Appendicitis in children: An increasing
health scourge in a developing country

Osarumwense David Osifo¹, Scott. O. Ogiemwonyi²

ABSTRACT

Objectives: The incidence of appendicitis is rising in developing countries. We aimed to determine the effects of late referrals and wrong treatment on the outcome of appendicitis in Benin City, Nigerian.

Methodology: A retrospective analysis of all children treated for appendicitis at the University of Benin Teaching Hospital, between January 1998 and December 2007. Pre/post operative morbidities, length of hospitalization, cost of treatment and mortality were compared between children who presented early, within 24 hours of first episode of symptoms, and those who presented later.

Results: A total of 481 children aged between 2 and 16 (mean 9.7 ± 2.8) years, comprising 265 males and 216 females with male/female ratio1.2:1 had appendicectomy which accounted for 5.7% of total pediatric operations and 47.5% of pediatric abdominal operations. Only 206 (42.8%) children presented during the first episode of symptoms and in clinically stable state while 275 (57.2%) were referred after wrong diagnosis and treatment by general practitioners which resulted in different complications ranging from appendix abscess 60 (12.5%), appendix mass 54 (11.2%), perforated appendix 47 (9.8%), gangrenous appendix 41 (8.5%) and peritonitis 34 (7.0%). These influenced post operative outcome with wound infection recorded in 91 (18.9%), wound break down 35 (7.3%), septicemia 31 (6.4%), pelvic abscess 13 (2.7%) and death 1 (0.2%). These were not recorded among those who presented early who also had significantly lower duration of hospitalization and cost of treatment (P<0.0001).

Conclusion: Late referral due to low index of suspicion was rampant which significantly increased associated morbidities and mortality among children managed with appendicitis.

KEYWORDS: Appendicitis, Children, Incidence, Outcome, Developing country.

Pak J Med Sci    April - June 2009 (Part-II)    Vol. 25 No. 3    490-495

How to cite this article:

Osifo OD, Ogiemwonyi SO. Appendicitis in children: An increasing health scourge in a developing country. Pak J Med Sci 2009;25(3): 490-495.

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1. Osarumwense David Osifo, MBBS, FWACS
2. Scott. O. Ogiemwonyi, WASC, MBBS
1,2: Paediatric Surgery Unit,
Dept. of Surgery,
University of Benin Teaching Hospital,
Benin City, Nigeria.

Correspondence

Osifo O.D,
E-mail: Leadekso@yahoo.com

* Received for Publication: Oct. 22, 2008
* Revision Received: May 13, 2009
* Revision Accepted: May 15, 2009

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INTRODUCTION

Appendicitis, the inflammation of vermiform appendix which can be acute, sub-acute or recurrent, is associated with high morbidity which can be prevented by timed appendicectomy.1,2 The incidence has been reported to be high in developed cities where diet is rich in fat and low in roughages. Although the exact incidence in sub-Saharan Africa is not known due to poor data base, it has been reported to be lower than in developed countries. This lower incidence in sub-Saharan Africa has been attributed to diet high in roughages which are said to be protective against inflammatory bowel lesions.3,4 There is endemicity of enteric infectious diseases such as typhoid fever, amoebic dysentery, gastroenteritis and helminthes infestation in this subregion which present as abdominal pain mimicking appendicitis. Consequently, many clinicians place appendicitis at a lower position in the list of differential diagnoses of abdominal pain in Nigerian children.5-8 Also, ignorance and poverty lead to delayed presentation of children with appendicitis which allow complications to occur, compounding the diagnostic difficulty.

Whereas appendicectomy done on clinically stable children with mildly inflamed appendix have favourable outcome, the reverse is the case in perforated or gangrenous appendix in clinically compromised children who may develop life threatening complications after surgery.1,2,9-11 Literatures3,4,12-15 searched on pediatric appendicitis in this subregion showed a progressive increase in incidence from early 1960, but these have had minimal effect on increasing awareness. As a result, severe morbidity resulting from delayed or wrongly managed cases suspected to be due to other causes of abdominal pain are increasing and have become worrisome. Moreover, African diets have been westernized and enteric infections/infestation has been on the decline due to improved standard of living. The need to reappraise the differential diagnosis of abdominal pain in children in this subregion cannot be overemphasized.

