|ORIGINAL RESEARCH REPORT
|Year : 2018 | Volume
| Issue : 4 | Page : 171-175
Pattern of presentation and outcome of management of acute appendicitis: A 10-year experience
Oludolapo O Afuwape1, Omobolaji O Ayandipo1, Oluwafunmilayo Soneye2, Adegbolahan Fakoya2
1 Department of Surgery, College of Medicine, U.I/University College Hospital, Ibadan, Nigeria
2 Department of Surgery, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||3-Dec-2018|
Dr. Oludolapo O Afuwape
Department of Surgery, College of Medicine, U.I/University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Appendicitis is one of the most common indications for nonelective abdominal surgery. This is true in both developed and developing countries. The aim of this study was to describe the pattern of presentation and outcome of management in a large hospital in the developing world. Methods: All patients of the general surgery divisions who had appendicectomy for clinical preoperative diagnosis of acute appendicitis between July 2007 and June 2016 were included in the study. Patients who had incidental appendicectomy were excluded from the study. Data were collected retrospectively using a data collection instrument designed for the study. Results: The total number of appendicectomy operations performed within the stipulated period was 1081. Male:female ratio was 1.37:1. The age range was from 12 years to 80 years. The most common symptom and sign remain the right lower quadrant pain and right iliac fossa tenderness, respectively. The duration of symptoms before presentation ranged from 10 h to 96 h. Approximately 20% or a fifth of the patients had ruptured appendix. Tumor associated appendicitis constituted 2.2%. The negative appendicectomy rate was 9.5%. About 47% of the patients were discharged <72 h after surgery. There were five mortalities in all. Conclusion: The diagnosis of acute appendicitis in the developing world may still be done with acceptable levels of accuracy based on in-depth medical history and clinical examination.
Keywords: Acute appendicitis, outcome, presentation
|How to cite this article:|
Afuwape OO, Ayandipo OO, Soneye O, Fakoya A. Pattern of presentation and outcome of management of acute appendicitis: A 10-year experience. J Clin Sci 2018;15:171-5
|How to cite this URL:|
Afuwape OO, Ayandipo OO, Soneye O, Fakoya A. Pattern of presentation and outcome of management of acute appendicitis: A 10-year experience. J Clin Sci [serial online] 2018 [cited 2019 Apr 18];15:171-5. Available from: http://www.jcsjournal.org/text.asp?2018/15/4/171/246763
| Introduction|| |
The term “acute appendicitis” was introduced by Ringald H Fitz in 1886, who attributed the condition called typhlitis to the acute inflammation of the vermiform appendix. Appendicitis is characterized histologically by the inflammation of the mucosa lining of the vermiform appendix which spreads to other anatomical parts of the appendix through the mechanism of venous stasis, organ ischemia and bacterial translocation leading to the development of different symptoms and signs elicited in the disease process. It is one of the most frequent acute surgical conditions of the abdomen, consequently making appendicectomy one of the most commonly performed operations in the world and probably the most common cause of surgical acute abdomen in the West African subregion. The accurate diagnosis of appendicitis remains a challenge to surgeons because of its protean forms of manifestation. Challenges in making accurate diagnoses are common because not all cases exhibit the commonly described clinical features. The standard treatment is acknowledged to be an appendicectomy.
The annual incidence of appendicitis in Nigeria is 22.1–49.8 new cases per 100,000. The lifetime risk of acute appendicitis in developed countries is about 6.7% for females and 8.6% for males. However, the lifetime chances of undergoing appendicectomy are much higher, i.e., 9.89% for males and 9.61% for females. This discrepancy between the frequency of surgery (appendicectomy) and appendicitis reveals the magnitude of the incidence of unnecessary appendicectomies. The consensus on the timing of the operation is in favor of early surgery, but the consequence of this approach of semi-emergency surgery for appendicitis is a high rate of unnecessary appendicectomy which is referred to as “negative appendicectomy.”
Negative appendicectomy is defined as the absence of inflammation or intramural neutrophils in the appendix on histopathology examinations in patients with suspected appendicitis. These may be related to systematic errors in the clinical diagnosis which place undue emphasis on variable symptoms and signs.
Diagnostic accuracy, however, needs to be improved to prevent unnecessary appendicectomies.
This study aimed to describe the pattern of presentation of the patients diagnosed as appendicitis, the mode of diagnosis, and the outcomes of management of acute appendicitis in a single hospital in Nigeria where access to modern ancillary investigations is limited by funds.
