Histopathological correlations of appendectomies: a clinical audit of a single center

Significance of Histopathology of Appendectomy Specimens: Analysis From a Teaching Hospital of Pakistan

Background Histopathology of a tissue specimen plays a crucial role in formulating the final diagnosis of any disease. It confirms whether the histopathological findings are in correspondence with the clinical diagnosis and thus suggests an optimal management plan. Standard surgical practices guide that every human tissue specimen must undergo postoperative tissue analysis unless indicated otherwise. Objective To determine the significance of histopathology in determining the final diagnosis of appendectomy specimens. Materials and methods This retrospective clinical study conducted in May 2022 included 100 patients operated for appendectomy from January 1, 2021, to December 31, 2021, in the emergency room of the Department of General Surgery, Unit-III, Lahore General Hospital, Lahore. Data were retrieved from patients' records and the picture archiving and communication system (PACS). A Google Forms-based pro forma (Google, Mountain View, CA) was generated to include the demographic details, clinical manifestations, and histopathology reports of the patients. Descriptive analysis was completed using a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA). Results Fifty-two patients were females out of the total 100. The mean age at presentation was 23.02 ± 12.02 years. Of the samples, 54% were not sent for histopathology. Among the remaining ones, 27% of cases were proven to be acute appendicitis. Alvarado score was 7-10 in 50% of patients. Other lesions proven by histopathology were appendiceal phlegmon (4%), perforated appendix (4%), mucocele (1%), carcinoid tumor (1%), tuberculosis (1%), and adenocarcinoma (1%). Conclusions Histopathological analysis is the gold standard for the tissue diagnosis of a disease. The high percentage of the samples not sent for histopathology is alarming since the appendix is not only a site for inflammatory pathologies but for neoplastic lesions as well. This practice depicts that the incidence of non-inflammatory pathologies is being ignored by healthcare professionals and there is a dire need to emphasize the significance of acquiring histopathology reports for the specimens of appendectomy in all circumstances.

IL-5 Serum and Appendicular Lavage Fluid Concentrations Correlate with Eosinophilic Infiltration in the Appendicular Wall Supporting a Role for a Hypersensitivity Type I Reaction in Acute Appendicitis

Appendicitis is the most common abdominal surgical emergency, but its aetiology is not fully understood. We and others have proposed that allergic responses play significant roles in its pathophysiology. Eosinophils and Interleukin (IL)-5 are involved in a hypersensitivity type I reaction. Eosinophil infiltration is common in the allergic target organ and is dependent on IL-5. In the presence of an allergic component, it is expected that the eosinophil count and IL-5 local and systemic concentrations become elevated. To address this hypothesis, we designed a prospective study that included 65 patients with acute appendicitis (grouped as acute phlegmonous or gangrenous according to the histological definition) and 18 patients with the clinical diagnosis of acute appendicitis, but with normal histological findings (control group) were enrolled. Eosinophil blood counts and appendicular wall eosinophil infiltration were determined. IL-5 levels in blood and appendicular lavage fluid were evaluated. Appendicular lavage fluid was collected by a new methodology developed and standardized by our group. Appendicular wall eosinophil infiltration was higher in acute phlegmonous appendicitis than in gangrenous appendicitis (p = 0.000). IL-5 blood levels were similar in both pathologic and control groups (p > 0.05). In the appendicular lavage fluid, the higher levels of IL-5 were observed in the phlegmonous appendicitis group (p = 0.056). We found a positive correlation between the appendicular wall eosinophilic infiltration and the IL-5 concentrations, in both the blood and the appendicular lavage fluid, supporting the IL-5 reliance in eosinophil local infiltration. We observed the highest presence of eosinophils at phlegmonous appendicitis walls. In conclusion, the present data are compatible with a hypersensitivity type I allergic reaction in the target organ, the appendix, during the phlegmonous phase of appendicitis.