The aim of this ten-year retrospective study was to review cases of children treated for appendicitis with a view to determine the incidence and compare the pre/post operative morbidities, length of hospitalizations, cost of treatment and mortality between those who presented early, within 24 hours of first episode of symptoms, and those who presented later. This is to determine the effect of late referral on the outcome of appendicitis so as to reduce avoidable morbidity and mortality in developing countries.

METHODOLOGY

University of Benin Teaching Hospital is a tertiary hospital located in Benin City, Edo State, in the South-South Geopolitical Zone of Nigeria. It is a referral pediatric surgical center to which children are referred from primary and secondary health institutions in the state. Analysis of cases of children managed with appendicitis at the center between January 1998 and December 2007 was done on retrieving their case files from medical records department. Data collated were age, sex, pattern of presentation, clinical state on arrival, diagnosis, preoperative morbidity, operation, intraoperative findings, post operative morbidity, the treatment/ length of hospitalization and outcome. Also, the socioeconomic status of parents, their level of education, place of residence and stable diets were noted. Two children on whom sufficient data were not available because their case files could not be retrieved were excluded from the study.

Statistical Analysis: The data obtained were analyzed using SPSS and presented as count, frequency and percentage. Continuous data were expressed as mean/standard deviation while categorical data were analyzed using Chi-square test and where necessary p-values less than 0.05 and greater than 0.05 were regarded as significant and non-significant respectively.

RESULTS

During the period, a total of 481 children were treated for appendicitis at the center. They were aged between 2 and 16 years (mean 9.7 years ± 2.8), comprising 265 males and 216 females with male/female ratio1.2:1. Appendicectomy accounted for 5.7% of the total 8456 pediatric operations and 47.5% of 1012 pediatric abdominal operations in ten years. Majority of the patients, 361 (75.1%), were children who resided in semi-urban and urban cities and whose parents belonged to the upper socioeconomic class that were able to afford and consumed more westernized diets while 120 (24.9%) were children of parents in low socioeconomic class. These children resided in rural areas with their parents and consumed more of diets rich in roughages. However, only 206 (42.8%) children presented to the unit directly within 24 hours of first episode of symptoms and in stable clinical state on arrival while 275 (57.2%) were referred late after wrong diagnoses and treatment with different complications.

Table-I shows the relative frequency of the signs and symptoms at presentation over ten years. Right iliac fossa pain 462 (96.0%) was the most common symptom with the least common symptom being impaired right leg movement and walking recorded in 69 (14.3%) children. Maximal right iliac fossa tenderness was the most common sign as recorded in 475 (98.8%) with jaundice recorded in 63 (13.1%) being the least frequent sign. The signs and symptoms occurred in various combinations in especially those children who presented with sub-acute and recurrent appendicitis. The classical signs and symptoms of appendicitis were altered by medications taken before presentation while many children already had complications on arrival. These resulted in diagnostic difficulty in many of them.

Delayed referrals and complications were more among children living in rural areas who did not seek medical attention early due mainly to ignorance and financial constraints. Of the 275 children with late referrals, 72 (26.2%) were referred from chemist shops after many years of treatment of recurrent episodes of abdominal pain, while the others came from private health institutions after 78 (28.4%) were treated for helminthes infestations, 76 (27.6%) for typhoid enteritis and 49 (17.8%) for amoebic dysentery. They were referred when they failed to respond to treatment with continued clinical deterioration. Due to late referrals, 236 children arrived in the unit with life threatening preoperative morbidity ranging from appendix abscess 60 (12.5%), appendix mass 54 (11.2%), perforated appendix 47 (9.8%), gangrenous appendix 41 (8.5%) and peritonitis 34 (7.0%) which were confirmed at exploratory laparotomy (Table-II). Therefore, an extremely significant statistical difference was observed when post operative morbidity and mortality recorded were compared between the children that presented early without preoperative morbidity and those that presented late (P<0.0001).

