BACKGROUND Acute abdominal pain in children often raises concern for surgical emergencies such as appendicitis. However, autoinflammatory disorders, including familial Mediterranean fever (FMF), may mimic acute abdomen, leading to diagnostic confusion and potentially unnecessary surgeries. CASE SUMMARY We present two contrasting pediatric cases, both of whom initially presented with acute right lower quadrant abdominal pain and tenderness. The first was a 5.5-year-old girl with fever who underwent appendectomy despite no sonographic evidence of appendicitis, yet her clinical score (Alvarado score) was highly suggestive of appendicitis. The second was a 5.5-year-old boy who was afebrile but had abdominal sonographic findings of a slightly inflamed appendix. He improved with conservative management and intravenous antibiotics. Upon second presentation, both were ultimately diagnosed with FMF. CONCLUSION FMF can mimic appendicitis in children; careful history, clinical suspicion, and judicious imaging help prevent unnecessary surgery during acute attacks.

Appendectomy is the current standard of care for acute appendicitis. However, accumulating international evidence suggests that medical antibiotic therapy is not inferior to appendectomy. Local factors may work for and against a medical approach. While prospective randomized trials are still to be performed in a South African setting, this study aimed to describe existing data within a geographically defined area. A retrospective audit from 01/01/2018-31/12/2023 was performed at George Regional Hospital, South Africa. All adults and children over 12years with a clinical or radiological diagnosis of acute appendicitis, without complicated disease mandating direct surgical appendectomy, were identified and separated into two groups, namely, those with initial medical management and those who underwent direct appendectomy. The primary aims were to compare the presentations and outcomes of acute appendicitis managed by antibiotic therapy or appendectomy. Secondary aims included describing the proportion of cases eligible for medical management, as well as post-treatment complications, including the recurrence rate. Analysis was descriptive and comparative with patients grouped as Direct Surgery (DS), Antibiotics Successful (AS) and Antibiotics Unsuccessful (AU). Direct surgical appendectomy was performed on 44% of the 650 cases. Of 365 (56%) cases that received antibiotic therapy, 190 (52%) were discharged without symptoms (AS), while 175 (48%) failed antibiotic therapy and underwent surgical appendectomy (AU) during first admission. Of the 190 patients who were discharged after antibiotic therapy only, 16 had recurrent symptoms, of which 14 underwent surgery and 2 had repeat antibiotic therapy. When comparing the AS to AU group, AS cases had a lower median heart rate (89 vs. 95 bpm; p<0.05), lower C-reactive protein level (51 vs. 108mg/L; p<0.01) and lower Alvarado score (6 vs. 7; p<0.01). Patients in the AS group had a median hospitalization of one day less than the DS group (p<0.001), and twodays less than the AU group (p<0.001). When compared with DS, patients in the AU group experienced significantly fewer (p<0.001) Clavien-Dindo grade 3-5 events. Half of patients with acute appendicitis treated medically, safely avoided appendectomy. In this context, antibiotic therapy may be considered in selected patients.

Preoperative prediction of complicated acute appendicitis using the appendicitis inflammatory response (AIR) score.

Background: Acute appendicitis in girls presenting with lower abdominal pain remains a frequent diagnostic dilemma because of the overlap in clinical presentation with gynaecological and non-surgical causes. This study aimed to evaluate the diagnostic performance of IL-6 and CD64 and to compare them with classical inflammatory markers and the Alvarado score. Methods: We conducted a prospective observational diagnostic-accuracy study over a three-year period (December 2022 to December 2025) at the First University Paediatric Surgery Clinic, General Hospital of Thessaloniki “Georgios Gennimatas”. Consecutive girls aged ≤16 years presenting with lower abdominal pain were included. The primary outcome was appendicitis (yes/no), defined by the final clinical diagnosis and, where applicable, intraoperative and/or histopathological confirmation. Diagnostic performance was assessed using ROC curves and AUCs with 95% confidence intervals estimated by the DeLong method. The prespecified primary regression model included the Alvarado score and IL-6; IL-6 was summarised on its original scale and log1p-transformed only for regression analyses to account for right-skewness. Additional multivariable models were exploratory. Results: Of 74 initially assessed cases, one was excluded (appendiceal neuroendocrine tumour, NET G1), yielding a final sample of 73 girls: 37 with appendicitis and 36 without appendicitis. IL-6 was higher in the appendicitis group (median 19.41 vs. 4.10 pg/mL) and showed moderate discrimination (AUC 0.696). CRP showed lower to borderline performance (AUC 0.595), whereas CD64 did not demonstrate useful discrimination (AUC 0.521). The Alvarado score had the highest discriminatory ability (AUC 0.885). In the subset with complete data, adding IL-6 to the Alvarado score did not materially improve discrimination. Conclusions: IL-6 showed moderate diagnostic performance as a standalone biomarker and may be useful as an adjunct, particularly when a clinical score is unavailable or unreliable. CD64 did not add meaningful diagnostic information in this setting. Larger, prespecified studies are required to determine clinically useful cut-offs and to clarify whether IL-6 offers incremental value beyond established clinical assessment.

