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DOI: http://dx.doi.org/10.18203/2349-2902.isj20174173
Original Research Article
*Correspondence:
Dr. Arun Kumar S. Lakshminarasimhaiah,
E-mail: arunsdumc006@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Tzanakis scoring system is a combination of clinical evaluation, ultrasonography and laboratory marker
of inflammatory response, used as accuracy of diagnosis of acute appendicitis. Objective of this study was to evaluate
the predictability of Tzanakis scoring system in preoperative diagnosis of acute appendicitis and compare its accuracy
with histopathological examination (HPE).
Methods: A prospective non-randomized study was designed to study those patients who suspected clinically as
acute appendicitis, admitting to Department of General Surgery, ESIC-MC PGIMSR, Bangalore between November
2013 to July 2015. After complete clinical examination, radiological and laboratory investigations Tzanakis score was
calculated and patients with score 8 or >8 underwent appendicectomy and HPE results were analyzed.
Results: Out of 218 participants, 200 patients underwent emergency appendicectomy and were selected for the study.
The sensitivity and specificity of Tzanakis score was 85.49% and 71.43% respectively. The overall diagnostic
accuracy was 85% with positive predictive value of 98.80% and negative value of 15.15%.
Conclusions: Tzanakis scoring system is an effective modality in the establishment of accuracy in diagnosis of acute
appendicitis, but the limitation is observer bias which may vary the scoring system.
appendicitis, admitting to Department of General the serosa, histological diagnosis of acute suppurative
Surgery, ESIC-MC PGIMSR, Bangalore between appendicitis was made. If the mucosa was absent, the
November 2013 to July 2015. Permission of institutional wall was necrotic and thrombosed vessels were present it
ethical committee was taken prior to the study. was diagnosed as gangrenous appendicitis.
Patients with the clinical diagnosis of acute appendicitis Histological reports were followed up and recorded in the
and undergoing surgery and willing to participate in the preformed performa sheet. The final diagnosis of acute
study were included in this study. Those patients having appendicitis was based on histological diagnosis.
generalized peritonitis, appendicular abscess,
appendicular lump/mass, blunt trauma abdomen, Statistical analysis
recurrent appendicitis and pregnancy were excluded from
the study. Out of 218 participants assessed for this study, Data was analysed using Microsoft excel 2013 and SPSS
200 patients underwent emergency appendicectomy and version 16. Frequencies, percentages, mean with standard
were selected for the study. Written informed consent deviation and p values were calculated. Significance of
was taken from the patients who fell into the inclusion the results was tested by using the independent T- test,
criteria of the study. chi-square test and Fisher's Exact Test. Measures of
binary classifications (i.e., sensitivity, specificity, positive
After complete clinical examination, radiological and predictive value (PPV), negative predictive value (NPV),
laboratory investigations Tzanakis score was calculated diagnostic accuracy) were calculated from confusion
and patients with score 8 or >8 underwent matrix, a two by two table dataset. The ‘p’ value of less
appendicectomy and HPE results were analyzed. Initial than 0.05 was regarded as significant.
evaluation of patients was conducted. Ultrasound of
abdomen and pelvis, total and differential leucocyte RESULTS
count, routine microscopic examination of the urine and
other necessary investigation were carried out. Detailed Two hundred eighteen patients with clinical diagnosis of
history, physical examination findings and investigation acute appendicitis were assessed for their eligibility from
report were recorded on a preformed Performa. The July 2013 to June 2014. Out of them 12 patients refused
diagnosis of acute appendicitis was done on the basis of to participate in the study and 6 patients had alternative
clinical judgment. Subsequently Tzanakis scoring was diagnosis during surgery (3 salpingitis, 2 patients with
done and recorded. Even when the new score was less ovarian cyst and meckeles diverticulum). Finally a total
than 8, if clinical suspension was high patient were of 200 patients underwent emergency appendicectomy
subjected for appendectomy. and were selected for study.
Tzanakis scoring:5
females and 33 males) were in third to fourth decade. (30) had score between 4 and 6, 5.5% (11) had score
Among the patients only two male patients were having between 7 and 9, majority 57.5% (115) were between
more than 60 years. score 10 to 12 and 22% had score more than 13.
33
35 30 AA 170 85.0
30 26 Total 200 100.0
25 21
20 Female Tzanakis scores in acute appendicitis, acute on chronic
14
15 Male (A on C) appendicitis and chronic appendicitis group is
10
44 4
6
4
presented in Table 4. The minimum Tzanakis score in
5 2 2 acute appendicitis (AA) group was 4 and maximum was
0
0 15 with a mean score of 10.24, while the mean score for
acute gangrenous appendicitis (AGA) group was 12.58,
mean score for acute suppurative appendicitis (ASA)
Age (in years) group was 13.03, for chronic appendicitis (CA) it was
8.95 and for normal histopathological group it was 6.43
with a significant p value.
