Preoperative Clinical Scores for Predicting Complicated Appendicitis İn Surgically Managed Adults: Comparative Performance of Alvarado, Ripasa, and Lintula

Preoperative Clinical Scores for Predicting Complicated Appendicitis İn Surgically Managed Adults: Comparative Performance of Alvarado, Ripasa, and Lintula | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preoperative Clinical Scores for Predicting Complicated Appendicitis İn Surgically Managed Adults: Comparative Performance of Alvarado, Ripasa, and Lintula SUAT EVİRGEN, yasin duran, önder karabay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8875060/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Objectives: Clinical scoring systems are frequently used to support decision-making in suspected acute appendicitis; however, their value for severity stratification is less well defined. We compared the diagnostic performance of the Alvarado, RIPASA, and Lintula scores in a surgically managed adult cohort and examined their relationship with histopathological subtypes. Methods: This retrospective observational study included 312 adults who underwent appendectomy for suspected acute appendicitis between May 2024 and April 2025 at Amasya University Şerefeddin Sabuncuoğlu Training and Research Hospital.Clinical variables recorded at emergency department presentation were used to derive Alvarado, RIPASA, and Lintula scores, which were calculated retrospectively from chart data. Histopathology served as the reference standard. Using literature-recommended cutoffs, sensitivity, specificity, positive and negative predictive values (PPV and NPV), accuracy, and the Youden index were calculated. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Results: Mean age was 29.77 ± 9.55 years, and 58.7% were male. Laparoscopic appendectomy was performed in 97.8% of cases. Appendicitis was confirmed histologically in 90.1%, with phlegmonous (49.4%), gangrenous (22.4%), and perforated (18.3%) subtypes; the negative appendectomy rate was 9.9%. At standard thresholds, sensitivity/specificity were 67.3%/71.0% (Alvarado), 76.1%/77.4% (RIPASA), and 70.1%/64.5% (Lintula). PPV was high (94.7%–96.8%), whereas NPV was low (19.2%–26.4%). AUC values were 0.765, 0.857, and 0.829 for Alvarado, RIPASA, and Lintula, respectively. Mean scores increased with histopathological severity (p < 0.001). In perforation-focused analysis, RIPASA showed the highest AUC (0.922). Conclusions: In this surgically managed cohort, all three scores demonstrated strong rule-in performance when positive. RIPASA showed the highest overall discrimination and favourable performance in perforation-focused analysis. Nevertheless, the consistently low NPV limits their utility as standalone rule-out tools; scoring systems should be interpreted alongside clinical assessment and imaging. acute appendicitis Alvarado RIPASA Lintula perforation complicated appendicitis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Acute appendicitis is among the most frequent causes of emergency abdominal surgical intervention. Delayed recognition of the disease may lead to important complications such as perforation, intra-abdominal abscess formation, and sepsis. The lifetime incidence of appendicitis in the general population has been reported to be approximately 7–12% ( 1 ). Although the typical clinical picture includes migratory abdominal pain, anorexia, nausea or vomiting, right lower quadrant tenderness, peritoneal irritation, and leukocytosis, a considerable proportion of patients present with atypical or equivocal features that complicate bedside decision-making ( 2 ). In the emergency setting, clinicians are frequently required to balance the risk of disease progression associated with delayed intervention against the potential morbidity of unnecessary surgery. To standardize clinical evaluation, several scoring systems have been proposed to assist diagnosis and reduce unnecessary appendectomy, however, none provides absolute diagnostic certainty, and all are intended to complement rather than replace clinical judgment ( 3 ). The Alvarado score was introduced in 1986 and continues to be commonly used in clinical practice because it is simple and practical to apply ( 4 ). The score integrates symptoms, physical examination findings, and laboratory parameters into a 10-point system (Table 1 ). A threshold of ≥ 7 is commonly applied to support a diagnosis of acute appendicitis, although reported performance has been moderate and variable across different populations and clinical pathways ( 5 ). A meta-analysis reported an average sensitivity of 72% and specificity of 77% for the Alvarado score ( 6 ), while subsequent studies have demonstrated a broad range of diagnostic estimates influenced by case mix and diagnostic strategy ( 7 ). These observations underscore the importance of defining the clinical contexts in which the Alvarado score may be most informative, as well as its recognized limitations. Table 1 Parameters and Scores of the Alvarado Scoring System Parameters Score allotted Migratory right iliac fossa pain 1 Anorexia 1 Nausea/vomiting 1 Tender right iliac fossa 2 Rebound tenderness 1 Fever 1 Leucocytosis 2 Left shift of neutrophils 1 Total Score 10 The RIPASA (Raja Isteri Pengiran Anak Saleha) scoring system was introduced in 2010 following concerns that previously established scoring methods might perform less effectively in some patient populations ( 8 ). In contrast to the Alvarado score, RIPASA incorporates additional demographic and clinical variables, including age, sex, symptom duration, and urinalysis findings, resulting in a 16.5-point scoring system (Table 2 ). Using a proposed cutoff value of ≥ 7.5, Chong et al. reported higher sensitivity and specificity compared with the Alvarado score in their original cohort ( 8 ). Subsequent studies have frequently demonstrated higher sensitivity for RIPASA, particularly in Eastern populations, although reported specificity has varied across different clinical settings ( 9 – 12 ). Table 2 Parameters and Scores of the RIPASA Scoring System Parameters Score allotted Male 1 Female 0.5 Age 40.0 0.5 Right iliac fossa pain 0.5 Migration of pain to RIF 0.5 Anorexia 1 Nausea and vomiting 1 Symptoms duration 48 hrs 0.5 Tender right iliac fossa 1 Guarding 2 Rebound tenderness 1 Rovsing’s sign 2 Fever 1 Elevated WBC count 1 Negative urine analysis 1 Total score 16.5 The Lintula score was initially developed for pediatric patients and relies mainly on clinical findings to assist rapid triage decisions ( 13 , 14 ). It consists of nine parameters, yielding a total score ranging from 0 to 32 (Table 3 ). In earlier studies, a score of ≥ 21 has generally been considered suggestive of appendicitis, whereas values ≤ 15 have been associated with a low likelihood of disease ( 15 ). Although initial reports described high diagnostic accuracy in children ( 13 ), subsequent investigations evaluating adult populations have yielded mixed results. Some studies have demonstrated strong discriminative performance, including favorable area under the curve values in adult cohorts ( 16 , 17 ), while others have reported performance comparable to that of the Alvarado score ( 18 , 19 ). Overall, existing evidence suggests that the diagnostic utility of the Lintula score may be context dependent. Table 3 Parameters and Scores of the Lintula Scoring System Parameters Score allotted Male 2 Severe pain 2 Migration of pain 4 Vomiting 2 RLQ pain 4 Fever (> 37.5°C) 3 Guarding 4 High pitched, tingling or absent bowel sounds 4 Rebound tenderness 7 Total score 32 Although many studies have compared the Alvarado and RIPASA scoring systems, relatively fewer investigations have explored the relationship between commonly used clinical scores and histopathological severity or specific subtypes of appendicitis ( 20 ). This issue has gained increasing clinical relevance, as preoperative differentiation between uncomplicated and complicated disease may influence management strategies. Patients at increased risk of perforation often require urgent surgical intervention and broader-spectrum antibiotic therapy, whereas non-operative management has been proposed for carefully selected cases of uncomplicated appendicitis ( 21 ). Accordingly, determining whether established scoring systems provide information beyond diagnosis and contribute to severity stratification is of practical importance. The components of the Alvarado, RIPASA, and Lintula scores and their areas of overlap are summarized in Table 4 . Table 4 Comparison of Alvarado, RIPASA, and Lintula Scoring Systems Parameter Alvarado Score RIPASA Score Lintula Score Sex - Female + 0.5, Male + 1 Female 0, Male + 2 Age - 40 + 0.5 - Duration of symptoms - 48 h + 0.5 - Intensity of pain - - Mild/moderate 0, Severe + 2 Anorexia 1 1 - Nausea or vomiting 1 1 2 Right iliac fossa (RIF) pain/tenderness 2 0.5 + 1 4 Elevated temperature 1 2 3 Guarding - 2 4 Rebound tenderness 1 1 7 Bowel sounds - - Absent/tinkling + 4, Normal 0 Rovsing's sign - 2 - Migration of pain to RIF - 0.5 4 Leukocytosis (> 10,000) 2 1 - Leukocyte left shift (> 75%) 1 - - Normal urine analysis - 1 - Total 10 16.5 32 The aim of the present study was to compare the diagnostic performance of the Alvarado, RIPASA, and Lintula scores in a single-center adult cohort and to evaluate their association with histopathological subtypes of appendicitis, with particular attention to perforated disease. 2. Materials and Methods 2.1. Study design, setting, and ethical approval This retrospective observational study was conducted at Amasya University Şerefeddin Sabuncuoğlu Training and Research Hospital and was based on a review of routinely collected clinical data. Adult patients who underwent appendectomy between May 2024 and April 2025 were evaluated. The study protocol was reviewed and approved by the institutional Ethics Committee (decision no: 2025/75; meeting date: 12 June 2025; approval letter no: E-76988455-050.04-272053, dated 04 July 2025). Due to the retrospective design and use of anonymized data, informed consent was waived in accordance with institutional policy. 2.2. Patient selection Patients aged 18 years or older who underwent appendectomy for suspected acute appendicitis during the study period were identified retrospectively using hospital electronic medical records and operating room appendectomy logs. Eligible patients were those initially evaluated in the emergency department with a preoperative diagnosis of acute appendicitis and subsequently managed surgically. Exclusion criteria included pregnancy; appendiceal mass (plastron) or intra-abdominal abscess; decompensated comorbid conditions such as heart failure or end-stage renal disease requiring dialysis; ongoing immunosuppressive therapy or chemotherapy; a history of major abdominal surgery; and active inflammatory bowel disease. During the study period, 337 patients met the initial screening criteria. Of these, 25 patients were excluded based on the predefined exclusion criteria, resulting in a final study cohort of 312 patients. 2.3. Clinical evaluation, laboratory tests, and imaging pathway Clinical history and physical examination findings documented at emergency department presentation were extracted from the electronic medical records. Laboratory parameters obtained as part of routine emergency assessment included complete blood count, C-reactive protein (CRP), and urinalysis. In accordance with the institutional diagnostic pathway, ultrasonography (US) was used as the first-line imaging modality and was performed by radiologists during regular working hours. Contrast-enhanced abdominal computed tomography (CT) was obtained when US findings were inconclusive or when patients presented outside routine radiology service hours. Initial evaluation was performed by emergency physicians, and surgical consultation was requested following completion of the diagnostic work-up. 2.4. Score derivation and interpretation The Alvarado, RIPASA, and Lintula scoring systems were not routinely applied during real-time clinical assessment in the study period. For the purposes of this study, all scores were calculated retrospectively based on clinical and laboratory data recorded at the time of emergency department presentation. Score calculation was performed during structured chart review by a general surgery specialist. Relevant variables were summed to obtain an Alvarado score (range 0–10), a RIPASA score (range 0–16.5), and a Lintula score (range 0–32). Imaging findings were not incorporated into score calculations to preserve consistency with the original design of the scoring systems. For performance analyses, widely used literature-based cutoff values were applied to define test-positive classifications: Alvarado ≥ 7, RIPASA ≥ 7.5, and Lintula ≥ 21. Scores below these thresholds were classified as test negative. 