Abstract Background: Acute appendicitis is a common surgical emergency with a lifetime incidence of 7–8%. Diagnosis remains challenging due to overlapping clinical features with other abdominal and pelvic conditions, leading to delayed treatment or negative appendectomy. Clinical scoring systems such as the Alvarado and RIPASA scores have been developed to improve diagnostic accuracy. However, comparative validation in the Indian population remains limited. Aims and Objectives: To compare the diagnostic accuracy of the Alvarado and RIPASA scoring systems in predicting acute appendicitis in an Indian population, using histopathology as the gold standard. Materials and Methods: A prospective study was conducted from June 2022 to January 2024 at two tertiary care hospitals in New Delhi. A total of 121 patients aged 1–70 years with suspected acute appendicitis who underwent appendectomy were included. Both Alvarado and RIPASA scores were calculated at presentation. Cut-off values of ≥7 (Alvarado) and ≥7.5 (RIPASA) were used. Histopathological examination confirmed the diagnosis. Diagnostic performance was evaluated using Receiver Operating Characteristic (ROC) curve analysis to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy. Results: Of 121 patients, 110 (90%) had histopathologically confirmed appendicitis. The mean Alvarado score was 6.5 ± 1.9, and the mean RIPASA score was 9.9 ± 1.9. ROC analysis showed good predictive ability for Alvarado (AUC = 0.789, P = 0.002) and excellent predictive ability for RIPASA (AUC = 0.991, P &lt; 0.001). The Alvarado score demonstrated sensitivity 58.2%, specificity 81.8%, and overall accuracy 60.3%, whereas the RIPASA score showed sensitivity 97.3%, specificity 90.9%, and overall accuracy 96.7%. Conclusion: The RIPASA score demonstrated superior diagnostic accuracy compared to the Alvarado score and may serve as a more reliable clinical tool for diagnosing acute appendicitis in the Indian population.

Background: The Alvarado score is widely used to risk-stratify suspected acute appendicitis; however, its diagnostic performance may vary across age groups.Aim: To compare the diagnostic discrimination of the Alvarado score between adults (≥18 years) and children (<18 years) using receiver operating characteristic (ROC) analysis, with the primary outcome being the difference in area under the curve (AUC) between groups. Secondary analyses evaluated diagnostic performance at predefined clinical thresholds (>7 and ≥5).Methods: This retrospective cohort study included 743 consecutive patients evaluated for suspected appendicitis. The index test was the Alvarado score derived from documented presentation findings. The reference standard was histopathological confirmation of appendicitis. Patients were categorized into children and adults. Discrimination was assessed using ROC analysis, and diagnostic performance was evaluated at predefined thresholds (high >7; equivocal ≥5), reporting sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ROC curves were compared between adults and children using the DeLong test.Results: The Alvarado score demonstrated moderate diagnostic discrimination in both groups. The area under the ROC curve (AUC) was 0.685 in adults and 0.732 in children, with no statistically significant difference between groups (DeLong p = 0.305). At the high threshold (>7), overall sensitivity was 50.5%, with 48.5% in adults and 55.7% in children, while specificity was 80.4% in adults and 78.7% in children (80.0% overall). At the equivocal threshold (≥5), sensitivity increased to 84.3% in adults, 91.4% in children, and 86.3% overall, with specificity decreasing to 25.7% in adults, 24.6% in children, and 25.4% overall. Positive predictive values ranged from 69.7% to 85.7%, while negative predictive values ranged from 43.5% to 55.6%.Conclusions: The Alvarado score demonstrated moderate diagnostic discrimination in both adults and children, with no statistically significant difference in ROC performance between groups. At the traditional high threshold (>7), sensitivity was limited, whereas lower thresholds (≥5) increased sensitivity with reduced specificity. These findings support the use of the Alvarado score as a clinical risk stratification tool in both age groups.