A Correlation of Blood Panel Results and Histologically Confirmed Appendicitis

Background

Appendicitis is the most common indication for emergency surgery in the world. There is no one laboratory or radiological test that is used to diagnose it. Various routine and novel blood markers have been identified, however none have proved to be conclusive. The aim of this study was to combine routine blood markers to increase the sensitivity and specificity in diagnosing histologically confirmed appendicitis.

Methods

We retrospectively reviewed the theatre logs for the calendar year of 2015 to identify all of the appendectomies which were performed. We reviewed all of the admission bloods for the patients - including their white blood cell (WBC) count, their neutrophil count, and their C-Reactive protein (CRP) value. We also reviewed all of the histology to identify the inflamed appendices, and analysed all of this information together.

Results

The neutrophil count is the most sensitive of the three blood markers with a score of 82%. It has a specificity of 63%. The CRP value is the most specific of the three blood markers with a value of 67% and a sensitivity of 76%. WBC has a sensitivity of 75% and a specificity of 63%. Combining all of the blood values (i.e. elevated white blood cell count or elevated neutrophil count or elevated CRP) demonstrates a sensitivity of 96% and a specificity of 45%.

Conclusion

Combining routine admission blood markers (WBC, neutrophil count, and CRP) can assist in diagnosing appendicitis in unwell patients with abdominal pain.

Routine Histopathological Evaluation After Appendectomy: Is It Necessary? A Systematic Review

Acute appendicitis is one of the most common reasons for acute abdominal pain. Fecaliths and lymphoid hyperplasia are the usual etiology of acute appendicitis, however, other unusual causes can also not be neglected which can be parasitic infections, benign or malignant lesions. Due to substantial lab costs and limited resources, the policy of routine histopathological examination (HPE) of appendectomy samples is being questioned.

PubMed, PubMed Central (PMC), and Google Scholar were used to look for relevant published studies. The following keywords were used both alone and in combination: “Acute appendicitis” and “routine histopathological examination”. Fifteen articles were selected for final review that collectively had 57,524 cases. All these studies included in this systematic review are peer-reviewed.

Based on the reviewed articles, it was found that though the probability of unusual findings in a patient of acute appendicitis is less but it is still significant and if found, often results in a change of management plan of the patient.

Therefore, it is recommended to perform a routine histopathological examination of all appendectomy specimens to rule out unusual pathologies.

Impact of routine histopathological examination of appendectomy specimens on patient management: a study of 4012 appendectomy specimens

Objectives

For a suspected diagnosis of acute appendicitis, appendectomy is one of the most common emergency abdominal operations performed. However, the need for routine histopathological examination (HPE) of all appendectomy specimens has recently been questioned. The aim of this study was to assess whether a routine HPE of appendectomy specimens is needed and whether routine HPE has an impact on further management of patients.

Material and Methods

From January 2009 to June 2017, all histopathology reports of 4012 consecutive appendectomy specimens for a clinical suspicion of acute appendicitis were retrospectively analyzed in two university hospitals.

Results

Out of the 4012 cases, 3530 (88%) patients showed findings consistent with acute appendicitis on HPE. Perforation rate was 5.8% and was significantly higher in male patients (p <0.001) and higher in the > 30 years age group (p= 0.024). Negative appendectomy rate was 5.6% and was significantly higher in female patients (p <0.001). There were 256 (6.4%) patients who demonstrated unusual findings in their HPE, which included chronic appendicitis (n= 207; 5.2%) patients, Enterobius vermicularis (n= 14), Schistosoma (n= 8), Crohn's disease (n= 1), neuroma (n= 10), carcinoid tumour (n= 5) and mucinous cystadenoma (n= 5), mucocele (n= 4) and mucinous cystadenocarcinoma (n= 2).

Conclusion

HPE of the appendix does not only confirm the diagnosis of acute appendicitis, but also detects other unusual diagnoses that may have an impact on a patient's management. A number of patients with unusual histopathological findings require anti-helmentic treatment, colectomy, gastroenterology follow-up or periodic surveillance. Hence, all appendectomy specimens must be submitted for routine HPE.