The management of right iliac fossa pain - is timing everything?

The Rate of Negative Appendicectomy and Perforated Appendicitis As Quality Indicators of the General Surgical Service in a District General Hospital in Cavan, Republic of Ireland

Introduction Appendicitis is a common surgical condition that can be difficult to diagnose due to its varied clinical presentations. Surgical removal of the inflamed appendix is often necessary, and the appendix is sent for histopathological assessment to confirm the diagnosis. However, in some cases, the analysis may return a negative result for acute inflammation, known as a negative appendicectomy (NA). The definition of NA varies among experts. While negative appendicectomies are not ideal, they are accepted by surgeons to reduce the rate of perforated appendicitis, which can have severe consequences for patients. A study was conducted to investigate the rates of negative appendicectomies and their impact at a local district general hospital in Cavan, Republic of Ireland. Methods The study was conducted retrospectively from January 2014 to December 2019 on patients who were admitted with suspected appendicitis and underwent appendicectomy for appendicitis, regardless of age and sex. The researchers excluded patients who underwent elective, interval, and incidental appendicectomies. Data were collected on patient demographics, duration of symptoms prior to presentation, the intraoperative appearance of the appendix, and the histology results of the appendix specimens. Descriptive statistics and the Chi-squared test were used for data analysis with the help of IBM Statistical Package for the Social Sciences (SPSS) Version 26. Results The study retrospectively reviewed 876 patients who underwent an appendicectomy for suspected appendicitis between January 2014 and December 2019. The age distribution of patients was non-uniform, with 72% presenting before the third decade. The overall perforated appendicitis rate was 7.08%, and the overall negative appendicectomy (NA) rate was 21.3%. A subset analysis showed a statistically significant lower NA rate in females than in males. The NA rate decreased significantly over time and has been sustained since 2014 at around 10%, which is consistent with other published studies. The majority of the histology findings were uncomplicated appendicitis. Discussion This article discusses the challenges of diagnosing appendicitis and the need to reduce unnecessary surgeries. Laparoscopic appendectomy is the standard treatment, with an average cost of £2222.53 per patient in the UK. However, patients with negative appendicectomies (NA) have longer hospital stays and higher morbidity than uncomplicated cases, making it crucial to reduce unnecessary surgeries. The clinical diagnosis of appendicitis is not always straightforward, and the rate of perforated appendicitis increases with a longer duration of symptoms, particularly pain. The selective use of imaging in suspected appendicitis could reduce NA rates, but a statistical difference has not been proven. Scoring systems like the Alvarado score have limitations and cannot be relied upon alone. Retrospective studies have limitations, and biases and confounding variables must be considered. Conclusion The study found that a thorough investigation of patients, particularly with preoperative imaging, can decrease the rate of unnecessary appendectomies without increasing the rate of perforation. This could save costs and reduce harm to patients.

Role of Laparoscopy in Diagnosing and Treating Acute Nonspecific Abdominal Pain

Background

Nonspecific abdominal pain (NSAP) is a pain for which no immediate cause is evident on acute admission and does not necessitate emergency surgical intervention. NSAP is a frequent reason for presentation in the emergency department (ED). Laparoscopy is a well-established technique that allows a surgeon to visualize the abdominal cavity after insufflation through a few small incision ports. Despite the increasing availability of laparoscopic investigation, the availability of a laparoscope in the ED settings in Pakistan is low due to the expense and maintenance needs of the system.

Objective

This study aimed to evaluate the role of laparoscopy in diagnosing the cause of acute NSAP and its role in treating the pathology of disease in patients presenting to the emergency department (ED) of Services Hospital, which is a government sector hospital in Lahore, Pakistan.

Materials and methods

This study was conducted in Services Hospital Lahore, Pakistan, from January 1, 2016 to December 31, 2019. The study included patients aged 12 to 70 years of either sex who presented to the ED with abdominal pain for whom no diagnosis could be achieved on clinical assessment, laboratory findings, and radiological findings (x-ray abdomen, ultrasonography, and computed tomography scan). All study participants underwent diagnostic laparoscopy under general anesthesia. Patients were monitored weekly via follow-up postoperatively for the first month and then monthly for 12 months. All study data were recorded on a predesigned proforma. The data were analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

Results

A total of 122 patients diagnosed with acute NSAP were enrolled in our study (mean age, 46.4 ± 20.3 years). The study population consisted of 52 male patients (42.6%) and 70 female patients (57.4%). Our study participants had a mean body mass index of 24.2 ± 3.3 kg/m². The most common ED presentation was lower abdominal pain. One hundred sixteen patients (95.1%) had positive findings on laparoscopy, while six patients (4.9%) had no identified pathology on laparoscopy. The most frequent pathology was appendicular in origin, followed by pelvic inflammatory disease. Surgical management of patients through laparoscopy was performed in 97 patients (79.5%). Conversion to laparotomy was done in 12 patients (9.8%). Definite diagnosis was established in 118 patients (96.7%). Port site infection occurred in four patients (3.3%), chest infection in five patients (4.1%), deep venous thrombosis in one patient (0.8%), and anastomotic leakage in one (0.8%) patient. Four patients (3.3%) developed recurrence of symptoms.