Diagnostic imaging (abdominal ultrasound scan, CT scan and plain abdominal X-rays) as well as relative leucocytosis on full blood count were useful in making diagnosis, although appendicitis was correctly diagnosed at exploratory laparotomy in 85 (17.7%) cases. Lanz incision centered at McBurney’s point was the preferred access in those correctly diagnosed preoperatively without features of peritonitis. Post operative morbidity was a reflection of preoperative clinical state; hence post operative morbidities were recorded among the 236 children who presented with complicated appendicitis.

The post operative morbidity, their management and outcome are shown in Table-III. Wound infection 91 (38.6%), wound break down 35 (14.8%), septicemia 31 (13.1%) and burst abdomen 3 (1.3%) were the most common post operative complications resulting in prolonged hospital stay. Other morbidities responded to treatment except one child with mortality recorded among the 3 (1.3%) children with burst abdomen. Overall, 236 (49.1%) children had post operative morbidities with 1 (0.2%) child succumbing to the illness and no morbidity and mortality was recorded among children that presented early and had appendicectomy. Also, mean hospital stay and total hospital bills were 5 days ± 2.1 and approximately 50 dollars ± 0.2 respectively in those that presented early, while those that presented late were 14 days ± 2.8 and approximately 120 dollars ± 0.9 respectively.

DISCUSSION

Rightly timed appendicectomy, open or laparoscopic, is the gold standard treatment of inflamed appendix with an excellent outcome in experienced hands. Neglected or wrongly managed appendicitis which allow preoperative complications to occur is associated with life threatening post operative morbidity as shown in this study and others.9,10,16 Of the 481 children treated, only 206 (42.8%) presented early while 275 (57.2%) presented late, 236 (49.1%) of them with preoperative complications that influenced post operative outcome. This resulted in an extremely significant statistical difference observed when outcome was compared between the children that presented early and those that presented late (P<0.0001) which is similar to other results.1,2,9,16

The age/sex distribution of affected children in this study tally with earlier reports but the incidence was much higher than what was observed by earlier authors3,4,12-15 which confirmed a steady increase in the incidence of appendicitis in sub-Saharan Africa. In this study, appendicectomy accounted for 5.7% of total pediatric operations and 47.5% of pediatric abdominal operations as against 0.43% and 18.0% in a similar research13 conducted a decade earlier in western Nigeria. Also, appendicitis related morbidity due to delayed and wrongly treated cases was correspondingly higher in this report than others4,13,14 which showed disparity between rising incidence of appendicitis and referrals due to low index of suspicion by family doctors. Therefore, 78 (28.4%) children in this series were treated for helminthes infestations, 76 (27.6%) for typhoid enteritis and 49 (17.8%) for amoebic dysentery, and were referred with complications when they failed to respond to the inappropriate treatment.5-7

Although clinical diagnosis of appendicitis is straight forward in adult, it has been reported8,17,18 to be more difficult in children because of their inability to give accurate history, many differentials, lack of cooperation during examination and absence of classical signs and symptoms, which may be compounded by medications taken before presentation that may have altered the clinical picture as shown in this study. In addition, the rapid progression of appendicitis to complications in children and higher chance of peritonitis due to poorly developed omentum as well as earlier literatures12,13 in this subregion which reported appendicitis to be uncommon in children led to delay in presentation and diagnostic difficulty in many children in this series which is similar to the experiences of earlier authors.8,18 Furthermore, preoperative morbidities recorded were more common and severe among children who resided in rural areas that presented very late. Among such children, life threatening preoperative morbidities, appendix abscess 60 (12.5%), appendix mass 54 (11.2%), perforated appendix 47 (9.8%), gangrenous appendix 41 (8.5%) and peritonitis 34 (7.0%), were more frequent as reported earlier.16,19 The importance of diagnostic imaging facilities in such cases have been documented18,20 which would prevent negative appendicectomy when there is diagnostic difficulty, but financial constraints in many developing countries make their use to be restricted. Therefore, exploratory laparotomy which was diagnostic as well as therapeutic was used more often in this series and others,14,15 in order to avoid further delay particularly in children with features of peritonitis.