Ultrasound (US) is the first-line imaging test for suspected pediatric acute appendicitis (AA), yet false-negative examinations remain a concern and may delay diagnosis. Clinical and inflammatory factors may influence this risk but have not been well defined. The aim of this study was to identify predictors of false-negative US in children with suspected AA. We conducted a prospective cohort study from 1 January 2022 to 31 October 2025 including children presenting with suspected AA whose initial abdominal US was negative. Multivariable logistic regression identified independent predictors of false-negative US. Among 1174 children evaluated, 610 had a negative US and were included in the analysis. Of these, 54 were ultimately diagnosed with AA (false-negative US). The median age was 10years and males accounted for 51.3% of the cohort. On univariable analysis, male sex, symptom duration >48h, Pre-hospital antibiotic administration, admission temperature >38°C, Alvarado score≥5, white blood cell count>10×109/L, and C-reactive protein (CRP)≥10mg/L were significantly associated with false-negative findings. In multivariable analysis, three factors remained independently predictive: Alvarado score ≥5 (OR 10.53; 95% CI 4.49-24.70; p<0.001), symptom duration >48h (OR 4.54; 95% CI 2.18-9.45; p<0.001), and CRP≥10mg/L (OR 2.25; 95% CI 1.03-4.92; p=0.042). False-negative US occurred in 8.9% of children with suspected AA. Higher Alvarado scores, prolonged symptoms, and elevated CRP were independently associated with missed AA despite negative imaging.

Acute appendicitis (AA) is one of the most common causes of acute abdomen. Its diagnosis requires the combined evaluation of clinical, laboratory, and radiological findings. This study aimed to compare the effectiveness of the MASS (Modified Alvarado Score), RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) Score, AIR (Appendicitis Inflammatory Response) Score, and AAS (Adult Appendicitis Score) in the diagnosis of AA. This single-center, prospective, observational cohort study was conducted in the emergency department (ED) of a tertiary hospital. Patients aged 18 years and older with suspected AA who presented to the ED were included in the study. Patients’ demographic characteristics, clinical findings, laboratory, and imaging results were recorded. MASS, RIPASA, AIR, and AAS scores were calculated. Patients were divided into two groups based on their ED management: surgical and conservative. In the surgical group, intraoperative findings and/or histopathological results were taken as the gold standard for the final diagnosis. In the conservative group, the presence of appendicitis in patients with alternative or indefinite diagnoses was re-evaluated after a 4-week follow-up period. Patients were divided into two groups based on their final diagnosis: ‘AA’ and ‘non-AA’, A total of 238 patients were included, of whom 110 (46.2%) were diagnosed with AA. All four scoring systems demonstrated statistically significant discrimination between AA and non-AA groups. The AUC values were 0.736 for MASS, 0.719 for RIPASA, 0.786 for AIR, and 0.822 for AAS. At the optimal cut-off values determined by the Youden index, AAS showed the highest sensitivity (81.8%), while AIR demonstrated the highest specificity (77.3%). Pairwise DeLong comparisons indicated that AAS had significantly higher AUC values than MASS and RIPASA. The negative appendectomy rate in this cohort was 12.1%. These findings, while specific to this cohort, suggest that AAS may function as a supportive tool in AA risk stratification; however, external validation is needed in larger, multicenter populations.

