Acute appendicitis: is it a seasonal disease?

INTRODUCTION

Appendicitis is known as inflammation of the vermiform appendix. The lifetime risk of appendicitis is 8.6% for males and 6.7% for females.^1,2 It is generally reported to be more common in men.^3-6 Appendicitis is the most common surgical cause of abdominal pain worldwide.^7,8 The etiology and pathogenesis of appendicitis are not entirely comprehended but probable hypotheses are stated which include obstruction of the appendiceal lumen either by fecaliths, hypertrophy of lymphoid tissue, neoplasm, or worms (oxyuris vermicularis). The progressive increment in intraluminal pressure that compromises the venous efflux, stagnation of luminal contents, which favors bacterial multiplication, triggers ischemia and inflammatory responses which ensuing tissue edema as well as neutrophilic infiltration of the lumen, muscular wall and peri appendiceal soft tissues. The most prominent etiologies of appendiceal lumen obstruction are lymphoid hyperplasia and fecaliths.^1,2,9,10 The perforation of appendix is related to multiple risk factors which encompasses extremes of age, immunosuppression, diabetes mellitus, previous abdominal surgery, pelvic appendix and fecalith obstruction.⁶ The clinical characteristics of appendicitis involve periumbilical pain which diffuse and finally localized to right lower quadrant (RLQ), anorexia, nausea, vomiting, diarrhea or constipation, signs include low-grade fever, tenderness with utmost at or nearby McBurney’s point, muscle guarding and rebound tenderness. Appendectomy is the lonely curative treatment of appendicitis.²

Objectives

The aim of this study was to know the common presenting symptoms of acute appendicitis, the time of incidence, work-up, type of management and the pathological diagnosis.

METHODS

Study design

The study design is retrospective records review.

Study area

The study was conducted in Almekhwah hospital, Almekhwah region, Albaha province, Saudi Arabia.

Study population

The study population comprised of all patients with appendicitis who were admitted at Almekhwah hospital.

Inclusion and exclusion criteria

The inclusion criteria of the study was all patients who have been diagnosed and operated on with appendicitis in Almekhwah hospital from January to December 2017. Patients who had been referred to another hospital were excluded.

Data collection

Data was collected by retrieving information from patients records at the hospital. We concentrated on demographic features of the patients, the presenting symptoms, the clinical signs, the imaging requested to the patients, what type of surgery was done and the histopathological reports if was requested.

Data analysis

Data was statistically analyzed using SPSS software version.25. A p value of less than 0.05 was considered significant.

Ethical concern

The ethical approval was obtained from university research ethical committee. Also the permission from the hospital administration was considered.

RESULTS

Demographic characteristics

The total number of the patients involved in this study was 114. These patients were presented to a rural hospital. All these patients were diagnosed with acute appendicitis and operated on. Table 1 shows the demographic features of the participants of this study. About 69.3% were males and 30.7% were females. Concerning the ages of the patients, unfortunately 36 patients had no age in their records. The mean age of those with recorded age was 25.11 years. We divided the 78 patients whose age we knew into the following the age groups. There was only one patient whose age was less than 10 years. Thirty one (27.2%) in the age group 11-20 years and 45 (39.5%) were above 20 years old.

Concerning the residence of the patients 37 (32.5%) were from Almekhwa, Albaha region where the hospital was, 11 (9.6%) were from outside Almekhwa and 66 (57.9%) of the patients their residence was not mentioned in their records. Thirty five (30.7%) patients were Saudi, 7 (6.1%) were non-Saudi and 72 (63.2%) patients, the records did not mention where their nationality. Concerning the seasonal incidence of the appendicitis. Table 2 shows an obvious increase in the cases started from July-September to October-December through January-March when the incidence reached its peak and then showed decline in the period April-June.

Clinical presentations

Regarding the symptoms and signs in our patients, Table 3 summaries it. The most common presenting symptom was RLQ pain which was present in 107 (93.9%) of the cases. There was only one patient who presented with epigastric pain and she was female. Anorexia was present in 49 (43%) of the patients with no statistical difference between the gender (p=0.986). Nausea mentioned by 57 (50%) of the patients (p=0.155) whereas the vomiting reported by 74 (64.9%) of the participants (p=0.332). Fever was detected in 42 (36.8%) which was more obvious in females than males (p=0.032) and diarrhea in 10 (8.8%) which was more common in females compared with males p=0.005), constipation was present in 11 (9.6%). Regarding the signs detected by the examiner of the case. Tenderness with utmost at or near McBurney's point was reported in 44 (38.6%) of the patients and muscle guarding in only one patient.