Conclusions

This study explored the role of laparoscopy in diagnosing and treating patients presenting to the ED with acute NSAP. According to our results, laparoscopy is a safe and effective method for diagnosing and treating acute NSAP with low postoperative morbidity and potentially decreased risk of postoperative complications. Physicians should consider laparoscopy as a first-line invasive investigation for patients presenting with undiagnosed acute abdominal pain.

Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis

Appendicitis is a common differential diagnosis of right lower quadrant pain. Clinical evaluation alone results in high negative appendicectomy rates. Alvarado scoring is the most commonly used clinical prediction rule. The study aimed to compare the recently developed appendicitis inflammatory response (AIR) score with the Alvarado score. This cross-sectional observational study included patients who underwent appendicectomy for clinical suspicion of appendicitis. The clinical and laboratory parameters required for obtaining Alvarado score and AIRS were gathered. Area under ROC curve was calculated for both Alvarado score and AIRS. The study included 130 patients (77 males and 53 females). The negative appendicectomy rate was 10.7%. The perforation rate was 10.3%. The area under ROC for Alvarado score was 0.821 and for AIR score was 0.901. The Alvarado score had a sensitivity of 72% and a specificity of 79% at score ≥6. The appendicitis inflammatory response score had a sensitivity of 98% for scores ≥5 and a specificity of 97% for score ≥6. The C-reactive protein (CRP) value was the best performing individual parameter with an area under ROC of 0.789, followed by WBC count with an area under ROC of 0.762. Appendicitis inflammatory response score is a recently developed score that outperforms the Alvarado score. AIR score has a higher specificity. The sound construction, gradation of parameters, the inclusion of CRP, and avoidance of subjective parameters make the AIR score an attractive clinical prediction rule which can decrease the rate of negative appendicectomy.

Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study

BACKGROUND

The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital.

METHODS

This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months.

RESULTS

A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001).

CONCLUSIONS

This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.

Diagnosis of pain in the right iliac fossa. A new diagnostic score based on Decision-Tree and Artificial Neural Network Methods

INTRODUCTION

Pain in the right iliac fossa (RIF) continues to pose diagnostic challenges. The objective of this study is the development of a RIF pain diagnosis model based on classification trees of type CHAID (Chi-Square Automatic Interaction Detection) and on an artificial neural network (ANN).

METHODS

Prospective study of 252 patients who visited the hospital due to RIF pain. Demographic, clinical, physical examination and analytical data were registered. Patients were classified into 4 groups: NsP (nonspecific RIFP group), AA (acute appendicitis), NIRIF (RIF pain with no inflammation) and IRIF (RIF pain with inflammation). A CHAID-type classification tree model and an ANN were constructed. The classic models (Alvarado [ALS], Appendicitis Inflammatory Response [AIR] and Fenyö-Linberg [FLS]) were also evaluated. Discrimination was assessed using ROC curves (AUC [95% CI]) and the correct classification rate (CCR).

RESULTS

53% were men. Mean age 33.3±16 years. The largest group was the NsP (45%), AA (37%), NRIF (12%) and IRIF (6%). The analytical model results were: ALS (0.82 [0.76-0.87]), AIR (0.83 [0.77-0.88]) and FLS (0.88 [0.84-0.92]). CHAID determined 10 decision groups: 3 with high probability for NsP, 3 high for AA and 4 special groups with no predominant diagnosis. CCR of ANN and CHAID were 75% and 74.2%, respectively.

CONCLUSIONS

The methodology based on CHAID-type classification trees establishes a diagnostic model based on four pain groups in RIF and generates decision rules that can help us in the diagnosis of processes with RIF pain.

Logistic regression model to predict acute uncomplicated and complicated appendicitis

INTRODUCTION

While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis.

MATERIALS AND METHODS

A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis.

RESULTS

Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis.

CONCLUSIONS

The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain

Background

Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain.

Methods

This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient.

Results

From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p < 0.001).

Conclusion

Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.

