Risk factors for appendicitis

Acute appendicitis in the elderly: risk factors for perforation

Acute appendicitis continues to be the commonest cause of surgical abdominal emergency. It was often thought to be the disease of the young but as a result of recent increases in lifetime expectancy, the incidence of acute appendicitis also increased in the elderly .

The incidence of appendiceal perforation in acute appendicitis is estimated to be in the range of 20-30% which increases to 32-72% in patients above 60 years of age . The reasons behind this high rate were postulated to be due to the late and atypical presentation, delay in diagnosis and surgical intervention, presence of comorbid diseases and to the age-specific physiological changes . In our study, perforated appendicitis was found in 87 (41%) patients, a result that lies within the range reported by many other reports . Also found in the study was the absence of sex predilection for perforation; 46 (53%) patients were males and 41 (47%) were females. Although 92 (43%) of all patients had co morbid diseases at presentation, the risk of perforation did not appear to depend upon their presence (Table 1). These results were in conformity to the finding of Storm-Dickerson et al..

Delay in presentation was found by many authors to be the reason behind the higher rate of perforation seen in the elderly population . Our study showed that perforation rate correlated well with delayed presentation (pre-hospital delay) but did not correlate with the in-hospital delay.

The triad of right lower abdominal pain and tenderness, fever and leukocytosis is reported to be present in not more than 26% of patients above 60 years . In this study, all patients presented to the hospital with abdominal pain. However, the classical migratory pain of appendicitis was present in only 47% of them. Localized tenderness in the right lower abdomen which is considered to be the most constant diagnostic physical sign for appendicitis was present in 84% of cases. Both features (migratory pain and localized tenderness) were seen more often in the nonperforated rather than in the perforated group (Table 3). This finding may be explained by the fact that patients with perforated appendix would show poor localization of pain as well as more generalized lower abdominal tenderness and guarding.

Our study showed that, fever (>38°C) was present in 41% of all patients and was much higher in the perforated group (Table 3), a result which is in agreement with the findings of other studies .

Also in the study, WBC was found elevated in 63% of all patients with 74% shifts to left. As expected, values were higher in the perforated group as 71% of them had high WBC with 94% shift to left (Table 3). Again, a result in agreement with many other studies .

There are many scoring systems that have been used in the diagnosis of acute appendicitis like Alvarado, Kharbanda and Lintula scores . In general, these clinical scoring systems have better Likelihood ratios (LRs) than individual symptoms or signs alone. However, they don’t have sufficient discriminatory or predictive ability to routinely be used alone to diagnose appendicitis. They have been used to determine the need for further radiologic studies or as a guide for dictating clinical management . The policy of our hospitals has not adopted the use of any scoring system so far.

Advances in diagnostic skills and improvements in diagnostic facilities (CT) scan and (US) advocated improving the diagnosis in patients with suspected appendicitis . US can often diagnose an inflamed appendix and detects free fluid in the pelvis but this simple method is influenced by the operator’s experience, the body built and co-operation of the patient. The wider use of CT scan for patients with suspected appendicitis has been shown to improve the accuracy of the diagnosis and decrease the negative laparotomy rates . Recent studies reported a high sensitivity of 91-99% in this age group . Storm-Dickerson TL et al. reported that the incidence of perforation declined over the past 20 years from 72% to 51% in his patients due to the earlier use of CT scan . In our patients, CT scan was only used in those with equivocal findings and in whom the diagnosis was not reached after repeated CA and US. We could not calculate the sensitivity and specificity of CA, US and CT scans in our patients because we studied the positive cases. However, we did not find any false positive result when the CT scan was used.

Elderly patients have a higher risk for both mortality and morbidity following appendectomy. It was estimated to be around 70% as compared to 1% in the general population .

In our study, the overall post operative complication rate was 21%, a figure which is a bit lower than 27-60% reported by others . As expected, complications were three times more frequent in the perforated as compared to the nonperforated group. This finding is in consistency with several other studies that have shown that perforation per se was the most predictive factor for post operative morbidity in the elderly patients with acute appendicitis .

The mortality rate in elderly patients following perforated appendicitis was reported between 2.3%-10%. Death is often related to septic complications compounded by the patient’s co morbidities .