2.5. Surgical management and histopathological classification Appendectomy was performed according to standard institutional practice following completion of the diagnostic evaluation. The choice of operative approach (laparoscopic or open) was determined by the attending surgeon. Intraoperative macroscopic findings of the appendix were documented based on direct visual inspection. All resected specimens were examined in the pathology laboratory using standard protocols. Histopathological evaluation served as the reference standard. Appendicitis was classified into three histopathological subtypes: phlegmonous (suppurative), gangrenous, and perforated appendicitis. Specimens reported as a normal appendix were categorized as negative appendectomy. 2.6. Statistical analysis Statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized as mean ± standard deviation, and categorical variables were presented as frequencies and percentages. Each scoring system was dichotomized as test positive or test negative using predefined cutoff values. True positives, false positives, true negatives, and false negatives were identified for each score. Diagnostic performance was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value. Overall test performance was summarized using the Youden index. Discriminative ability was evaluated using receiver operating characteristic (ROC) curve analysis, with calculation of the area under the curve (AUC) and corresponding 95% confidence intervals. AUC values were compared using the DeLong test. For subgroup analyses, patients were classified according to histopathological findings as normal appendix, phlegmonous appendicitis, gangrenous appendicitis, or perforated appendicitis. Mean score values among groups were compared using one-way analysis of variance, and when statistically significant, post hoc comparisons were performed using the Tukey test. A two-sided P value < 0.05 was considered statistically significant. 3. Results 3.1. Patient characteristics and perioperative data A total of 312 patients were included in the study. The mean age was 29.77 ± 9.55 years (range, 18–72 years). Of the study population, 183 patients (58.7%) were male and 129 (41.3%) were female. The mean interval from emergency department admission to surgical intervention was 9.48 ± 2.94 hours (range, 5–14 hours). With regard to preoperative imaging, ultrasonography (US) alone was performed in 100 patients (32%), contrast-enhanced computed tomography (CT) alone in 162 patients (52%), and US followed by CT after an inconclusive US examination in 50 patients (16%). Imaging findings compatible with appendicitis were reported in 42% of patients who underwent US alone, 74% of those who underwent CT alone, and 92% of patients evaluated with both modalities. Laparoscopic appendectomy was performed in 305 patients (97.8%), while open appendectomy was required in 7 patients (2.2%). No major perioperative complications were documented in the available medical records, and all patients were discharged without major incident according to discharge summaries (Table 5 ). Table 5 Demographic and Clinical Characteristics of the Study Group Characteristic Value (n = 312) Age, years (mean ± SD, range) 29.77 ± 9.55 (range: 18–72) Gender (Male/Female) 58.7% / 41.3% Time from admission to surgery (mean ± SD) 9.48 ± 2.94 hours Diagnostic imaging USG 32%, CT 52%, USG + CT 16% Surgical approach Laparoscopic 97.8%, Open 2.2% Postoperative complications None (no major complications observed) 3.2. Histopathological findings Histopathological examination confirmed acute appendicitis in 281 patients (90.1%). Among these, phlegmonous (suppurative) appendicitis was the most common subtype, identified in 154 patients (49.4%), followed by gangrenous appendicitis in 70 patients (22.4%) and perforated appendicitis in 57 patients (18.3%). A normal appendix, corresponding to negative appendectomy, was reported in 31 patients (9.9%) (Table 6 ). Table 6 Distribution of Appendectomy Histopathology Results Histopathological Diagnosis Number of Cases (n = 312) Percentage (%) Acute appendicitis (total) 281 90.1 -Phlegmonous appendicitis 154 49.4 -Gangrenous appendicitis 70 22.4 – Perforated appendicitis 57 18.3 Normal appendix (negative appendectomy) 31 9.9 3.3. Score distributions and relationship with histopathology Across the entire cohort, the mean Alvarado score was 6.98 ± 1.60, the mean RIPASA score was 9.11 ± 2.57, and the mean Lintula score was 22.78 ± 5.09. Mean score values were higher in patients with histopathologically confirmed appendicitis than in those with a normal appendix. In the negative appendectomy group (n = 31), mean scores were 5.48 for Alvarado, 6.10 for RIPASA, and 17.26 for Lintula. In contrast, in patients with confirmed appendicitis (n = 281), mean scores were 7.49, 10.10, and 24.86, respectively (Table 7 ). Table 7 Comparison of Mean Scores Between Negative and Positive Appendectomy Groups Scoring System All Patients (mean) n = 312 Negative Appendectomy (mean) n = 31 Positive Appendectomy (mean) n = 281 Alvarado Score 6.98 5.48 7.49 RIPASA Score 9.11 6.10 10.10 Lintula Score 22.78 17.26 24.86 When stratified according to histopathological subtype, all three scoring systems demonstrated a stepwise increase in mean values with increasing disease severity. Mean Alvarado, RIPASA, and Lintula scores were 6.49, 8.10, and 20.56 in phlegmonous appendicitis; 7.51, 10.04, and 25.07 in gangrenous appendicitis; and 8.47, 12.32, and 28.95 in perforated appendicitis, respectively (Table 8 ). One-way analysis of variance revealed statistically significant differences between groups for all three scores (p < 0.001), with F values of 48.294 for Alvarado, 115.257 for RIPASA, and 113.466 for Lintula. The largest mean score differences were observed between patients with a normal appendix and those with perforated appendicitis (Table 8 ). Table 8 Between-Groups ANOVA Comparison According to Diagnostic Scoring Systems Group (Pathology) Alvarado Score (mean) RIPASA Score (mean) Lintula Score (mean) Normal(negative appendectomy) 5.48 6.10 17.26 Phlegmonous appendicitis 6.49 8.10 20.56 Gangrenous appendicitis 7.51 10.04 25.07 Perforated appendicitis 8.47 12.32 28.95 3.4. Performance at literature-recommended cutoffs Diagnostic performance metrics at commonly used literature-based cutoff values (Alvarado ≥ 7, RIPASA ≥ 7.5, and Lintula ≥ 21) are summarized in Table 9 . At these thresholds, Alvarado demonstrated a sensitivity of 67.3% and specificity of 71.0%, with a positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 19.3%, accuracy of 67.6%, and a Youden index of 0.382. RIPASA showed a sensitivity of 76.1% and specificity of 77.4%, with PPV of 96.8%, NPV of 26.4%, accuracy of 76.3%, and a Youden index of 0.535. For Lintula, sensitivity was 70.1%, specificity was 64.5%, PPV was 94.7%, NPV was 19.2%, accuracy was 69.6%, and the Youden index was 0.346 (Table 9 ). Table 9 Diagnostic Performance Metrics of Scoring Systems Scoring System Sensitivity Specificity Accuracy PPV NPV Youden Index Alvarado 0.673 0.71 0.676 0.955 0.193 0.382 RIPASA 0.761 0.774 0.763 0.968 0.264 0.535 Lintula 0.701 0.645 0.696 0.947 0.192 0.346 Histopathologically confirmed appendicitis was present in 189 of 198 patients with an Alvarado score ≥ 7, in 214 of 221 patients with a RIPASA score ≥ 7.5, and in 197 of 208 patients with a Lintula score ≥ 21. Among patients with scores below the respective cutoff values, a normal appendix was identified in 22 of 114 patients with Alvarado < 7, 24 of 91 patients with RIPASA < 7.5, and 20 of 104 patients with Lintula < 21 (Table 10 ). Table 10 Patient Distribution According to Scoring System Cut-off Values Scoring System (Cut-off) Total Patients Positive Cases Negative Cases Alvarado ≥ 7 198 189 9 RIPASA ≥ 7.5 221 214 7 Lintula ≥ 21 208 197 11 Alvarado < 7 114 92 22 RIPASA < 7.5 91 67 24 Lintula < 21 104 84 20 3.5. ROC analysis for appendicitis Receiver operating characteristic (ROC) curve analyses comparing the discriminative ability of the three scoring systems for appendicitis are presented in Fig. 1 . The area under the curve (AUC) was 0.765 (95% CI: 0.714–0.811) for the Alvarado score, 0.857 (95% CI: 0.813–0.894) for the RIPASA score, and 0.829 (95% CI: 0.782–0.869) for the Lintula score (Table 11 ). Table 11 Discriminative Ability of Scoring Systems According to ROC Analysis (AUC Values) Model AUC (95% CI) Alvarado 0.765 (0.714–0.811) RIPASA 0.857 (0.813–0.894) Lintula 0.829 (0.782–0.869) 3.6. ROC analyses for perforation and histopathological subtypes ROC analyses focusing on perforated appendicitis are shown in Fig. 2 and summarized in Table 12 . For perforation, the AUC was 0.846 (95% CI: 0.801–0.884) for Alvarado, 0.922 (95% CI: 0.886–0.949) for RIPASA, and 0.915 (95% CI: 0.878–0.943) for Lintula. Corresponding Youden indices were 0.5692, 0.7340, and 0.6499, with optimal cutoff values of > 7 for Alvarado, > 10 for RIPASA, and > 25 for Lintula. At these thresholds, sensitivities were 89.47%, 89.47%, and 84.21%, and specificities were 67.45%, 83.92%, and 80.00%, respectively (Table 12 ). Table 12 Diagnostic performance comparison of perforations. Scoring System AUC (95% CI) Youden's Index Optimal Threshold Sensitivity (%) Specificity (%) Alvarado 0.846 (0.801–0.884) 0.5692 > 7 89.47 67.45 RIPASA 0.922 (0.886–0.949) 0.7340 > 10 89.47 83.92 Lintula 0.915 (0.878–0.943) 0.6499 > 25 84.21 80.00 Additional ROC analyses for phlegmonous and gangrenous appendicitis are presented in Fig. 3 /Table 13 and Fig. 4 /Table 14 , respectively. ROC-based evaluation for negative appendectomy is shown in Fig. 5 and Table 15 . A summary of the best-performing scoring system by AUC according to histopathological category is provided in Table 16 . Table 13 Diagnostic performance comparison of scoring systems for phlegmon Scoring System AUC (95% CI) Youden's Index Optimal Threshold Sensitivity (%) Specificity (%) Alvarado 0.690 (0.636–0.741) 0.3224 ≤ 7 73.38 58.86 RIPASA 0.729 (0.676–0.778) 0.4156 ≤ 10 91.56 50.00 Lintula 0.760 (0.708–0.806) 0.4391 ≤ 24 84.42 59.49 Table 14 Comparison of diagnostic performance of scoring systems for gangrenous conditions. Scoring System AUC (95% CI) Youden's Index Optimal Threshold Sensitivity (%) Specificity (%) Alvarado 0.690 (0.636–0.741) 0.3224 ≤ 7 73.38 58.86 RIPASA 0.729 (0.676–0.778) 0.4156 ≤ 10 91.56 50.00 Lintula 0.760 (0.708–0.806) 0.4391 ≤ 24 84.42 59.49 Table 15 Evaluation of Scoring Systems' Diagnostic Performance in Normal Appendicitis Scoring System AUC (95% CI) Youden's Index Optimal Threshold Sensitivity (%) Specificity (%) Skorlama Sistemi AUC (%95 GA) Youden İndeksi Optimal Eşik Duyarlılık (%) Özgüllük (%) Alvarado 0.765 (0.714–0.811) 0.3823 ≤ 6 70.97 67.26 RIPASA 0.857 (0.813–0.894) 0.5358 ≤ 7 77.42 76.16 Lintula 0.829 (0.782–0.869) 0.5552 ≤ 22 100.00 55.52 Table 16 Summary table, 16 presents the comparative summary of all pathologies. Pathology Best Score (AUC) Key Feature Perforation RIPASA (0.922) High specificity (83.92%) Gangrenous Lintula (0.760) Balanced sensitivity-specificity Phlegmonous Lintula (0.760) High AUC Normal Appendicitis RIPASA (0.857) Balanced sensitivity-specificity (76.16%) 4. Discussion Clinical scoring systems are frequently used as supportive tools in the evaluation of patients with suspected acute appendicitis, especially when clinical findings are not clearly diagnostic or when immediate imaging is not available. In this surgically managed adult cohort, we compared the Alvarado, RIPASA, and Lintula scores against histopathological findings and examined whether score magnitude was associated with disease severity. Three main findings were identified in the present study. First, at commonly used cutoff values, all three scoring systems demonstrated high positive predictive values (94.7%–96.8%), indicating that higher scores were strongly associated with histologically confirmed appendicitis within this operative pathway. Second, negative predictive values were consistently low (19.2%–26.4%), showing that lower scores did not reliably exclude appendicitis. Third, overall discriminative performance differed between scoring systems, with RIPASA demonstrating the highest area under the curve for appendicitis (0.857), followed by Lintula (0.829) and Alvarado (0.765). These findings should be interpreted in the context of the diagnostic and management pathway. The study population consisted exclusively of patients who proceeded to appendectomy, resulting in a high prevalence of appendicitis (90.1%). In such settings, high positive predictive values are expected, whereas negative predictive values are inherently constrained. Accordingly, while a positive score may increase diagnostic confidence when appendicitis is already suspected, a low score should not be used as a stand-alone rule-out criterion. This interpretation is supported by the observed score distributions, in which