ABSTRACT
A total of fifty patients; thirty one (62) HIV seronegatives and nineteen (38) seropositives who presented with features suggestive of appendicitis and had surgery are presented. Thirteen (68.4); three (15.8) and three (15.8) of the nineteen HIV positive patients were in clinical stages 1;2 and 3 of the WHO staging system for HIV infection and diseases respectively. Pre-operative diagnosis of appendicitis was clinical in all patients. None of the signs of an inflammed appendix on plain abdominal radiograph namely: Signs of localised paralytic ileus affecting the terminal ileum; caecum; or ascending colon; a radio-opaque appendicular faecolith; free intra-peritoneal or retro-peritoneal gas etc. was seen in four (8) patients who underwent this investigation. Three patients had a clinical diagnosis of appendicitis; and small bowel obstruction as the second differential. Two had essentially normal x-ray films but had histologically confirmed appendicitis. Both of them were HIV seronegative. The x-ray film of the third patient showed features of small bowel obstruction. At laparotomy; he was found to have ileo-caecl intussusception due to caseous mesenteric lymphadenopathy; which were proved to be tuberculosus at histology. he was HIV seronegative. The fourth patients had a clinical diagnosis of acute abdomen. His abdominal x-ray film looked normal. He had non specific mesenteric adenitis and a histologically normal appendix. She was HIV seropositive. High resolution (5-7.5 Megahertz) transabdominal ultrasonography using curved array transducer for the diagnosis of appendicitis has a sensitivity and a specificity of 50-60in experienced hands in Mulago Hospital (Personal communication). This investigation did not contribute to the diagnosis of appendicitis in two patients in whom it was done. In one patient; the ultrasonographic diagnosis was an appendicular mass. The mass did not improve on conservative treatment. Exploratory laparotomy revealed mesenteric lymphadenopathy which were found to be tuberculous at histology. He was HIV seropositive. In the reamining patient; the abdomen was essentially normal at ultrasonography but had bilateral Ovarian cysts and mildly inflammed fallopian tubes at laparotomy. There was no correlation between appendicitis and white blood cell counts in both HIV seronegative and seropositive patients (table 11 and 12). Common conditions which mimicked appendicitis in this study included : cholecystisis; carcinoma of the caecum; pelvic inflammatory disease; acute abdomen of no obvious cause etc. (table 14).These were found in nine (29.0) of thirty one HIV seronegative and one (5.3) of nineteen seropositive patients. Conditions that were considered to be HIV related which mimicked apendicitis namely:- terminal ileitis; tuberculous mesenteric adenitis and non-specific haemorrhoaegic mesenteric masseses were found in one (3.2) of thirty one HIV seronegative and nine (46.8) of nineteen HIV seropositive patients (Table 14). There were thirty histologically confirmed appendicitis. Twenty one (70) and nine (30 (Kakande et al; 1978) and 28.8 (Personal findings; 1995). the improved diagnosis of appendicitus in Mulago Hospital during this study period could have been due to improved clinical diagnostic skills that are being stressed on all the time in all clinical practice as the key to effective management of patients; but awareness of such a study being carried out in the hospital could have influenced the deisions to operate on patients who presented with features suggestive of appendicitis. However; the negative appendicectomy rates in the two groups were three (14.3) in twenty one and two (22.2) in nine HIV seronegative and seropositive patients respectively. The appendix specimens of two patients autolysed before a historical diagnosis was made. They were however perforated appendix at surgery. A disease appendix can macrospically look normal at operation and hencethe need for a historical diagnosis. In this study; an appendix that looked normal to the surgeon was categorised as a negative appendix although this is not a reliable way of dagnosing appendicitis. Appendicectomy was not done in thirteen patients. In twelve patients; the appendices looked normal at surgery and other conditions were found (table 14). In the remainingpatient; appendicectomy had been done in the yaer 1995! He was found to have perforated urinary bladder. From this study; it can be concluded that the HIV seropositive rate of 38among patients who presented with features suggestive of appendicitis was not very different from that of the general population which was given in 1992 (30) of Kampala. Secondly; that appendicitis was more common in HIV seronegative than seropositive patients with ratio of 2:1.Thirdly; that conditions which mimicked appendicitis in this study included those which are known all over the world; but some of the conditions that are said to be emerging and are considered to be HIV related were also encountered namely: terminal ileitis; tuberculous mesenteric adenitis and nonspecific haemorraegic mesenteric masses. fourthly that HIV has not lead to increased negative appendicectomy rate in Mulago but that there was a trend towards higher chances of falsely diagnosed appendicitis in HIV seropositive patients. This could have been most probably due to a bigger number of conditions that were considered to be HIV related in this group of patients as compared to their seronegative counterparts. Lastly; tuberculosis can present as appendicitis