RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGLORE -54

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS
ADDRESS FOR CORRESPONDENCE / DR. MANJUNATH METRI
S/O M NARASAPPA
HOUSE NO. 1-4-89/42
S. R. G. COLONY, I. B. ROAD
RAICHUR – 584 101
DR. MANJUNATH METRI
POSTGRADUATE STUDENT
DEPARTMENT OF GENERAL SURGERY
M. S. RAMAIAH MEDICAL COLLEGE
BANGALORE – 560 054
2. / NAME OF THE INSTITUTION / M. S. RAMAIAH MEDICAL COLLEGE
BANGALORE
3. / COURSE OF THE STUDY AND SUBJECT / M.S. (GENERAL SURGERY)
4. / DATE OF ADMISSION TO THE COURSE / 31-05-2012
5. / TITLE OF THE STUDY / COMPARATIVE STUDY OF
ALVARADO SCORE AND ULTRASOUND
IMAGING IN THE DIAGNOSIS OF
ACUTE APPENDICITIS

6 .BRIEF RESUME OF INTENDED WORK:

6.1: NEED FOR THE STUDY

Acute appendicitis is still the most common abdominal surgical emergency, but its diagnosis remains a challenge. The procedure is plagued by a high rate of negative explorations1.

In conditions like acute appendicitis it is impractical to have definitive diagnosis by gold standard test (histopathology) before surgery, we would like a simple assessment like Alvarado scoring system which depends on the presence and absence of certain variables and which provides an accurate guide to whether or not the patient has the

acute appendicitis2.

Graded compression ultrasonography is one of the new diagnostic technique that is

reported to have improved the diagnostic accuracy and clinical outcome3.

Hence a study on alvardo score and usg imaging in management of Acute appendicitis will aid in early detection and reduction of negative explorations.

6.2: REVIEW OF THE LITERATURE:

Acute appendicitis is the acute inflammation of the appendix, is the most common cause of “Acute surgical abdomen”4

Rate of appendectomy for appendicitis is at 10 per 10,000 patients per year.5

The disease is slightly more common in males, with a male:female ratio of 1.4:1. Young age is a risk factor, as nearly 70% of patients with acute appendicitis are less than 30 years of age.. It is more common in people with western dietary habit.6

A comprehensive scoring system, developed by Alvarado in 1986, in an attempt to reduce the negative appendectomy rate without causing an increase in the morbidity and mortality, has been evolved in making an affirmative diagnosis of Acute Appendicitis7.

The ultrasound in the diagnosis of acute appendicitis was first popularized by Puylaert in

19868.

A negative appendectomy rate of 20-40% has been reported in literature and many surgeons would accept rate of 30% as inevitable9.

Removing normal appendix is an economic burden both on patients and health resources. Misdiagnosis and delay in surgery can lead to complications like perforation and finally peritonitis10.

At present many scoring systems for the diagnosis of acute appendicitis are available. Alvarado scoring system is one of them and is purely based on history, clinical examination and few laboratory tests and is very easy to apply11.

Combined use of modified Alvarado score and USG, in decision making for appendectomy, has high sensitivity and accuracy, so that patients can be diagnosed in early acute appendicitis stage, decreasing the morbidity, postoperative complications and negative explorations12.

Kalan et al. using modified version of Alvarado score found negative appendectomy of 14.6%, sensitivity of 93% in males and 67% in females13.

Among patients with abdominal pain,ultrasonography has a sensitivity of about 85% and a specificity of more than 90% for the diagnosis of acute appendicitis14.

6.3 OBJECTIVES OF THE STUDY

1. To correlate Alvarado score with USG imaging in diagnosis of Acute Appendicitis.

2. To study the usefulness of incorporating USG imaging in patients with low /equivocal

Alvarado Score in improving the diagnostic accuracy in acute appendicitis.

3.To avoid negative laparotomies.

7.MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

Patients from M.S.Ramaiah Medical College and Hospitals Bengaluru.

7.2 METHOD OF COLLECTION OF DATA:

A. STUDY DESIGN

Validation Study.

B. STUDY PERIOD

November 2012 to July 2014

C. PLACE OF STUDY

M.S.Ramaiah Medical College and Hospitals Bengaluru.

D. SAMPLE SIZE

90(Ninety only)

Rationale For Sample Size:

From the literature review,it has been observed that the sensitivity for diagnosing acute appendicitis

was 88% using Alvarado score and 87% using ultrasonography15.

In the present study we need 90 subjects to get similar results with precision of 95% confidence,

80% power and keeping reference sensitivity of 97%.

E. INCLUSION CRITERIA

1. All patients presenting with right iliac fossa pain were included in

this study.

2. Patients 18 years and above were included in the study.

F. EXCLUSION CRITERIA

1. Clinically patients with gynaecological and urological diseases were

excluded from this study.