Consequent on wrong diagnosis and late referrals, post operative wound infection in 91 (38.6%) children, wound break down 35 (14.8%), septicemia 31 (13.1%) and pelvic abscess 13 (5.5%) were recorded which were very challenging to manage and these resulted in prolonged hospitalization with resultant increment in treatment bills as also reported by earlier researcher.1,2,10,21 Preoperative peritonitis has been reported to result in post operative band and adhesion formation with resultant intestinal obstruction which may necessitate re-exploration and adhesiolysis but these were rare in this series (Table-II). Similarly, wound infections have resulted in incisional hernias which are successfully repaired as seen in this and other studies.13,14 However, enterocutaneous fistula, portal pyemia and burst abdomen were difficult post operative morbidities to manage in this study and one child who had burst abdomen succumbed due to overwhelming sepsis. This is at variance with previous report14 in this subregion in which no mortality was recorded despite similar spectrum of post operative morbidity. The 0.2% mortality recorded in this study however agreed with literatures1,2,10,21 but morbidity recorded in 236 (49.1%) children was exceptional.

CONCLUSION

In conclusion, the incidence of pediatric appendicitis is rising in sub-Saharan Africa and the number of children treated in this review was higher than earlier reports but under diagnosis, wrongly treated cases and delayed referral which allowed life threatening complications to set in were alarming. This is sequel to other causes of abdominal pains being given priority as differential diagnosis because incidence of appendicitis was believed to be very low in Nigerian children. However, appendicitis related morbidity which led to increased length of hospitalization, cost of treatment and mortality were worrisome, especially when no morbidity and mortality was recorded in children that presented early and had timely appendicectomy. Parents/caregivers should be suspicious of appendicitis and present children with abdominal pain to hospital early. Physicians in this subregion should give priority to appendicitis and refer children early for surgical consultation because the classical clinical pictures of appendicitis may have been altered by self medications before presentation.

REFERENCES

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2. Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med 2000;36:39-51.

3. Mungadi IA, Jabo BA, Agwu NP. A review of appendicectomy in Sokoto North-western Nigeria. Niger J Med 2004;13:240-243.

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13. Adejuyigbe O, Fadiora OA. Pattern of acute appendicitis in Nigerian children. Ann Trop Pediatr 1989;9:93-7.

14. Achibong AE, Ekanem I, Jibrin P. Appendicitis in South-eastern Nigerian Children. Cent Afr J Med 1995;41:94-7.

15. Ohene-Yoboah M, Togbe B. An audit of appendicitis and appendicectomy in Kumasi, Ghana. West Afr J Med 2006;25:138-143.

16. Zoguereh DD, Lemaitre X, Ikoli JF, Delment J, Chamlian A, Madaba JL, et al. Acute appendicitis at the National University Hospital in Bangui, Central African Republic: epidemiologic, clinical, paraclinical and therapeutic aspects. Sante 2001;11:117-125.

17. Holland A, Gollow IJ. Acute abdominal pain in children: an analysis of admissions over a three year period. J Qual Clin Pract 1996;16:151-5.

18. Stamm D. Acute abdominal pain in children. Diagnostic orientation. Rev Pract 2000;50:1923-30.

19. Okafor PI, Orakwe JC, Chianakwana GU. Management of appendiceal masses in a peripheral hospital in Nigeria: review of thirty cases. World J Surg 2003;27:800-03.

20. Weinberger E, Winters WD. Abdominal pain and vomiting in infants and children: Imaging evaluation. Compr Ther 1997;23:679-86.

21. Perovic Z. Drainage of the abdominal cavity and complications in perforating appendicitis in children. Med Pregl 2000;53:193-196.

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