appendicitis remained common among patients below the respective cutoff values, underscoring the need for continued clinical reassessment and appropriate imaging when clinical suspicion persists ( 3 ). The rate of negative appendectomy has decreased over time, mainly because imaging techniques are used more frequently in the diagnostic process. Earlier series reported substantially higher rates, whereas contemporary imaging-supported diagnostic pathways generally demonstrate lower negative appendectomy frequencies ( 23 , 24 ). In the present cohort, the negative appendectomy rate was 9.9%. Given the extensive use of computed tomography in routine evaluation, this finding should not be attributed solely to clinical scoring systems. Rather, the results suggest that within an imaging-supported operative pathway, positive score classifications align well with histopathological findings and may contribute to structured clinical decision-making, while imaging remains central to diagnostic confirmation. At literature-recommended thresholds, RIPASA provided the most favorable balance between sensitivity and specificity (76.1% and 77.4%, respectively) and yielded the highest Youden index (0.535). Previous studies and meta-analyses have frequently reported higher sensitivity for RIPASA compared with the Alvarado score, although specificity has varied across different populations and clinical environments ( 27 , 28 ). The present findings are consistent with this body of evidence and support RIPASA as a practical option when improved overall discrimination is desired in adult patients evaluated within an imaging-supported setting. The Alvarado score remains widely used because of its simplicity and ease of bedside application ( 4 ). In this cohort, Alvarado demonstrated moderate sensitivity (67.3%) and specificity (71.0%) at the commonly applied cutoff of ≥ 7. From a practical standpoint, this suggests that Alvarado may be useful as an initial structured assessment tool, but that a low score should not be considered reassuring when clinical suspicion remains, particularly in settings where imaging is readily available to clarify equivocal presentations. The Lintula score, initially developed for pediatric populations, has been evaluated in adult cohorts with mixed results ( 13 – 19 , 29 ). In the present study, Lintula demonstrated an AUC of 0.829; however, at the ≥ 21 threshold, its specificity was lower than that of RIPASA (64.5% vs 77.4%), and the corresponding Youden index was modest (0.346). One potential advantage of the Lintula score is its reliance predominantly on clinical findings without the need for laboratory parameters, which may be advantageous when laboratory turnaround times are prolonged ( 15 ). Nevertheless, the low negative predictive value observed in this cohort indicates that low Lintula scores should not be used to exclude appendicitis without further diagnostic evaluation. Beyond diagnostic support, preoperative severity stratification has gained increasing importance with the growing discussion of non-operative treatment strategies for selected cases of uncomplicated appendicitis ( 31 – 34 ). Current recommendations generally emphasize the combined use of clinical assessment, scoring systems, and imaging to differentiate uncomplicated from complicated disease and to guide management decisions ( 35 ). In this study, mean score values increased stepwise with histopathological severity, progressing from phlegmonous to gangrenous and perforated appendicitis (p < 0.001). In perforation-focused receiver operating characteristic analyses, RIPASA demonstrated the highest discriminative ability (AUC 0.922), followed by Lintula (0.915) and Alvarado (0.846). At ROC-derived thresholds, sensitivities for perforation were high across all three scores, while specificity was greatest for RIPASA (83.92%). These findings suggest that higher preoperative score values, particularly with RIPASA, may help identify patients at increased risk of perforation and support operative prioritization and timely surgical planning, although imaging remains essential for confirmation of complicated disease and definition of management strategy ( 35 , 36 ). Some limitations of this study should be taken into account when interpreting the results. This was a single-center study limited to patients who underwent appendectomy, resulting in a high prevalence of appendicitis and limiting the generalizability of predictive values to unselected emergency department populations. Scores were calculated retrospectively from charted presentation data rather than applied prospectively at the bedside, which may introduce information bias related to incomplete documentation. In addition, imaging was incorporated into routine preoperative decision-making; therefore, the present results reflect score performance within an imaging-supported pathway rather than as independent diagnostic tools. Finally, patients managed non-operatively or discharged after evaluation were not included, precluding assessment of score performance in these settings. Overall, the three clinical scoring systems showed good diagnostic confirmation when scores were high, but low scores were not reliable for excluding appendicitis in this surgically treated adult population. RIPASA showed the highest overall discrimination for appendicitis and favorable performance in perforation-focused analyses. These findings support the use of clinical scoring systems as adjuncts to clinical assessment and imaging rather than as stand-alone tools, and highlight the need for future prospective studies including non-operated patients and external validation across different diagnostic pathways ( 37 , 38 ). Declarations Conflicts of interest: The authors declare no conflicts of interest. Ethics approval: Ethical approval was obtained from the institutional Ethics Committee (decision no: 2025/75; meeting date: 12 June 2025; approval letter no: E-76988455-050.04-272053; dated 04 July 2025). Informed consent: Informed consent was not obtained because of the retrospective design and use of anonymized routinely collected data, in accordance with institutional policy and Ethics Committee approval. Funding: The authors received no specific funding for this work. Author Contribution Author Contributions Statement:All aspects of the study—including conceptualization, data collection, analysis, interpretation, manuscript writing, and final approval—were carried out solely by the author. The author accepts full responsibility for the work.Author Contributions Statement:Conceptualization, data collection, analysis and interpretation, manuscript drafting, and final approval were carried out by Suat Evirgen, Yasin Duran, and Önder Karabay. All authors contributed to the work, reviewed the final version, and approved it for publication.Corresponding Author:Suat [email protected] @gmail.com Acknowledgements: The authors thank the emergency department and pathology staff for their contributions to patient care and routine documentation. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. References -Echevarria S, Rauf F, Hussain N, Zaka H, Farwa UE, Ahsan N, Broomfield A, Akbar A, Khawaja UA (2023) Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review. Cureus 15(4):e37024. 10.7759/cureus.37024 PMID: 37143626; PMCID: PMC10152406 Di - S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Catena F (2020) Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg surgery: WJES 15(1):27. https://doi.org/10.1186/s13017-020-00306-3 -Shahmoradi L, Safdari R, Mirhosseini MM et al (2023) Development and evaluation of a clinical decision support system for early diagnosis of acute appendicitis. Sci Rep 13:19703. https://doi.org/10.1038/s41598-023-46721-9 - Al-Wageeh S, Alyhari QA, Ahmed F, Altam A, Alshehari G, Badheeb M (2024) Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study. Open Access Emerg Med 16:159–166 PMID: 38994039; PMCID: PMC11236940 - Awayshih MMA, Nofal MN, Yousef AJ (2019) Evaluation of Alvarado score in diagnosing acute appendicitis. Pan Afr Med J 34:15. 10.11604/pamj.2019.34.15.17803 PMID: 31762884; PMCID: PMC6859007 - Jose T, Rajesh PS (2021) Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis. Surg J (N Y) 7(3):e127–e131. 10.1055/s-0041-1731446 PMID: 34295969; PMCID: PMC8289675 - Naeem MT, Jamil MA, Anwar MI, Raza H, Asad A, Jamil H, Tahir MJ, Bai J, Ejaz Chauhan TM, Asghar MS (2022) Diagnostic accuracy of Alvarado scoring system relative to histopathological diagnosis for acute appendicitis: A retrospective cohort study. Ann Med Surg (Lond) 81:104561 PMID: 36147117; PMCID: PMC9486849 Alvarez-Lozada LA, Fernandez-Reyes BA, Arrambide-Garza FJ, García-Leal M, Alvarez-Villalobos NA, Martínez-Garza JH, Fernández-Rodarte B, Elizondo-Omaña RE, Quiroga-Garza A (2025) Clinical scores for acute appendicitis in adults: A systematic review and meta-analysis of diagnostic accuracy studies. Am J Surg 240:116123 Epub 2024 Dec 5. PMID: 39667296 - Korkut M, Bedel C, Karancı Y, Avcı A, Duyan M (2020) Accuracy of Alvarado, Eskelinen, Ohmann, RIPASA and Tzanakis Scores in Diagnosis of Acute Appendicitis; a Cross-sectional Study. Arch Acad Emerg Med 8(1):e20 PMID: 32259117; PMCID: PMC7130437 - Esmer Gökçe M, Korkmaz İ, Tekin Y, Yurtbay S, Demirtaş E, Özsoy O, Özbay S (2020) Kukul Güven F. Comparison of alvarado and ripasa scores in patients with acute appendicitis. CMJ Dec 42(4):500–506. 10.7197/cmj.828748 - Akbar I, Shehzad JA, Ali S (2019 Jul-Sep) Diagnostic Accuracy Of Ripasa Score. J Ayub Med Coll Abbottabad 31(3):411–414 PMID: 31535517 - Dezfuli SAT, Yazdani R, Khorasani M, Hosseinikhah SA (2020) Comparison between the specificity and sensitivity of the RIPASA and Alvarado Scoring systems in the diagnosis of acute appendicitis among patients with complaints of right iliac fossa. AIMS Public Health 7(1):1–9. 10.3934/publichealth.2020001 PMID: 32258184; PMCID: PMC7109537 - Kaewlai R, Tongsai S, Teerasamit W, Wongsaengchan D, Noppakunsomboon N, Khamman P, Chatkaewpaisal A, Apisarnthanarak P (2023) Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings. Insights Imaging 14(1):191. 10.1186/s13244-023-01540-4 PMID: 37973644; PMCID: PMC10654319 - Alemrajabi M, Zadeh MK, Davani SZ, Nasiri F, Riazi S, Nasiri M (2022) Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children. J Med Life 15(4):443–447. 10.25122/jml-2021-0049 PMID: 35646183; PMCID: PMC9126464 - Ghali MS, Hasan S, Al-Yahri O, Mansor S, Al-Tarakji M, Obaid M, Shah AA, Shehata MS, Singh R, Al-Zoubi RM, Zarour A (2023) Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis. Surg Open Sci 14:96–102 PMID: 37577253; PMCID: PMC10413131 Yılmaz -M, Aytekin A, Yılmaz L, Bulut A (2023) Evaluation of the Efficiency of Four Different Scoring Systems in the Diagnosis of Acute Appendicitis. CBU-SBED 01 Aralık 10(4):399–404. 10.34087/cbusbed.1183468 - Zeb M, Khattak SK, Samad M, Shah SS, Shah SQA, Haseeb A (2023) Comparison of Alvarado score, appendicitis inflammatory response score (AIR) and Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score in predicting acute appendicitis. Heliyon 9(1):e13013 PMID: 36711320; PMCID: PMC9876948 - Dr (2020) Ali Saadi Omar and Dr. Sattar Jabbar Kadhim. Accuracy of lintula score versus alvarado score in diagnosis of acute appendicitis in Al-yarmouk teaching hospital. Int J Surg Sci 4(4):18–23. https://doi.org/10.33545/surgery.2020.v4.i4a.532 - Dr, Ojuka D, Sangoro M (2018) Alvarado vs Lintula Scoring Systems in Acute Appendicitis. Annals of African Surgery. 14. 10.4314/aas.v14i1.5 - Poillucci G, Podda M, Oricchio D, Medina KL, Manetti G, De Angelis R (2022) Comparison between AIR, Alvarado and RIPASA scores in the diagnosis of acute appendicitis in a Western population. A retrospective cohort study. Ann Ital Chir 93:427–434 PMID: 36156491 - Sevinç B, Damburacı N, Karahan Ö (2025) Nonoperative management of uncomplicated acute appendicitis; results of 5 years follow. Langenbecks Arch Surg 410(1):292. 10.1007/s00423-025-03811-8 PMID: 41055745; PMCID: PMC12504381 - Güler İ, Satılmış D, Ömeroğlu S, Balcı N (2023) The Effectiveness of Appendicitis Inflammatory Response Score in the Evaluation of Acute Appendicitis: A Meta-analysis. Hamidiye Med J 4(1):15–21. https://doi.org/10.4274/hamidiyemedj.galenos.2023.98159 - Arslan HC, Kilic TY, Idil H, Imamoglu T, Yesilaras M (2019) Computed Tomography In Differential Diagnosis Of Abdominal Pain Among Patients With Suspected Acute Appendicitis. Anatol J Emerg Med 2(3):17–20. https://izlik.org/JA94AK42ZH - Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ (2008) The impact of helical computed tomography on the negative appendectomy rate: a multi-center comparison. J Emerg Med 34(1):3–6. 10.1016/j.jemermed.2007.05.042 Epub 2007 Nov 26. PMID: 18022782 - Henriksen SR, Christophersen C, Rosenberg J, Fonnes S (2023) Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis. Langenbecks Arch Surg. ;408(1):205. 