Date:

To

The Registrar,

KNR University of Health Sciences,

Warangal.

Respected Sir,

Sub - PG Dissertation Title registration with KNR UHS, Warangal.

I am Dr. ABHISHEK THUNGA doing my Post Graduation (MS) in General Surgery

(2021 -2022 Batch) Mamata Medical College, Khammam.

I am doing my dissertation under the guidance of Dr. T. SEETHARAMAIAH M.S.

Professor, in the Department of General Surgery.

I am here with submitting the Dissertation title and Abstract for registration with

KNR UHS, Warangal.

Hence, I request you to grant permission to do the above dissertation work.

Thanking You,

Yours sincerely,

Dr. ABHISHEK THUNGA

 Registration of Dissertation Topic

Name of the student : Dr. ABHISHEK THUNGA

PG Degree course in the subject : General Surgery

Name of the Medical College : MAMATA MEDICAL COLLEGE

Title of the topic : A COMPARATIVE STUDY OF APPENDICITIS

INFLAMMATORY RESPONSE SCORE AND TZANAKIS

SCORE FOR DIAGNOSING PATIENTS WITH ACUTE

APPENDICITIS.

Name of the Guide : Dr. T. SEETHARAMAIAH,M.S.,

Date of joining the course : 04/07/2022

Date of commencement of course : 01/02/2022

Date of presentation or submission : 20/07/2022

Sl.No. Points to be considered (Guidelines)

1 Interest shown in selecting a topic

2 Appropriate review of literature

3 Discussion with guide and other faculty

4 Quality of protocol

5 Preparation of proforma

Sl.No. Name of the faculty and designation Average grade

Signatures of Dissertation Committee

Signatures of Candidate

Signature of Guide

Signature of the HOD with office seal Signature of the Principal with office seal
A COMPARATIVE STUDY OF APPENDICITIS INFLAMMATORY RESPONSE
SCORE AND TZANAKIS SCORE FOR DIAGNOSING PATIENTS WITH ACUTE
APPENDICITIS

DISSERTATION TOPIC TO
KNR University of Health Sciences, Warangal.

By

Dr. ABHISHEK THUNGA, M.B.B.S.

Under the guidance of

Dr. T. SEETHARAMAIAH, M.S.

Professor, Department of General Surgery,
Mamata Medical College & General Hospital, Khammam
 ABSTRACT

TITLE OF DISSERTATION:A COMPARATIVE STUDY OF APPENDICITIS

INFLAMMATORY RESPONSE SCORE AND TZANAKIS SCORE FOR DIAGNOSING
PATIENTS WITH ACUTE APPENDICITIS

INTRODUCTION

Appendicitis is defined as inflammation of appendix. It was first coined by “Reginald

Heber Fitz” from Boston and identified it as the common cause of right lower quadrant
pain. Appendectomy was first performed by Lawson Tait in England.1 Acute appendicitis
(AA) stands out amongst the most widely recognized reasons for acute abdomen. This
condition warrants quick heath care and treatment. 2 A negative appendicectomy rate up
to 17.5% is noted in India following appendicectomy based on clinical suspicion. This
necessitates accurate diagnosis prior to performing appendicectomy. 3 Imaging studies
such as USG and CT are examiner dependent. The diagnostic accuracy of acute
appendicitis can be improved by combining clinical examination, laboratory parameters
and imaging techniques into a clinical scoring system.

Clinical scoring systems like Appendicitis Inflammatory Response (AIR) Score,

ALVARADO score, RIPASA score, TZANAKIS score, Pediatric appendicitis score, etc.
are being deployed to clinically diagnose acute appendicitis. 3 The Alvarado score is the
most well-known and best performing in validation studies, but it has some drawbacks. 4
The recently introduced appendicitis inflammatory response (AIR) score was designed
to overcome these drawbacks. In 2005, Tzanakis and his coworkers published a
simplified system with four variables and a total score of 15 for diagnosis of acute
appendicitis which is termed as Tzanakis scoring system. 5 Tzanakis scoring system is a
unique scoring system in the sense that it includes ultrasonography with clinical
evaluation (right lower abdominal tenderness and rebound tenderness) and laboratory
parameters (total leukocyte count estimation) for evaluating acute appendicitis. The
present study will be undertaken to compare accuracy of Appendicitis Inflammatory
Response Score and Tzanakis score in diagnosing Acute Appendicitis.
AIMS AND OBJECTIVES

1. To assess the role of Appendicitis inflammatory response score in diagnosing Acute

Appendicitis .

2. To assess the role of Tzanakis score in diagnosing Acute Appendicitis.

3. To compare the accuracy of Appendicitis inflammatory response score with

Tzanakis score.

MATERIALS AND METHODS

STUDY DESIGN : Prospective Comparative Study .

STUDY PERIOD : July 2022 – August 2024.
STUDY PLACE : Department of General Surgery, Mamata General Hospital,
Khammam.
SAMPLE SIZE : Minimum of 30 patients.

METHOD OF COLLECTION OF DATA

This study will comprise a minimum of 30 patients with clinical diagnosis of Acute
Appendicitis admitted in the surgical wards of Mamata General Hospital with following
inclusion and exclusion criteria.

