Battle of the scores: validating the AIR, Alvarado and Tzanakis scores in acute appendicitis

Vaibhav Srivastava; Piyush S. Tripathi; Harshit Sharma; Nishant Shukla

doi:10.18203/2349-2902.isj20253012

Authors

Vaibhav Srivastava Department of Surgery, Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India https://orcid.org/0009-0007-0647-6949
Piyush S. Tripathi Department of Surgery, Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India
Harshit Sharma Department of Surgery, Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India https://orcid.org/0009-0008-3403-9786
Nishant Shukla Department of Surgery, Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India

DOI:

https://doi.org/10.18203/2349-2902.isj20253012

Keywords:

Tzanakis score, Acute appendicitis, Diagnostic accuracy, Appendicitis inflammatory response score, Alvarado score

Abstract

Background: Acute appendicitis is one of the most common surgical emergencies, yet its diagnosis remains challenging. Scoring systems such as the Modified Alvarado Score (MAS), Appendicitis Inflammatory Response (AIR) score and Tzanakis score have been proposed to improve diagnostic accuracy.

Methods: A prospective observational study was conducted on 92 patients presenting with suspected acute appendicitis at Moti Lal Nehru Medical College, Prayagraj after obtaining approval from Institutional Ethics Committee. Each patient was assessed using MAS, AIR and Tzanakis scores. Final diagnosis was confirmed by histopathological examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each scoring system.

Results: The Tzanakis score showed the highest diagnostic performance (sensitivity 95.12%, specificity 91.34%, PPV 96.42%, NPV 89.58%), followed by AIR score (sensitivity 93.25%, specificity 88.17%, PPV 94.78%, NPV 85.21%). MAS demonstrated comparatively lower accuracy (sensitivity 83.0%, specificity 71.4%). Patients evaluated with Tzanakis score also had the highest proportion of timely appendicectomies and the lowest rate of unnecessary surgeries.

Conclusions: The Tzanakis score emerged as the most reliable tool for diagnosing acute appendicitis due to its integration of clinical, laboratory and ultrasonographic data. The AIR score also showed high diagnostic utility, especially in settings lacking immediate imaging. MAS, while useful as an initial assessment tool, demonstrated limited diagnostic precision.

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References

Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R Coll Surg Engl. 1994;76(6):418–9.

Andersson RE, Andersson B. Appendicitis Inflammatory Response Score: Outperforms Alvarado in acute appendicitis. World J Surg. 2008;32(8):1843–9. DOI: https://doi.org/10.1007/s00268-008-9649-y

Tzanakis NE, Efstathiou SP, Danulidis K. A new approach to accurate diagnosis of acute appendicitis. World J Surg. 2005;29(9):1151–6. DOI: https://doi.org/10.1007/s00268-005-7853-6

Gupta A, Singh R, Kaur N. Appendicitis Inflammatory Response Score versus Alvarado Score in diagnosing acute appendicitis. Int Surg J. 2018;5(4):1390–4.

Patel H, Sharma A, Verma Y. A comparative evaluation of AIR, MAS and Tzanakis scoring systems in acute appendicitis. Indian J Surg. 2023;85(2):245–51.

Saxena D, Yadav S, Sharma S. AIR versus Tzanakis scoring in acute appendicitis. Int J Res Med Sci. 2020;8(10):3750–4.

Tadvi MK. Comparative accuracy of Alvarado and Tzanakis scores in Indian patients with acute appendicitis. Int J Acad Med Pharm. 2023;6(3):928–31.

Shah BS, Dar H, Malyar A. Comparative study: AIR vs Alvarado. Balkan Med J. 2015;18:72–7. DOI: https://doi.org/10.5455/bmmr.180876

Ramesh S. Appendicitis Inflammatory Response Score vs Alvarado Score in Early Diagnosis of Appendicitis. Int Surg J. 2022;9(5):1242–6.

Kularatna M, Lauti M, Haran C, MacFater W, Sheikh L, Huang Y, et al. Clinical Prediction Rules for Appendicitis in Adults: Which Is Best. World J Surg. 2017;41(7):1769-81. DOI: https://doi.org/10.1007/s00268-017-3926-6

Noori IF, Jabbar AS, Noori AF. Clinical scores (Alvarado and AIR scores) versus imaging (ultrasound and CT scan) in the diagnosis of equivocal cases of acute appendicitis: a randomized controlled study. Ann Med Surg (Lond). 2023;85(4):676-83. DOI: https://doi.org/10.1097/MS9.0000000000000270

Castro SM, Ünlü C, Steller EP, van Wagensveld BA, Vrouenraets BC. Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis. World J Surg. 2012;36(7):1540-5. DOI: https://doi.org/10.1007/s00268-012-1521-4

Aleem Khalid AU, Quarrell A, Chandran A, Javed T, Ahmad N. Diagnostic accuracy of the modified alvarado score and serum c-reactive protein in acute appendicitis. Cureus. 2024;16(11):73664. DOI: https://doi.org/10.7759/cureus.73664