In this study, there were 6 (3%) deaths in both groups, four in the perforated and two in the nonperforated group. Three patients died due to septic complications while the others due to respiratory and cardiovascular causes.

As compared to younger age groups, the length of the hospital stay is usually longer in the elderly patients. This is usually ascribed to the higher rate of complications, prolonged need of antibiotics, treatment of other comorbidities and difficulties in communication . Our result of 7.4 and 4.2 days for perforated and nonperforated groups was found in agreement with these studies.

When comparing our result to a previous study that was done in the same region 10 years back , we found that the incidence of appendiceal perforation did not decrease over the past ten years in spite of improved health care programs and diagnostic facilities. We think that this failure was due to the underestimation of the seriousness of the abdominal pain in this age group by both the patients and the primary health care providers.

Other factors that may influence the patient outcomes were not specifically addressed in this analysis, but are relevant to medical decision making in cases of appendicitis.

Reports in the literature had appeared describing the advantages of laparoscopic surgery over the open technique in terms of decreasing post operative pain, time to recovery, wound complications and post operative hospital stay, while others found that referring an elderly patient with complicated appendicitis to laparoscopic surgery will increase the operative time, conversion rate and length of hospital stay . In a recent study published in 2013, Wray CJ et al. concluded that, the question of whether or not appendectomy should be performed via an open or laparoscopic technique has been inherently difficult to answer because both approaches offer similar advantages, namely, a small incision, low incidence of complications, a short hospital stay, and rapid return to normal activity . At our hospitals, the laparoscopic approach has been adopted for the treatment of appendicitis in the younger age groups but so far, not for the elderly patients.

Despite the fact that appendectomy has been regarded as the standard treatment for appendicitis for more than 100 years, several reports have appeared in the literature over the last few years describing nonoperative management of acute, uncomplicated appendicitis. This conservative treatment which consists of nil by mouth, intravenous fluids and broad spectrum antibiotics had proved effective with less pain but had high recurrence rate, a risk that should be compared with the complications after appendectomy . However, Wray CJ et al. considered that the available evidence regarding this nonoperative management is provocative and that level 1 data to suggest this is an alternative treatment option are not universally accepted . Although the main object of our study was not the management of acute appendicitis in elderly patients, but after reviewing the literature, we think that the non operative management of acute appendicitis in this age group should be comprehensively studied.

The result of this study should be read with limitations. First, it is a retrospective study and in order to highlight the risk factors leading to appendiceal perforation one would ideally collect clinical data before and not after perforation occurred. Second, the rate of perforation differs according to the patient’s accessibility to medical health services.

Photo Credit Paul Rogers

Personal Health

Jane Brody on health and aging.

Gwen Deely’s story is an example of how not to deal with a health crisis when traveling abroad. She realizes she’s lucky to be alive.

Ms. Deely, a 66-year-old living in Manhattan, was on an overnight flight from New York to Venice in October when she developed what she thought was food poisoning, perhaps from the tuna sandwich she had eaten at home that day. She weathered the night armed with more than a dozen airsickness bags and figured it would pass.

But it didn’t, and she spent the entire week in Venice in bed staring at the ceiling in the Airbnb apartment she and her partner had rented. She attributed her low-grade fever and chills to the flu shot she had received just before the trip.

“I would have had to take a boat to get to a doctor, and I couldn’t even stand up,” she said. Her decision not to go to a hospital that was a water taxi ride away was reinforced by a reluctance to seek medical help where she didn’t speak the language. “Had I been in a hotel, I would have asked to see a doctor who spoke English,” she said.

Ms. Deely somehow managed to fly home as scheduled, trying not to act sick on the plane, and went from the airport to the emergency room, where blood tests and a CT scan revealed a ruptured appendix.

Riddled with infection, she spent five days in a hospital on intravenous antibiotics, followed by months of antibiotic treatment and abdominal drainage at home. Finally, in mid-February, she was healthy enough for her ailing appendix to be removed with laparoscopic surgery, involving several tiny incisions in the abdomen.

A ruptured appendix is a life-threatening condition. Blindsided by atypical flulike symptoms rather than the stabbing abdominal pain one usually associates with a ruptured appendix, Ms. Deely failed to realize how close she came to dying. She now knows better than to try to “tough it out” when unexplained, debilitating symptoms occur.