10.1007/s00423-023-02935-z . PMID: 37219616 - Engin O, Calik B, Yildirim M, Coskun A, Coskun GA (2011) Gynecologic pathologies in our appendectomy series and literature review. J Korean Surg Soc 80(4):267–271. 10.4174/jkss.2011.80.4.267 Epub 2011 Apr 12. PMID: 22066046; PMCID: PMC3204677 - Chisthi MM, Surendran A, Narayanan JT (2020) RIPASA and air scoring systems are superior to alvarado scoring in acute appendicitis: Diagnostic accuracy study. Ann Med Surg (Lond) 59:138–142 PMID: 33024555; PMCID: PMC7527659 - Frountzas M, Stergios K, Kopsini D, Schizas D, Kontzoglou K, Toutouzas K (2018) Alvarado or RIPASA score for diagnosis of acute appendicitis? A meta-analysis of randomized trials. Int J Surg 56:307–314 Epub 2018 Jul 12. PMID: 30017607 - Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M (2005) A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 390(2):164–170. 10.1007/s00423-005-0545-8 Epub 2005 Feb 19. PMID: 15723233 - Banlı Cesur İ, Sarı Gökay S (2021) Comparison of Appendicitis Scoring Systems in Pediatric Patients. J Contemp Med July 11(4):510–514. 10.16899/jcm.876825 - Bom WJ, Scheijmans JCG, Salminen P, Boermeester MA (2021) Diagnosis of Uncomplicated and Complicated Appendicitis in Adults. Scand J Surg. ;110(2):170–179. doi: 10.1177/14574969211008330. Epub 2021 Apr 14. PMID: 33851877; PMCID: PMC8258714 - Talan DA, Di Saverio S (2021) Treatment of Acute Uncomplicated Appendicitis. N Engl J Med. ;385(12):1116–1123. 10.1056/NEJMcp2107675 . PMID: 34525287 - Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM (2015) Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. ;313(23):2340-8. 10.1001/jama.2015.6154 . PMID: 26080338 - Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM CODA Collaborative, Flum, D. R., Davidson, G. H., Monsell, S. E., Shapiro, N. I.,Odom, S. R., Sanchez, S. E., Drake, F. T., Fischkoff, K., Johnson, J., Patton, J.H., Evans, H., Cuschieri, J., Sabbatini, A. K., Faine, B. A., Skeete, D. A., Liang,M. K., Sohn, V., McGrane, K., Kutcher, M. E., … Talan, D. A. (2020). A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. The New England journal of medicine , 383 (20), 1907–1919. https://doi.org/10.1056/NEJMoa2014320 Di - S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R (2016) WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 11:34. 10.1186/s13017-016-0090-5 PMID: 27437029; PMCID: PMC4949879 - Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA (2015) Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 102(8):979–990. 10.1002/bjs.9835 Epub 2015 May 12. PMID: 25963411 - Khan S, Usama M, Basir Y, Muhammad S, Jawad M, Khan T, Usman A, Abbas A Evaluation Of Modified Alvarado, Ripasa And Lintula Scoring System As Diagnostic Tools For Acute Appendicitis. J Ayub Med Coll Abbottabad 2020 Jan-Mar ;32(1):46–50. PMID: 32468754. - Rodriguez-Garcia FA, Rodríguez-Sánchez CE, Naranjo-Chávez JC, Torres-Ortiz-Ocampo CJ, Rojas-Larios F, Covarrubias-Ramírez K, Evangelista-Ruiz EM, Torres-Salazar QL (2025) Assessment of negative appendectomy in acute appendicitis diagnoses. Surg Pract Sci 21:100281 PMID: 40270918; PMCID: PMC12017968 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8875060","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606191555,"identity":"c42c4437-e0a8-40d4-8d42-2efffa3c5d4c","order_by":0,"name":"SUAT 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systems\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/ad8dd59c53d01e5863deea18.jpg"},{"id":104867597,"identity":"dc9df76d-2958-4142-a20d-15580f31603f","added_by":"auto","created_at":"2026-03-18 07:13:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":138664,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of scoring systems for diagnosing \u003c/em\u003eperforated appendicitis\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/b9a426ee396b7b127ecab4ca.jpg"},{"id":104867653,"identity":"7876061f-5ae1-4801-acc8-b3542838f01f","added_by":"auto","created_at":"2026-03-18 07:13:34","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":109518,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of scoring systems for diagnosing phlegmon\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/ad61b23067e7e1da2aaf967f.jpg"},{"id":104867601,"identity":"ba64764d-bf45-4010-869d-b418720a5315","added_by":"auto","created_at":"2026-03-18 07:13:20","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":126431,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eComparison of scoring systems for diagnosing gangrenous appendicitis\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/b203e3f03511fabaac6ef470.jpg"},{"id":104867661,"identity":"fef37240-8e8e-4d3e-b5f2-615216fea3ad","added_by":"auto","created_at":"2026-03-18 07:13:36","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":96208,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of scoring systems in the diagnosis of normal appendicitis\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/399ce5b16f3b404beb94addd.jpg"},{"id":104867678,"identity":"70eb493a-ea83-4d94-97ec-fe726a3dc3d4","added_by":"auto","created_at":"2026-03-18 07:13:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1952404,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8875060/v1/98adce86-11f1-4e8f-97d0-4dffdbd9c46e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePreoperative Clinical Scores for Predicting Complicated Appendicitis İn Surgically Managed Adults: Comparative Performance of Alvarado, Ripasa, and Lintula\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAcute appendicitis is among the most frequent causes of emergency abdominal surgical intervention. Delayed recognition of the disease may lead to important complications such as perforation, intra-abdominal abscess formation, and sepsis. The lifetime incidence of appendicitis in the general population has been reported to be approximately 7\u0026ndash;12% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although the typical clinical picture includes migratory abdominal pain, anorexia, nausea or vomiting, right lower quadrant tenderness, peritoneal irritation, and leukocytosis, a considerable proportion of patients present with atypical or equivocal features that complicate bedside decision-making (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the emergency setting, clinicians are frequently required to balance the risk of disease progression associated with delayed intervention against the potential morbidity of unnecessary surgery. To standardize clinical evaluation, several scoring systems have been proposed to assist diagnosis and reduce unnecessary appendectomy, however, none provides absolute diagnostic certainty, and all are intended to complement rather than replace clinical judgment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Alvarado score was introduced in 1986 and continues to be commonly used in clinical practice because it is simple and practical to apply (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The score integrates symptoms, physical examination findings, and laboratory parameters into a 10-point system (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A threshold of \u0026ge;\u0026thinsp;7 is commonly applied to support a diagnosis of acute appendicitis, although reported performance has been moderate and variable across different populations and clinical pathways (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A meta-analysis reported an average sensitivity of 72% and specificity of 77% for the Alvarado score (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), while subsequent studies have demonstrated a broad range of diagnostic estimates influenced by case mix and diagnostic strategy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These observations underscore the importance of defining the clinical contexts in which the Alvarado score may be most informative, as well as its recognized limitations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters and Scores of the Alvarado Scoring System\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore allotted\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigratory right iliac fossa pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea/vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTender right iliac fossa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRebound tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeucocytosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft shift of neutrophils\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe RIPASA (Raja Isteri Pengiran Anak Saleha) scoring system was introduced in 2010 following concerns that previously established scoring methods might perform less effectively in some patient populations (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In contrast to the Alvarado score, RIPASA incorporates additional demographic and clinical variables, including age, sex, symptom duration, and urinalysis findings, resulting in a 16.5-point scoring system (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Using a proposed cutoff value of \u0026ge;\u0026thinsp;7.5, Chong et al. reported higher sensitivity and specificity compared with the Alvarado score in their original cohort (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Subsequent studies have frequently demonstrated higher sensitivity for RIPASA, particularly in Eastern populations, although reported specificity has varied across different clinical settings (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters and Scores of the RIPASA Scoring System\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore allotted\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight iliac fossa pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigration of pain to RIF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea and vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms duration\u0026thinsp;\u0026lt;\u0026thinsp;48 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms duration\u0026thinsp;\u0026gt;\u0026thinsp;48 hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTender right iliac fossa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuarding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRebound tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRovsing\u0026rsquo;s sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated WBC count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative urine analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Lintula score was initially developed for pediatric patients and relies mainly on clinical findings to assist rapid triage decisions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It consists of nine parameters, yielding a total score ranging from 0 to 32 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In earlier studies, a score of \u0026ge;\u0026thinsp;21 has generally been considered suggestive of appendicitis, whereas values\u0026thinsp;\u0026le;\u0026thinsp;15 have been associated with a low likelihood of disease (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Although initial reports described high diagnostic accuracy in children (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), subsequent investigations evaluating adult populations have yielded mixed results. Some studies have demonstrated strong discriminative performance, including favorable area under the curve values in adult cohorts (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), while others have reported performance comparable to that of the Alvarado score (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Overall, existing evidence suggests that the diagnostic utility of the Lintula score may be context dependent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters and Scores of the Lintula Scoring System\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore allotted\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigration of pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRLQ pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever (\u0026gt;\u0026thinsp;37.5\u0026deg;C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuarding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh pitched, tingling or absent bowel sounds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRebound tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAlthough many studies have compared the Alvarado and RIPASA scoring systems, relatively fewer investigations have explored the relationship between commonly used clinical scores and histopathological severity or specific subtypes of appendicitis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This issue has gained increasing clinical relevance, as preoperative differentiation between uncomplicated and complicated disease may influence management strategies. Patients at