Acute Appendicitis Research Paper
Acute appendicitis is the most common acute surgical abdominal emergency occurrence worldwide. It is most common between the ages of 10 and 20 years, but can affect any age. The male to female ratio is 1.4:1, and the lifetime risk is 8.6% for males and 6.7% for females1.
A perforated appendix is a complication of untreated acute appendicitis. Ischemic necrosis of portion of the appendiceal wall will lead to perforation. Fecoliths are responsible for the perforation in about 90% of cases, but there are other causes of luminal obstruction including seeds of fruits and vegetables, lymphoid hyperplasia, intestinal worms especially Ascaris, malignancy and foreign body2.
Perforation of the appendix is reported to be more common in the elderly …show more content…
patients as a result of the late and atypical presentation, delay in the diagnosis, delayed in the decision for surgery, and to the age acquired physiological changes. The mortality and morbidity rates had increased because the perforation could lead to prolonged and difficult treatment, convalescence, and could lead to death3.
The most important factor contributing in perforation of the appendix is the late presentation of the patients. As the delay in time between the onset of symptoms and the treatment increases, the chances of complications increase4. The age is proved to be a significant risk factor, patients under l0 years and more than 40 years are at a significant risk of increased morbidity and mortality5. Diabetes mellitus increases the mortality and morbidity significantly. Pregnancy with acute appendicitis is reported to increase the morbidity and mortality in both the mother and fetous6.
The clinical presentation of appendicitis is influenced by various symptoms and signs with almost infinite variations and about 20% to 30% of the patients present with atypical symptoms, signs, or laboratory findings.
The patient-related factors are reported in many clinical studies to constitute the main reason of delays, Although physician-related diagnostic and management delays have been also reported7.
Some clinical studies suggested a close relation between the level of inflammation or perforation and duration of inflammation8, however, there have been a lack of evidence based data on the progress of appendicitis in time, and it is not proven scientifically if the risk of perforation is related to the duration of inflammation or it is because of the patient related factors9.
Clinical studies had demonstrated that Computed tomography provides a high degree of sensitivity (95%) and specificity (95%) for diagnosing perforation, the reported specific findings on a CT scan that can lead to identifying a perforated appendix are: the presence of a localized right iliac fossa abscess or phlegmon, a clear demonstrable defect in the appendiceal wall, an extraluminal air locules or free intraperitoneal air, the presence of appendicolith outside the appendix or within the right iliac fossa abscess, an intraperitoneal leak of rectal contrast, and the presence of multiple appendicoliths in association with thickened appendix or periappendiceal inflammation. Ultrasound is reported to be less reliable than a contrast enhanced
CT10.
The management of perforated appendicitis is different than that of acute nonperforated disease. The patients who progress to perforated appendicitis will have a longer duration of symptoms, high fever, and a higher white blood count. Most of these patients have an established peritonitis and should receive a broad-spectrum intravenous antibiotic therapy, which should start as soon as the diagnosis is established11.
Surgical management is through two possible approaches: an open laparotomy or
Laparoscopy, but controversy regarding the use of laparoscopy in patients with advanced disease does exist because of the high incidence of postoperative intra-abdominal abscess formation12.
We aim in this study to evaluate the effect of time on perforated appendicitis cases to determine whether the delay in presentation or the delay in treatment have a role in the progressing of acute appendicitis to perforation of the appendix.
A perforated appendix is a complication of untreated acute appendicitis. Ischemic necrosis of portion of the appendiceal wall will lead to perforation. Fecoliths are responsible for the perforation in about 90% of cases, but there are other causes of luminal obstruction including seeds of fruits and vegetables, lymphoid hyperplasia, intestinal worms especially Ascaris, malignancy and foreign body2.
Perforation of the appendix is reported to be more common in the elderly …show more content…
patients as a result of the late and atypical presentation, delay in the diagnosis, delayed in the decision for surgery, and to the age acquired physiological changes. The mortality and morbidity rates had increased because the perforation could lead to prolonged and difficult treatment, convalescence, and could lead to death3.
The most important factor contributing in perforation of the appendix is the late presentation of the patients. As the delay in time between the onset of symptoms and the treatment increases, the chances of complications increase4. The age is proved to be a significant risk factor, patients under l0 years and more than 40 years are at a significant risk of increased morbidity and mortality5. Diabetes mellitus increases the mortality and morbidity significantly. Pregnancy with acute appendicitis is reported to increase the morbidity and mortality in both the mother and fetous6.
The clinical presentation of appendicitis is influenced by various symptoms and signs with almost infinite variations and about 20% to 30% of the patients present with atypical symptoms, signs, or laboratory findings.
The patient-related factors are reported in many clinical studies to constitute the main reason of delays, Although physician-related diagnostic and management delays have been also reported7.
Some clinical studies suggested a close relation between the level of inflammation or perforation and duration of inflammation8, however, there have been a lack of evidence based data on the progress of appendicitis in time, and it is not proven scientifically if the risk of perforation is related to the duration of inflammation or it is because of the patient related factors9.
Clinical studies had demonstrated that Computed tomography provides a high degree of sensitivity (95%) and specificity (95%) for diagnosing perforation, the reported specific findings on a CT scan that can lead to identifying a perforated appendix are: the presence of a localized right iliac fossa abscess or phlegmon, a clear demonstrable defect in the appendiceal wall, an extraluminal air locules or free intraperitoneal air, the presence of appendicolith outside the appendix or within the right iliac fossa abscess, an intraperitoneal leak of rectal contrast, and the presence of multiple appendicoliths in association with thickened appendix or periappendiceal inflammation. Ultrasound is reported to be less reliable than a contrast enhanced
CT10.
The management of perforated appendicitis is different than that of acute nonperforated disease. The patients who progress to perforated appendicitis will have a longer duration of symptoms, high fever, and a higher white blood count. Most of these patients have an established peritonitis and should receive a broad-spectrum intravenous antibiotic therapy, which should start as soon as the diagnosis is established11.
Surgical management is through two possible approaches: an open laparotomy or
Laparoscopy, but controversy regarding the use of laparoscopy in patients with advanced disease does exist because of the high incidence of postoperative intra-abdominal abscess formation12.
We aim in this study to evaluate the effect of time on perforated appendicitis cases to determine whether the delay in presentation or the delay in treatment have a role in the progressing of acute appendicitis to perforation of the appendix.