Role of C-Reactive Protein, White Blood Cell Counts, Bilirubin Levels, and Imaging in the Diagnosis of Acute Appendicitis as a Cause of Right Iliac Fossa Pain

Background Right iliac fossa (RIF) pain is one of the most common modalities of presentation to surgical emergency. It remains a challenge to the treating clinicians to accurately diagnose or to rule out appendicitis. Objective The aim of the study was to compare the efficacy of clinical impression, biochemical markers, and imaging in the diagnosis of RIF pain with special reference to appendicitis and their implication in reducing the negative appendicectomy rates. Methods All patients presenting to casualty with RIF pain were included in the study. Blood investigations including C-reactive protein (CRP), serum bilirubin, white blood cell counts (WBC), and ultrasound (USG) were done. Based on the clinical impression, patients were either posted for appendicectomy or observed in equivocal cases. Patients who had recurrent pain on follow-up underwent appendicectomy or underwent contrast-enhanced computed tomography (CECT) in equivocal cases. Patients who only had a single self-limiting episode with no other alternative diagnosis or had a normal CECT report were included in a non-specific RIF pain group. Results The negative appendicectomy rate was 8.2%. The mean value of WBC counts (9.57x109/L vs 7.88x109/L; p<0.05) and that of serum bilirubin (1.37 mg/dl vs 0.89mg/dl; p<0.05) in the appendicitis and non-appendicitis group, respectively, were statistically significant. The percentage of CRP positivity was higher in the appendicitis group (51.9% vs 15%; p<0.05). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for USG (84.2%, 77.17%, 85.4%, and 75.5%), for CRP (51.8%, 85%, 82%, and 57%), for WBC count (45.1%, 88%, 86.6%, and 48.3%), and for serum bilirubin (69.2%, 75%, 81.4%, and 60.5%) were statistically significant between the groups. Conclusion Imaging and biochemical investigations including bilirubin can act as useful adjuncts to the clinical diagnosis of appendicitis.

Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females

BACKGROUND

Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint.

AIMS

We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain.

METHODS

This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis.

RESULTS

5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment.

CONCLUSION

The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response Score and clinical assessment

BACKGROUND

Patients presenting with suspected appendicitis pose a diagnostic challenge. The appendicitis inflammatory response (AIR) score has outperformed the Alvarado score in two retrospective studies. The aim of this study was to evaluate the AIR Score and compare its performance in predicting risk of appendicitis to both the Alvarado score and the clinical impression of a senior surgeon.

METHODS

All parameters included in the AIR and Alvarado scores as well as the initial clinical impression of a senior surgeon were prospectively recorded on patients referred to the surgical on call team with acute right iliac fossa pain over a 6-month period. Predictions were correlated with the final diagnosis of appendicitis.

RESULTS

Appendicitis was the final diagnosis in 67 of 182 patients (37 %). The three methods of assessment stratified similar proportions (~40 %) of patients to a low probability of appendicitis (p = 0.233) with a false negative rate of <8 % that did not differ between the AIR score, Alvarado score or clinical assessment. The AIR score assigned a smaller proportion of patients to the high probability zone than the Alvarado score (14 vs. 45 %) but it did so with a substantially higher specificity (97 %) and positive predictive value (88 %) than the Alvarado score (76 and 65 %, respectively).

CONCLUSIONS

The AIR score is accurate at excluding appendicitis in those deemed low risk and more accurate at predicting appendicitis than the Alvarado score in those deemed high risk. Its use as the basis for selective CT imaging in those deemed medium risk should be considered.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

OBJECTIVES

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.

METHODS

Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression.

RESULTS

Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).

CONCLUSIONS

Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.

Ovarian tuberculosis masquerading as ovarian cancer in HIV infected patient: a plea to avoid unnecessary surgery

Female patients who present with adnexial mass and weight loss should not be presumed to have ovarian carcinoma until after extensive investigation. This is to avoid the mistake of radical surgery with its attendant morbidity and mortality. An important disease to consider in our environment is ovarian TB that respond well to medication. A 35 year old HIV-1 positive house wife presented with fever, persistent vomiting, progressive weight loss, vague abdominal pain and swelling. Patient occasionally ingest unpasteurized milk since childhood but had no sustained contact with adult with chronic cough. She had no menstrual abnormality. Imaging studies revealed right ovarian mass measuring 11.8 cm x 10 cm. Right ovarian malignancy was highly suspected, for which she underwent exploratory laporotomy. Histopathology result was consistent with tuberculous granuloma. Chest radiograph was normal. Her CD4 count was 541 cells/ul. Patient was commenced on anti tuberculotic therapy based on the Nigerian National TB control and she responded well. Tuberculosis of the ovary can masquerade as ovarian cancer, especially among HIV patients in regions where TB-HIV co infections is endemic, it should be ruled out before performing extended surgery.

