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The management of right iliac fossa pain – Is timing everything?
the surgeon 8 (2010) 211–217
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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
The management of right iliac fossa pain – Is timing everything? D.P. McCartan, F.J. Fleming, P.A. Grace* Department of Surgery, Mid-Western Regional Hospital, University of Limerick, Limerick, Ireland
article info
abstract
Article history:
Background: Right iliac fossa (RIF) pain remains the commonest clinical dilemma encoun-
Received 30 November 2009
tered by general surgeons. We prospectively audited the management of acute RIF pain,
Accepted 30 November 2009
examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.
Keywords:
Methods: Over a six-month period, 302 patients, median age 18 years, 59% female, were
Right iliac fossa pain
admitted with RIF pain. Symptoms, clinical findings and laboratory results were docu-
Acute appendicitis
mented. Patient management, timing of radiological investigations and operations, and
Diagnosis
outcome were recorded prospectively. Results: Non-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n ¼ 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) ( p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis. Conclusion: The majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity. ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Appendicitis remains the most common general surgical emergency in developed countries. However, appendicitis can simulate other benign causes of acute abdominal pain and is frequently imitated by other pathologies, thus it presents a significant diagnostic challenge to the assessing surgeon. Traditional management of patients with suspected appendicitis has focused on early surgical intervention with
the aim of preventing disease progression, as it is well recognised that advanced appendicitis carries a higher rate of both morbidity and mortality.1,2 The impact of in-hospital assessment time after presentation to hospital on outcomes in appendicitis remains unclear. Clyde et al., in a recent retrospective review of 1200 patients from a large community surgical practice concluded that short delays, the average time to surgical intervention was 7.1 h after seeking medical attention, in surgical intervention for acute appendicitis are
* Corresponding author. Tel.: þ353 (0) 61 482121; fax: þ353 (0) 61 482122. E-mail address: [email protected] (P.A. Grace). 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.11.008
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Age/Sex Prolife Nu m b er of P a t ien t s
80 70
Male
60
Female
50 40 30 20 10 0 <15
15-25
25-35
35-45
45-55
>55
Age (years) Fig. 1 – Patient demographics.
well tolerated.3 In contrast, a similarly powered retrospective review from Connecticut concluded that hospital interval was associated with advanced grade of appendicitis.4 A fundamental limitation of these studies, acknowledged by the authors in both cases, is that they are retrospective and only examine patients who undergo appendicectomy, thus there is a paucity of prospective studies examining all patients who present with right iliac fossa (RIF) pain. The objectives of this study were to prospectively evaluate the assessment and management of all patients presenting to our hospital with acute right iliac fossa pain. We aimed to examine the relationship between presenting symptoms and clinical signs, the use of pre-operative radiological imaging and type of operative intervention on patient management and outcome.
Methods Over a six-month period, all patients referred to the General Surgical team on-call with acute RIF pain were included. Our hospital has an immediate catchment population of 185,000 and is the regional paediatric unit for a population of 361,000. The hospital does not have a dedicated emergency operating theatre. The General Surgical on-call rota is shared between seven surgeons with a range of sub-specialist interests including breast surgery, vascular surgery, colorectal surgery and urology. All data were collected prospectively on a specifically designed proforma that was completed by the General Surgical Senior House Officer (Surgical Trainee Year 1 or 2) who assessed the patient in the Emergency Department. Recorded information included details on