Comparision of ultrasonographic diagnosis with ‘Tzanakis’ Score in acute appendicitis

Abstract

Introduction: Acute appendicitis is one of the most common acute surgical abdominal conditions requiring surgery. Ever since the inflamed appendix was demonstrated in the 1980’s by Ultrasonography, it has been used as an aid to clinically diagnose acute appendicitis. Tzanakis scoring system is a combination of clinical examination, Ultrasonography and inflammatory markers.

Methods: A retrospective non-randomized observational study was conducted from April 2014 to March 2015 on all cases of acute appendicitis, which underwent preoperative ultrasound before appendectomy (open/laparoscopic) at the Department of surgery, Nepal Medical College Teaching Hospital. Ultrasound findings and Tzanaki score were compared in the cases. No studies could be found in literature comparing ultrasound diagnosis with Tzanaki score in appendicitis.

Results: The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 73%, 50%, 95% and 12% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of Tzanaki were 87%, 50%, 96% and 23% respectively. Tzanaki score is better than ultrasound alone as a diagnostic test for acute appendicitis.

Conclusion: Tzanaki score is better than ultrasound in diagnosis of acute appendicitis.

Full text

89JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal
JSSN 2016; 19 (1) JSSN 2016; 19 (1)
Original Article
Comparision of ultrasonographic diagnosis with
‘Tzanakis’ Score in acute appendicitis
Ashish Prasad Rajbhandari1, Nischal Dhakal2, Robin Koirala1, Manohar Lal Shrestha1
1 Department of Surgery, Nepal Medical College Teaching Hospital
2 Department of Community Medicine, Nepal Medical College Teaching Hospital
Correspondence: Dr Ashish Prasad Rajbhandari,
Email: ashish_rajbhandari@hotmail.com
Abstract
Introduction: Acute appendicitis is one of the most common acute surgical abdominal
conditions requiring surgery. Ever since the inamed appendix was demonstrated in the 1980’s
by Ultrasonography, it has been used as an aid to clinically diagnose acute appendicitis. Tzanakis
scoring system is a combination of clinical examination, Ultrasonography and inammatory markers.
Methods: A retrospective non-randomized observational study was conducted from April 2014 to
March 2015 on all cases of acute appendicitis, which underwent preoperative ultrasound before
appendectomy (open/laparoscopic) at the Department of surgery, Nepal Medical College Teaching
Hospital. Ultrasound ndings and Tzanaki score were compared in the cases. No studies could be
found in literature comparing ultrasound diagnosis with Tzanaki score in appendicitis.
Results: The sensitivity, specicity, positive predictive value and negative predictive value of
ultrasound were 73%, 50%, 95% and 12% respectively. The sensitivity, specicity, positive predictive
value and negative predictive value of Tzanaki were 87%, 50%, 96% and 23% respectively. Tzanaki
score is better than ultrasound alone as a diagnostic test for acute appendicitis.
Conclusion: Tzanaki score is better than ultrasound in diagnosis of acute appendicitis.
Key Words: Appendicitis; Tzanakis score; ultrasonography.
Introduction
Acute appendicitis is one of the most common acute
surgical abdominal conditions requiring surgery.1-3 A
history of migrating abdominal pain, classically beginning
in the periumbilical region and traveling to McBurney’s
point, combined with leukocytosis and other associated
symptoms such as anorexia remains the best diagnostic
clue.4 Clinical examination is helpful in diagnosis of acute
appendicitis in only 70-87% of the cases.5 A variety of
scoring systems are used for the clinical diagnosis of acute
appendicitis.
Ever since the inamed appendix was demonstrated in the
1980’s by ultrasonography, it has been used as an aid to
clinically diagnose acute appendicitis.6 Ultrasonographic
diagnosis of acute appendicitis is based on various criteria.7-9
Evaluation by meta-analysis suggests that ultrasound
is useful for diagnosis of acute appendicitis.6 Tzanakis
scoring system is a combination of clinical examination,
ultrasonography and inammatory markers.10 Studies have
advocated that Tzanakis score is superior to Alvarado score
in diagnosing appendicitis.11, 12
This study was done to compare ultrasonographic
diagnosis with Tzanaki score in cases of acute
appendicitis.