| Methods|| |
This was a descriptive retrospective study which included patients who had appendicectomy under the General Surgical Divisions at the University College Hospital Ibadan over a 10-year period (July 2007 to June 2016). The hospital is a tertiary healthcare facility with a capacity of a thousand beds comprising all major subspecialties. It services Oyo state of Nigeria primarily and other surrounding states. All patients of the general surgery divisions who had appendicectomy for clinical preoperative diagnosis of acute appendicitis between July 2007 and June 2016 were included in the study. A consultant surgeon supervised data extraction from ward admission registers, theater records, the divisions' operation registers, and histology reports of appendicectomy specimens. Patients who had incidental appendicectomy and patients with overt features of generalized peritonitis were excluded from the study. All the patients were admitted through the emergency department or the surgical outpatient clinics of the hospital. The patients were reviewed by a consultant or a senior registrar in the department of surgery. The diagnosis was based on the clinical history of the patient, the clinical signs elicited by the surgeons on examination and the results of investigations inclusive of which were the complete blood count (CBC), abdominopelvic ultrasound scan and rarely an abdominal computed tomography (CT). Routine practice in the department is to have CBC, serum electrolytes, and urea with urinalysis for all patients. Female patients routinely had an abdominopelvic ultrasound scan. Only one patient had a CT scan. All but 33 female patients did not have an abdominopelvic ultrasound due to machine delays whereas 6 male patients with the equivocal diagnosis had abdominopelvic ultrasound scan. The criteria for the clinical diagnosis of acute appendicitis was based on a constellation of signs and symptoms including migratory abdominal discomfort with localization of pain in the right iliac fossa pain, presence of nausea or two or less episodes of vomiting, anorexia, tenderness, and rebound tenderness in the right iliac fossa, raised total leukocyte count. All, but eight patients had open appendicectomy. The patients had open appendicectomy using the Lanz incision which is more cosmetic. However, patients with palpable right iliac fossa masses or evidence of localized peritonitis had a lower midline incision which was extended if required at surgery. The findings at surgery were retrieved from the patient records. All surgical specimens were submitted for histopathology. The data collected was entered into a structured data collection tool and analyzed by the SPSS (version 15.0, SPSS Inc., Chicago, IL, USA).
| Results|| |
The total number of appendicectomy operations performed within the stipulated period was 1081 consisting of 619 (57.3%) male and 453 (41.9%) female of the available records. The male:female ratio was 1.37:1. The age range was from 12 years to 80 years with a peak in the third decade. The pattern of presenting symptoms and signs are shown in [Table 1]. The diagnosis of acute appendicitis was made clinically on the history of vague epigastric or periumbilical discomfort with a shift to the right lower quadrant with the accompanying incidence of right lower quadrant tenderness and/or rebound tenderness in most of the patients. Other demonstrable signs such as Rovsing's, psoas, and obturator signs further established the diagnosis. The white blood cell count (WBC) range was between 3.7–12.8 × 103/UL. All the patients had the Alvarado score computed for them; however, this did not change the decision to operate the patients if the clinical signs were strongly suggestive of appendicitis [Table 2]. Not all the patients had an abdominal ultrasound at presentation [Table 3]. The duration of hospital admission before surgery is shown in [Table 4]. Surgery was performed in 12.3%, 11.1%, and 76.6% by consultant surgeons, registrars, and senior registrars, respectively. The intraoperative findings documented are summarized in [Table 5]. The duration of admission ranged from “2” to “54” days with a median of “3” days. The variable complications associated with appendicectomy in the population studied [Table 6].
| Discussion|| |
In developing countries, the dearth of funds limits the extent of ancillary investigations available in making clinical diagnosis. Despite this limitation, the need to make accurate diagnoses in a brief time and at minimal cost to the patient cannot be compromised. Consequently, the clinical experience remains the main tool for diagnosing many acute conditions which include appendicitis. The most readily available tools are CBC, urinalysis, and abdominal ultrasonography.
The normal white blood count (WBC) in Nigerians is (4.4–4.8 × 103/UL). 89.7% of these patients had leukocytosis WBC >7.0 × 103/UL. However, these figures may have been altered due to the indiscriminate use of antibiotics and consequently may not be an accurate reflection of the inflammatory process and response.
Abdominal ultrasonography was usually often requested for in females of the reproductive age group to exclude other pelvic conditions which may mimic appendicitis. However, in other sets of patients with equivocal diagnoses, an abdominopelvic ultrasound may be done. Despite the selection of patients for ultrasonography, its sensitivity as a diagnostic tool in acute appendicitis even in the female population in whom it is routinely done is of limited value with a positive predictive value of 80.9%. The only patient who had a CT scan done had a left-sided appendix. Even though 60% of our patients did not have sonography, the rate of negative appendicectomy was within the range of published figures. Despite the introduction of ultrasonography and CT scans the rates of diagnosis of appendicitis have not changed significantly.
Over the 10-year period of review, 1081 procedures were performed. The male:female ratio of 1.37:1 is similar to the Canadian data, but the study in Sudan which consists of mostly African population demonstrates a higher male predominance. However, a study which demonstrates the rare case of a female predominance in this same region was in a pediatric population. The most common symptom at presentation was right lower quadrant pain. Although this was present in 98.5% of the patients the occurrence of the other symptoms and signs was associated with the location of the appendix. About 75% appendices are retrocecal while the rest were sub-cecal or pelvic or para-ileal. Right lower quadrant pain/tenderness is an early phenomenon with retrocecal appendices but may be absent or late in pelvic, para-ileal locations of the appendix. Rather these other locations of the inflamed appendix may be associated with more frequent incidences of vomiting, diarrhea, and dysuria.
