The Sensitivity and Specificity of the Conventional Symptoms and Signs in Making a Diagnosis of Acute Appendicitis

Introduction: Simple appendicitis can progress to perforation; which is associated with a much higher morbidity and mortality. So; surgeons have therefore been inclined to operate when the diagnosis is probable rather than wait until it is certain. Objective: This study is designed to evaluate the sensitivity and specificity of clinical examination in the diagnosis of acute appendicitis.Methods: The study included 866 patients of acute appendicitis who had undergone appendicectomy with preoperative diagnosis of acute appendicitis. They were analyzed retrospectively. The parameters evaluated were age/gender; clinical presentation (signs and symptoms) and total white blood cell counts. The operative findings were recorded and the inflammation of the appendix was graded into normal; acutely inflamed and gangrenous. Results: Clinical diagnosis was made correctly in 807 (93.2) of the patients. White blood cells count ranged from 3.70 to 45.30 /mm3 (mean 17.5353 /mm3). It was 10;000/mm3 in 133 (15.4) patients.Conclusions: Clinical assessment is the best criterion to reach a confident diagnosis. Investigations may supplement the diagnosis but are never a substitute for it

Prospective Evaluation of the Bengezi and Al-Fallouji Modified Alvarado Score for Presumptive Accurate Diagnosis of Acute Appendicitis in University of Port Harcourt Teaching Hospital; Port Harcourt

Background: The accurate diagnosis of acute appendicitis (AP) in a patient is valuable to the busy clinician. Decision making in cases of AP poses a clinical challenge especially in developing countries where advanced radiological investigations are not readily available and do not appear cost effective; clinical parameters remain the mainstay of diagnosis. Time and resources wasted on surgical intervention; with the added risks of surgery and anaesthesia; only to discover that this was unnecessary remains a big challenge. This prospective study was carried out to assess the accuracy of the Bengezi and Al-Fallouji modified Alvarado score in presumptive diagnosis of AP and its effect on the negative appendicectomy rate (NAR) at the University of Port Harcourt Teaching Hospital. Methods: A retrospective study of the NAR of this hospital between June 2000 and May 2002 was carried out. All consecutive patients (128) who presented with presumptive diagnosis of AP between June 2003 and May 2004 were scored using the Bengezi and Al-Fallouji modified Alvarado scoring system and correlated with histological diagnosis. Patients discharged without surgery based on score; were reviewed in the outpatient's clinic for one month to ascertain that they did not need surgical intervention. The NAR for all appendicectomies performed by surgeons for presumptive diagnosis of AP without scoring between June 2004 and May 2005 was determined as control. Validity of the scoring system was assessed by calculating sensitivity; specificity; positiveand negative predictive values. Results: A total of 128 patients were scored. Forty patients with scores less than 4 after eight hours observations and re-evaluation at the Accident and Emergency were discharged without surgery. Eighty eight patients had appendicectomies as treatment for scores 5- 10. There were 39 males and 49 females. In eighty patients; the appendix was histologically inflammed and 8 were normal; giving a NAR of 9.09. High sensitivity of 92.93and specificity of 92.93were recorded in the study. The NAR of the retrospective study was 26.4and 19.05for the control group operated without scoring

Un appendicite de localisation atypique : apport de la coloscopie au diagnostic

Le diagnostic de l'appendicite a gauche est fait en dehors de la laparotomie a l'imagerie medicale (echographie et scanner). Les auteurs rapportent ici un cas ou le diagnostic a ete fait a la coloscopie. Ils militent a travers une analyse basee sur le cas rapporte et ceux de la litterature en faveur de l'emploi de la coloscopie comme moyen diagnostic de confirmation des appendicites lorsque l'imagerie medicale (scanner) est inaccessible ou est pris a defaut

Acute appendicitis in children in Kumasi, Ghana: macroscopic findings at laparotomy

Background A lot has been written about acute appendicitis in children in the developed countries but very little is written about this condition among children in the sub Saharan region. It used to be said that acute appendicitis is rare in Africa but this is no longer the case. We are unable to find, in the literature, any reference to acute appendicitis in children in Ghana. We, therefore, reviewed our experience with this pathology, especially the operative findings, in children using the Kumasi metropolitan area.Patients and Methods Ninety-six children admitted and treated for acute appendicitis from January 2001 to December 2003 were considered. The macroscopic findings at laparotomy were meticulously noted down and these form the basis for the analysis. Appendicectomy was carried out in all the 96 children.Results In all there were 67 boys and 29 girls, a boy to girl ratio of 2.2:1. the ages ranged from 1.8 years to 14.0 years with a mean age of 10.1 ± 2.8 years. Macroscopically, simple acute appendicitis (uncomplicated) was found in 13 (13.5%) and obstructive appendicitis (complicated) in 83 (86.5%) children. Postoperative complications consisted of superficial surgical site infection in 4, deep surgical site infection in 3 and incomplete wound dehiscence in 2. there was one death in the series- a mortality rate of 1.0%.Conclusion Acute appendicitis is no more a rarity in the sub-saharan setting as more and more people live affluently and adopt the western style of life. As a result of prehospital delay and also delays in diagnosis, complicated appendicitis was common among our group of patients

Seroprevalence of HIV in patients who present with features suggestive of acute appendicitis

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