Middle East Journal of Family Medicine

Dr. Mohammed Ahmed Rashaideh MD., Dr. Khaled Nawayseh MD., Dr. Mohammed Bdoor MD., Dr.Omar Abu-aleish MD.

ABSTRACT

Background: Acute appendicitis is a common surgical problem and making the diagnosis can be difficult. Appendicectomy is the most common surgical procedure performed in general practice. The appendix can also be the site of a variety of neoplasms and unusual inflammatory conditions.

Methods: The hospital databases and records of 200 patients who underwent appendicectomy were analyzed retrospectively. The reports were analyzed for the following parameters: age-related incidence of acute appendicitis, rate of negative appendicectomy, and the incidence of other pathologies encountered.

Results: Age range was 5 to 70 years; 42% of the study group were females, 80% were less than 40 years. Negative appendicectomy rate (total=22.5%) was higher in females (34.5%) than males (13.8%). Right iliac fossa pain was the most common symptom. Localized right iliac fossa tenderness was the most common sign. Radiology was of little benefit apart from CT. Other pathologies included carcinoid (0.5%), adenocarcinoid (0.5%), parasitic infestation (2%).

Conclusions: Clinical examination is an adequate diagnostic tool in most cases of appendicitis. Laboratory results and ultrasound did not significantly alter clinical judgment. There are still a number of unusual histologies found in appendicectomy specimens, supporting the continued use of routine histology.

Acute appendicitis is one of the commonest clinical presentations in emergency surgical practice and the diagnosis is made primarily on the basis of the history and the physical findings, with additional assistance from laboratory examinations and radiological studies. The percentage of appendicectomies performed where the appendix is subsequently found to be normal varies between 15% and 30%. Some clinicians advocate delaying surgery to improve diagnostic accuracy in selected doubtful cases; however there have previously been reports that may lead to increased perforation rates and significant mortality. Proponents of "active observation and repeated re-evaluation", claim a reduction in negative appendicectomy rates with no significant increase in perforation rates or other morbidity.

Plain radiology has little role in the diagnosis of appendicitis, but ultrasonography in experienced hands can be accurate, although false-negatives can occur. It is probably most useful in excluding gynaecological pathology. Computed Tomography (CT) is not so operator dependent and is the investigation of choice, with reports of up to 100% accuracy and negative appendicectomy rates of 7%. High radiation exposure makes it undesirable for the paediatric population, and CT tends to be reserved for more difficult cases, at the extremes of age, where more sinister pathologies exist. Within the areas of the world where these technologies are unavailable, the onus still remains on clinical examination.

The aim of this study was to review the appendicectomy management in our unit. By comparing our results to the published data we hope to identify the optimum management strategy.

We conducted a retrospective review of the hospital databases and records of two hundred patients who underwent appendicectomy at Prince Rashid hospital. The list of patients was obtained from the operating theatre database, and the clinical records and investigations database were subsequently reviewed.

The pre-operative clinical diagnosis in all cases was acute appendicitis, based on history, clinical examination, laboratory tests and if necessary, radiological investigations. All appendicectomies were open method using grid-iron muscle splitting or small transverse (Lanz's) incision. Where there was a high clinical index of suspicion, surgery was performed on the same day as admission, after review by the on-call specialist or consultant. In uncertain cases, patients were actively observed on the ward overnight and assessed the next morning by a senior member of the team before a decision was made to operate. All appendixes were removed and sent for histological examination. Records were studied; the inflammation of appendix was graded as uncomplicated, complicated and normal, correlating with the clinical presentation, results of investigations, and operative findings.
Accuracy of diagnoses was defined as the number of histologically confirmed cases per 100 procedures.

Two hundred consecutive appendicectomy procedures were performed for presumed acute appendicitis between November 2006 and June 2007. The age range was from 5 to 70 years with a mean age of 24 years; 58% were males and 42% females, of which 80% were less than 40 years of age. The negative appendicectomy rate was 22.5%, and was significantly lower in males (13.8%) than in females (34.5%). The mean length of inpatient stay was 2 days.

The most common clinical presentation (56%) was localized right iliac fossa (RIF) pain, with migratory RIF pain (26%) and pain elsewhere (18%) being the next most common presentations. 67% of patients had symptoms of nausea and vomiting, but anorexia was present in 87% of cases. The mean duration of symptoms was 24 hours. Febrile symptoms and pyrexia were only present in 33% of patients. Guarding and rebound was elicited in 77% and 61% of patients respectively.
29 patients were subjected to plain radiology, 3 of which revealed only non-specific features. Ultrasonography revealed appendiceal pathology in 15% of cases.

The operative findings in patients with a normal appendix included pelvic inflammatory disease, mesenteric lymphadenitis, ruptured ovarian cyst, carcinoid of the appendix, terminal ileitis.