 Informed written consent will be taken from the patients after full explanation of
the study.
 Ethical committee clearance will be taken prior to the study .

Inclusion Criteria:

1. Patients above the age of 16 years irrespective of gender.

2. Patients willing to undergo appendicectomy after the diagnosis of acute

appendicitis on the basis of clinical assessment .

3. Patients willing to participate in the study.

Exclusion Criteria :

1.Pregnant women.

2. Patients with right iliac fossa mass.

3. Patients with previous history of pelvic inflammatory disease.

4. Patients not willing to participate in the study.

METHODOLOGY

▪ Clinically suspected cases of acute appendicitis, admitted in the surgical wards of

Mamata General Hospital, will be included in the study after obtaining consent for
the same.

▪ Detailed history, clinical findings, along with relevant investigations like

hematological examination, biochemical parameters as required, ultrasound of
abdomen etc. will be recorded in the proforma for individual patients.

▪ Every patient will be scored with both Appendicitis inflammatory response score
and Tzanakis scoring systems.

▪ A score of > 8 will be taken as high probability of acute appendicitis for Tzanakis
scoring system and a score of > 8 for Appendicitis inflammatory response score.
The decision on appendicectomy will be solely based on the concerned
surgeon’s clinical judgment after taking into consideration all the clinical findings,
laboratory and radiological investigations.

▪ Operative findings and diagnosis will be recorded in the concerned proforma for
the respective patients. Histopathological findings of the excised appendix will be
recorded in the respective proforma for correlation with the pre and post
operative diagnosis as well as with both the scores.
APPENDICITIS INFLAMMATORY RESPONSE SCORE 6
CLINICAL CHARACTERISTIC SCORE (POINTS)
vomiting +1
pain in right iliac fossa +1
Rebound tenderness
light +1
medium +2
strong +3
Body Temperature ≥ 38.50C +1
Polymorphonuclear leucocytes
70% - 84% +1
≥ 85% +2
WBC count (x109/L)
10,000 – 14,999 +1
≥ 15,000 +2
C – Reactive protein
10 – 49 mg/L +1
≥ 50 mg /L +2

SCORE INTERPRETATION
TOTAL POINTS RISK RECOMMENDATION
0–4 LOW Outpatient Follow up (if unaltered general
condition)
5–8 INTERMEDIATE In - hospital active observation with serial
examination, imaging, or diagnostic laparoscopy
according to local practice.
9 – 12 HIGH Surgical exploration.
Tzanakis scoring system7
FEATURE SCORE

Right lower abdominal tenderness 4

Right lower abdominal rebound tenderness 3

Laboratory findings: presence of white 2

blood cells >12,000 (x109/L)

Ultrasound finding: presence of positive 6

findings on ultrasound scan for acute
appendicitis

Total-15 points >8: Diagnostic of acute appendicitis, requires surgery.

STATISTICAL ANALYSIS

• The outcomes will be recorded and analyzed at the end of the study using statistical
package for social science (SPSS) .
REFERENCES

4. A Seal. Appendicitis: a historical review. Can J Surg 1981 Jul;24(4):427-433.

PMID: 7023636 .

5. Dron S, Koujalagi R S. A comparative study to assess efficacy of Tzanakis score

and Alvarado score for effective diagnosis of patients with acute appendicitis at a
tertiary care center in North Karnataka: a one-year prospective analytical study.
Int Surg J 2020 Jun;7(6):1742-1745 doi: 10.18203/2349-2902.isj20202091 .

6. Toney J, P S Rajesh. Appendicitis Inflammatory Response Score in Comparison

to Alvarado Score in Acute Appendicitis. Surg J (NY) 2021;7: e127–e131. doi
10.1055/s-0041-1731446 .

7. de Castro, C Unlu, Steller, Wagensveld, Vrouenraets. Evaluation of the

Appendicitis Inflammatory Response Score for Patients with Acute Appendicitis.
World J Surg 2012; 36(7): 1540–1545. doi: 10.1007%2Fs00268-012-1521-4.
PMID: 22447205.

8. Arun K, S Lakshminarasimhaiah, Nagaraja A L, Srinivasaiah M. Evaluation of

Tzanakis scoring system in acute appendicitis: a prospective study. Int Surg J
2017 Oct;4(10):3338-3343. doi: 10.18203/2349-2902.isj20174173 .

9. Scott A J, Mason S E, Arunakirinathan M , Y Reissis, J M Kinross, J J Smith. Risk

stratification by the Appendicitis Inflammatory Response score to guide decision-
making in patients with suspected appendicitis. Br J Surg 2015;102(5):563-572.
doi: 10.1002/bjs.9773 .

10. Malik A A, Mir M F, Khurshid S U, Imtiaz W, Riyaz D. Modified Alvarado Score

Versus Tzanakis Score for Diagnosing Acute Appendicitis in Changing Clinical
Practice. International Journal of Clinical and Experimental Medical Sciences,
2016, doi: 10.11648/j.ijcems.20160205.13.

Name of the student: Name of the guide:

Dr. Abhishek Thunga Dr. T. Seetharamaiah M.S

Speciality: General Surgery Professor

Department of General Surgery

Signature Signature