Figure 1 shows that abdominal ultrasound was requested to confirm the diagnosis in 96 (84%), 58% in males and 26% in females. Chest X-ray was requested in only (18%) of the patients. Figure 2 shows the histopathology of the removed appendix was performed in 65 (57%) specimen. The most common histological diagnosis was acute suppurative appendicitis with peri-appendicitis in 15 (13.2%) followed with early acute appendicitis in 12 (10.5%). There were two specimens in which a worm (Enterobius vermicularis) was detected.

DISCUSSION

One hundred and fourteen patients were diagnosed with acute appendicitis and underwent open appendicectomy. All these cases were done in a period of one year from January to December 2017 at Almekhwah rural hospital, AlBaha, Saudi Arabia. The lack of the laparoscope made open appendicectomy the only option of the surgery. The overall mean age of the participants was 25.11 years. This was in agreement with several published articles.^11-13 In this study the number of males far exceeded that of the females. The same result with male more than females reported by other studies.^3-6,14-16 The most affected age group were those above 20 years old though some patients had no recorded age in their records.

The vast majority of the cases presented in period January to March and lower presentation was in April to June. This variation in the presentation was definitely different from one climate to another climate. Studies in some warmer countries like United States, Canada, Iran and South Africa showed peak incidence of acute appendicitis during the warmer periods.¹⁷ This was in contrast to our finding because the occurrence was low in period April/June and this period was considered as summer in our study area. The high incidence was observed in January/March and this time was part of winter.

The most presenting symptom in our patients was abdominal pain in the right lower quadrant region which was present in 93.9%. This finding was typical presentation when pain started as central or general abdominal pain and most of patients presented with pain in this region by the time come to seek medical advice. This finding was similar to what was concluded by other studies.¹⁷ In our study nausea in (50%) and vomiting in (64.9%) this was lower compared to some studies, which reported presence of these in more than 80%.^15-18 Diarrhea and constipation were present in 8.8% and 9.6% respectively and this very close to some published literature and far less to what mentioned by Mallik (30.6%).¹⁵ This can be explained in the context that the population study of Mallik were pre-school children.¹⁸ Fever associated with acute appendicitis was general low grade unless there was complications like peritonitis and abscess. Fever in our participants was detected in 36.8%. This was in contrast to other studies in which fever was present in 64.1%.¹⁸ Dysuria in our patients in just 0.9%, which was close to 2%, but was very low percent to other studies which gave a figure a bit higher 4% and 5.6%, respectively.^15,18,19 We cannot find an appropriate explanation for this difference.

Concerning the physical signs, tenderness in right iliac fossa was detected in 38.6% and this was consistent with that found by Victor 39%.¹⁵ Muscle guarding presented in only one patient in our group 0.9%. This can be explained by early presentation of our patients though we had no specific question about the exact time between the onset of the symptoms and hospital presentation. Muscle guarding was usually associated with late presentation and peritonitis. The preoperative images that used to confirmed the diagnosis included abdominal ultrasound which used in 84% of the patients. The ultrasound generally was used in females, children, elderly and when a complication was suspected. however, in 35-40% of cases the clinical features of acute appendicitis were nonspecific and unclear also in this case ultrasound was used.¹⁹ According to some studies, the clinical and laboratory findings alone were not enough to diagnose acute inflammation of the appendix and this may show why ultrasound was used in vast majority of this study.^20-22 Here the modality was used more common in male than in female which was bit unusual.

The histopathological examination was performed in 57% of the removed appendix. The most common histological diagnosis was acute suppurative appendicitis with peri appendicitis followed with early acute appendicitis. This finding was reverse to one Saudi study which showed the early acute appendicitis the most common followed with acute suppurative.²³ The worm infestation was Enterobius vermicularis in two cases (1.8%). This was typical in some literature whereas the same study showed schistosomiasis the most common one followed by E. vermicularis.^23,24 This finding in the late study due to Egyptian patients in the above study and at the same time the region where our study done has no schistosomiasis. Egypt is well known of endemicity of schistosoma. Other studies showed E. vermicularis in 7% of the cases.²⁵ This high percentage may be attributed to pediatric population of the study. Normal appendix and cancer were not reported in our samples of the histology. We think this may be due to only more than half of the specimens were examined.

CONCLUSION

From this study we concluded that male are more affected with acute appendicitis. The most common season of acute appendicitis the winter. The most common presenting symptom was right lower quadrant pain. The vast majority of the cases were in the winter. Ultrasound has been used in the most cases particularly in male more than in females. The most common histological diagnosis was acute suppurative appendicitis. Open appendicectomy is the main operative management in our patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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