Appendicitis, after all, is very treatable, and surgery is no longer the only option. Patients are now increasingly being offered a trial of antibiotics instead of being rushed into surgery to remove an inflamed appendix (the suffix “-itis” in appendicitis means inflamed). Without treatment, an inflamed appendix can rupture in two to three days after symptoms develop and can spill dangerous microorganisms throughout the abdomen. Thus, it is important to see a doctor as soon as possible.

Symptoms of appendicitis vary, and fewer than half of patients have them all. They often start with abdominal bloating and pain around the navel, which then moves to the lower right side of the abdomen and becomes sharp and continuous. The abdomen is likely to be tender to the touch, and a cough, sneeze, sudden movement or deep breath can intensify the pain. Mild fever, nausea and vomiting, diarrhea or constipation may occur.

Such symptoms are a clear warning that requires prompt medical attention. However, a third to a half of people with appendicitis do not have these typical symptoms, making cases like Ms. Deely’s especially challenging.

The appendix is a finger-shaped pouch attached to the large intestine (colon), usually on the lower right side of the abdomen. Long considered a vestigial organ with no known function, many people, young and old, have theirs removed in the course of another operation.

However, there are now indications that the appendix serves as a repository of healthy bacteria that can replenish the gut after an extreme attack of diarrhea. People who have had appendectomies, for example, are more likely to experience recurrent infections with the bacterium Clostridium difficile, a debilitating intestinal infection that causes severe, difficult-to-treat diarrhea.

Appendicitis occurs most often in children and young adults, and more often in men than women, but the risk of rupture is highest in older adults. The estimated lifetime chance of developing appendicitis ranges from 7 percent to 14 percent.

Acute appendicitis is the nation’s most common surgical emergency. It is most often performed laparoscopically, which is associated with faster recovery, less pain and lower risk of infection than an open operation. Some 300,000 people in the United States undergo an appendectomy each year, but sometimes, the appendix turns out not to have been inflamed, meaning the operation was not necessary.

The results of several recent studies suggest that patients with uncomplicated appendicitis should not be rushed into surgery and instead should be offered the option of a trial of antibiotics.

In a controlled study among 540 adult patients, 72.7 percent of 257 patients randomly assigned to take antibiotics in lieu of an operation did not require subsequent surgery a year later, and those who did need surgery had no bad effects from the delay.

In another nonrandomized study of 3,236 patients who were not operated on initially, the nonsurgical treatment failed to cure the appendicitis in 5.9 percent of cases, and the inflammation recurred in 4.4 percent.

Some patients may choose an operation so they won’t have to worry about developing another attack of appendicitis, but if they aren’t told they have a choice, they can hardly make one.

Writing in JAMA last month, Dr. Dana A. Telem, a surgeon at Stony Brook University Medical Center, noted that “the notion of nonoperative treatment of appendicitis has not been well-received by the majority of the surgical community.” This is hardly surprising, because doctors, like many of us, are creatures of habit, and surgeons who don’t operate miss out on a hefty fee.

But Dr. Telem pointed out that under the Affordable Care Act, it may soon become necessary for physicians to inform patients of nonsurgical options, which may include “watch and wait,” as some cases of appendicitis disappear without any treatment, and there may be nothing wrong with the appendix in others.

“Surgeons would be well served to take a leadership role in proactively developing decision aids to inform patients about the benefits and risks for both nonoperative antibiotic treatment and surgical treatment of appendicitis,” Dr. Telem said. She added, however, that the information should include the fact that data on the long-term outcome of nonsurgical treatment is currently lacking.

Also lacking is a large controlled trial in which patients with uncomplicated appendicitis are randomly assigned to antibiotic or surgical treatment and followed for perhaps five or more years. Such a study could define exactly which patients do best with nonoperative therapy and which require immediate surgery.

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Appendicitis is swelling (or inflammation) of the appendix, a narrow, tube-shaped organ attached to the large intestine on the lower right side of the abdomen. The condition may cause the appendix to rupture, a complication that can be life-threatening.

Appendicitis is the leading cause of emergency abdominal operations in the United States, according to the National Institutes of Health. Anyone can develop the condition, but most people who get appendicitis are 10 to 30 years old. More than 5 percent of the U.S. population develops appendicitis at some point in their lives, the NIH says.