symptom type, duration and associated symptoms such as nausea. Findings on clinical examination including assessment of the abdomen were documented. Results of the serum white cell count and urinalysis at time of initial assessment were recorded. Both adult and paediatric patients, defined as patients aged under 14 years of age, were eligible for inclusion. Further details on patient management were recorded with the knowledge of the clinical team. As the aim of this study was to evaluate current management of RIF pain rather than implement a change of practice, the decision to proceed with either a radiological investigation or with surgery was left to
the discretion of the consultant surgeon in care of the patient and not determined by criteria defined by the study. The timing, results and influence on clinical decisions of any radiological investigations were documented. The decision to proceed to surgery was taken in conjunction with the consultant in charge in each case and the choice of surgical approach was at the discretion of the consultant surgeon. The level of surgeon performing the operation varied between clinical teams. Any operation performed by a trainee, with the exception of two senior registrars, was supervised by a consultant. It is departmental policy that at laparoscopy, if no other cause for the patient’s symptoms can be identified, an appendicectomy is performed even if macroscopically normal. Patients were assessed for post-operative morbidity at a once off out patient visit six weeks post-discharge as well as for readmission with similar symptoms. Patients who did not undergo surgery were not followed up as out patients as a matter of routine but only if further investigations were deemed necessary. A diagnosis of appendicitis was based on histological findings. Classification of perforated appendicitis, i.e. perforation or abscess formation, was based on macroscopic findings at operation. Other diagnoses considered included acute non-specific abdominal pain (ANSAP), defined as acute abdominal pain of under 7 days’ duration and for which there is no diagnosis after examination and baseline investigations. This included patients who had a histologically normal appendix removed in the absence of other pathology. A gynaecological cause for RIF pain was attributed to females with the finding of a gynaecological abnormality on radiological imaging or at surgery. Mesenteric adenitis was considered as a diagnosis in patients aged less than 14 years of age with evidence of a concomitant viral respiratory tract infection with associated pyrexia, whose clinical condition improved with non-operative management. Statistical analysis was performed using SPSS statistical software, version 12.0 (SPSS Inc, Chicago, IL, USA). Stepwise logistic regression analysis was used to predict acute appendicitis with regard to a number of variables. Categorical variables were assessed using Fisher’s exact test. Continuous variables were examined using either the Kruskall–Wallis test or the Mann–Whitney test for non-parametric data.
Results Over the six-month period, a total of 302 patients were referred to the general surgical team with acute RIF pain. More females presented with RIF pain than males (Fig. 1). Twentythree (13%) of the female cohort had attended the emergency department within the previous 12 months with similar symptoms compared to seven (6%) of the male patients. Appendicitis was the final diagnosis in 119 patients (39%) admitted with RIF pain (Table 1). More males than females had appendicitis (57% vs. 27%, p < 0.001). There was no difference between the sexes in rate of perforated appendicitis (24% male vs. 25% female, p ¼ 1.00). Of 105 females aged between 15 and 50 years at admission, a gynaecological cause for their RIF pain was identified in 53 patients (50%) with 25 patients (24%) having appendicitis. Twenty-nine of the 65 females with
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Table 1 – Breakdown of final diagnosis in all patients admitted with right iliac fossa pain.
Simple appendicitis Perforated appendicitis Acute non-specific abdominal pain Gynaecological cause Mesenteric adenitis Other Total
Female
Male
Total
36 (20) 12 (7) 40 (23)
54 (43) 17 (14) 38 (21)
119 (39)
65 (37) 8 (5) 16 (9)
–
177
78 (26)
6 (5) 10 (8)
65 (22) 14 (5) 26 (9)
125
302
Values in parentheses are percentages.