Approximately 20% or a fifth of the patients had a ruptured appendix at surgery; while this may appear relatively high, it should be stated that the average duration of symptoms prior to presentation ranged between 10 h and 96 h with most patients being symptomatic for between 43–48 h prior to hospital presentation for surgery. This study demonstrates the consistent delayed presentation in the developing world as >80% of patients come for treatment after >24 h of the onset of symptoms. In addition, many of our patients had experienced recurrent episodes of right lower quadrant pain with the administration of several varied brands of oral and parenteral medications. Studies have demonstrated that the average risk of perforation after 36 h of onset of symptoms is between 16% and 36%. This risk further increases by 5% after every subsequent 12-h period. Most of our patients had appendicectomy within 24 h of presentation [Table 4]. The delays witnessed were often due to the need for ancillary investigations, the need to re-evaluate the patient for an appropriate diagnosis or funds for surgical intervention in patients without health insurance policies. There is a good correlation between intraoperative findings and the histological diagnosis [Table 5].
Laparoscopic surgery is relatively new in the hospital and not yet accepted by many of the older surgeons for the treatment of appendicitis. Despite this, laparoscopic appendicectomy with its advantages, which include cosmesis, reduced morbidity such as wound infection and early return to work, is becoming the gold standard in surgical practice. Although all but eight cases were open appendicectomy, the duration of postoperative stay was <36 h and <72 h in 19.8% and 27.2% of the patients, respectively. All the patients who had laparoscopic Appendicectomy requested for this method of surgery despite the relatively higher cost of the procedure. They had no complications and duration of surgery compared favorably with the open approach. All patients who had laparoscopic appendicectomy were discharged on the 1st postoperative day. A tenth of the total number of patients was discharged home within 48 h after surgery. However, one of our patients who developed an enterocutaneous fistula was managed conservatively which required a prolonged admission for 54 days. The mortality and morbidity rates are related to the stage at presentation and increased with the occurrence of perforation. These rates are higher in developing countries due to delayed presentation. The perforation rates in this study is a total of 28.6% which is slightly higher than the published figures of 25% and 23.2%, in this sub-region and much smaller than 51% because of the predominantly pediatric population in the study by Talabi et al. However, despite our relatively high rate of perforation before surgery our morbidity rates are as stated in [Table 6]. The wound infection rates in the literature range from 5% in simple appendicectomy to 20% in perforated appendicitis. Our rates of superficial surgical site infection (5%) and deep surgical site infection (5.1%) are relatively low. Administration of ciprofloxacin and metronidazole as routine first-line drugs may account for these relatively low postoperative infection rates. Forty-two patients (4%) developed enterocutaneous fistula. A further review of patients who developed enterocutaneous fistulae showed no clear-cut predisposing factors. Six of them had intraoperative findings of appendix abscess eight had perforated appendices. There was no correlation between the duration of symptoms. Consequently, the surgical technique of closure of the appendiceal stump and the integrity of the ceacal wall may be considered as some of the probable factors. All but one of the patients with enterocutaneous fistula were managed conservatively before discharge due to a high output fistula. However, three required surgery 6–12 months after appendicectomy for which a limited right hemicolectomy and ileo-colic anastomosis was fashioned at surgery. One of the patients who developed a high output Enterocutaneous fistula was re-operated and consequently spent 54 days on admission. All the patients who had prolonged ileus had an exploratory laparotomy for perforated appendicitis. There were five mortalities in all. All the patients who died had significant widespread intra-operative purulent spoilage indicative of generalized peritonitis secondary to perforated appendicitis. The clinical features of generalized peritonitis may have been masked by prior antibiotics and analgesics administered before the presentation. These patients had presented for treatment after 36 h of onset of symptoms. Two of the mortalities were aged 70 and 73 years while the others were in their third decade of life.
A review of world published figures on the incidence of negative appendicectomy demonstrates a consistent decline in negative appendicectomy rate. This downward trend in negative appendicectomy rates is also reflected in a review of literature from this sub-region as demonstrated with a published rate of 16.1% (2005), 15.1% (2010) and 4.1% (2015). The histological diagnosis in this study revealed a negative appendicectomy rate of 9.5%. This falls in between quoted world figures ranging between 6.9% and 31%., The incidence of malignancy from the histological evaluation was 3%. Not all the intraoperative diagnosis of tumors was accurate as some of the cecal masses were inflammatory lesions after pathologic examination. The incidence of tumor associated appendicitis in the study population is low which is probably explained by the relatively young population presenting with appendicitis.
| Conclusion|| |
The diagnosis of acute appendicitis in the developing world may still be done with acceptable levels of accuracy based on in-depth medical history and clinical examination. Majority of the patients do not seek medical treatment within the initial 24 h period. The Alvarado scoring system may be utilized. However, the clinical acumen of the surgeon has a superior pick-up rate for appendicitis. This is demonstrated by the relatively lower number of normal appendices despite the apparently noninflamed status suggested by the Alvarado score.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]