Symptoms

Abdominal pain is the most common symptom of acute appendicitis. The pain typically begins near the belly button, and then moves to the lower right side of the abdomen, usually over a period of 12 to 24 hours, according to the NIH. The pain often gets worse if the patient moves around, takes deep breaths, coughs, or sneezes.

People who experience persistent abdominal pain should see their health care provider right away, said Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York City. “The longer you wait the more concerning the risk of complication,” Glatter said.

Other symptoms of appendicitis include:

  • loss of appetite
  • nausea or vomiting
  • constipation or diarrhea
  • low-grade fever
  • abdominal swelling/bloating

Although loss of appetite and fever are common symptoms of appendicitis, not all patients will have these symptoms, Glatter said.

Appendicitis can be harder to diagnose in the elderly, because they may not have physical symptoms that younger people have, such as tenderness in the abdomen, Glatter said.

In pregnant women, appendicitis pain may be in the upper right hand side of the abdomen, because the appendix migrates upward during pregnancy, Glatter said.

Causes

A blockage of the appendix — by feces, a foreign object, or in some rare cases, a tumor — is the most common cause of appendicitis, according to the NIH. When the appendix is blocked,the normal bacteria in the organ multiply, causing swelling and infection.

Risk factors

Appendicitis is most common in people in their teens and twenties, but it can happen at any age. There is no evidence that certain diets can prevent appendicitis, the NIH says.

Appendicitis can run in families, so having a family history of appendicitis can increase a person’s risk of the condition, Glatter said.

Diagnosis

To diagnose appendicitis, doctors can perform the following tests: A physical exam that applies gentle pressure to the abdomen, blood tests to check for infection, urine tests to test for kidney problems, and imaging tests, including a CT scan or ultrasound, according to the Mayo Clinic.

Doctors typically preform a CT scan for adults, and an ultrasound for children, Glatter said.

Treatment

In the United States, appendicitis is typically treated with surgery to remove the appendix, called an appendectomy. Prompt surgery decreases the chances that the appendix will burst, the NIH says.

However, in Europe there has been a shift towards treating mild cases of appendicitis with antibiotics alone, Glatter said. A 2012 study in the United Kingdom found that patients with mild appendicitis who were treated with antibiotics were about 30 percent less likely to experience complications, such as wound infection, compared to those who underwent surgery. In these cases, people treated with antibiotics may not need surgery at all, or they may have their appendix removed at a later date, Glatter said.

In the United States, it is less common to treat appendicitis with antibiotics alone, but some academic centers are considering it, Glatter said.

Most people with appendicitis recover quickly after surgery, and don’t need to make any changes to their lifestyle. Patients who’ve had their appendix burst may take longer to recover, the NIH says.

Ruptured appendix

If an inflamed appendix isn’t removed quickly, it can rupture. When the appendix ruptures, it can spill the infection throughout the abdomen, leading to a potentially dangerous condition called peritonitis, in which the lining of the abdominal cavity is infected. The condition can lead to sepsis, or a serious infection of the bloodstream.

People who have a rupture appendix may feel less pain for a short time, but the pain will soon become worse than before and likely cause sickness.

In most cases of peritonitis, the appendix is removed immediately with surgery. This is usually done through a laparotomy (a single incision). When the infection and inflammation are under control (usually after about six to eight weeks), surgeons remove what is left of the burst appendix.

In some cases, an abscess forms around the burst appendix. Surgeons typically drain the pus from the abscess before surgery using a tube placed through the abdominal wall. After surgery, the drainage tube is left in for around two weeks, while the patient takes antibiotics.

Appendix function

The appendix is a thin tube, about 4 inches long, which lies at the junction of the small intestine and the large intestine on the right side of the abdomen. It produces mucus that travels into the large intestine.

The appendix is often thought of as a “useless” organ that serves no function in humans, but was left over from a human ancestor. However, in recent years, some scientists have hypothesized that the appendix does indeed have a purpose. One theory is that the appendix may be a storage unit for good bacteria, which can help reboot the digestive system after a bacterial infection. A 2013 study in the journal Comptes Rendus Palevol found that an appendix-like organ has evolved independently 32 times in different mammal species, suggesting that the organ may play a role in mammalian health.

Jessie Szalay contributed to this article.