Background: One of the most frequent emergency surgeries is an appendectomy. It is necessary to differentiate the diagnosis from other causes of discomfort in that area of the abdomen, such as right-sided salphingoophoritis and acute ureteric colic. These days, the preferred diagnostic techniques include contrast-enhanced CT scans and ultrasounds. The necessity for a trustworthy scoring system for the diagnosis of acute appendicitis is increased by the fact that, despite the availability of these facilities in urban regions, rural areas continue to struggle with delayed diagnosis and negative appendectomy. The modified Alvardo scoring system for the diagnosis of acute appendicitis will be assessed here. Methods: 92 consecutive cases of suspected acute appendicitis that were admitted, examined, and treated between February 2025 and July 2025 are included in this observational cross-sectional hospital-based study at SKMCH, Muzaffarpur, Bihar. Each patient's modified Alvardo score is computed and compared to the histological results of the appendix that was operated on. Results: According to the above study, the modified Alvardo score 7-9 has a high sensitivity of 93.10% for male and 77.78% for female. The modified Alvardo score of 7-9 showed an overall sensitivity of 83.63%. Conclusions: We conclude that the modified Alvardo score of 7-9 is an effective diagnostic tool for male. However, it can be utilized as a diagnostic tool in addition to imaging investigations in females because of its lesser sensitivity and high percentage of negative appendectomy results.

Acute Appendicitis stands as the leading cause of acute abdominal pain necessitating surgical intervention in the world. The initial clinical assessment of patients suspected of having acute appendicitis remains crucial. The aim is to quickly confirm or rule out the diagnosis to minimize delays, avoid unnecessary surgeries. The aim of our study is to evaluate the predictive value of multiple scoring systems for Diagnosis of acute appendicitis cases with correlation between scores prediction results and surgical interventions results. This a prospective study carried out in Mansoura university hospitals and Mansoura emergency hospital in the period between December 2024 and June 2025. Patients included in the study were admitted at emergency department of General Surgery at Mansoura University Hospital. The study was explained in details to the whole patients sharing in the study and a written informed consent was taken from all the patients. All patient presented with suspected acute appendicitis were subjected to four scores with comparing between them : Alvarado score, Appendicitis Inflammatory Response score (AIR), The RIPASA (Raja Isteri Pengiran Anak Saleha Appendicitis) score and AAS (Adult Appendicitis Score). ROC curve analysis demonstrated variable diagnostic performance among the evaluated scoring systems for acute appendicitis. The Adult Appendicitis Score (AAS) showed the highest discriminatory ability with an AUC of 0.988 (p = 0.001), followed by the Appendicitis Inflammatory Response (AIR) score (AUC = 0.920, p = 0.005) and the RIPASA score (AUC = 0.825, p = 0.03). The Alvarado score demonstrated comparatively lower accuracy (AUC = 0.715, p = 0.155). At their respective optimal cutoff points, AAS and AIR achieved high sensitivity and overall accuracy, with AAS demonstrating an apparent specificity of 100%. These findings suggest superior diagnostic performance of AAS and AIR compared with Alvarado and RIPASA in the studied population. Among the evaluated clinical scoring systems, the Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score demonstrated the highest diagnostic accuracy for acute appendicitis, with AAS showing the best overall performance. These scoring systems may represent reliable tools for supporting clinical decision-making and improving diagnostic confidence, potentially reducing unnecessary imaging or negative appendectomies. However, further validation in larger, more diverse cohorts is required before firm recommendations can be made.

Background: Multiple studies demonstrate that the Alvarado Score is less effective than other studies in predicting the incidence of patients with suspected acute appendicitis. It does not distinguish between ages and does not suggest a clinical stage of the disease. However, its use is still current in our unit and in most hospitals in our country. General Objective: To identify the utility of the Alvarado Score in patients with suspected acute appendicitis in relation to imaging results. Materials and Methods: Descriptive, observational, cross-sectional, retrospective study, which was carried out with 62 records of patients with suspected acute appendicitis and who were requested imaging studies at the Regional General Hospital 1 of Orizaba, Veracruz with the suspected diagnosis of Acute Appendicitis during the period from December 1, 2017 to November 30, 2022. Patients of any age group and both sexes who came to the emergency service with pain in the right iliac fossa and classified with the Alvarado scale that met the selection criteria were included. This study was conducted from March 1 to September 30, 2023. Data analysis included descriptive statistics for qualitative variables using frequencies and percentages, as well as measures of dispersion. For quantitative variables, such as mean and standard deviation, the Fisher exact test was used between variables with two categories based on the nature of the categorical variables. SPSS 23 and GraphPad Prism 8 software were used. Resources and infrastructure: those of the institution, the patients, and the researcher. Group experience: There is a master's degree in science and a radiologist with experience in ultrasound and CT interpretation. A resident physician who will carry out the activities of the research project. Results: The female sex predominated with a frequency of 40 patients (56.33%) with a mean age of 28.80 years, standard deviation +/- 19.36 (95% CI 22.61-34.99), of the male sex a frequency of 31 patients (43.66%) was observed with a mean age of 28.16 years, standard deviation +/- 17.69, the time of onset of symptoms: 35 patients (49.3%) began with symptoms at 24 hours, followed by 15 patients (21.1%) at 12 hours, 11 patients (15.5%) at 72 hours, 7 patients reported onset of symptoms at 48 hours (9.9%). The relationship between the Alvarado scale and imaging studies was identified using Fisher's exact test. The P value was 0.8791, which is considered statistically insignificant. Conclusion: The Alvarado score has proven to be a useful, simple, noninvasive, and rapid tool for guiding the diagnosis of acute appendicitis. However, due to its low specificity, the use of imaging studies is always recommended to confirm suspected diagnoses.

