European Journal of Cardiovascular Medicine

The term "acute appendicitis" was coined by Ringald H Fitz in 1886, who associated the illness known as typhlitis with the acute inflammation of the vermiform appendix.[1] Appendicitis is histologically defined as inflammation of the mucosa lining the vermiform appendix.

This inflammation can spread to other parts of the appendix due to venous stasis, organ ischemia, and bacterial translocation. These processes lead to the development of various symptoms and signs associated with the disease.[2] Appendicitis is a highly prevalent acute surgical condition of the abdomen, making appendicectomy one of the most frequently done surgeries worldwide[3]. It is likely the primary cause of surgical acute abdomen in the West African sub area.[4]Surgeons continue to face difficulties in accurately diagnosing appendicitis due to its varied and unpredictable manifestations.

Encountering difficulties in achieving precise diagnoses is a frequent occurrence due to the fact that not all patients display the generally reported clinical characteristics. An appendicectomy is widely recognised as the standard treatment.

In affluent countries, the lifetime risk of acute appendicitis is approximately 6.7% for females and 8.6% for males.[5] Nevertheless, the probability of getting appendicectomy during one's lifetime is significantly higher, specifically 9.89% for males and 9.61% for females.[6] The disparity between the rate of appendectomy surgeries and the occurrence of appendicitis highlights the extent of needless appendectomies. The prevailing opinion regarding the time of the procedure leans towards early surgery. However, this strategy of doing semi-emergency surgery for appendicitis carries the risk of a significant number of unneeded appendectomies, also known as "negative appendicectomy."

Negative appendicectomy refers to the absence of inflammation or the presence of intramural neutrophils in the appendix, as determined by histopathology studies, in patients who are thought to have appendicitis. These could be linked to systematic errors in the clinical diagnosis that excessively prioritise changeable symptoms and indicators.[7]

Enhancing diagnostic precision is crucial in order to avoid needless appendectomies.

The objective of this study was to assess presentation and management of acute appendicitis in a tertiary care hospital in Central India.

This prospective observational study was conducted in tertiary care centre from Central India and patients were followed from the time of evaluation at the adult emergency department to the day of discharge from the hospital. Inclusion criteria were all adult patients aged 18 years and above who were operated on for the impression of acute appendicitis, while pediatric patients were excluded from the study.

Patients were initially evaluated at the adult emergency department by trained surgical residents using several pre- defined clinical parameters including history and physical examination. Physical examination consists of measurement of the vital signs (temperature, blood pressure, pulse rate and respiratory rate) and abdominal examination.

Normal vital signs were defined as follows: temperature: morning temperature of <37.2°C or afternoon temperature of <37.7°C, axillary; blood pressure systolic 90–130 mmHg and diastolic 60–85 mmHg, pulse rate 60–100 beats per minute, respiratory rate 14–22 breaths per minute.

Abdominal examination findings which were looked for were direct and rebound tenderness, guarding and palpable right lower quadrant mass. Abdominal Ultrasound parameters used for the diagnosis of acute appendicitis were the presence of oedematous appendiceal wall measuring > 6 mm, a peristaltic appendix, non-compressible appendix, appendiceal fat stranding, the presence of right lower quadrant free fluid, sonography tenderness at McBurney’s point and visualization of appendicolith.

Except for the visualization of appendicolith which was considered definitive, the presence of only one parameter constituted probable acute appendicitis while the presence of two or more parameters was considered definite acute appendicitis. In the absence of all the above parameters and without other alternative diagnosis, a normal or unre- markable finding was reported.

The AIR score parameters (right lower quadrant pain, intensity of rebound tenderness or muscular defence, CRP concentration, WBC count, proportion of neutrophils, body temperature, and history of vomiting) were prospectively registered. Duration of symptoms and the level of experience of the physician managing the patient on arrival were noted. The use of diagnostic imaging (ultrasound, US, and/ or computerized tomography, CT), any surgical intervention, per-operative and discharge diagnoses, and use of antibiotics, were noted at the discharge.

A total of 300 patients were evaluated at the adult emergency department of Hospital with a diagnosis of acute appendicitis based on clinical, laboratory and imaging parameters in the study period and all underwent surgery. Acute appendicitis was the most common emergency surgical procedure accounting for 46.4% of the emergency operations in the study period.

Males took the major share of the study population accounting for 63.9% and with a male to female ratio of 1.8:1. The mean age was 27.62 ± 8.6 years with a range of 18–70 years. Half of the study participants belong to the age group of 18–25 years . As to the place of residence, the majority of the patients (88.5%) came from the capital city.

The mean duration of symptoms was 51.34 ± 100.5 hours with a range of 4 hours to 10 days while the median and the mode were 29 hours and 24 hours, respectively. The most common presenting symptom was abdominal pain, 98.2%, followed by migration of abdominal pain, 81.9%, and anorexia, 70%, while the most common physical sign was right lower abdominal tenderness, 93.4%. At initial evaluation in the emergency department, 31.7% of the patients were tachycardic while 17% were febrile and 1.0% were hypotensive.