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Appendicitis is a medical emergency. It that happens when your appendix becomes sore, swollen, and diseased.

The appendix is a thin tube that is joined to the large intestine. It sits in the lower right part of your belly (abdomen). When you are a young child, your appendix is a working part of your immune system. The immune system helps your body to fight disease. When you are older, your appendix stops working this way. And other parts of your body help you fight infection.

The appendix does not keep working when you are older, but it can get infected. If not treated it can burst. This is serious and can lead to more infection and even death.

Appendicitis happens when the inside of your appendix gets blocked by something. This makes it swell up. If you have appendicitis, there is a serious risk that your appendix may burst. This can happen as soon as 48 to 72 hours after you start having symptoms. Because of this, appendicitis is a medical emergency. If you have symptoms, see your healthcare provider right away.

Appendicitis may be caused by various infections such as virus, bacteria, or parasites, in your digestive tract. Or it may happen when the tube that joins your appendix with your large intestine gets blocked or trapped by stool. Sometimes tumors can cause appendicitis.

The appendix then becomes sore and swollen. The blood supply to the appendix stops as the swelling and soreness get worse. All of the organs in your body need the right amount of blood flow to stay healthy.

Without enough blood flow, the appendix starts to die. The appendix will burst as its walls start to get holes. These holes let stool, mucus, and other things leak through and get inside your belly. You may get peritonitis. This is a serious infection in the belly that happens when the appendix has a hole.

Appendicitis is the most common cause of sudden (acute) belly pain that requires surgery. It mostly happens in teens and young adults in their 20s, but can happen at any age. Having a family history of appendicitis may raise your risk, especially if you are a male. Having cystic fibrosis also seems to raise the risk of getting appendicitis in children.

Appendicitis is a medical emergency. It is likely the appendix will burst and cause a serious, deadly infection. For this reason, your healthcare provider will most likely tell that you need to have surgery to remove your appendix.

The appendix will be removed in 1 of 2 ways:

  • Traditional (open) surgery method. You are given anesthesia. A cut (incision) is made in the lower right-hand side of your belly. The surgeon finds the appendix and takes it out. If the appendix has burst, a small tube (shunt) may be put in to drain out pus and other fluids in the belly. The shunt will be taken out in a few days, when your surgeon feels the infection has gone away.

  • Laparoscopic method. You are given anesthesia. This surgery uses several small cuts (incisions) and a camera (laparoscope) to look inside your belly. The surgical tools are placed through a few small cuts. The laparoscope is placed through another cut. A laparoscopy can often be done even if the appendix has burst.

If your appendix has not burst, then your recovery from an appendectomy will only take a few days. If your appendix has burst, your recovery time will be longer and you will need antibiotic medicine.

You will be treated for a few weeks with antibiotics and drainage if the infection around the appendix is too severe for immediate surgery. You will have surgery to remove the appendix at a later time.

You can live a normal life without your appendix. Changes in diet or exercise are usually not needed.

At this time, there is no known way to stop appendicitis from happening.

If you have any of the symptoms of appendicitis listed above, call your healthcare provider right away. Or go to your closest emergency room. Appendicitis is a serious medical emergency. It should be treated as quickly as possible.

Key points about appendicitis

  • Appendicitis is when your appendix becomes sore, swollen, and diseased.

  • It is a medical emergency. You must seek care right away.

  • It happens when the inside of your appendix gets filled with something that causes it to swell, such as mucus, stool, or parasites.

  • Most cases of appendicitis happen between ages 10 and 30.

  • It causes pain in the belly, but each person may have different symptoms.

  • Your healthcare provider will tell you that you need to have surgery to remove your appendix.

  • You can live a normal life without your appendix.

Next steps

Tips to help you get the most from a visit to your health care provider:

  • Know the reason for your visit and what you want to happen.

  • Before your visit, write down questions you want answered.

  • Bring someone with you to help you ask questions and remember what your provider tells you.

  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

  • Ask if your condition can be treated in other ways.

  • Know why a test or procedure is recommended and what the results could mean.

  • Know what to expect if you do not take the medicine or have the test or procedure.

  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.

  • Know how you can contact your provider if you have questions.

