|Year : 2018 | Volume
| Issue : 2 | Page : 34-37
Acute appendicitis at University of Benin Teaching Hospital, Benin city
Nnamdi Jude Nwashilli, Chukwunonso Nnamdi Agogbua
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||14-Mar-2016|
|Date of Decision||30-Apr-2020|
|Date of Acceptance||08-May-2020|
|Date of Web Publication||1-Aug-2020|
Dr. Nnamdi Jude Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Acute appendicitis is the most common surgical abdominal emergency worldwide. The diagnosis is mainly clinical and the treatment of choice is appendicectomy. Aim: The aim of the study was to examine the clinical features, diagnoses, treatments, and outcomes in patients with acute appendicitis. Patients and Methods: This was a prospective descriptive study carried out over a year period from September 2009 to August 2010 at the University of Benin Teaching Hospital, Benin City. All consenting and consecutive adult patients from the age of 18 years and above with a diagnosis of acute appendicitis were recruited. Demographic, clinical features, treatments, and outcomes were noted and entered into a pro forma and later analyzed using SPSS 16 version. Results: Acute appendicitis was preoperatively diagnosed in 86 patients but confirmed in 71 patients on histology. Twenty-nine were male, while 57 were female with a mean age of 28.36 ± 10.40 years. The most common age range affected was 21–30 years. All the patients had appendicectomy. Fifteen patients had a negative histology, of which two were male, while 13 were female, with an overall negative appendicectomy rate of 17%. All the patients were well and discharged. Conclusion: Acute appendicitis occurred most commonly in the age range of 21–30 years. Females accounted for a higher number of acute appendicitis, although negative appendicectomy rate was higher in them. The overall outcome was good.
Keywords: Acute appendicitis, diagnosis, treatment and outcome
|How to cite this article:|
Nwashilli NJ, Agogbua CN. Acute appendicitis at University of Benin Teaching Hospital, Benin city. Niger J Surg Sci 2018;28:34-7
| Introduction|| |
Acute appendicitis is the leading cause of surgical acute abdomen in many studies,, with a decline in its incidence at extremes of age. It accounts for 15%–40% of all emergency surgery carried out in most hospitals in Nigeria. The peak incidence occurs in the 2nd–3rd decade of life with a male preponderance.
Its diagnosis remains challenging because clinical evaluation yields sensitivity of 39%–74% and specificity of 57%–84%. In spite of technological advances, the diagnosis of appendicitis is still based primarily on the patient's history and physical examination. In the late 1960s and 1980s, intestinal obstruction from obstructed/strangulated groin hernia was the most common cause of surgical abdominal admissions in some tropical African countries.,, Recently, there has been a change in this pattern, and appendicitis has become the major cause of emergency hospital admissions.,
The actual etiology is unknown, but some predisposing factors are known. These include higher social class, low-fiber diet, infection, hereditary and familial tendency, and luminal obstruction from faecolith, lymph node hyperplasia, or helminthes., Being a common disease, it must remain in the differential diagnosis of any undiagnosed patient with persistent abdominal pain, particularly in the right lower abdominal quadrant.
The aim of the study was to examine the clinical features, diagnoses, treatments, and outcomes in patients with acute appendicitis.
| Patients and Methods|| |
This was a prospective descriptive study carried out over a 1-year period from September 2009 to August 2010 at the University of Benin Teaching Hospital, Benin City, located in the South-South zone of Nigeria with over 600 hospital bed capacity. The study population included all consenting and consecutive adult patients from 18 years and above admitted into the surgical ward with a diagnosis of acute appendicitis. The study was approved by the Research and Ethics committee of the University of Benin Teaching Hospital, Benin City.
All patients who met the inclusion criteria had their demographic data, symptoms and signs, abdominal findings, diagnosis at admission, the findings at surgery, postoperative diagnosis, and outcomes of treatment entered into a pro forma. The outcome of the patients' treatment was categorized into those who were uneventful and discharged; those with complications, managed appropriately and discharged and those who died (in-hospital or death within 30 days of operative procedure).
Data analysis was carried out using the Statistical Package for the Social Sciences (SPSS version 16) (SPSS Inc., Chicago, IL, USA), and the results were summarized in texts and tables.
| Results|| |
Acute appendicitis was preoperatively diagnosed in 86 patients. Twenty-nine were male, while 57 were female. The age range of the patients was 18–65 years with a mean age of 28.36 ± 10.40 years. The most common age range affected in appendicitis was 21–30 years [Table 1].
Abdominal ultrasound was carried out in 53 patients. Forty-five were female, while eight were male. Twenty-six females and seven males had positive findings suggestive of appendicitis ranging from probe tenderness in the right iliac fossa and fluid collection in the right iliac fossa and pelvis and appendix, with a diameter >6 mm.
Sixty-three patients had appendicectomy under spinal anesthesia, while 23 were operated under general anesthesia. Ten patients had perforated appendix, of which seven were male and three were female. The 10 patients with perforated appendix had laparotomy and appendicectomy, while the remaining 76 had appendicectomy through Lanz incision. Appendicitis was confirmed in 71 patients on histology out of 86 patients preoperatively diagnosed, of which 27 were male, while 44 were female giving a male-to-female ratio of 1:1.6. Fifteen patients had a negative histology, of which two were male, while 13 were female with an overall negative appendicectomy rate of 17%.
