Critical Evaluation of Appendicitis in Paediatric Age Group.

INTRODUCTION : Acute Appendicitis remains the most common indication for emergency abdominal Surgery. The life time risk is 9% for men and 7% for women. Considerable morbidity continues to be associated with appendicitis despite what is currently considered to be appropriate antibiotic and surgical care. Although the overall mortality rate is less than 1 % in many series, the mortality associated with appendicitis in elderly and infants ranges between 5 % and 15 %. The incidence of perforation commonly ranges from 17 % to 40% and is increased at both spectrums of age and is well known to be associated with significant morbidity. In the early eighties in our department the incidence of appendicitis was so low, that a clinical diagnosis of acute appendicitis was not the first choice when a child presented with vomiting, pain, toxemia and acute abdomen. Surgical doctrine suggests that a percentage of negative laparotomies are necessary and acceptable to limit the rate of perforation as the diagnosis of acute appendicitis is essentially clinical. Current studies demonstrate the negative Laparotomy rate to range from 15% to 30% and to be associated with significant morbidity. With the available gamut of investigations this can be lowered. The purpose of this study is to know the accuracy of clinical diagnosis in appendicitis by correlating histopathological examination report of removed appendix specimen against clinical diagnosis in Madurai Medical College Hospital over a period of two years between August 2005 to June 2007 and discuss it in the light of available literature. AIM : The objectives of this clinical study are : 1. To know the accuracy of clinical diagnosis in appendicitis by comparing with histopathological examination report of removed appendix specimen. 2. To find out the cause or causes for the increased incidence. MATERIALS AND METHODS : Materials - This work includes the study of 202 patients with clinical diagnosis of acute appendicitis admitted in Madurai Medical College Hospital between Aug.2005 to June 2007. All of them were admitted as emergency. Methods - This includes detailed history from the patients, clinical examination, blood studies (total count, differential count), plain X- ray abdomen and urine examination. All the information were entered in the proforma specially designed for this study. CONCLUSION : Appendicitis is common in 5 - 13 years of age. In 202 surgically treated patients diagnostic accuracy was nearing cent percent. The incidence of Appendicitis is significantly higher in males (67%) as compared to females (33%). We found that the proportion of children with complicated disease did not change during the 10-year period. Young children had the lowest incidence of acute appendicitis, but they had a 5-fold greater risk of complicated disease than older children. The annual crude incidence of acute appendicitis was 89 % in the surgeries performed in our Department. The overall perforation rate was 15%. Perforation rates and complication rates were higher in smaller children. There were no differences between genders. Acute appendicitis is essentially clinical diagnosis, but is aided by the present gamut of investigations. Detailed clinical history and examination can reduce the removal of normal appendix. Logistic regression analysis showed that a history of nausea or vomiting and pain migration to the right iliac fossa independently predicted a correct diagnosis of acute appendicitis. The clinical diagnostic accuracy is better in male sex than in female. Commonly used inflammation markers (CRP, WCC, fraction of neutrophil granulocytes and rectal body temperature) are useful in predicting active disease. By appropriate use of Ultrasound and CT Abdomen removal of normal appendix in equivocal cases can be reduced further. In fact if laparoscopy is included as a diagnostic tool the incidence of negative Appendicectomy would be 0 %. Total white blood cell count may be normal in acute appendicitis. Acute appendicitis was histologically proven in all the cases. Increased usage of ultrasound may be the reason for early reference. “Natives live on a diet abundant in cellulose and fibres are immune from this disease. When they adopt the diet of civilization they loose that immunity.” - William Boyd. The incidence of appendicitis is higher in more affluent societies that have a prevalence of low-fiber diets. Low-fiber diets change the bacterial flora, increasing stool viscosity, bowel transit time, and intra luminal pressure, which encourage the formation of faecoliths. These diets contribute to lowresidue stool, which can become impacted within the appendiceal lumen. We believe that the changes we see in the economic status, life style and food habits of people who live in rural and semi urban areas may be the causes for this increased incidence, as evinced by Bush’s recent statements that there is a demand for increased amount of posh food stuffs in the third world countries