Abstract

Background: Acute appendicitis (AA) is the most common surgical emergency in childhood. The risk of rupture is negligible within the first 24 h, climbing to 6% after 36 h from the onset of symptoms. Because of difficulty in accurate diagnosis of AA a significant number of children still are being managed when it is already perforated. There is always a need to make an early diagnosis of AA and to find out the risk factors associated with development of complication in this condition. Patients and Methods: A total of 102 patients with a clinical diagnosis of AA were admitted during the study period. On admission, a good clinical history and proper physical examination was performed. All the eligible patients who finally diagnosed clinically as having AA were planned for emergency open appendectomy. The removed appendix was sent for histopathological examination in all the study subjects. Results: Out of 102 cases, 93 cases were histopathologically appendicitis, rest nine cases showed no evidence of inflammation so the rate of negative appendectomy was around 9%. On histopathology normal appendix was found in nine patients (8.9%), AA in 71 patients (69.6%), complicated appendicitis (CA) which includes perforated and gangrenous appendicitis was present in 22 patients (21.5%). Perforations were more common in patients who were younger than 5 years. >60% patients presented with CA when the duration of pain was >72 h. Presence of appendicolith increased the probability of CA.

Keywords: Acute appendicitis, children, complication

How to cite this article:
Singh M, Kadian YS, Rattan KN, Jangra B. Complicated appendicitis: Analysis of risk factors in children. Afr J Paediatr Surg 2014;11:109-13

Introduction

Acute appendicitis (AA) is the most common surgical emergency in childhood. It occurs in almost all age-groups and is particularly difficult to diagnose in its early stage in infants and toddlers. The lifetime risk of developing appendicitis is approximately 9% in males and 7% in females. Approximately 30-75% of children present with perforation, especially in younger children (<5 years).
The risk of rupture is negligible within the first 24 h, climbing to 6% after 36 h from the onset of symptoms and remains steady at approximately 5% for each ensuring 12 h period, establishing a 36 h period from the onset of symptoms to surgery as a low risk period for appendiceal perforation. ,
The diagnosis of AA is challenging specially in the paediatric population, due to potential atypical clinical presentation in this age group, non-specific clinical symptoms and also a wide range of differential diagnoses. The initial misdiagnosis rate for appendicitis range from 28% to 57% for older children and may reach up to 100% for those 2 years or younger, despite clinical history, physical examination and diagnostic armamentarium including total leucocytes count (TLC), C-reactive protein (CRP), ultrasound, computed axial tomography scan and magnetic resonance imaging. The early diagnosis is vital for the successful outcome because the delay in diagnosis can lead to gangrene or perforation with increased morbidity including wound infection, abscess formation, prolonged hospitalization, and mortality with an increased risk of malpractice litigation.Because of difficulty in accurate diagnosis of AA a significant number of children still are being managed when it is already perforated. There is always a need to make an early diagnosis of AA and to find out the risk factors associated with development of complication in this condition. The present study was done to determine the risk factors for complications in AA in paediatric patients.

