Many in medicine have found that they love the blood and gore of surgery and dream of someday running an emergency situation in which involves an immediate surgery. Acute appendicitis is the most common surgical abdominal emergency. Delayed treatment increases the incidence of complications. The aim of this study was to investigate the presentation, incidence, and predictors of complications, and histological findings in adult patients with clinical diagnosis of acute appendicitis. This paper will discuss adult patients to include patients aged 12 years and older diagnosed with acute appendicitis.
Data collected included demographic data, clinical presentation, duration of symptoms and reasons for presentation delay, diagnostic investigations, operative and histology findings, length of hospital stay, and mortality so we can gain a better understanding of an ailment which has caused many emergency and operating room visits. Predominant presenting symptoms for one study of a patient with appendicitis were right iliac fossa pain (95%), nausea (80%), and vomiting (73%), with 63% of patients presenting 2 days after onset of symptoms.
Fever was present in 15% and only 31% of patients gave a typical history of acute appendicitis of vague peri-umbilical pain. The negative predictive values of white cell count and C-reactive protein for acute appendicitis were 28% and 50%, respectively. Sensitivity of the ultrasound to detect acute appendicitis was 60% with a negative predictive value of 31%; 30% of patients had complicated appendicitis. Histology results showed a normal appendix in 11% of patients. The 30-day mortality rate was 1. 4%. Though we are told in many books of the infamous belly pain, patients with acute appendicitis rarely present with a typical history of vague peri-umbilical pain.
The negative predictive values of both white cell count and ultrasound proved that neither of these measurements was accurate in the diagnosis of acute appendicitis. Most of these patients with complicated disease present late, with the most common reasons for this delay being lack of access to a medical clinics and prior treatment by general practitioners. Appendicectomy is the most common emergency surgical procedure worldwide. The peak incidence of acute appendicitis is between 10 and 30 years of age. The diagnosis of acute appendicitis is mainly clinical and presentation of acute appendicitis may be typical or atypical.
Typical presentation starts with vague peri-umbilical pain for several hours, which later migrates to the right iliac fossa, associated with lack of appetite, nausea, or vomiting. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. If left untreated, acute appendicitis may lead to complications, leading to inflammatory mass, appendix abscess, or rupture, with generalized peritonitis. Diagnosis of complicated acute appendicitis is clinically supplemented by ultrasound or CT scan.
However, it is common in practice to admit and observe patients with an uncertain diagnosis and to delay their surgery until the diagnosis is more definite in order to reduce the negative appendicectomy rate. Pre-admission delay on the part of the patient and post-admission delay by the surgeon are responsible for combined delay in diagnosis and definitive management. Patients’ files were reviewed on admission and after discharge. Data retrieved included patients’ demographics, clinical presentation, and duration of symptoms before presentation to the hospital, results of diagnostic investigations and evidence of complicated disease at presentation, length of hospital stay, intensive care unit (ICU) admission, negative appendicectomy, and mortality rate.
Most importantly, the findings further confirms the predominance of acute appendicitis in young males. The average duration of symptoms in a patient suffering from appendicitis is about 4. 5 ? days. Compared to other studies, the average duration of symptoms before seeking medical attention was high, which might explain the heightened rate of complicated appendicitis found in our study. One study found that the mean duration of illness prior to seeking medical attention was 3. 7 days, while another, at Prince Mshiyeni Memorial Hospital, found delays of 3.
5 days in presentation. Importantly, one study confirms a statistically significant difference in patients with uncomplicated and complicated appendicitis after two days of symptoms (P <0. 001). Indeed, some finding is in agreement with various studies showing that the rate of complicated appendicitis increased two days after onset of symptoms. A present study included all the standard different investigations required in the diagnosis of acute appendicitis cases. It was found that the inflammatory marker, CRP, sensate has been discovered that the CRP sensitivity to be 93% and the specificity 86%, while the total leukocyte count had a NPV of 50% and CRP had a NPV of 50%.