Acute appendicitis is the most common diagnosis considered in patients presenting to the emergency department with right lower quadrant pain. However, atypical presentations often lead to unnecessary surgeries and increased healthcare costs. This study aimed to improve diagnostic accuracy in acute appendicitis using a hybrid machine learning (ML) model. A retrospective analysis was performed on 395 patients who underwent appendectomy for suspected acute appendicitis between 2020 and 2024 at Ankara University Faculty of Medicine, Department of General Surgery. Demographic, clinical, laboratory, and radiological variables were collected. ML algorithms, including NaiveBayes, MultilayerPerceptron, IBk, AdaBoost, RandomForest, and a hybrid model combining NaiveBayes, AdaBoost, and RandomForest, were applied. The dataset was evaluated using 10-fold cross-validation, repeated 1,000 times. Accuracy, F-measure, Matthews Correlation Coefficient (MCC), receiver operating characteristic (ROC) area, and precision-recall curve (PRC) area were used as performance criteria. Among the 395 patients, 52.9% were male, with a mean age of 37.3+-15.6 years. Histopathological examination confirmed acute appendicitis in 341 (86.3%) patients and negative appendectomy in 54 (13.7%) patients. The diagnostic accuracy of the Alvarado score at a cut-off value of ≥6 was 79.0%. Among the ML algorithms, the hybrid model achieved the best performance, with 92.9% accuracy, 93% F-measure, 70.4% MCC, 90.8% ROC area, and 93.4% PRC area. This model correctly predicted 95.6% of acute appendicitis cases and 75.9% of negative appendectomy cases. The hybrid ML model demonstrated superior diagnostic accuracy compared to the Alvarado score for acute appendicitis. Integration of such models into clinical practice could reduce negative appendectomy rates and enhance patient management by enabling faster and more reliable diagnosis.

Background: Appendicitis remains a significant cause of acute abdomen and is characterized by high complication rates despite advancements in surgical care. Factors influencing post appendectomy outcomes, including clinical presentation, intraoperative findings, and procedural interventions, require detailed documentation in our context. Methods: This retrospective study analyzed 108 patients who were managed surgically for appendicitis. Demographic data, clinical parameters, intraoperative findings, hospital stays, and postoperative complications were assessed. Multivariate logistic regression identified factors associated with unfavorable outcomes (p&lt;0.05). Results: Among the 108 patients, 51.9% were male, with the highest incidence of appendicitis in the 20-39 years age group. Common presentations included RLQ pain (45.4%) and tenderness (86.9%), with 39.0% exhibiting tachycardia &gt;100 bpm. The subumbilical midline incision (SUMI) was predominant (54.6%), while 20.4% presented with a ruptured appendicular abscess. Postoperatively, 23.6% of the patients experienced complications, predominantly constipation (43.5%) and surgical site infections (20.3%). Factors significantly increasing the odds of unfavorable outcomes included age 40-59.9 years (aOR=9.66; 95% CI 1.82-15.2), symptom duration &gt;5 days (aOR=6.14; 95% CI 1.69-12.2), ruptured appendicular abscess (aOR=23.96; 95% CI 1.75-11.97), and peritoneal lavage (aOR=7.72; 95% CI 1.69-9.1). Conclusions: In this study, most of the patients presented nonspecifically and late with complicated forms of appendicitis, indicating a high incidence of unfavorable postoperative outcomes. We therefore need to increase awareness of the nonspecific presentation and unfavorable outcomes related to late presentation of the condition to all health workers and communities. The adoption of screening protocols such as the Alvarado score could help ensure timely diagnosis and prediction of treatment outcomes to reduce the burden of unfavorable outcomes.

