy rates range from 20 -35%. 5 So far, acute appendicitis is based on history, physical examination and laboratory examination, namely leukocyte count >10,000 /mm 3 . And calculate the type of leukocytes with a shift to the left that is an increase in the percentage of neutrophils. 1,6 However, one third of cases (mainly elderly) leukocytes and leukocytes count are within normal limits or elevation of leukocytes and the percentage of neutrophils do not compare directly with the severity of appendicitis. 1,5 The Clinical Scoring System (CSS) has been developed to assist doctors in grouping patients into low, medium or high risk groups for acute appendicitis and to provide appropriate management strategies based on their risk categories. Of these, Alvarado scores and Pediatric Appendicitis (PAS) scores have been widely evaluated in the pediatric population with sensitivity and specificity ranging from 70-100% and 60-90% depending on the chosen cut-off threshold value. 7.8 The RIPASA Score, also known as the Appendicitis Score of the King of Pengiran's Child Saleha's, named after the hospital where it was developed, is the latest CSS. The RIPASA score is reported to have sensitivity, specificity and accuracy of 98%, 81.3% and 91.8%, respectively, evaluated in populations with an average age of 25 years. 4 In another study it was found that RIPASA had better sensitivity, specificity, and accuracy than Alvarado and pediatric appendicitis scores in pediatric patients under the age of 18 at 96.7%, 84.4%, and 90.9% . 9 even for the negative rate of RIPASA appendectomy had a lower value of 14.7% compared to Alvarado 19.2% and PAS 27.5% . 9

Method
This study is a cross sectional study to assess the level of concordance between RIPASA score and PAS score in diagnosing acute appendicitis, with the gold standard of Histopathological examination.
The study population was patients who went for surgery to the Palembang General Hospital Dr. Mohammad Hoesin Palembang and clinically diagnosed with acute appendicitis and undergoing emergency appendectomy surgery.
The RIPASA Score research variable was composed of 14 parameters on symptoms and signs, and 1 additional unique parameter in the form of demographic data from patients. Gender, age, symptoms (nausea and vomiting, anorexia, migration pain, RIF pain, duration), signs (RIF tenderness, guarding, rebound tenderness, Roving sign, fever 37-39ºC, laboratory results Sampling is taken by consecutive method by taking all samples that meet the inclusion criteria until the number of samples is met.
RIPASA score and PAS score in the form of ordinal data with a score of 0-16 for the RIPASA score and a score of 0-10 for the PAS score, using SPSS 20 which is then determined by the cut-off point using ROC analysis, and this is used as a positive and negative nominal limit for acute appendicitis.

Results
This study was to assess the suitability of the RIPASA score and the Pediatric Appendicitis The characteristics of the sex and age of the study sample are shown in Table 1  To assess whether the RIPASA scoring system can be used as a good tool to predict acute appendicitis, a suitability level test (Kappa value) is performed with a comparison of the Pediatric Appendicitis Score scoring system. The analysis results obtained: Kappa value of 0.444. The results of calculating the level of appropriateness of the Kappa score between the RIPASA score and the Pediatric Appendicitis Score were 0.444 and categorized as Good.

Discussion
This study was to assess the suitability of the RIPASA score and Pediatric Appendicitis The level of concordance between RIPASA and Pediatric Appendicitis Score obtained 0.444 means that it is a good fit, which means that in predicting acute appendicitis the RIPASA score can be used as well as the Pediatric Appendicitis Score. 30

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This study still has many limitations where the number of samples is limited. A larger number of studies are needed, involving several hospitals and increasing sample criteria in patients suspected of having acute appendicitis early but not undergoing surgery to get better results.
The limitation of the sample is also caused by the fact that this research was conducted at Dr. Mohammad Hoesin General Hospital, a national referral hospital in the southern Sumatra region, so that patients with pediatric appendicitis who are seeking treatment, are pediatric appendicitis patients who cannot be treated in network hospitals, or patients who live around hospitals.
This research is in the form of screening as well as other Clinical Scoring Systems in helping surgeons assess their diagnosis of acute appendicitis.

Conclusion
The RIPASA score has better sensitivity and accuracy than PAS in diagnosing acute appendicitis in pediatric patients and can be used as a clinical scoring system to assist in making decisions regarding the diagnosis of acute appendicitis in children.