Figure 2: Age-wise distribution of sex.
Table 3: Tzanakis score-wise distribution of patients.
Patients had acute appendicitis, subacute and chronic
appendicitis accounting to 85%, 0.5% and 11% of the Tzanakis Score Frequency Percentage (%)
total patients respectively. The results are shown in Table 0-3 0 0.0
2. 4-6 30 15.0
7-9 11 5.5
In this study of 200, none had Tzanakis score less than 3, 10-12 115 57.5
in score between 4-6, 7-9, 10-12 and 13-15 patients had 13-15 44 22.0
histological evidence of acute appendicitis were 30, 11, Total 200 100
115, 44 respectively (Table 3). Out of 200 patients 15%
Table 5 shows definite association between Tzanakis among the study participants were having 10-12 scores
score and histopathological outcome with significant p followed by 13-15 (44; 22%).
value. The highest numbers of patients (115; 57.5%)
HPE
Tzanakis Score Total P-value
A ON C AA AGA ASA CA N RA SAA
0-3 0 0 0 0 0 0 0 0 0
4-6 1 16 0 0 7 4 2 0 30
7-9 0 2 4 2 2 1 0 0 11 0.005
10-12 6 79 5 7 11 2 4 1 115
13-15 0 2 17 22 2 0 1 0 44
Total 7 99 26 31 22 7 7 1 200
N- Normal HPE; AA- acute appendicitis; ASA- acute suppurative appendicitis; AGA- acute gangrenous appendicitis; A ON C- acute
on chronic appendicitis; CA- chronic appendicitis; RA- reccurent appendicitis.
HPE
Tzanakis Score Total
N SAA CA UA
<8 5 0 8 20 33
8 2 1 14 150 167
Total 7 1 22 170 200
N- Normal HPE; CA- chronic appendicitis.
HPE diagnosis
Tzanakis score Total Kappa Value (p-value)
Positive Negative
Positive 165 2 167
0.204
Negative 28 5 33
(0.000)
Total 193 7 200
Negative appendicectomy is not devoid of complications, systems. This scoring system has the sensitivity,
though the mortality is low, it can be associated with the specificity and diagnostic accuracy was 95.4%, 97.4%
mortality of 10 to 15%. Negative appendicectomy is and 96.5% respectively.9 The sensitivity and specificity
associated with significant hospital stay. Hence, negative of Tzanakis score ≥ in diagnosis of acute appendicitis in
appendicectomy should be lowered as low as possible.6 this study was 85.49% and 71.43% respectively. The
overall diagnostic accuracy was 85% with positive
Gallego et al reported the incidence of appendicitis in 2nd predictive value of 98.80% and negative value of
and 4th decade of life was 52%.7 We found incidence of 15.15%.
acute AA, in 80 patients (40%) patients in 2nd to 3rd
decade and 27% in 3rd to 4th decade which is similar to Negative appendectomy rate was low in our institute and
the reported results. Sharma et al also reported similar the current study has also supported this fact. Previously
findings in their studies. They found mean study the negative appendectomy rate was ten percent whereas
population was 24.81±11.69 years with sex ratio this study has shown a negative appendectomy rate of six
(male:female) 1.13:1.8 In this study we found, the mean percent. Majority of our patients have delayed
age of study participants was 27.81±11.06 years with sex presentation which increases rate of positive clinical
ration (m:f) 1.6:1 which is comparable with the previous findings as well as laboratory parameters for AA. This
reports. has probably led to more accurate preoperative diagnosis
and hence the lower rate of negative appendectomy in our
Along with clinical examination, various laboratory setup.
parameters of inflammation (TLC, CRP), USG, CT and
laparoscopy are used to establish an accurate diagnosis of Present study has a sensitivity and positive predictive
acute appendicitis. Numerous scoring systems have been value and diagnostic accuracy which is comparable with
developed to aid in preoperative diagnosis of acute the original Tzanakis scoring system with specificity at a
appendicitis viz. Alvarado and modified Alvarado score lesser side. But sensitivity and specificity is better than
is being used worldwide.4 The Tzanakis scoring system many existing scoring systems as shown in the table.
found to be superior to the previously formulated scoring
Figure 3: Inflammed appendix with gangrenous Figure 4: Inflamed appendix with enlarged tip.
changes at the base.
And another study by Malla BR et al for a sample size of
Sigdel et al, reported, for a sample size of 100 patients 200 patients with sensitivity, specificity, positive
with sensitivity, specificity and overall diagnostic predictive value and negative predictive value 86.9%,
accuracy were 91.48%, 66.66% and 90% respectively.10,11 75.0%, 97.5% and 33% respectively.12
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