a gynaecological diagnosis underwent surgery and in all of these cases, ovarian pathology was identified in the form of ovarian cysts. The remaining 36 gynaecological diagnoses were established on pelvic ultrasound demonstrating a range of abnormalities from simple ovarian cysts (n ¼ 21), ovarian malignancy (n ¼ 2), fibroids (n ¼ 1) and free pelvic fluid suggestive of a ruptured cyst with a normal ovary visualised (n ¼ 12). Of the 23 female patients who had attended the emergency department within the previous 12 months, 10 were found to have a gynaecological cause for their pain on ultrasound and five had acute appendicitis. No cause for the pain could be identified in the remaining seven, all of whom had normal ultrasound scans. Of the 78 patients with a diagnosis of acute non-specific abdominal pain (ANSAP), 22 (28%) had a normal ultrasound. A further 28 patients (36%) proceeded to surgery and all of these had a histologically normal appendix removed in the absence of any other visible pathology. Ten of the 78 patients with ANSAP were readmitted in the 6 months post-surgery with a similar type of pain at a median time of 43 days post-surgery. Other causes for RIF pain were identified in 26 patients (9%). These included urinary tract infection (six), chronic RIF pain on further assessment (six), gastroenteritis (five), small bowel obstruction (three), acute diverticulitis (two), terminal ileitis (two) and a patient with a benign leiomyoma of the small bowel. A history of anorexia was the only significant symptom that proved helpful in discriminating between appendicitis and other diagnoses (Table 2). On clinical examination the
finding of either a tachycardia of greater than 100 beats per minute or rebound tenderness in the right iliac fossa on examination was significantly associated with an ultimate diagnosis of appendicitis. Of the 25 patients who were tachycardic, pyrexial and had right iliac fossa guarding on examination, 23 (92%) turned out to have a final diagnosis of appendicitis. All of these patients had an elevated serum white cell count of greater than 11.0 109/L. The sensitivity of an elevated white cell count for acute appendicitis was 0.81 with a specificity of only 0.63. When the overall patient-timeline, from development of symptoms to surgery is examined (Fig. 2), it is clear that those with perforated appendicitis had a significantly longer duration of pre-hospital symptoms (median 50.0 h) compared to those patients with simple appendicitis (median 16.5 h) or other diagnosis (median 22.0 h) ( p < 0.001). Patients who presented to a primary practitioner (n ¼ 211, 70%) prior to attending hospital, had a significantly longer duration of prehospital symptoms (median 24.1 h) than those who self-presented to the Emergency Department (15.2 h) ( p < 0.001). The median time from attending a primary practitioner to presentation at hospital was 3.3 h. However, the patients who attended a primary practitioner were as likely to have an ultimate diagnosis of appendicitis as those who presented straight to the emergency department (40% vs. 37%) ( p ¼ 0.508). The rate of perforated appendicitis did not differ in patients with private health insurance and those without (26% vs. 23%) ( p ¼ 0.732). Ninety-four patients (31%) lived greater than 20 miles from the hospital however, this group did not significantly differ in duration of pre-hospital symptoms (median 24.0 h vs. 21.0 h, p ¼ 0.068) or in rate of advanced appendicitis (26% vs. 24%) ( p ¼ 0.820) compared to those that lived within 20 miles of the hospital. A major difference in management after initial surgical assessment was that the time taken to decide to operate was significantly shorter in patients with both simple (median 4.7 h) and perforated (median 2.0 h) appendicitis when compared to those with another diagnosis (median 14.9 h) ( p < 0.001). This suggests that clinical indecision is of shorter duration for those with acute appendicitis than in those in whom the clinical picture is not one of acute appendicitis. One hundred and nine patients were listed for theatre after initial clinical assessment. Radiological imaging was used as an
Table 2 – Clinical assessment. Other diagnosis
Acute appendicitis
Odds ratio (95% CI)
p Value
Sex (male) Nausea Vomiting Anorexia Temperature >37.5 C Tachycardia Rebound tenderness RIF Elevated WCC
54 (30%) 131 (72%) 72 (39%) 73 (40%) 23 (13%) 24 (13%) 35 (19%) 68 (37%)
71 (60%) 97 (82%) 77 (65%) 87 (73%) 36 (30%) 45 (38%) 64 (54%) 96 (81%)
4.70 (2.50, 8.82) 0.79 (0.36, 1.77) 1.20 (0.62, 2.34) 3.97 (2.12, 7.44) 1.26 (0.56, 2.84) 2.42 (1.11, 5.27) 2.47 (1.32, 4.62) 5.51 (2.93, 10.35)
<0.001 0.570 0.584 <0.001 0.576 0.027 0.005 <0.001
Total
183 (61%)
119 (39%)
Values in parentheses in both the ‘other diagnosis’ and ‘acute appendicitis’ columns are percentages, with those in the ‘Odds ratio’ column representing 95% confidence intervals.