increased risk of perforation often require urgent surgical intervention and broader-spectrum antibiotic therapy, whereas non-operative management has been proposed for carefully selected cases of uncomplicated appendicitis (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Accordingly, determining whether established scoring systems provide information beyond diagnosis and contribute to severity stratification is of practical importance. The components of the Alvarado, RIPASA, and Lintula scores and their areas of overlap are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Alvarado, RIPASA, and Lintula Scoring Systems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlvarado Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRIPASA Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLintula Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u0026thinsp;+\u0026thinsp;0.5, Male\u0026thinsp;+\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale 0, Male\u0026thinsp;+\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u0026thinsp;+\u0026thinsp;1, \u0026gt;40\u0026thinsp;+\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;48 h\u0026thinsp;+\u0026thinsp;1, \u0026gt;48 h\u0026thinsp;+\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntensity of pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMild/moderate 0, Severe\u0026thinsp;+\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea or vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight iliac fossa (RIF) pain/tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u0026thinsp;+\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated temperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuarding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRebound tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel sounds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbsent/tinkling\u0026thinsp;+\u0026thinsp;4, Normal 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRovsing's sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigration of pain to RIF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocytosis (\u0026gt;\u0026thinsp;10,000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocyte left shift (\u0026gt;\u0026thinsp;75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal urine analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe aim of the present study was to compare the diagnostic performance of the Alvarado, RIPASA, and Lintula scores in a single-center adult cohort and to evaluate their association with histopathological subtypes of appendicitis, with particular attention to perforated disease.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design, setting, and ethical approval\u003c/h2\u003e \u003cp\u003eThis retrospective observational study was conducted at Amasya University Şerefeddin Sabuncuoğlu Training and Research Hospital and was based on a review of routinely collected clinical data. Adult patients who underwent appendectomy between May 2024 and April 2025 were evaluated. The study protocol was reviewed and approved by the institutional Ethics Committee (decision no: 2025/75; meeting date: 12 June 2025; approval letter no: E-76988455-050.04-272053, dated 04 July 2025). Due to the retrospective design and use of anonymized data, informed consent was waived in accordance with institutional policy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Patient selection\u003c/h2\u003e \u003cp\u003ePatients aged 18 years or older who underwent appendectomy for suspected acute appendicitis during the study period were identified retrospectively using hospital electronic medical records and operating room appendectomy logs. Eligible patients were those initially evaluated in the emergency department with a preoperative diagnosis of acute appendicitis and subsequently managed surgically.\u003c/p\u003e \u003cp\u003eExclusion criteria included pregnancy; appendiceal mass (plastron) or intra-abdominal abscess; decompensated comorbid conditions such as heart failure or end-stage renal disease requiring dialysis; ongoing immunosuppressive therapy or chemotherapy; a history of major abdominal surgery; and active inflammatory bowel disease.\u003c/p\u003e \u003cp\u003eDuring the study period, 337 patients met the initial screening criteria. Of these, 25 patients were excluded based on the predefined exclusion criteria, resulting in a final study cohort of 312 patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Clinical evaluation, laboratory tests, and imaging pathway\u003c/h2\u003e \u003cp\u003eClinical history and physical examination findings documented at emergency department presentation were extracted from the electronic medical records. Laboratory parameters obtained as part of routine emergency assessment included complete blood count, C-reactive protein (CRP), and urinalysis.\u003c/p\u003e \u003cp\u003eIn accordance with the institutional diagnostic pathway, ultrasonography (US) was used as the first-line imaging modality and was performed by radiologists during regular working hours. Contrast-enhanced abdominal computed tomography (CT) was obtained when US findings were inconclusive or when patients presented outside routine radiology service hours. Initial evaluation was performed by emergency physicians, and surgical consultation was requested following completion of the diagnostic work-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Score derivation and interpretation\u003c/h2\u003e \u003cp\u003eThe Alvarado, RIPASA, and Lintula scoring systems were not routinely applied during real-time clinical assessment in the study period. For the purposes of this study, all scores were calculated retrospectively based on clinical and laboratory data recorded at the time of emergency department presentation. Score calculation was performed during structured chart review by a general surgery specialist.\u003c/p\u003e \u003cp\u003eRelevant variables were summed to obtain an Alvarado score (range 0\u0026ndash;10), a RIPASA score (range 0\u0026ndash;16.5), and a Lintula score (range 0\u0026ndash;32). Imaging findings were not incorporated into score calculations to preserve consistency with the original design of the scoring systems.\u003c/p\u003e \u003cp\u003eFor performance analyses, widely used literature-based cutoff values were applied to define test-positive classifications: Alvarado\u0026thinsp;\u0026ge;\u0026thinsp;7, RIPASA\u0026thinsp;\u0026ge;\u0026thinsp;7.5, and Lintula\u0026thinsp;\u0026ge;\u0026thinsp;21. Scores below these thresholds were classified as test negative.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Surgical management and histopathological classification\u003c/h2\u003e \u003cp\u003eAppendectomy was performed according to standard institutional practice following completion of the diagnostic evaluation. The choice of operative approach (laparoscopic or open) was determined by the attending surgeon. Intraoperative macroscopic findings of the appendix were documented based on direct visual inspection.\u003c/p\u003e \u003cp\u003eAll resected specimens were examined in the pathology laboratory using standard protocols. Histopathological evaluation served as the reference standard. Appendicitis was classified into three histopathological subtypes: phlegmonous (suppurative), gangrenous, and perforated appendicitis. Specimens reported as a normal appendix were categorized as negative appendectomy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables were presented as frequencies and percentages.\u003c/p\u003e \u003cp\u003eEach scoring system was dichotomized as test positive or test negative using predefined cutoff values. True positives, false positives, true negatives, and false negatives were identified for each score. Diagnostic performance was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value. Overall test performance was summarized using the Youden index.\u003c/p\u003e \u003cp\u003eDiscriminative ability was evaluated using receiver operating characteristic (ROC) curve analysis, with calculation of the area under the curve (AUC) and corresponding 95% confidence intervals. AUC values were compared using the DeLong test. For subgroup analyses, patients were classified according to histopathological findings as normal appendix, phlegmonous appendicitis, gangrenous appendicitis, or perforated appendicitis. Mean score values among groups were compared using one-way analysis of variance, and when statistically significant, post hoc comparisons were performed using the Tukey test. A two-sided P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Patient characteristics and perioperative data\u003c/h2\u003e \u003cp\u003eA total of 312 patients were included in the study. The mean age was 29.77\u0026thinsp;\u0026plusmn;\u0026thinsp;9.55 years (range, 18\u0026ndash;72 years). Of the study population, 183 patients (58.7%) were male and 129 (41.3%) were female. The mean interval from emergency department admission to surgical intervention was 9.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94 hours (range, 5\u0026ndash;14 hours).\u003c/p\u003e \u003cp\u003eWith regard to preoperative imaging, ultrasonography (US) alone was performed in 100 patients (32%), contrast-enhanced computed tomography (CT) alone in 162 patients (52%), and US followed by CT after an inconclusive US examination in 50 patients (16%). Imaging findings compatible with appendicitis were reported in 42% of patients who underwent US alone, 74% of those who underwent CT alone, and 92% of patients evaluated with both modalities.\u003c/p\u003e \u003cp\u003eLaparoscopic appendectomy was performed in 305 patients (97.8%), while open appendectomy was required in 7 patients (2.2%). No major perioperative complications were documented in the available medical records, and all patients were discharged without major incident according to discharge summaries (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Characteristics of the Study Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;312)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.77\u0026thinsp;\u0026plusmn;\u0026thinsp;9.55 (range: 18\u0026ndash;72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.7% / 41.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from admission to surgery (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94 hours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSG 32%, CT 52%, USG\u0026thinsp;+\u0026thinsp;CT 16%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaparoscopic 97.8%, Open 2.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone (no major complications observed)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Histopathological findings\u003c/h2\u003e \u003cp\u003eHistopathological examination confirmed acute appendicitis in 281 patients (90.1%). Among these, phlegmonous (suppurative) appendicitis was the most common subtype, identified in 154 patients (49.4%), followed by gangrenous appendicitis in 70 patients (22.4%) and perforated appendicitis in 57 patients (18.3%). A normal appendix, corresponding to negative appendectomy, was reported in 31 patients (9.9%) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Appendectomy Histopathology Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistopathological Diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases (n\u0026thinsp;=\u0026thinsp;312)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute appendicitis (total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-Phlegmonous appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-Gangrenous appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Perforated appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal appendix (negative appendectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Score distributions and relationship with histopathology\u003c/h2\u003e \u003cp\u003eAcross the entire cohort, the mean Alvarado score was 6.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60, the mean RIPASA score was 9.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57, and the mean Lintula score was 22.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09. Mean score values were higher in patients with histopathologically confirmed appendicitis than in those with a normal appendix. In the negative appendectomy group (n\u0026thinsp;=\u0026thinsp;31), mean scores were 5.48 for Alvarado, 6.10 for RIPASA, and 17.26 for Lintula. In contrast, in patients with confirmed appendicitis (n\u0026thinsp;=\u0026thinsp;281), mean scores were 7.49, 10.10, and 24.86, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Mean Scores Between Negative and Positive Appendectomy Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll Patients (mean) n\u0026thinsp;=\u0026thinsp;312\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative Appendectomy (mean) n\u0026thinsp;=\u0026thinsp;31\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003ePositive Appendectomy (mean) n\u0026thinsp;=\u0026thinsp;281\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e17.