Patients and Methods

The present study, a prospective type of study was carried out in the Department of Paediatric-surgery at Pt. B. D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak. All the paediatric patients (up to 14 years of age) presented to the Emergency Department, PGIMS, Rohtak in 1 calendar year (February 2012-January 2013), for acute right lower abdominal pain and admitted to Paediatric Surgery Department with provisional clinical diagnosis of AA were included in this study. A total of 102 patients with a clinical diagnosis of AA were admitted during the study period. Patients with nonspecific symptoms, not suspected to have appendicitis and patient with appendicular lump on per abdominal examination were excluded from the study. Such patients were managed conservatively and were kept under observation.
On admission, a good clinical history and proper physical examination was performed on all the subjects admitted with a clinical diagnosis of AA. After recording basic information like name, age, sex and address of the patients, a good clinical history focusing on describing the abdominal pain, duration of pain, site of start of pain and any history of migration of pain from periumbilical region to the right iliac fossa, nausea/vomiting, anorexia, diarrhoea and fever was recorded. Past history of similar pain was also extracted.
A good general physical examination was performed starting from general looks, vital signs like pulse rate and temperature and the same was recorded. Whether, a patient was having normal pulse rate or tachycardia, decided after considering expected normal pulse rate for the same age. After general physical examination, child was first asked to point out the site of maximum pain. A per-abdominal palpation was started from the site opposite to the site of maximum pain with warm hands. A detailed examination was carried out giving special attention to right lower quadrant, point of maximum tenderness, rebound tenderness, muscle guarding and any palpable lump. Informed consent was taken from guardian of the patient before starting the interview. All patients were investigated by doing TLC, differential count, left shift and complete urine examination. A preoperative ultrasonography was also done.
All the eligible patients who finally diagnosed clinically as having AA were planned for emergency open appendectomy and the patient counselling was carried out before surgery. Guardians of all the subjects were explained clearly beforehand for the least possibility of misdiagnosis resulting to negative exploration and other differentials as a universal rule in AA. Afterwards, emergency appendectomy was done by conventional method. Intra-operative findings like location of appendix, gross appearance of appendix i.e., whether it was inflamed or not, perforation status of the appendix, etc., was recorded. In case of perforation, site of perforation in the appendix was also recorded.
The removed appendix was sent for Histopathological Examination (HPE) in all the study subjects. Post-operative stay and any wound infection were also recorded. HPE report was made available and was taken as final diagnosis. According to the histopathological results, patients were classified into the following groups: Normal appendix (no evidence of any inflammation in any layer of appendix), AA, gangrenous appendicitis (diffuse infiltration of granulocytes or areas of necrosis extending through the wall) and perforated appendicitis. AA was grouped under simple appendicitis (SA) and gangrenous and perforated under complicated appendicitis (CA) subgroups.
Statistical analysis
All the collected data were entered in Microsoft Excel spread sheet. All the categorical variables were analysed by applying Chi-square test and continuous variables were analysed by applying independent t-test. All the analyses were done in the Statistical Package for Social Sciences version 17, a software package used for statistical analysis, officially named “IBM SPSS Statistics”.

Results

A total of 102 consecutive cases were operated based on clinical diagnosis of AA. Out of these 93 cases were histopathologically appendicitis, rest nine cases showed no evidence of inflammation so the rate of negative appendectomy was around 9%. On histopathology the appendix was normal appendix in nine patients (8.9%), AA in 71 patients (69.6%), CA which included perforated and gangrenous appendicitis in 22 patients (21.5%). Thus, one-fourth patients presented with CA.
Perforation was more common in females (30.4% vs. 13.9) whereas distribution of other types of appendicitis was almost similar in both groups. Although perforation was more common in females, (P = 0.288).

Table 1: Sex wise distribution of histopathologic features of appendix
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With respect to age, four (44.4%) out of nine patients who were <5 years had perforation, whereas five (12.5%) out of 40 patients who were aged between 5 and 10 years had perforation. Thus, perforations were more common in patients who were younger than 5 years, (P = 0.060).

Table 2: Age wise distribution of perforation
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More than half (64%) of the patients were operated with pain duration of <24 h while about one-fourth were operated with pain duration between 24 and 72 h. Mean duration of pain of all patients was 38.6 h. Over 60% patients presented with CA when the duration of pain was >72 h, (P < 0.001).

Table 3: Duration of symptoms and perforation
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Perforations were more common in patient from rural than urban areas (18.8 vs. 15.2) (P = 0.80).

Table 4: Distribution of perforation with locality
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Intra-operatively, appendicolith was found in 13 cases (12.7%) out of which seven cases were non-perforated and six cases were of CA (4 perforated, 2 gangrenous). Thus, out of 18 perforated appendices appendicolith was present in four cases (22.3%) and out of four cases of gangrenous appendices it was present in two cases (50%), suggesting the presence of appendicolith increases the probability of CA (P < 0.027) .

Table 5: Appendicolith and perforation

The most common site of perforation was body of appendix. About half perforation was on the body, one-third on the tip and the rest at the base of appendix .