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Duration of Pre Hospital Symptoms (hrs)
140 120 100 80 60 40 20 0
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Time to decision to operate after surgical assessment (hrs)
Emergency Department Assessment (hrs)
10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0
40 35 30 25 20 15 10 5
12 10 8
(hrs)
Time to theatre after decision to operate
0
6 4 2 0
Fig. 2 – Relationship between final diagnosis and prehospital symptom duration, emergency department delay, delay in decision to operate and time to theatre. Data are expressed as medians with bars representing 25th and 75th percentile.
adjunct in 109 of the remaining 193 patients of whom 48 proceeded to theatre along with an additional 27 patients who were listed for surgery based on repeated clinical examination alone. Fifty-seven patients did not have surgery or radiological imaging with repeated clinical assessment alone determining management. Radiological imaging was more frequently used in females (Table 3). Ultrasound was the most commonly utilised imaging modality for patients presenting with RIF pain. Of the 54 patients who had a normal ultrasound scan, five had a subsequent CT scan with appendicitis diagnosed on four of these scans. Twenty-five patients with a normal ultrasound scan proceeded to surgery with the resultant finding of appendicitis in five patients and a gynaecological abnormality in 11 patients. CT was used in the assessment of 22 patients with appendicitis with the sensitivity of CT for appendicitis in this small group 0.92 and a specificity of 1.00. The use of pre-operative imaging did not result in a significant decrease in the rate of negative appendicectomy.
The use of pre-operative radiological imaging was associated with a significantly increased time to operative intervention in patients with appendicitis. Those with appendicitis who did not have pre-operative imaging (n ¼ 96) reached the operating theatre at a median time of 9.4 h from initial assessment by the surgical team compared to 21.4 h in those who did have pre-operative imaging (n ¼ 21) ( p < 0.001). However, this increased time to surgery was not associated with an increased rate of perforated appendicitis ( p ¼ 0.326) or increased post-operative morbidity ( p ¼ 0.520). Patients who proceeded to surgery without radiological imaging were more likely to have rebound tenderness in the RIF on examination than those who were imaged (49% vs. 21% p ¼ 0.001). They were also more likely to have a raised serum white cell count (68% vs. 44%, p ¼ 0.006) and were ultimately more likely to have a final diagnosis of acute appendicitis (56% vs. 27%, p ¼ 0.002) but the rates of perforated appendicitis did not differ in the two groups. One hundred and eighty four patients (61%) proceeded to surgery during their admission (Table 4). Four patients had pathology identified on pre-operative imaging that was not acute appendicitis but required surgery. The remaining patients proceeded to operative intervention for suspected appendicitis with a laparoscopic approach adopted in 43% of patients. Patients aged under 14 were less likely to undergo a laparoscopic procedure (27% vs. 48%, p ¼ 0.009). Conversion from laparoscopy to an open procedure occurred in 11 cases (14%) due to surgeon preference for managing perforated appendicitis, when identified at laparoscopy, via an open procedure. Of the 158 appendices removed, 40 (25%) were normal on histological examination. The rate of normal appendicectomy was higher in patients undergoing a laparoscopic procedure (37%) than an open appendicectomy (19%) ( p ¼ 0.021). There was no post-operative morbidity in any of the 40 patients who had a normal appendix removed, however five were readmitted within six months of discharge with a similar pain. There was no post-operative mortality. Post-operative morbidity was 7.1% for all patients undergoing operative intervention. The complication rate was comparable between open (6.5%) and laparoscopic procedures (7.8%) ( p ¼ 0.785). The complication rate was higher in patients with perforated appendicitis (21%) when compared to patients with either simple appendicitis (7%) or another diagnosis (3%) who underwent surgery ( p < 0.001). In-hospital time to theatre did not differ between patients who developed a post-operative complication (median 15.8 h) and those who did not (median 17.9 h) ( p ¼ 0.591). There were six localised infectious complications; five wound infections and one pelvic abscess. One patient developed septic shock in the early post-operative period and one patient had a prolonged post-operative pyrexia, yet no pelvic collection was demonstrable on imaging. The significant non-infectious complication was one case of a pulmonary embolus in spite of adequate prophylaxis. The remaining complications were acute urinary retention, prolonged post-operative paralytic ileus, and two cases of chest pain, neither of which had biochemical or electrocardiograph evidence of myocardial ischaemia. One hundred and twenty three patients did not undergo operative intervention during their admission to hospital. Of