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen stratified according to histopathological subtype, all three scoring systems demonstrated a stepwise increase in mean values with increasing disease severity. Mean Alvarado, RIPASA, and Lintula scores were 6.49, 8.10, and 20.56 in phlegmonous appendicitis; 7.51, 10.04, and 25.07 in gangrenous appendicitis; and 8.47, 12.32, and 28.95 in perforated appendicitis, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). One-way analysis of variance revealed statistically significant differences between groups for all three scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with F values of 48.294 for Alvarado, 115.257 for RIPASA, and 113.466 for Lintula. The largest mean score differences were observed between patients with a normal appendix and those with perforated appendicitis (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBetween-Groups ANOVA Comparison According to Diagnostic Scoring Systems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup (Pathology)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlvarado Score (mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRIPASA Score (mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLintula Score (mean)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal(negative appendectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhlegmonous appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGangrenous appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerforated appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Performance at literature-recommended cutoffs\u003c/h2\u003e \u003cp\u003eDiagnostic performance metrics at commonly used literature-based cutoff values (Alvarado\u0026thinsp;\u0026ge;\u0026thinsp;7, RIPASA\u0026thinsp;\u0026ge;\u0026thinsp;7.5, and Lintula\u0026thinsp;\u0026ge;\u0026thinsp;21) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e. At these thresholds, Alvarado demonstrated a sensitivity of 67.3% and specificity of 71.0%, with a positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 19.3%, accuracy of 67.6%, and a Youden index of 0.382. RIPASA showed a sensitivity of 76.1% and specificity of 77.4%, with PPV of 96.8%, NPV of 26.4%, accuracy of 76.3%, and a Youden index of 0.535. For Lintula, sensitivity was 70.1%, specificity was 64.5%, PPV was 94.7%, NPV was 19.2%, accuracy was 69.6%, and the Youden index was 0.346 (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic Performance Metrics of Scoring Systems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAccuracy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYouden Index\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.761\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHistopathologically confirmed appendicitis was present in 189 of 198 patients with an Alvarado score\u0026thinsp;\u0026ge;\u0026thinsp;7, in 214 of 221 patients with a RIPASA score\u0026thinsp;\u0026ge;\u0026thinsp;7.5, and in 197 of 208 patients with a Lintula score\u0026thinsp;\u0026ge;\u0026thinsp;21. Among patients with scores below the respective cutoff values, a normal appendix was identified in 22 of 114 patients with Alvarado\u0026thinsp;\u0026lt;\u0026thinsp;7, 24 of 91 patients with RIPASA\u0026thinsp;\u0026lt;\u0026thinsp;7.5, and 20 of 104 patients with Lintula\u0026thinsp;\u0026lt;\u0026thinsp;21 (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Distribution According to Scoring System Cut-off Values\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System (Cut-off)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive Cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative Cases\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u0026thinsp;\u0026ge;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u0026thinsp;\u0026ge;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u0026thinsp;\u0026ge;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u0026thinsp;\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u0026thinsp;\u0026lt;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u0026thinsp;\u0026lt;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.5. ROC analysis for appendicitis\u003c/h2\u003e \u003cp\u003eReceiver operating characteristic (ROC) curve analyses comparing the discriminative ability of the three scoring systems for appendicitis are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The area under the curve (AUC) was 0.765 (95% CI: 0.714\u0026ndash;0.811) for the Alvarado score, 0.857 (95% CI: 0.813\u0026ndash;0.894) for the RIPASA score, and 0.829 (95% CI: 0.782\u0026ndash;0.869) for the Lintula score (Table\u0026nbsp;\u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiscriminative Ability of Scoring Systems According to ROC Analysis (AUC Values)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.765 (0.714\u0026ndash;0.811)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.857 (0.813\u0026ndash;0.894)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.829 (0.782\u0026ndash;0.869)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.6. ROC analyses for perforation and histopathological subtypes\u003c/h2\u003e \u003cp\u003eROC analyses focusing on perforated appendicitis are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and summarized in Table\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e12\u003c/span\u003e. For perforation, the AUC was 0.846 (95% CI: 0.801\u0026ndash;0.884) for Alvarado, 0.922 (95% CI: 0.886\u0026ndash;0.949) for RIPASA, and 0.915 (95% CI: 0.878\u0026ndash;0.943) for Lintula. Corresponding Youden indices were 0.5692, 0.7340, and 0.6499, with optimal cutoff values of \u0026gt;\u0026thinsp;7 for Alvarado, \u0026gt;\u0026thinsp;10 for RIPASA, and \u0026gt;\u0026thinsp;25 for Lintula. At these thresholds, sensitivities were 89.47%, 89.47%, and 84.21%, and specificities were 67.45%, 83.92%, and 80.00%, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab12\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 12\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic performance comparison of perforations.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYouden's Index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Threshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.846 (0.801\u0026ndash;0.884)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.922 (0.886\u0026ndash;0.949)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.915 (0.878\u0026ndash;0.943)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditional ROC analyses for phlegmonous and gangrenous appendicitis are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e/Table\u0026nbsp;\u003cspan refid=\"Tab13\" class=\"InternalRef\"\u003e13\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e/Table\u0026nbsp;\u003cspan refid=\"Tab14\" class=\"InternalRef\"\u003e14\u003c/span\u003e, respectively. ROC-based evaluation for negative appendectomy is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab15\" class=\"InternalRef\"\u003e15\u003c/span\u003e. A summary of the best-performing scoring system by AUC according to histopathological category is provided in Table\u0026nbsp;\u003cspan refid=\"Tab16\" class=\"InternalRef\"\u003e16\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab13\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 13\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic performance comparison of scoring systems for phlegmon\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYouden's Index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOptimal Threshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.690 (0.636\u0026ndash;0.741)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.3224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.729 (0.676\u0026ndash;0.778)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.4156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.760 (0.708\u0026ndash;0.806)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.4391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab14\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 14\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of diagnostic performance of scoring systems for gangrenous conditions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYouden's Index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Threshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.690 (0.636\u0026ndash;0.741)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.729 (0.676\u0026ndash;0.778)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.760 (0.708\u0026ndash;0.806)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab15\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 15\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of Scoring Systems' Diagnostic Performance in Normal Appendicitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoring System\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYouden's Index\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Threshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkorlama Sistemi\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC (%95 GA)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYouden İndeksi\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Eşik\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuyarlılık (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026Ouml;zg\u0026uuml;ll\u0026uuml;k (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlvarado\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.765 (0.714\u0026ndash;0.811)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3823\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIPASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.857 (0.813\u0026ndash;0.894)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLintula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.829 (0.782\u0026ndash;0.869)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab16\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 16\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary table, 16 presents the comparative summary of all pathologies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBest Score (AUC)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Feature\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerforation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIPASA (0.922)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh specificity (83.92%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGangrenous\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLintula (0.760)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalanced sensitivity-specificity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhlegmonous\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLintula (0.760)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh AUC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNormal Appendicitis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIPASA (0.857)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBalanced sensitivity-specificity (76.16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eClinical scoring systems are frequently used as supportive tools in the evaluation of patients with suspected acute appendicitis, especially when clinical findings are not clearly diagnostic or when immediate imaging is not available. In this surgically managed adult cohort, we compared the Alvarado, RIPASA, and Lintula scores against histopathological findings and examined whether score magnitude was associated with disease severity. Three main findings were identified in the present study. First, at commonly used cutoff values, all three scoring systems demonstrated high positive predictive values (94.7%\u0026ndash;96.8%), indicating that higher scores were strongly associated with histologically confirmed appendicitis within this operative pathway. Second, negative predictive values were consistently low (19.2%\u0026ndash;26.4%), showing that lower scores did not reliably exclude appendicitis. Third, overall discriminative performance differed between scoring systems, with RIPASA demonstrating the highest area under the curve for appendicitis (0.857), followed by Lintula (0.829) and Alvarado (0.765).