Acute appendicitis is the most common cause of abdominal surgery. The lifetime probability of experiencing appendicitis is 7%. History and findings are crucial in the diagnosis of appendicitis. However, many other conditions must be considered in the differential diagnosis. Diagnosing appendicitis can be difficult, especially in small centers lacking imaging centers. Therefore, scoring systems have been developed to robustly predict the diagnosis of appendicitis without imaging methods. The most commonly used is the Alvarado Score. When the Alvarado Scores and computed tomography scans of the 360 patients included in the study were compared: The mean Alvarado Score of 280 patients (77.82%) diagnosed with suppurative appendicitis on computed tomography was 6.59±1.53; the mean Alvarado Score of 12 patients (3.40%) diagnosed with perforated appendicitis was 8.27±1.13; the mean Alvarado Score of 54 patients (15.13%) interpreted as suspected appendicitis was 6.19±2.67; and the mean Alvarado Score of 14 patients (3.88%) interpreted as normal appendix was 5.62±1.39. According to these results, we see that the prediction of appendicitis diagnosis in computed tomography imaging of patients with high Alvarado Scores is high. The preoperative mean Alvarado Score of 293 patients (81.4%) diagnosed with suppurative appendicitis according to pathology results was 6.7±1.55. The mean Alvarado Score for 44 patients (12.3%) with perforated appendicitis was 6.91±1.56, and for 23 patients (6.3%) with normal appendixes, the mean Alvarado Score was 5.49±1.47. According to these results, the lower Alvarado Score in patients without appendicitis compared to those with acute appendicitis and perforated appendicitis was found to be statistically significant (p=0.001). In conclusion, suspected appendicitis is suspected in patients with an Alvarado Score of 5-6. We believe that using computed tomography (CT) in these patients can more accurately diagnose appendicitis and reduce the negative appendectomy rate.

Background: Acute appendicitis is still one of the most prevalent surgical emergencies. To lower the rates of negative appendectomies and complications, it is important to make an accurate diagnosis as soon as possible. The Modified Alvarado Score (MAS) is a simple clinical scoring system that helps doctors make diagnoses, especially in places where resources are limited. Objectives: To evaluate the diagnostic accuracy of the Modified Alvarado Score in patients with suspected acute appendicitis. This prospective study took place at PMCH in Patna, Bihar, over a span of 10 months, from February 2025 to December 2025. A total of 76 patients were clinically suspected of having acute appendicitis. We estimated MAS for all patients and compared it to what we found after surgery and in the histopathological examination (HPE). Results: Of the 76 patients (48 males, 28 females), those with MAS ≥7 exhibited significant sensitivity and specificity. The diagnostic accuracy of MAS was 88.2%. Higher scores were substantially correlated with histopathologically confirmed appendicitis (p &lt; 0.05). Conclusion: The Modified Alvarado Score is a reliable, cost-effective, and simple tool for diagnosing acute appendicitis, especially in settings with limited access to advanced imaging technology.

Background: Acute appendicitis is the common surgical condition presenting in emergency worldwide, thus making appendectomy the most frequently performed emergency abdominal operation. Due to its nonspecific presentation, diagnosing acute appendicitis can be challenging, often leading to diagnostic delays resulting in increased morbidity and mortality.Materials and Methods: Prospective study in the Department of General Surgery, over a period of one year. It involved 200 patients presenting to emergency department with features suggestive of acute appendicitis. Assessments included the Modified Alvarado and Fenyo Lindberg Scores, alongside histopathological examination for validation.Results: Among 200 patients, 137 patients were males and 63 were females with a male to female (M:F) ratio of 2.17:1. RIF pain was observed in 150 patients followed by pain aggravating with cough seen in 149patients. 37 had a MAS of