Bearing in mind that ultrasound is operator-dependent, it has found sensitivity to be 60%, specificity 66%, PPV 86. 9%, and NPV 31%. In contrast, one physician has found an ultrasound sensitivity of 84. 8% and a specificity of 83. 3%, with a PPV and a NPV of 93. 3% and 66. 7%, respectively. In general, ultrasound seems to have better PPV than NVP. The first study shows, as many previous studies have shown, that CT scanning is the best method of investigation to confirm or to invalidate the diagnosis of appendicitis.
The first study shows that 63% of patients presented with delays, with the major reason for delay being lack of disease awareness and health facilities. Of those who presented late, 30% had self-medicated; 19% of the delayed presentations had been treated previously by general practitioners and most of these patients had been put on antibiotics. Thirty percent of acute appendicitis cases in the primary study were complicated appendicitis. A physician, in their audit of 1997, found the rate of perforation at CHBAH to be 22%.
Another physician at King Edward VIII Hospital in Durban, showed a perforated appendicitis rate of 34% and has associated this with delayed presentation. Physicians at Edendale Hospital, found perforation of appendix cases to be 57% (114/200), of which 19% (38/200) were referred from the surrounding primary healthcare clinics and 2. 5% (5/200) were referred from local general practitioners; referrals from the four rural referral hospitals constituted 35% (70/200) of admissions. In the primary study it was found that a lower rate of perforation compared to that of other hospitals in South Africa, such as Edendale Hospital and Frere Hospital.
This study also shows that 83% of all admissions underwent surgery. In their trial of treating acute appendicitis with antibiotics, another physician study found that 12% of patients on anti-biotherapy underwent appendicectomy during the first 30 days, while 30% underwent appendicectomy between 1 month and 1 year later. It has also been found that 23% of appendicectomies take place after a failure to initial anti-biotherapy. The treatment of acute appendicitis with antibiotics requires specific protocols and thorough follow-up of the patients.
Outcome strongly depends on the presentation of acute appendicitis (uncomplicated or complicated), the age at presentation, the duration of symptoms, re-operations, and ICU stays of more than two days, and that hospital stays of longer than two days in complicated appendicitis were significant compared to cases of uncomplicated appendicitis. This was also found in other studies which assessed the outcome in cases of acute appendicitis. The overall mortality rate is 2/146 (1. 37%); patients who died in the primary study were above 45 years of age. Some mortality rate was acceptable compared to acceptable mortality rate of <1%.
Similarly, a physician, at Prince Mshiyeni Memorial Hospital, reported a mortality of 1. 2%, with all cases from the perforated group and another physician, at Edendale Hospital, reported an overall mortality rate of 2%. All of the patients who died in the study by at Prince Mshiyeni Memorial Hospital had intra-abdominal contamination in all four quadrants and all patients required initial ICU admission. Patients with acute appendicitis rarely present with a typical history of vague peri- umbilical pain. Leukocyte count is not reliable in the diagnosis of acute appendicitis.
Most of our patients present late, with complicated diseases, and the most common reason for delay in presentation being a lack of disease awareness and/or health facilities and prior treatment by general practitioners. Complications were higher in males and the elderly. Appendicitis is one of the most common reasons emergency physicians run from the emergency room to the operating room due to a “tummy ache. ” We must remain vigilant of the signs and symptoms which may quickly or insidiously arise in our patients to ensure we are able to preserve health and life.
The submarine population hold prime candidates to succumb to the medical emergency such as appendicitis so it is our duty to ensure we are well educated and prepared to serve those who serve by our sides. By being educated we can keep our brothers in arms by our side and return them home to the families that they work so hard for day in and day out. Regardless of age or sex we have a duty to educate ourselves to the point where we can identify a life threatening emergency. In this paper I have discussed many signs and symptoms that contribute to a proper diagnosis of appendicitis and have a gained knowledge of how important it is to identify these patients and get them to a higher echelon of care.