No other pathology was found in the 15 patients with negative appendicectomy. Wound infection occurred in two patients, while a patient had superficial wound dehiscence. The average duration of hospital stay after appendicectomy was 3.6 ± 1.94 days, with a range of 2–11 days. All the patients were well and discharged and followed up in the outpatient clinic. Other results are shown in the [Table 1], [Table 2] and [Table 3] below.
| Discussion|| |
Our study showed that acute appendicitis was more common in females than in males. Okobia et al. reported a similar finding of higher incidence of acute appendicitis in females than in males, which is similar to what Mangete and Kombo reported on acute appendicitis in Port Harcourt, Nigeria. However, this differs from other studies, that reported a higher incidence of appendicitis in males.
The mean age of the patients was 28.36 ± 10.40 years and 21–30 years being the most common age range. This mean age was within the third decade of life when acute appendicitis is much more common. Flum et al. reported a higher mean age of 31 ± 18 years over a 20-year study of misdiagnosis of appendicitis and the use of diagnostic imaging. However, Oguntola et al. in South-Western Nigeria reported a lower mean age of 25.79 years. The peak incidence of acute appendicitis worldwide is between 10 and 30 years of age.
Right lower abdominal quadrant pain was present in all the patients. Other symptoms were nausea, vomiting, anorexia, and fever, while localized tenderness in the right iliac fossa, guarding, and rebound tenderness were remarkable abdominal signs [Table 2]. Abdominal pain located in the right lower quadrant is the most common symptom of acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower abdominal quadrant occurs only in 15% of patients. A meta-analysis of the symptoms and signs associated with acute appendicitis was unable to identify anyone diagnostic finding but showed that a migration of pain from the periumbilical region to the right iliac fossa was associated with a diagnosis of acute appendicitis. Right iliac fossa tenderness, guarding, and rebound tenderness are the most reliable clinical findings suggestive of acute appendicitis.
Forty-five of 53 patients had positive findings suggestive of acute appendicitis on ultrasonography. These findings include probe tenderness in the right iliac fossa and fluid collection in the right iliac fossa and pelvis and appendix with a diameter >6 mm. A meta-analysis and a systematic review on the role of ultrasonography and computed tomography scanning in the diagnosis of acute appendicitis concluded that these investigations should be carried out only in patients in whom a clinical and laboratory diagnosis of appendicitis cannot be made., Ultrasonography studies are operator dependent and require careful examination. A computed tomography scan is preferable to ultrasonography as it has a greater diagnostic accuracy. However, cost, availability, and exposure to radiation limit its use in our environment. Radiological investigations are rarely needed to confirm a diagnosis of acute appendicitis.
Appendicectomy was carried out in all the patients. This is the treatment of choice in appendicitis. In uncomplicated appendicitis, surgery is carried out through a Lanz incision in the right iliac fossa. However, following rupture with generalized peritonitis, a laparotomy may be required to allow for thorough peritoneal lavage. Sixty-three patients had appendicectomy under spinal anesthesia, while 23 had it under general anesthesia. The choice of anesthesia was decided by the anesthetist after patients' review based on some parameters which included presence of complications of appendicitis, availability of opioids given together with bupivacaine intrathecally to obtund visceral pain in spinal anesthesia, presence of comorbidity, and patients' choice to be awake during surgery. The advantages of spinal anesthesia over general anesthesia include simplicity of technique, rapid onset, and exclusion of aspiration. It improves the quality of intraoperative as well as immediate postoperative analgesia without increasing its side effects such as itching, nausea, vomiting, hypotension, bradycardia, and urinary retention. Appendicectomy was carried out in 63 (73%) patients with uncomplicated appendicitis under spinal anesthesia. Appendicectomy under spinal anesthesia improves the acceptability of surgery as most patients accepted surgery on the ground that they will be awake during surgery and will not have pain.
Appendicitis was confirmed on histology in 71 patients out of 86 preoperatively diagnosed with a negative appendicectomy rate of 17% [Table 3]. Negative appendicectomy is the absence of inflammation or pathology in the appendix. Negative appendicectomy rates of 17%–36% have been reported by some centers.,, Of the 15 patients with negative appendicectomy, 13 were female, while two were male. The 13 females were aged between 20 and 33 years. This coincides with the reproductive age group in our environment as gynecological disorders can mimic acute appendicitis. No other pathology was found in the patients with negative appendicectomies. It is interesting to note that all the patients with histologically normal appendix were cured of their abdominal pain after appendicectomy. This raises a question if a patient can have appendicitis without positive histological features?
Wound infection occurred in two patients, while a patient had superficial wound dehiscence. Khattak et al. in a study of 663 cases of acute appendicitis reported wound infection in 123 (18.55%) cases as the most common postoperative complications, which agrees with this study. Other complications they observed included bleeding (0.75%), paralytic ileus (4.07%), intra-abdominal abscess (7.84%), intestinal obstruction (3.61%), and a case of deep-vein thrombosis.
There was no mortality in this study. The mortality rate of uncomplicated appendicitis is <1%; however, perforated appendix carries a higher mortality of 5%.
| Conclusion|| |
Acute appendicitis occurred most commonly in the age range of 21–30 years. Females accounted for a higher number of cases, though a negative appendicectomy rate was higher in them. Appendicectomy was well tolerated under spinal anesthesia, and the overall outcome was good with no mortality.
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Conflicts of interest
There are no conflicts of interest.
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