Definite acute appendicitis was identified in 218 cases, with 163 classified as simple/uncomplicated and 50 as complicated. Additionally, there were 5 cases where acute appendicitis was definitively diagnosed but not further categorized. In cases where appendicitis was deemed probable, comprising a total of 20 instances, 15 were considered simple/uncomplicated, while 5 were classified as complicated. Among the ultrasound results, 23 cases were determined to be normal or unremarkable. Of these, 20 were subsequently confirmed as simple/uncomplicated, while 3 were found to be complicated during intra-operative assessment. A portion of the cases, totalling 33, did not have abdominal ultrasounds performed. Within this group, 24 were eventually diagnosed with definite acute appendicitis, 9 with complicated appendicitis, and none with simple/uncomplicated appendicitis. Finally, there were 6 cases where the ultrasound revealed other pathologies aside from appendicitis. Among these, 2 were determined to be simple/uncomplicated, 2 were complicated, and 2 were not further categorized. In summary, the ultrasound findings generally correlated with the intra-operative stage of appendicitis, with the majority of definite acute appendicitis cases being accurately identified. However, there were also instances where complications or other pathologies were detected, highlighting the importance of thorough evaluation and clinical judgment in appendicitis diagnosis.

For patients with symptoms lasting less than 48 hours, 158 cases were classified as simple/uncomplicated, 18 as complicated, and 2 as non-inflamed, totaling 178 instances.

On the other hand, among those with symptoms lasting 48 hours or longer, 65 cases were identified as simple/uncomplicated, 52 as complicated, and 5 as non-inflamed, amounting to 122 cases in total.

In summary, a higher proportion of complicated appendicitis cases occurred in patients with symptoms persisting for 48 hours or more, whereas simple/uncomplicated cases were more prevalent in those with symptoms lasting less than 48 hours. Additionally, there were a few cases where the appendix was found to be non-inflamed regardless of symptom duration.

Acute appendicitis primarily affects young individuals, with the highest occurrence observed during the second and third decade of life. This phenomenon was also observed in our study, where half of the participants fell within the age range of 18-25 years. Similar trends were noted in additional research conducted in Africa.[8,9-16]Our study, along with other reports, also observed a well-documented male predominance.[17-20,21-23]The average duration of symptoms exceeded 2 days in this study, consistent with comparable studies conducted both locally and in South Africa.[8,9,12,23]The majority of patients exhibited abdominal pain, consistent with findings from previous studies conducted in Ethiopia, Nigeria, and South Africa. [8,9,13,15] In this study, the majority of patients (81.9%) experienced the common migratory type of abdominal pain. This percentage is higher than what was observed in a study conducted in South Africa, where only one-third of the patients had this type of pain, and a study in India, where it was reported in 52% of the patients.[21,22]Right lower quadrant tenderness was the prevailing physical observation, observed in 93.4% of patients, a finding consistent with other studies.[19,9,15,22]Leucocytosis was observed in only 33% of our patients, which is a lower percentage compared to other studies conducted at Zewditu Memorial Hospital in Ethiopia and India, where 50.7% and 70% of patients, respectively, exhibited leucocytosis.[19,22]

Abdominal ultrasound, as a supplementary imaging study, was conducted in 81% of our patients. While the exact proportion of patients who underwent imaging for diagnosing acute appendicitis was not specified in comparable local studies, our observations suggest that our figure may be relatively high. This can be partially attributed to the fact that our institution serves as a referral hospital, where the majority of our patients are first assessed and examined at a primary health-care facility before being referred to our institution. Therefore, the majority of patients undergo ultrasound upon their arrival to the emergency department of our hospital.

Another notable observation is the growing inclination among physicians to utilize imaging modalities, a trend that is consistent with findings from other studies.[23,24] Some reports have indicated that the growing use of preoperative imaging has resulted in a decrease in the rate of unnecessary appendectomies, and this practice should be promoted.[24,25]In this study, the right lower quadrant transverse incision was the most frequently employed approach for appendectomy, as it was utilized in three-quarters of the cases involving patients with simple appendicitis. 23% of the patients were diagnosed with complicated appendicitis, a finding that aligns with certain reports.[19,26,11,15] while it was found to be lower than some reports.[9,21] The operating surgeon's assessment revealed that 1.8% of the patients had an appendix that appeared to be normal in appearance.

The correlation between intra-operative findings and histopathological reports is a subject of debate, with reported similarities ranging from 46.6% to 93.5% in various literature sources.[27-31]The study revealed a complication rate of 3.8%, which was markedly lower compared to similar studies.[11,21,23] The predominant postoperative complication observed was superficial surgical site infection, a finding consistent with previous studies, albeit with a significantly lower incidence.[9,15,21] The occurrence of an intra-abdominal collection was the second most frequent complication, which necessitated re-exploration.The relaparotomy rate in this study is 1.85%, which is similar to a report from Sweden, but significantly lower than a study conducted in a rural area of South Africa.

The decreased incidence of post-operative intra-abdominal collections may be attributed to the fact that most of the patients Patients exhibit uncomplicated appendicitis. The mortality rate observed in this study was comparatively lower than that reported in previous local studies, possibly indicating an enhanced health-seeking behavior within the society or improved surgical care.[19,9,31] The average duration of hospitalization was observed to be shorter compared to previous studies.[9,11,16,21,32,33]

Acute appendicitis ranked as the predominant emergency surgical operation during the study period. The majority of patients underwent abdominal ultrasound as an adjunctive imaging technique for diagnosing acute appendicitis. The predominant intraoperative finding was uncomplicated appendicitis, which contributed significantly to the morbidity and mortality rates that were deemed acceptable.