The accurate clinical diagnosis of acute right iliac fossa pain remains a difficult clinical problem as the differential diagnosis of such pain is not always straightforward. Acute appendicitis is the most common non-traumatic surgical emergency. In spite of all diagnostic modalities it is confusing for the clinician. The main concern relates to delay in diagnosis, leading to risk of perforation, abscess formation and increased morbidity. New diagnostic techniques such as estimation of C-reactive protein, scoring and computer analysis, graded compression ultrasonography, computed tomography, non contrast helical computed tomography and laparoscopy have been introduced in recent years. The drawback with these techniques is involvement of additional costs and lack of free availability. Due to these factors these modalities have not gained wide acceptance as routine diagnostic investigations of acute appendicitis. The diagnosis of acute appendicitis is still primarily based on history and physical examination. In a study evaluating clinical assessment alone in diagnosing appendicitis, accuracy ranged from 78%-97% with values correlating with the surgeon's experience. Although true prevalence of acute appendicitis varies from country to country and race to race, it is not uncommon in our country. As it is said that appendicitis is the disease of younger age, our study supports this view, but no age is immune to appendicitis. In this series the maximum number of patients was seen in the second and third decades (80% less than 40 years). In comparative international study the commonest age group was 10-30 years as 90%.

Pain was the most important presenting symptom and was present in all the patients of our study. This is similar to the study of Adesunkanmi AR, who reported lower abdominal pain in all cases of appendicitis. In our study, the majority of the patients (56%) pain started in the right iliac fossa. In 26% of patients, pain started in the umbilical or epigastric region and later migrated to the right iliac fossa. In the literature, migratory or shifting of pain to the right iliac fossa is variable and is found in 30-64% of patients. Anorexia was the other most common symptom after pain in this study. It was found in 87% of the patients. This figure more or less compares with the literature. According to two studies, anorexia was present in 82% and 77.7% of patients respectively. In one textbook it is the characteristic of acute appendicitis, positive in more than 90% of cases. It seems a reliable symptom and one should deeply inquire about this symptom. Anorexia was also present in 55.5% of cases with normal appendix. In our study 67% of patients experienced nausea and vomiting, once or twice, usually in the early part of disease. This complaint always followed the pain. Review of literature shows that 51-69% of patients with appendicitis vomit. It seems that this symptom has high sensitivity rate but less specificity, as quite a large group of patients (30-50%) with normal appendix also had this symptom.

Tenderness was present in all patients. The degree of tenderness was different in each individual patient, but in obese patients and in older age groups tenderness was elicited on deep palpation. These patients had relatively mild tenderness. Degree of tenderness also depends on difference in sensitivity to pain in different individuals. After a review of different studies, the importance of right iliac fossa tenderness has been concluded that in the absence of tenderness acute appendicitis is unlikely. Muscle guarding and involuntary rigidity were noted in 77% of cases. In our study rebound tenderness was found in 61% of cases and was helpful in diagnosis. It was more marked and persistent in cases of perforated and gangrenous acute appendicitis. It was also present in 22.2% cases of normal appendixes. In two different studies, rebound tenderness was present in 70% and 77.5% of all cases.

The total leukocyte count is widely used to aid the diagnosis of acute appendicitis. Its diagnostic value varies from useful to misleading. The total leukocyte count alone is not diagnostic because it has low specificity. Various studies have reported that 80% to 85% of patients with acute appendicitis will have a total white cell count of over 10,000/mm3. Neutrophilia of more than 75% occurred in 78% of patients. When the white cell count and neutrophil counts are considered together, less than 4% of patients will have normal values. However the present study shows that only 61.3% cases had TLC>10,000/mm3 which is almost similar to the findings of a series that reported a raised TLC>10,000/mm3 in only 49% of 354 patients. A raised TLC is regarded as a sensitive test for acute appendicitis but is not diagnostic because of its relatively low specificity and does not add much to the management in patients with undoubtful clinical findings.
The negative exploration rate of 22.5% in the present study is consistent with the figure of 5.4-30% mentioned in various studies. Normal appendicectomy rate is higher in females (34.5%) than males (13.8%). In a study by Anderson et al, the rate of normal appendix being removed was twice (24%) higher in women than in men 12%.

We conclude from our study that the judgment of an experienced clinician is an adequate diagnostic tool in the majority of cases. We followed a policy "active observation and repeated re-evaluation" which yielded results comparable to published data without significant morbidity. We found that laboratory investigations provide an adjunct to what is primarily a clinical diagnosis, although cross-sectional radiology can be of assistance in difficult cases at the extremes of age. Our results suggest that optimum management could include further use of diagnostic radiology and laparoscopy to reduce negative appendicectomy rates particularly in females of child-bearing age. This has implications on radiology resources.