2. Patients who were managed conservatively were excluded.

3. Patients with recurrent appendicitis were excluded.

4. Patients with appendicular mass on usg were excluded.

G. METHODOLOGY

A prospective study of 90 patients suspected of suffering from acute appendicitis

requiring emergency surgery for the same were evaluated from Nov 2012 to July 2014.

All patients were evaluated by the Alvarado scoring system and Ultrasonogram of the

abdomen was performed in patients and subjected to surgery.

Appendix specimen sent for HPE for final confirmation for diagnosis.

Brief outline of Alvarado Score as follows.

Symptoms / Score
Migratory right iliac fossa pain / 1
Anorexia / 1
Nausea/Vomiting / 1
Signs
Tenderness in right iliac fossa / 2
Rebound tenderness in right iliac fossa / 1
Elevated Temperature / 1
Laboratory findings
Leucocytosis / 2
Shift to left of Neutrophils / 1
Total / 10

A score of 5 or 6 is compatible with the diagnosis of acute appendicitis.

A score of 7 or 8 indicates a probable appendicitis.

A score of 9 or 10 indicates a very probable acute appendicitis.

H. STATISTICAL ANALYSIS

Descriptive statistics of sensitivity and specificity for diagnosis of acute appendicitis using USG and Alvarado score would be analysed and expressed in terms of percentages. Mc-Nemer test would be used to compare the sensitivity and specificity between USG and Alvarado Score.

7.3: DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY:

1. It does’nt require any intervention on animals

2. Investigations only with patient’s consent

The following tests would be carried out for patients

Routine blood investigations (i.e. complete blood count,Prothrombin time,aPTT,INR,

Random Blood sugar, Blood urea, Serum creatinine, ESR,ECG, Chest X-ray,

Urine examination (routine & microscopy), USG abdomen and other relevant investigations.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3

YES(copy enclosed)

8. LIST OF REFERENCES (In Vancouver style)

1.  Sijo K. John, Josmy Joseph, S. Raghunath Shetty, Avoiding negative appendectomies in rural surgical practice: Is C-reactive protein estimation useful as a diagnostic tool?, The National Medical Journal Of India, 2011 vol. 24, page no. 3.

  1. Ikramullah Khan, Ata ur Rehman, Application Of Alvarado Scoring System In Diagnosis Of Acute Appendicitis, J Ayub Med Coll Abbottabad journal 2005;17(3)

3.  Mohammad Akbar Ali Mardan et al, Role Of Ultrasound In Acute Appendicitis, J Ayub Med Coll Abbottabad 2007; 19(3)

4.  Norman S. Williams et al, Bailey and Love’s short practice of surgery, 25th ed, London: Edward Arnold Ltd; 2008, p.1204-1218

5.  Charles Brunicardi et al. Schwartz’s principles of surgery.29th Chapter, the Appendix, 8th ed. McGraw Hill; 2006 p. 784-799

6.  Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910–925 [PubMed: 2239906]

7.  Alvarado A.: A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15: 557-564

8.  Seal A, Appendicitis: a historical review, Can J Surg, 1981; 24(4):427-33

  1. 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 1994;76:418-9.

10.  Ohmann C, Yang Q, Franke C: the abdominal pain study group. Diagnostic scores for acute appendicitis. Eur J Surg 1995;161:273-81.

  1. Alverado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-65.

12.  Hemant Nautiyal · Shabi Ahmad · N. K. Keshwani · D. N. Awasthi, Combined use of modifi ed Alvarado score and USG in decreasing negative appendicectomy rate, Indian J Surg (January–February 2010) 72:42–48.

13.  Kalan M, Talbot IJ, Lunline WJ (1994) Evaluation to the modifi ed Alvarado score in the diagnosis of acute appendicitis– a prospective study: Ann R Coll Surg Engl 76:418–419

14.  Courtney M. Townsend et al. Sabiston text book of surgery, 18th edition, Philadelphia: Saunders, An Imprint of Elsevier; 2008, p.1333-1347

9. / SIGNATURE OF THE CANDIDATE
10. / REMARKS OF THE GUIDE / Good clinical study to prevent negative laparotomies.
11. / NAME AND DESIGNATION OF
(IN BLOCK LETTERS)
11.1. GUIDE / DR. H. K. RUDRESH
ASSOCIATE PROFESSOR
DEPARTMENT OF GENERAL SURGERY
M. S. RAMAIAH MEDICAL COLLEGE
BANGALORE – 54
11.2. SIGNATURE
11.3. HEAD OF THE DEPARTMENT / DR. S. V. KULKARNI
PROFESSOR & HEAD OF DEPARTMENT
DEPARTMENT OF GENERAL SURGERY
M. S. RAMAIAH MEDICAL COLLEGE
BANGALORE – 54
11.4 . SIGNATURE
12. / 12.1. DEAN OF THE INSTITUTION / DR. SARASWATHI G. RAO
PRICIPAL & DEAN
M. S. RAMAIAH MEDICAL COLLEGE
BANGALORE – 54
12.2. SIGNATURE
12.3. REMARKS

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