Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 6  |  Page : 753-757  

Epidemiological aspects of appendicitis in a rural setup


Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Web Publication18-Nov-2014

Correspondence Address:
Murtuza Ali Asger Calcuttawala
Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.144867

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  Abstract 

Aim: The aim was to study the 3-year epidemiological trend of acute appendicitis in a rural setup. Materials and Methods: This is a retrospective study of patients who were admitted with a diagnosis of appendicitis over a period of 3 years excluding negative appendectomy cases. Totally, 130 cases were diagnosed as an acute appendicitis, on clinical suspicion and investigations during this period. We reviewed and studied these cases regarding incidence of appendicitis in different age groups, sex, according to dietary pattern and seasonal trend. Results: Occurrence of appendicitis was the highest in the 11-20 years age group which constituted 44.6%. Followed by 21-30 years age group, which constituted 36.1%. The incidence of appendicitis between the age group 31 and 40 years constituted 11.5% while between 0 and 10 years age group was 3%. Between 41-50 years and 51-75 years of age group 2.3% each. The youngest case recorded was 8 years of age and the oldest 65 years of age. In this study occurrence of appendicitis in both male and female was almost equal. Nonvegetarians were affected more than vegetarians. The occurrence of appendicitis was peak in the spring and low in the summer. Conclusion: Acute appendicitis should be suspected irrespective of age, sex and socioeconomic status of individual. Age-specific occurrence, sex ratio of appendicitis give the impression that epidemiologic features of acute appendicitis are different with worldwide data. It is difficult to diagnose appendicitis in young children, young women and elderly people. Total leukocyte count, urine microscopy, ultrasonography and computed tomography abdomen should be used as a diagnostic aid in doubtful cases in association with physical findings, but it does not replace the clinical skills of a general surgeon.

Keywords: Epidemiology, appendicitis, rural setup


How to cite this article:
Lohar HP, Asger Calcuttawala MA, Nirhale DS, Athavale VS, Malhotra M, Priyadarshi N. Epidemiological aspects of appendicitis in a rural setup. Med J DY Patil Univ 2014;7:753-7

How to cite this URL:
Lohar HP, Asger Calcuttawala MA, Nirhale DS, Athavale VS, Malhotra M, Priyadarshi N. Epidemiological aspects of appendicitis in a rural setup. Med J DY Patil Univ [serial online] 2014 [cited 2020 Feb 26];7:753-7. Available from: http://www.mjdrdypu.org/text.asp?2014/7/6/753/144867


  Introduction Top


Acute Appendicitis forms an important emergency in the day-to-day surgical practice. It affects human beings irrespective of age, nationality and religion.

In United States, 250,000 cases of appendicitis are reported annually. The incidence of acute appendicitis has been declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000 population.

In Asian and African countries, the incidence of acute appendicitis is probably lower because of dietary habits of the inhabitants of these geographic areas. Dietary fiber is thought to decrease the viscosity of faeces, decrease bowel transit time and discourage the formation of faecolith, which predispose individuals to obstructions of the appendiceal lumen. [1]

The incidence of appendicitis gradually rises from birth, peaks in the late 10 years and gradually declines in the geriatric years. It is most prevalent in the 10-19-year-old age group. [2] In recent years, the number of cases in patients aged 30-69 has increased to 6.3%. [3]

Despite the advances in diagnostic medicine and therapeutics, the accurate diagnosis of appendicitis and pain in the right iliac fossa remains a clinical challenge.

Over 120 years ago, the sequence of appendicitis - perforation - abscess formation and peritonitis was described and the literature is replete with reassessments of the criteria which should be used to reach an accurate diagnosis, yet each year many apparently normal appendices are removed. This is partly due to many other intra-abdominal pathologies which may mimic appendicitis, especially in females in their reproductive years.

It is evident from reviewing the vast amount of literature published on disease processes in the appendix that it is difficult to diagnose appendicitis, especially in the very young and very old patients. Clinician must maintain a high index of suspicion in all age groups.

There are limited Indian studies regarding epidemiology of acute appendicitis and difficulties in diagnosis, so this study was done to throw more light on it.


  Materials and Methods Top


This is a retrospective study of patients attending surgical department and those admitted with a diagnosis of appendicitis over a period of 3 years in a rural setup. Exclusion criteria were negative appendectomy cases. All diagnosed cases of appendicitis managed either surgically or conservatively.

Conservative management (Oschner - Sherren regimen) mainly used for cases of appendicular mass and patient not willing for surgery.

Anesthesia

The patients were subjected to general anesthesia as well as spinal anesthesia as per need.

Incisions

Gridiron and lanz incisions were used in cases where diagnosis was definite, lanz incision used in young girls for cosmetic purpose. Rutherford Morrison incision used where exposure was not sufficient. Lower Midline incisions used when diagnosis was in doubt, particularly in the presence of intestinal obstruction or when gynecological problems could not be ruled out.