Table 6: Site of perforation in perforated appendix

Discussion

AA traditionally has been a clinical diagnosis and remains so to this day. The diagnosis can be difficult to make in many children who may present with atypical sign and symptoms or an equivocal physical examination. Delay in diagnosis, especially in children can lead to morbidity and even mortality. To prevent delay in diagnosis various investigations have been tried but diagnosis of AA is still clinical. Until date, we have no laboratory parameters that could indicate or reliably point on the presence or absence of AA. The clinical diagnosis will remain the cornerstone in AA; nevertheless, laboratory investigations provide significant complimentary aid in diagnosis. In this study, perforated appendices were found in 18 cases (17.6%). Perforation rates which have been described in the literature vary between 5% and 62%, respectively. , Various risk factors associated with increased incidence of perforation have been studied which includes; extremes of ages, male sex, race, rural locality, delays in presentation or diagnosis, lack of insurance or financial coverage status, hospital volume, presence of appendicolith, elevation in the blood parameters, namely neutrophils count and CRP. ,,,,

Young children have less ability to understand or articulate their developing symptomatology compared with adolescents, the accuracy of diagnosis in this age group is also less, the immaturity of omentum and the reduction of defence mechanism results higher perforation rate. Perforation rates have been reported to be as high as 82% in children younger than 5 years and nearly 100% of 1-year-old. , In this study, out of nine patients who were <5 years 4 (44.4%) had perforation, out of 40 patients who were between 5 and 10 years, 5 (12.5%) had perforation. Thus, perforation was more common in patients who were younger than 5 years which is similar to findings in some other studies. Delays in presentation or diagnosis causing elevated perforation rates have been documented to occur for reasons other than age. Children with perforation are much more likely to have been initially referred to a paediatrician rather than a surgeon. In this study, we found that as the duration of symptoms increases, the proportion of simple to CA decreases thereby number of patients with perforation or gangrene increases. >60% patients presented with CA when the duration of pain was >72 h, a finding confirmed by other studies. A study evaluated 126 children with AA in which 26% of patients underwent surgery at the first 6 h and 74% at the first 6-24 h after the onset of symptoms, but there weren’t any significant differences of perforation between these two groups. Another research in America, was conducted on 219 patients and was found that rupture risk was ≤2% in patients with <36 h of untreated symptoms. For patients with untreated symptoms beyond 36 h, the risk of rupture rose to and remained steady at 5% for each ensuing 12-h period. Rupture was greater in patients with 36 h or more of untreated symptoms. Papaziogas et al. in a study of 169 patients found that the risk of perforation was negligible within the first 12 h of untreated symptoms, but then increased to 8% within the first 24 h. It then decreased to approximately 1.3-2% during 36-48 h, and subsequently rose again to approximately 6% (7.6-5.8%) for each ensuing 24-h period. Augustin et al. found that there is an early risk of perforated appendicitis even within the first 36 h of symptoms. This risk appears to be higher in males and patients older than 55 years, a quarter of who are perforated within the first 36 h of symptom duration. In addition, perforation in AA may be more of continuous phenomena worsening exponentially with duration of symptoms rather than a threshold phenomenon.
It would logically follow that patients who do not have good access to medical care would be more likely to present with perforation. Patients from rural areas have higher rates of perforation with AA than urban patients. This difference persists when accounting for other factors associated with perforation. In this study, perforations were more common in patient from rural locality than urban (18.8 vs. 15.2) but this difference was found statistically insignificant (P = 0.80).

Appendicolith

The appendicolith, also known as “fecalith” or “corpolith” is composed of firm faeces and some mineral deposits. Presence of appendicolith is a well-established risk factor for perforation now. Perforation is more common in male because males have been found to have a higher incidence of appendicular faecoliths and calculi. Appendicolith may obstruct the appendix lumen, causing appendicitis and is found in approximately 10% of patients with appendix inflammation. Case reports of the presence of an appendicolith and its strong correlation to AA can be found in the literature. Appendicitis which is caused by appendicolith is more commonly associated with perforation and abscess formation. , In the present study appendicolith was found in 13 cases (12.7%) out of which seven cases were non-perforated and six cases were of CA (4 perforated, 2 gangrenous). Thus, out of 18 perforated appendices appendicolith was present in four cases (22.3%) and out of four cases of gangrenous appendices it was present in two cases (50%), suggesting the presence of appendicolith increases the probability of CA.

Conclusions

The perforations were more common in females and patients who were younger than 5 years, but statistically it was not significant. As the duration of pain increases, the proportion of complicated to SA increases significantly. Presence of appendicolith significantly increased the probability of CA.

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Correspondence Address:
Dr. Mahavir Singh
11/11 J (UH), Medical Campus, Pt. B. D. Sharma PGIMS, Rohtak – 124 001, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0189-6725.132796

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