10 11JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal
JSSN 2016; 19 (1) JSSN 2016; 19 (1)
Methods
A retrospective nonrandomized observational study was
conducted from April 2014 to March 2015 on all cases
of acute appendicitis, which underwent preoperative
ultrasound before appendectomy (open/laparoscopic)
at the Department of surgery, Nepal Medical College
Teaching Hospital. Ultrasound ndings and Tzanaki score
were compared in the cases. The Ultrasound machine was
nemio (Toshiba) and high frequency probe (6-11MH) was
used and all were performed consultant radiologists. The
procedure was performed with patient in supine position.
Tzanki score of more than 8 was regarded as positive. All
cases were diagnosed as appendicitis based upon modied
Alvarado scoring (history, clinical examination and
investigation). Cases of complications of appendicitis were
excluded in the study.
Ultrasonographic diagnosis of acute appendicitis was based
on the following criteria7-9:
1. Non-compressible, immobile, blind ended tubular
structure with target like appearance in transverse
view, with greatest maximal diameter of visualized
structure more than or equal to 6 mm.
2. Appendix with muscular wall thickness equal or more
than 3mm with a symmetry and edema of the wall.
3. The nding of appendicolith (faecolith).
4. If the appendix is not visualized or if a non-
appendicular pathology is discovered, the scan was
considered as normal.
5. Findings like localized uid collection, dilated
bowel loops were not considered suggestive of acute
appendicitis.
6. Presence of Probe tenderness only was not regarded as
a nding for acute appendicitis.
Statistical analysis was done with the help of SPSS V20.
McNemar Test was done to compare ultrasonography with
Tzanaki score.
Result
Total of 128 cases of suspected appendicitis were examined
in the emergency during the study period. Nine cases refused
admission/went to another hospital. Twelve cases were
excluded upon further pre operative investigations. A total
of 107 cases were diagnosed as appendicitis and underwent
appendectomy. Of them, 85 cases underwent preoperative
ultrasound, 79 had appendicitis on histopathological
examination and 6 cases did not. Six cases, which did not
undergo ultrasound, also showed a normal appendix but
were not included in the study.
Out of the 85 cases 52(62%) were male and 33(38%)
were female. The age ranged from 9-52 years with mean
age of 25.61(73%) had a positive ultrasound nding and
72(85%) had a positive Tzanaki score. Comparing Tzanaki
with ultrasound nding as a diagnostic test which shows
a signicant p value of 0.007.59(69%) cases had both
Tzanaki positive and ultrasound nding of appendicitis.
Also a majority of Tzanaki positive cases had a positive
ultrasound nding (59/72). (Table 1)
The sensitivity, specicity, positive predictive value and
negative predictive value of ultrasound were 73%, 50%,
95% and 12% respectively. The sensitivity, specicity,
positive predictive value and negative predictive value of
Tzanaki were 87%, 50%, 96% and 23% respectively.
Out of the 79 cases of histological positive for appendicitis,
ultrasound was positive in 58(73%) and Tzanki in 69(87%).
The frequency of the individual variables of Tzanaki
score in descending order was as follows, Mc burney’s
tenderness seen in 78(92%), rebound tenderness seen in
69(81%), positive ultrasound in 61(73%) and leucocytosis
in 56(65%).
Modied Alvarado score was positive for acute appendicitis
in 67(78%). However, 60(70%) had both Modied Alvarado
and Tzanaki score positive for acute appendicitis where
as 48(56%) had both Modied Alvarado and ultrasound
positive. (p <0.0001).
Discussion
Our study showed that appendicitis prevails mostly in young
males. The age and gender statistics are in accordance with
local and international studies.13-5
Ultrasound has been widely used as an aid to clinical
diagnosis of acute appendicitis since the 1980s. The
diagnosis is on basis of specic morphological criteria.7-9
Visualization of the inamed appendix is operator dependent
and depends on the position of appendix, gas lled bowel
loops, body build, obesity and presence of guarding/rigidity
of abdomen.6, 16 In the evaluation of acute appendicitis, the
visualization rate varies from institution to institution, from
a high of 98% to a low of 22%.17 In this study the rate was
73% which is similar to other studies reported from Nepal

10 11JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal
JSSN 2016; 19 (1) JSSN 2016; 19 (1)
and Pakisthan.13,16 Studies have advocated the superiority
of ultrasound diagnosis to clinical decision making while
others have supported it as a useful aid in diagnosis.14, 19,
20, 21 The sensitivity of ultrasound has varied from 49%
to 98%; specicity from 58% to 100%.13,14,16,18-24 The low
specicity in our study may be due to the low sample size
and low false positive cases. The positive predictive value
has ranged from 65% to 100% and negative predictive
value from 6.7% to 95%.13,14,20,22-24 The low predictive value
in this study is probably due to a low sample size as those
with a large sample size all had high values of negative
predictive value.
Tzanakis introduced a scoring system for diagnosis of
appendicitis, which is a quantitative combination of the
clinical evaluation with Ultrasound imaging and a marker
of inammatory response.10 Studies have compared
Tzanakis score with Alvarado score for diagnosis of
appendicitis and have shown Tzanakis score to be an
eective if not superior modality for diagnosis.11, 12 In
our study too, Tzanakis score was a superior scoring
system than Alvarado score. The diagnostic accuracy,
sensitivity, positive predictive value and negative
predictive value are similar though two studies done in
India had a higher specicity.11,12,25,26
In this study Tzanakis score was superior to ultrasound
for diagnosis of appendicitis (p<0.007). This is probably
due to added parameters of clinical evaluation (tenderness
and rebound tenderness) and leucocytosis. A majority of
Tzanakis positive cases however had a ultrasound diagnosis
of appendicitis.
Tzanakis score is applied for diagnosis of appendicitis
only but if applied to other acute abdominal conditions,
it could show positive scores due to tenderness, rebound
tenderness and leucocytosis. There could be a possibility
of false positive results but no studies have been found in
this regard.
No studies could be found comparing ultrasound diagnosis
with Tzanaki score in appendicitis. In this study we found
Tzanaki score to be superior to that of ultrasound diagnosis
alone.
Conclusion
Tzanaki score is superior to that of ultrasound alone for the
diagnosis of acute appendicitis.
Table 1: Comparison of ultrasonography abdomen with
Tzanaki score
Positive Ultrasonography McNemar
Test
Negative p-value
Tzanki
Score
Positive 59 13
Negative 211 .007a
Total 61 24
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