Procedure

Appendectomy done in all, except in cases of appendicular mass.

In doubtful cases like females in reproductive age group, we took lower midline incision and did appendectomy after appendix was found to be inflamed.


  Results Top


We treated 130 cases diagnosed as acute appendicitis on clinical suspicion and investigations. These cases were operated, appendectomy carried out, and subsequent histopathological examination also confirmed the diagnosis. Appendicular mass patients were treated conservatively followed by interval appendectomy. In the case of perforated appendix with pelvic abscess, was managed with laprotomy, drainage of pus, and appendectomy. In the case of Mekel's diverticulum we did resection anastomosis. Postoperatively patients were treated with iv fluids, antibiotics and analgesics. Once bowel sounds were heard, oral feeds were allowed. Most of the patients had uneventful postoperative recovery. Mild infection of the wound was seen in about 10 cases. One patient developed enterocutaneous fecal fistula, who was having gangrenous appendix intraoperatively, which was managed medically and subsequently with right hemicolectomy by taking lower midline incision. Wound dehiscence was noted in one case, an obese individual and managed by regular dressing and secondary suturing.

Difficulties in diagnosis

  • In this study, we faced diagnostic difficulties in three age groups of patient which were in young children, young women of children bearing age and in elderly people due to atypical presentation.
  • In these cases, we did computed tomography (CT) abdomen for the diagnosis.
  • Young children presented typically with features suggestive of gastro enteritis, high fever, vague abdominal pain. Inability of children to give an accurate history was also one of the factors causing difficulty in diagnosis.
  • In young women at times, it was difficult to rule out gynecological conditions. e.g., pelvic inflammatory diseases, salpingitis, twisted ovarian cyst, and ectopic pregnancy.
  • Elderly patients presented with features suggestive of inflammatory bowel disease, intestinal obstruction. On examination, localization was poor, and tenderness in right iliac fossa was difficult to elicit [Table 1].
    Table 1: Number of cases with atypical presentation in different age groups

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Incidence of appendicitis among patients attending surgical department

Incidence of appendicitis among patients attending surgical department remained almost the same during 3 years study period [Table 2].
Table 2: Incidence

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Age

Occurrence of appendicitis was the highest in the 11-20 years age group which constituted 44.6%. Followed by the 21-30 years age group which constituted 36.1%. The incidence of appendicitis between the age group 31 and 40 years constituted 11.5% while between 0 and 10 years age group was 3%. Between 41 and 50 years and 75 years of age group 2.3% each. The youngest case recorded was 8 years of age and the oldest 65 years of age [Table 3].
Table 3: Age

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Sex

In this study, occurrence of appendicitis in both male and female was almost equal [Table 4].
Table 4: Sex

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Age specific sex ratio

The age-specific occurrence of appendicitis has different patterns in male and female. The incidence was the highest in males aged 21-30 years. Whereas in females, the highest incidence was observed in 11-20 years age group. Above 30 years of age group male and female were affected equally [Table 5].
Table 5: Age-specifi c sex ratio

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Dietary pattern

The occurrence of appendicitis was more in the nonvegetarians than vegetarians. Nonvegetarians constituted 53.8% while vegetarians constituted 15.3% while persons on mixed diet constituted 30.7% [Table 6].
Table 6: Diet

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Seasonal trends

The occurrence of appendicitis was peak in the spring and at a low in the summer [Table 7].
Table 7: Seasonal variation

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Intra operative findings

On the exploration of the abdomen, appendix was found to be inflamed in 89% of cases [Figure 1]. Gangrenous in 6.1% cases [Figure 2] and perforated in 1.5% cases [Figure 3].
Figure 1: Excised infl ammed appendix

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Figure 2: Gangrenous appendix

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{Figure 2}
Figure 3: Perforated appendix

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While we found appendicular mass, fimbrial cyst, Meckel's diverticulum in three different cases, respectively.


  Discussion Top


Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency. In fact, this illness is one of the more common causes of acute abdominal pain. The incidence of acute appendicitis is around 7% of the population in the United States and European countries. The higher incidence of appendicitis is believed to be related to poor fiber intake in such countries.

In our study, the annual incidence of appendicitis was 3.18 per 1000 per year in 1 st year, 4.17 per 1000 per year in second and 3.85 per 1000 per year in 3 rd year. Hence, it remained almost stable during the study period of 3 years. Same observation was noted by Pederson, Bru of Rogaland central hospital, Stavanger, Norway, in their study. [4]

Majority of studies have shown that appendicitis is more common in persons taking poor fiber diet which we observed in our study where appendicitis was found to be more common in nonvegetarians, that is, in 70 cases (53.8%), and less common in individuals taking vegetarian and mixed diets that is 15.3% and 30.7%, respectively.