Background: In order to detect acute appendicitis in children as quickly and accurately as possible, a number of scoring systems, including Alvarado and PAS, have been established. Comparing different scoring systems' effectiveness and diagnostic usefulness was the aim of this research. Materials and Methods: This prospective study was conducted in the pediatric surgery department of Bangladesh Medical University. Dhaka, Bangladesh from July 2022 to July 2024 over a period of 24 months. Data analysis was done by Statistical Package for Social Science (SPSS) software (version 26.0; SPSS Inc., Chicago, IL). Specificity, sensitivity, negative and positive likelihood ratios, diagnostic accuracy, negative and positive predictive values of the three scoring systems were analyzed after comparing the histopathology report. Receiver operating curve (ROC) was used to analyze the performance characteristics of the three scoring systems. P value of &lt; 0.05 was considered statistically significant. Results: A total number of 200 cases were studied to compare the predictive values of Alvarado and PAS scoring systems for the diagnosis of acute appendicitis. Maximum age group was between 8-10 years with a Mean ± SD of 8.0 ± 2.8 years. PAS scoring system had a better sensitivity (96.81%) than Alvarado (89.89%) scoring systems. Specificity was also more in PAS (85.82%) than Alvarado (63.64%). Diagnostic accuracy of PAS scoring system was 90.00% which is more than Alvarado (79.00%) scoring systems. Area under Curve (AUC) of Alvarado and PASA scoring systems are 0.809 and 0.864 respectively. Statistically significant difference (p&lt;0.05) is found in the difference of Area Under Curves (AUC) of Receiver Operative Characteristic (ROC) between PAS and Alvarado scoring systems. Conclusions: According to the current study, the PAS scoring system outperforms the Alvarado scoring systems in terms of sensitivity and specificity. Additionally, it has a low negative appendectomy rate due to its improved diagnostic accuracy, high positive predictive value, and high negative predictive value.

Introduction: Acute appendicitis is one of the most common surgical emergencies worldwide. Despite its frequency, accurate diagnosis remains challenging due to atypical presentations, leading to high rates of negative appendectomy and missed diagnoses. A wide array of diagnostic tools exists, including clinical scoring systems, laboratory biomarkers, and imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). However, there is significant heterogeneity in their reported accuracy, and an optimal, context-specific diagnostic pathway is still debated. This systematic review aimed to comprehensively compare the diagnostic performance of all available approaches and synthesize evidence to guide clinical decision-making. Methods: A systematic review was conducted following a predefined protocol. Electronic databases were searched for studies published up to 2025. Eligibility criteria included original research (RCTs, cohort studies, diagnostic accuracy studies) involving patients with suspected acute appendicitis that evaluated at least one diagnostic method and reported sufficient data to calculate performance metrics. Data on diagnostic methods, study population, reference standard, performance metrics (sensitivity, specificity, AUC), and moderating factors were extracted. Methodological quality was assessed. Results: Eighty studies were included. CT demonstrated the highest and most consistent diagnostic accuracy across populations, with pooled sensitivity of 94–97% and specificity of 94–98%. Low-dose CT protocols provided comparable accuracy to standard-dose CT while reducing radiation exposure by approximately 78% (Yoon et al., 2018; Sippola et al., 2020). Ultrasound performance was highly variable (sensitivity 55–97%), heavily dependent on operator expertise and patient selection. Emergency physician-performed point-of-care ultrasound (POCUS) showed excellent performance, particularly in pediatrics (Miller et al., 2025). MRI was highly accurate (sensitivity 92–96%, specificity 97–98%), especially in pregnant women (Kave et al., 2019; D'Souza et al., 2021). Among clinical scores, the Appendicitis Inflammatory Response (AIR) score outperformed the Alvarado score (Andersson &amp; Stark, 2025), while the RIPASA score had high sensitivity but low specificity (Favara et al., 2022). The neutrophil-to-lymphocyte ratio (NLR) emerged as a promising biomarker, with a cut-off &gt;4.7 showing good diagnostic accuracy (Hajibandeh et al., 2019). Discussion: The diagnostic performance of any tool is not absolute but is significantly moderated by clinical context, patient factors, technical protocols, and operator skill. CT remains the gold standard imaging modality for most adults, but its use must be balanced against radiation risk. Ultrasound is the recommended first-line imaging in children and pregnant women, with MRI as an excellent second-line option. Clinical scores and biomarkers are most valuable in resource-limited settings or as part of integrated algorithms. The review reconciles apparent contradictions in the literature by highlighting these moderating factors. Conclusion: No single diagnostic approach is universally superior. An integrated, context-specific framework is recommended: CT (preferably low-dose) for typical adults; US first-line for children, with selective CT/MRI; MRI for pregnant women; and clinical scores (AIR) combined with biomarkers (NLR, WBC/CRP) in resource-limited settings. Future research should focus on validating AI tools, standardizing ultrasound training, and evaluating cost-effectiveness of tailored pathways.