\u003c/p\u003e \u003cp\u003eThese findings should be interpreted in the context of the diagnostic and management pathway. The study population consisted exclusively of patients who proceeded to appendectomy, resulting in a high prevalence of appendicitis (90.1%). In such settings, high positive predictive values are expected, whereas negative predictive values are inherently constrained. Accordingly, while a positive score may increase diagnostic confidence when appendicitis is already suspected, a low score should not be used as a stand-alone rule-out criterion. This interpretation is supported by the observed score distributions, in which appendicitis remained common among patients below the respective cutoff values, underscoring the need for continued clinical reassessment and appropriate imaging when clinical suspicion persists (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rate of negative appendectomy has decreased over time, mainly because imaging techniques are used more frequently in the diagnostic process. Earlier series reported substantially higher rates, whereas contemporary imaging-supported diagnostic pathways generally demonstrate lower negative appendectomy frequencies (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In the present cohort, the negative appendectomy rate was 9.9%. Given the extensive use of computed tomography in routine evaluation, this finding should not be attributed solely to clinical scoring systems. Rather, the results suggest that within an imaging-supported operative pathway, positive score classifications align well with histopathological findings and may contribute to structured clinical decision-making, while imaging remains central to diagnostic confirmation.\u003c/p\u003e \u003cp\u003eAt literature-recommended thresholds, RIPASA provided the most favorable balance between sensitivity and specificity (76.1% and 77.4%, respectively) and yielded the highest Youden index (0.535). Previous studies and meta-analyses have frequently reported higher sensitivity for RIPASA compared with the Alvarado score, although specificity has varied across different populations and clinical environments (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The present findings are consistent with this body of evidence and support RIPASA as a practical option when improved overall discrimination is desired in adult patients evaluated within an imaging-supported setting.\u003c/p\u003e \u003cp\u003eThe Alvarado score remains widely used because of its simplicity and ease of bedside application (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In this cohort, Alvarado demonstrated moderate sensitivity (67.3%) and specificity (71.0%) at the commonly applied cutoff of \u0026ge;\u0026thinsp;7. From a practical standpoint, this suggests that Alvarado may be useful as an initial structured assessment tool, but that a low score should not be considered reassuring when clinical suspicion remains, particularly in settings where imaging is readily available to clarify equivocal presentations.\u003c/p\u003e \u003cp\u003eThe Lintula score, initially developed for pediatric populations, has been evaluated in adult cohorts with mixed results (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the present study, Lintula demonstrated an AUC of 0.829; however, at the \u0026ge;\u0026thinsp;21 threshold, its specificity was lower than that of RIPASA (64.5% vs 77.4%), and the corresponding Youden index was modest (0.346). One potential advantage of the Lintula score is its reliance predominantly on clinical findings without the need for laboratory parameters, which may be advantageous when laboratory turnaround times are prolonged (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Nevertheless, the low negative predictive value observed in this cohort indicates that low Lintula scores should not be used to exclude appendicitis without further diagnostic evaluation.\u003c/p\u003e \u003cp\u003eBeyond diagnostic support, preoperative severity stratification has gained increasing importance with the growing discussion of non-operative treatment strategies for selected cases of uncomplicated appendicitis (\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Current recommendations generally emphasize the combined use of clinical assessment, scoring systems, and imaging to differentiate uncomplicated from complicated disease and to guide management decisions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In this study, mean score values increased stepwise with histopathological severity, progressing from phlegmonous to gangrenous and perforated appendicitis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In perforation-focused receiver operating characteristic analyses, RIPASA demonstrated the highest discriminative ability (AUC 0.922), followed by Lintula (0.915) and Alvarado (0.846). At ROC-derived thresholds, sensitivities for perforation were high across all three scores, while specificity was greatest for RIPASA (83.92%). These findings suggest that higher preoperative score values, particularly with RIPASA, may help identify patients at increased risk of perforation and support operative prioritization and timely surgical planning, although imaging remains essential for confirmation of complicated disease and definition of management strategy (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome limitations of this study should be taken into account when interpreting the results. This was a single-center study limited to patients who underwent appendectomy, resulting in a high prevalence of appendicitis and limiting the generalizability of predictive values to unselected emergency department populations. Scores were calculated retrospectively from charted presentation data rather than applied prospectively at the bedside, which may introduce information bias related to incomplete documentation. In addition, imaging was incorporated into routine preoperative decision-making; therefore, the present results reflect score performance within an imaging-supported pathway rather than as independent diagnostic tools. Finally, patients managed non-operatively or discharged after evaluation were not included, precluding assessment of score performance in these settings.\u003c/p\u003e \u003cp\u003eOverall, the three clinical scoring systems showed good diagnostic confirmation when scores were high, but low scores were not reliable for excluding appendicitis in this surgically treated adult population. RIPASA showed the highest overall discrimination for appendicitis and favorable performance in perforation-focused analyses. These findings support the use of clinical scoring systems as adjuncts to clinical assessment and imaging rather than as stand-alone tools, and highlight the need for future prospective studies including non-operated patients and external validation across different diagnostic pathways (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the institutional Ethics Committee (decision no: 2025/75; meeting date: 12 June 2025; approval letter no: E-76988455-050.04-272053; dated 04 July 2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was not obtained because of the retrospective design and use of anonymized routinely collected data, in accordance with institutional policy and Ethics Committee approval.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthor Contributions Statement:All aspects of the study\u0026mdash;including conceptualization, data collection, analysis, interpretation, manuscript writing, and final approval\u0026mdash;were carried out solely by the author. The author accepts full responsibility for the work.Author Contributions Statement:Conceptualization, data collection, analysis and interpretation, manuscript drafting, and final approval were carried out by Suat Evirgen, Yasin Duran, and \u0026Ouml;nder Karabay. All authors contributed to the work, reviewed the final version, and approved it for publication.Corresponding Author:Suat [email protected]@gmail.com\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eThe authors thank the emergency department and pathology staff for their contributions to patient care and routine documentation.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e-Echevarria S, Rauf F, Hussain N, Zaka H, Farwa UE, Ahsan N, Broomfield A, Akbar A, Khawaja UA (2023) Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review. Cureus 15(4):e37024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.37024\u003c/span\u003e\u003cspan address=\"10.7759/cureus.37024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 37143626; PMCID: PMC10152406\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi - S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Catena F (2020) Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg surgery: WJES 15(1):27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-020-00306-3\u003c/span\u003e\u003cspan address=\"10.1186/s13017-020-00306-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e-Shahmoradi L, Safdari R, Mirhosseini MM et al (2023) Development and evaluation of a clinical decision support system for early diagnosis of acute appendicitis. Sci Rep 13:19703. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-023-46721-9\u003c/span\u003e\u003cspan address=\"10.1038/s41598-023-46721-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Al-Wageeh S, Alyhari QA, Ahmed F, Altam A, Alshehari G, Badheeb M (2024) Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study. Open Access Emerg Med 16:159\u0026ndash;166 PMID: 38994039; PMCID: PMC11236940\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Awayshih MMA, Nofal MN, Yousef AJ (2019) Evaluation of Alvarado score in diagnosing acute appendicitis. Pan Afr Med J 34:15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj.2019.34.15.17803\u003c/span\u003e\u003cspan address=\"10.11604/pamj.2019.34.15.17803\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 31762884; PMCID: PMC6859007\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Jose T, Rajesh PS (2021) Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis. Surg J (N Y) 7(3):e127\u0026ndash;e131. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0041-1731446\u003c/span\u003e\u003cspan address=\"10.1055/s-0041-1731446\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 34295969; PMCID: PMC8289675\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Naeem MT, Jamil MA, Anwar MI, Raza H, Asad A, Jamil H, Tahir MJ, Bai J, Ejaz Chauhan TM, Asghar MS (2022) Diagnostic accuracy of Alvarado scoring system relative to histopathological diagnosis for acute appendicitis: A retrospective cohort study. Ann Med Surg (Lond) 81:104561 PMID: 36147117; PMCID: PMC9486849\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvarez-Lozada LA, Fernandez-Reyes BA, Arrambide-Garza FJ, Garc\u0026iacute;a-Leal M, Alvarez-Villalobos NA, Mart\u0026iacute;nez-Garza JH, Fern\u0026aacute;ndez-Rodarte B, Elizondo-Oma\u0026ntilde;a RE, Quiroga-Garza A (2025) Clinical scores for acute appendicitis in adults: A systematic review and meta-analysis of diagnostic accuracy studies. Am J Surg 240:116123 Epub 2024 Dec 5. PMID: 39667296\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Korkut M, Bedel C, Karancı Y, Avcı A, Duyan M (2020) Accuracy of Alvarado, Eskelinen, Ohmann, RIPASA and Tzanakis Scores in Diagnosis of Acute Appendicitis; a Cross-sectional Study. Arch Acad Emerg Med 8(1):e20 PMID: 32259117; PMCID: PMC7130437\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Esmer G\u0026ouml;k\u0026ccedil;e M, Korkmaz İ, Tekin Y, Yurtbay S, Demirtaş E, \u0026Ouml;zsoy O, \u0026Ouml;zbay S (2020) Kukul G\u0026uuml;ven F. Comparison of alvarado and ripasa scores in patients with acute appendicitis. CMJ Dec 42(4):500\u0026ndash;506. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7197/cmj.828748\u003c/span\u003e\u003cspan address=\"10.7197/cmj.828748\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Akbar I, Shehzad JA, Ali S (2019 Jul-Sep) Diagnostic Accuracy Of Ripasa Score. J Ayub Med Coll Abbottabad 31(3):411\u0026ndash;414 PMID: 31535517\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Dezfuli SAT, Yazdani R, Khorasani M, Hosseinikhah SA (2020) Comparison between the specificity and sensitivity of the RIPASA and Alvarado Scoring systems in the diagnosis of acute appendicitis among patients with complaints of right iliac fossa. AIMS Public Health 7(1):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3934/publichealth.2020001\u003c/span\u003e\u003cspan address=\"10.3934/publichealth.2020001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 32258184; PMCID: PMC7109537\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Kaewlai R, Tongsai S, Teerasamit W, Wongsaengchan D, Noppakunsomboon N, Khamman P, Chatkaewpaisal A, Apisarnthanarak P (2023) Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings. Insights Imaging 14(1):191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13244-023-01540-4\u003c/span\u003e\u003cspan address=\"10.1186/s13244-023-01540-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 37973644; PMCID: PMC10654319\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Alemrajabi M, Zadeh MK, Davani SZ, Nasiri F, Riazi S, Nasiri M (2022) Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children. J Med Life 15(4):443\u0026ndash;447. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25122/jml-2021-0049\u003c/span\u003e\u003cspan address=\"10.25122/jml-2021-0049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 35646183; PMCID: PMC9126464\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Ghali MS, Hasan S, Al-Yahri O, Mansor S, Al-Tarakji M, Obaid M, Shah AA, Shehata MS, Singh R, Al-Zoubi RM, Zarour A (2023) Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis. Surg Open Sci 14:96\u0026ndash;102 PMID: 37577253; PMCID: PMC10413131\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYılmaz -M, Aytekin A, Yılmaz L, Bulut A (2023) Evaluation of the Efficiency of Four Different Scoring Systems in the Diagnosis of Acute Appendicitis. CBU-SBED 01 Aralık 10(4):399\u0026ndash;404. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.34087/cbusbed.1183468\u003c/span\u003e\u003cspan address=\"10.34087/cbusbed.1183468\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Zeb M, Khattak SK, Samad M, Shah SS, Shah SQA, Haseeb A (2023) Comparison of Alvarado score, appendicitis inflammatory response score (AIR) and Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score in predicting acute appendicitis. Heliyon 9(1):e13013 PMID: 36711320; PMCID: PMC9876948\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Dr (2020) Ali Saadi Omar and Dr. Sattar Jabbar Kadhim. Accuracy of lintula score versus alvarado score in diagnosis of acute appendicitis in Al-yarmouk teaching hospital. Int J Surg Sci 4(4):18\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.33545/surgery.2020.v4.i4a.532\u003c/span\u003e\u003cspan address=\"10.33545/surgery.2020.v4.i4a.532\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Dr, Ojuka D, Sangoro M (2018) Alvarado vs Lintula Scoring Systems in Acute Appendicitis. Annals of African Surgery. 14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4314/aas.v14i1.5\u003c/span\u003e\u003cspan address=\"10.4314/aas.v14i1.5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Poillucci G, Podda M, Oricchio D, Medina KL, Manetti G, De Angelis R (2022) Comparison between AIR, Alvarado and RIPASA scores in the diagnosis of acute appendicitis in a Western population. A retrospective cohort study. Ann Ital Chir 93:427\u0026ndash;434 PMID: 36156491\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Sevin\u0026ccedil; B, Damburacı N, Karahan \u0026Ouml; (2025) Nonoperative management of uncomplicated acute appendicitis; results of 5 years follow. Langenbecks Arch Surg 410(1):292. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-025-03811-8\u003c/span\u003e\u003cspan address=\"10.1007/s00423-025-03811-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 41055745; PMCID: PMC12504381\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- G\u0026uuml;ler İ, Satılmış D, \u0026Ouml;meroğlu S, Balcı N (2023) The Effectiveness of Appendicitis Inflammatory Response Score in the Evaluation of Acute Appendicitis: A Meta-analysis. Hamidiye Med J 4(1):15\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4274/hamidiyemedj.galenos.2023.98159\u003c/span\u003e\u003cspan address=\"10.4274/hamidiyemedj.galenos.2023.98159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Arslan HC, Kilic TY, Idil H, Imamoglu T, Yesilaras M (2019) Computed Tomography In Differential Diagnosis Of Abdominal Pain Among Patients With Suspected Acute Appendicitis. Anatol J Emerg Med 2(3):17\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://izlik.org/JA94AK42ZH\u003c/span\u003e\u003cspan address=\"https://izlik.org/JA94AK42ZH\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ (2008) The impact of helical computed tomography on the negative appendectomy rate: a multi-center comparison. J Emerg Med 34(1):3\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jemermed.2007.05.042\u003c/span\u003e\u003cspan address=\"10.1016/j.jemermed.2007.05.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2007 Nov 26. PMID: 18022782\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Henriksen SR, Christophersen C, Rosenberg J, Fonnes S (2023) Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis. Langenbecks Arch Surg. ;408(1):205. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-023-02935-z\u003c/span\u003e\u003cspan address=\"10.1007/s00423-023-02935-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37219616\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Engin O, Calik B, Yildirim M, Coskun A, Coskun GA (2011) Gynecologic pathologies in our appendectomy series and literature review. J Korean Surg Soc 80(4):267\u0026ndash;271. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4174/jkss.2011.80.4.267\u003c/span\u003e\u003cspan address=\"10.4174/jkss.2011.80.4.267\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2011 Apr 12. PMID: 22066046; PMCID: PMC3204677\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Chisthi MM, Surendran A, Narayanan JT (2020) RIPASA and air scoring systems are superior to alvarado scoring in acute appendicitis: Diagnostic accuracy study. Ann Med Surg (Lond) 59:138\u0026ndash;142 PMID: 33024555; PMCID: PMC7527659\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Frountzas M, Stergios K, Kopsini D, Schizas D, Kontzoglou K, Toutouzas K (2018) Alvarado or RIPASA score for diagnosis of acute appendicitis? A meta-analysis of randomized trials. Int J Surg 56:307\u0026ndash;314 Epub 2018 Jul 12. PMID: 30017607\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M (2005) A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 390(2):164\u0026ndash;170. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-005-0545-8\u003c/span\u003e\u003cspan address=\"10.1007/s00423-005-0545-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2005 Feb 19. PMID: 15723233\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Banlı Cesur İ, Sarı G\u0026ouml;kay S (2021) Comparison of Appendicitis Scoring Systems in Pediatric Patients. J Contemp Med July 11(4):510\u0026ndash;514. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.16899/jcm.876825\u003c/span\u003e\u003cspan address=\"10.16899/jcm.876825\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Bom WJ, Scheijmans JCG, Salminen P, Boermeester MA (2021) Diagnosis of Uncomplicated and Complicated Appendicitis in Adults. Scand J Surg. ;110(2):170\u0026ndash;179. doi: 10.1177/14574969211008330. Epub 2021 Apr 14. PMID: 33851877; PMCID: PMC8258714\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Talan DA, Di Saverio S (2021) Treatment of Acute Uncomplicated Appendicitis. N Engl J Med. ;385(12):1116\u0026ndash;1123. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMcp2107675\u003c/span\u003e\u003cspan address=\"10.1056/NEJMcp2107675\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34525287\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Salminen P, Paajanen H, Rautio T, Nordstr\u0026ouml;m P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Gr\u0026ouml;nroos JM (2015) Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. ;313(23):2340-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2015.6154\u003c/span\u003e\u003cspan address=\"10.1001/jama.2015.6154\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 26080338\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Salminen P, Paajanen H, Rautio T, Nordstr\u0026ouml;m P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Gr\u0026ouml;nroos JM CODA Collaborative, Flum, D. R., Davidson, G. H., Monsell, S. E., Shapiro, N. I.,Odom, S. R., Sanchez, S. E., Drake, F. T., Fischkoff, K., Johnson, J., Patton, J.H., Evans, H., Cuschieri, J., Sabbatini, A. K., Faine, B. A., Skeete, D. A., Liang,M. K., Sohn, V., McGrane, K., Kutcher, M. E., \u0026hellip; Talan, D. A. (2020). A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. \u003cem\u003eThe New England journal of medicine\u003c/em\u003e, \u003cem\u003e383\u003c/em\u003e(20), 1907\u0026ndash;1919. https://doi.org/10.1056/NEJMoa2014320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi - S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R (2016) WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 11:34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13017-016-0090-5\u003c/span\u003e\u003cspan address=\"10.1186/s13017-016-0090-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 27437029; PMCID: PMC4949879\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA (2015) Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 102(8):979\u0026ndash;990. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/bjs.9835\u003c/span\u003e\u003cspan address=\"10.1002/bjs.9835\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2015 May 12. PMID: 25963411\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Khan S, Usama M, Basir Y, Muhammad S, Jawad M, Khan T, Usman A, Abbas A Evaluation Of Modified Alvarado, Ripasa And Lintula Scoring System As Diagnostic Tools For Acute Appendicitis. J Ayub Med Coll Abbottabad 2020 Jan-Mar ;32(1):46\u0026ndash;50. PMID: 32468754.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Rodriguez-Garcia FA, Rodr\u0026iacute;guez-S\u0026aacute;nchez CE, Naranjo-Ch\u0026aacute;vez JC, Torres-Ortiz-Ocampo CJ, Rojas-Larios F, Covarrubias-Ram\u0026iacute;rez K, Evangelista-Ruiz EM, Torres-Salazar QL (2025) Assessment of negative appendectomy in acute appendicitis diagnoses. Surg Pract Sci 21:100281 PMID: 40270918; PMCID: PMC12017968\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute appendicitis, Alvarado, RIPASA, Lintula, perforation, complicated appendicitis","lastPublishedDoi":"10.21203/rs.3.rs-8875060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8875060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e Clinical scoring systems are frequently used to support decision-making in suspected acute appendicitis; however, their value for severity stratification is less well defined. We compared the diagnostic performance of the Alvarado, RIPASA, and Lintula scores in a surgically managed adult cohort and examined their relationship with histopathological subtypes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective observational study included 312 adults who underwent appendectomy for suspected acute appendicitis between May 2024 and April 2025 at Amasya University Şerefeddin Sabuncuoğlu Training and Research Hospital.Clinical variables recorded at emergency department presentation were used to derive Alvarado, RIPASA, and Lintula scores, which were calculated retrospectively from chart data. Histopathology served as the reference standard. Using literature-recommended cutoffs, sensitivity, specificity, positive and negative predictive values (PPV and NPV), accuracy, and the Youden index were calculated. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Mean age was 29.77 ± 9.55 years, and 58.7% were male. Laparoscopic appendectomy was performed in 97.8% of cases. Appendicitis was confirmed histologically in 90.1%, with phlegmonous (49.4%), gangrenous (22.4%), and perforated (18.3%) subtypes; the negative appendectomy rate was 9.9%. At standard thresholds, sensitivity/specificity were 67.3%/71.0% (Alvarado), 76.1%/77.4% (RIPASA), and 70.1%/64.5% (Lintula). PPV was high (94.7%–96.8%), whereas NPV was low (19.2%–26.4%). AUC values were 0.765, 0.857, and 0.829 for Alvarado, RIPASA, and Lintula, respectively. Mean scores increased with histopathological severity (p \u0026lt; 0.001). In perforation-focused analysis, RIPASA showed the highest AUC (0.922).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e In this surgically managed cohort, all three scores demonstrated strong rule-in performance when positive. RIPASA showed the highest overall discrimination and favourable performance in perforation-focused analysis. Nevertheless, the consistently low NPV limits their utility as standalone rule-out tools; scoring systems should be interpreted alongside clinical assessment and imaging.\u003c/p\u003e","manuscriptTitle":"Preoperative Clinical Scores for Predicting Complicated Appendicitis İn Surgically Managed Adults: Comparative Performance of Alvarado, Ripasa, and Lintula","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 07:12:06","doi":"10.21203/rs.3.rs-8875060/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-12T07:02:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-11T18:14:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-11T03:10:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bulletin of the National Research Centre","date":"2026-03-09T21:08:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa3012fb-7569-4d10-bd23-ec376792703d","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T17:25:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 07:12:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8875060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8875060","identity":"rs-8875060","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}