Study conducted by Al-Omran, Mc leod Institute for Clinical Evaluative Sciences, Toronto in 1998 on epidemiological features of acute appendicitis showed that appendicitis is more common in males, in those aged 11-20 years. [5] but in our study, we found that appendicitis is common in females, in those aged 11-20 years (35 cases out of 58 cases of this age group).

In most of the studies, it is observed that appendicitis is common in the youngest age group which we also observed in our study where 58 cases (44.65) of 11-20 years age group out of 130 cases and 47 cases (36.1%) of 21-30 years of age group were there.

Study conducted by Nudeh, Sadigh, Ahmadnia of Iran University of Medical Sciences, Tehran in 2006 showed that appendicitis is more common in males, in those aged 21-30 years whereas in females the highest occurrence was observed in 11-20 years of age group. [6] Similarly, in our study, 29 out of 47 cases were male in 21-30 years age group while 35 out of 58 cases were female in 11-20 years age group.

In our study males and females are almost equally affected. Number of male cases were 64 (49.2%) out of 130 cases while no. of female cases were 66 (50.7%). Hence, male to female ratio was 1:1.03 which is in contrast to most of the studies quoting male predominance.

Seven years period study conducted by Gallerani, Boari of St. Anna hospital, Italy in 2004 showed seasonal variation of appendicitis with peak in summer and not in spring, [7] but in our study occurrence of appendicitis was peak in spring (42 cases out of 130 cases) and low in summer (15 cases out of 130 cases). The classic form of appendicitis may be promptly diagnosed and treated. When appendicitis appears with atypical presentation, it remains a clinical challenge. In such cases, laboratory and imaging investigations CT Abdomen and diagnostic laparoscopy may be useful in establishing the diagnosis. In our study, we found diagnostic difficulties especially in cases of young children, young women of child bearing age and elderly persons mostly because of their atypical presentation of appendicitis. This same observation of diagnostic difficulty in such patients is quoted by many studies such as Rothrock and Pagane study, Paris and Klein. [8],[9]

If left untreated, appendicitis has the potential for severe complications including perforation or sepsis and may even cause death.

Although many antibiotics control infections, appendicitis remains a surgical disease. In fact, appendectomy is the only rational therapy for acute appendicitis. It avoids clinical deterioration and may avoid chronic or recurrent appendicitis.

The methods of diagnosis and management of appendicitis vary significantly among surgeons and medical centers according to the patients clinical status.


  Conclusion Top


Acute Appendicitis should be suspected irrespective of age, sex, and socioeconomic status of the individual.

Age-specific occurrence, sex ratio of appendicitis give the impression that epidemiologic features of acute appendicitis are different with worldwide data.

Appendicitis is more common in males, in those aged 21-30 years and in females, in those aged 11-20 years.

Occurrence of appendicitis was high during the spring in the patients attending our Hospital which differs from worldwide data.

Difficulties in diagnosis of appendicitis in young children, young women, and elderly persons are in a good agreement with other studies.

The total leukocyte count, urine microscopy ultrasound and CT abdomen should be used as a diagnostic aid in doubtful cases in association with physical findings, but it does not replace the clinical skills of the general surgeon.

 
  References Top

1.
Craig S, Inceu L, Taylor C. Appendicitis. Medscape 2014;17:773895.  Back to cited text no. 1
    
2.
Partrick DA, Janik JE, Janik JS, Bensard DD, Karrer FM. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediatr Surg 2003;38:659-62.  Back to cited text no. 2
    
3.
Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United States: Study period 1993-2008. J Surg Res 2012;175:185-90.  Back to cited text no. 3
    
4.
Körner H, Söreide JA, Pedersen EJ, Bru T, Söndenaa K, Vatten L. Stability in incidence of acute appendicitis. A population-based longitudinal study. Dig Surg 2001;18:61-6.  Back to cited text no. 4
    
5.
Al-Omran M, Mamdani M, McLeod RS. Epidemiologic features of acute appendicitis in Ontario, Canada. Can J Surg 2003;46:263-8.  Back to cited text no. 5
    
6.
Noudeh YJ, Sadigh N, Ahmadnia AY. Epidemiologic features, seasonal variations and false positive rate of acute appendicitis in Shahr-e-Rey, Tehran. Int J Surg 2007;5:95-8.  Back to cited text no. 6
    
7.
Gallerani M, Boari B, Anania G, Cavallesco G, Manfredini R. Seasonal variation in onset of acute appendicitis. Clin Ter 2006;157:123-7.  Back to cited text no. 7
    
8.
Rothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis and management. Ann Emerg Med 2000;36:39-51.  Back to cited text no. 8
    
9.
Paris CA, Klein EJ. Abdominal pain in children and the diagnosis of appendicitis. West J Med 2002;176:104-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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