Introduction: Acute appendicitis is one of the most prevalent surgical emergencies worldwide, with complications arising from delayed diagnosis or misdiagnosis. Accurate and timely diagnosis is critical to prevent complications like perforation, abscess, and peritonitis, while minimising unnecessary surgeries. Aim: To study the diagnostic accuracy of Tzanakis Scoring (TS) versus the Alvarado scoring system, considering histopathology as a gold standard. Materials and Methods: A prospective observational study was conducted at the Outpatient Department (OPD) of Surgery and Emergency Room (ER), S Nijalingappa Medical College (SNMC), HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Bagalkot, Karnataka, India from August 2022 to February 2024. A total of 100 patients who presented with right lower quadrant pain were included. Both the Modified Alvarado Score (MAS) and TSs were calculated for each patient. The diagnostic performance of each scoring system was evaluated against histopathological findings. The sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and diagnostic accuracy were calculated for both the MAS and TS. Receiver Operating Characteristic (ROC) curves were constructed to determine the optimal cut-off values for each scoring system. Results: The mean age was 29.3±11.8years, and out of 100 patients, 54 were males. A total of 75 had histologically confirmed appendicitis. The TS demonstrated higher sensitivity (92.0% vs 88.0%), specificity (80.0% vs 76.0%), and diagnostic accuracy (89.0% vs 85.0%) compared to MAS. The Area Under the ROC Curve (AUC) was 0.895 for the TS and 0.860 for MAS (p-value&lt;0.001 for both). Cut-off values were ≥8 for the TS and ≥7 for MAS. Both scoring systems reduced negative appendectomy rates compared to clinical judgment alone (4.1% for TS, 5.6% for MAS, vs 8.5% for clinical judgment). Conclusion: Both the MAS and TS are effective tools for diagnosing acute appendicitis, with the TS showing slightly superior performance. These scoring systems can aid in clinical decision-making and potentially reduce negative appendectomy rates. Further large-scale studies are warranted to validate these findings across diverse populations.

Tuberculosis remains endemic in India, with extrapulmonary manifestations being relatively common. However, gastrointestinal tuberculosis is infrequent, representing only 3% of extrapulmonary tuberculosis cases, and appendicular tuberculosis is even rarer, affecting approximately 1% of gastrointestinal tuberculosis cases. We present a case of a 19-year-old male who presented with clinical features consistent with acute appendicitis. Physical examination revealed right iliac fossa tenderness with guarding. Laboratory investigations showed leukocytosis with an Alvarado score of 7. Ultrasonography suggested possible appendicular collection. The patient underwent emergency open appendicectomy. Intraoperatively, multiple firm nodules measuring 3-5 millimeters were noted on the appendix and adjoining cecum. Histopathological examination revealed granulomatous lesions with caseous necrosis in the serosa and muscularis propria, consistent with tuberculosis. The diagnosis was confirmed using GeneXpert molecular testing. The patient was started on anti-tuberculous therapy. Two weeks postoperatively, the patient developed pleural effusion with elevated adenosine deaminase levels, consistent with tuberculous pleural effusion. The abdominal symptoms resolved completely with normal wound healing. This case highlights that tuberculous appendicitis mimics acute appendicitis clinically and is typically diagnosed only through postoperative histopathological examination. In tuberculosis-endemic regions, surgeons should maintain high clinical suspicion when intraoperative findings reveal peritoneal or appendicular nodules.