Acute appendicitis in a developing country

BACKGROUND

This prospective audit of appendicitis at a busy regional hospital reviews the spectrum and outcome of acute appendicitis in rural and peri-urban South Africa.

METHOD

We conducted a prospective audit from September 2010 to September 2011 at Edendale Hospital in Pietermaritzburg, South Africa.

RESULTS

Over the year under review, a total of 200 patients with a provisional diagnosis of acute appendicitis were operated on at Edendale Hospital. There were 128 males (64 %) in this cohort. The mean duration of illness prior to seeking medical attention was 3.7 days. Surgical access was by a midline laparotomy in 62.5 % and by a Lanz incision in 35.5 %. Two percent of patients underwent a laparoscopic appendicectomy. The operative findings were as follows: macroscopic inflammation of the appendix without perforation in 35.5 % (71/200) and perforation of the appendix in 57 % (114/200). Of the perforated appendices, 44 % (51/114) were associated with localised intra-abdominal contamination and 55 % (63/114) had generalised four-quadrant soiling. Thirty percent (60/200) required temporary abdominal closure (TAC) with planned repeat operation. Major complications included hospital-acquired pneumonia in 12.5 % (25/200), wound dehiscence in 7 % (14/200), and renal failure in 3 % (6/200). Postoperatively 89.5 % (179/200) were admitted directly to the general wards, while 11 % (21/200) required admission to the intensive care unit. The overall mortality rate was 2 % (4/200).

CONCLUSIONS

The incidence of acute appendicitis amongst African patients seems to be increasing. Although it is still lower than the reported incidence amongst patients in the developed world, it is a common emergency that places a significant burden on the South African health service. The disease presents late and is associated with a high incidence of perforation which translates into significant morbidity and even mortality.

Accuracy of clinical coding from 1210 appendicectomies in a British district general hospital

AIMS

The primary aim of this study was to assess the accuracy of clinical coding in identifying negative appendicectomies. The secondary aim was to analyse trends over time in rates of simple, complex (gangrenous or perforated) and negative appendicectomies.

METHODS

Retrospective review of 1210 patients undergoing emergency appendicectomy during a five year period (2006-2010). Histopathology reports were taken as gold standard for diagnosis and compared to clinical coding lists. Clinical coding is the process by which non-medical administrators apply standardised diagnostic codes to patients, based upon clinical notes at discharge. These codes then contribute to national databases. Statistical analysis included correlation studies and regression analyses.

RESULTS

Clinical coding had only moderate correlation with histopathology, with an overall kappa of 0.421. Annual kappa values varied between 0.378 and 0.500. Overall 14% of patients were incorrectly coded as having had appendicitis when in fact they had a histopathologically normal appendix (153/1107), whereas 4% were falsely coded as having received a negative appendicectomy when they had appendicitis (48/1107). There was an overall significant fall and then rise in the rate of simple appendicitis (B coefficient -0.239 (95% confidence interval -0.426, -0.051), p = 0.014) but no change in the rate of complex appendicitis (B coefficient 0.008 (-0.015, 0.031), p = 0.476).

CONCLUSIONS

Clinical coding for negative appendicectomy was unreliable. Negative rates may be higher than suspected. This has implications for the validity of national database analyses. Using this form of data as a quality indictor for appendicitis should be reconsidered until its quality is improved.

Tubercular tubo-ovarian cystic mass mimicking acute appendicitis: a case report

INTRODUCTION

Female genital tuberculosis is a rare form of extrapulmonary tuberculosis. It is an asymptomatic disease usually diagnosed during the search for causes of infertility. However, it can present with a number of abdominopelvic symptoms. Herein we report a case of tubo-ovarian tuberculosis mimicking acute appendicitis.

CASE PRESENTATION

A 17-year-old single Turkish woman presented to our hospital with complaints of right lower quadrant abdominal pain, nausea, and vomiting. Her physical examination findings, ultrasonogram, and leukocyte count were consistent with acute appendicitis. A cystic mass (15 cm × 6 cm) was detected on the right tubo-ovarian structure by laparotomy. The mass was excised while the tubo-ovarian structures were preserved and the need for an appendectomy was avoided. No microbiological evaluation was performed. The histopathological examination of the cystic mass revealed a granuloma with central caseating necrosis surrounded by epithelioid histiocytes. The patient was treated with anti-tuberculosis therapy for six months. No recurrence was observed during a 10-month follow-up period.

CONCLUSION

Genital tuberculosis should be considered in the differential diagnosis of right lower quadrant pain in women who live in tuberculosis-endemic regions.