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Table 3 – Use of radiological imaging in establishing a diagnosis. Female (n ¼ 177) Radiological investigation 1st investigation: ultrasound 1st investigation: computed tomography Time from surgical assessment to investigation report (h)* Median (Range) Mean (S.D.) Normal investigation Further radiological imaging Subsequent operation Final diagnosis of appendicitis
Male (n ¼ 125)
94 (53%) 87 (49%) 7 (4%)
15 (12%) 10 (8%) 5 (4%)
15.6 (1–68) 20.0 (15.4) 45 (48%) 10 (11%) 39 (41%) 18 (19%)
17.1 (4–61) 23.0 (15.0) 9 (60%) 2 (13%) 9 (60%) 5 (33%)
Time from surgical review to theatre in those with appendicitis and pre-operative imaging (h)* Median (Range) 25.7 (7–61) 17.1 (6–53) Mean (S.D.) 32.1 (26.1) 24.2 (19.7) Post-operative morbidity 0 2 (22%)
Total (n ¼ 302) 109 (36%) 97 (32%) 12 (4%)
15.9 20.4 54 12 48 23
(1–68) (15.3) (50%) (11%) (44%) (21%)
21.5 (6–61) 30.2 (24.7) 2 (4%)
Values in parentheses are percentages unless indicated otherwise. * (h) = hours
these, 19 (15%) were readmitted with a similar presentation within six months, with a median time from discharge to readmission of 29 days (range 2–165 days). Upon readmission, six patients had a radiological investigation with ovarian pathology identified in four female patients. None of the patients readmitted were diagnosed with appendicitis on the second admission. Radiological imaging was less frequently used in patients under 14 years of age when compared to adult patients (18% vs. 46%, p < 0.001) (Table 5). There was no difference in prehospital symptom duration, emergency department delay or time to decision made to operate between adult and paediatric patients although paediatric patients did reach theatre more quickly than their adult counterparts. Paediatric patients were also more likely to undergo open appendicectomy.
Discussion The current study is unique in the modern setting, in prospectively examining all patients presenting with acute RIF
Table 4 – Operative intervention.
Open appendicectomy Laparoscopic appendicectomy Laparoscopy: convert to open appendicectomy Diagnostic laparoscopy Laparotomy Other Total appendicectomy Normal appendices removed Total operative intervention
Female
Male
Total
28 (30) 33 (35) 7 (8)
69 (76) 10 (11) 4 (4)
97 (53) 43 (23) 11 (6)
22 1 2 70 23 93
1 (1) 6 (7) 1 (1) 88 (70) 17 (19) 91 (73)
23 (13) 7 (4) 3 (2) 158 (52) 40 (25) 184 (61)
(24) (1) (2) (40) (33) (53)
Values in parentheses are percentages. The percentage values for specific procedures are a percentage of total operative intervention for each group.
pain. In adopting this approach, the aim was to evaluate the overall outcome of what is a heterogeneous patient cohort not only in terms of final diagnosis but also in terms of management strategy and presenting signs and symptoms. The incidence of acute appendicitis in patients presenting with RIF pain is not commonly reported. In our study, acute appendicitis accounted for the final diagnosis in 39% of the patients, with appendicitis being more common in men in accordance with a previous study by Andersson et al.5 The most common final diagnosis in female patients aged between 15 and 50 years was gynaecological in contrast to a previous study of women of child bearing age that established appendicitis as the most common diagnosis.6 In our unit, all female patients presenting with acute RIF pain are admitted under the general surgical service, which may explain the high proportion of patients with a gynaecological abnormality. An accurate history and physical examination are integral to the clinical management of patients presenting with RIF pain. A study by Korner et al., found a history of migratory pain and a history of nausea or vomiting, to be significant predictors of appendicitis.7 In contrast to our study where the finding of either a tachycardia or rebound tenderness were significant predictors of acute appendicitis, physical signs were of no predictive value in the Korner study, probably reflecting the fact that patients included all underwent operative intervention for suspected appendicitis and thus, were more likely to have physical signs. Ninety two percent of patients in our study who were pyrexial, tachycardic, had RIF guarding on examination and had a raised serum white cell count at initial assessment had a histological diagnosis of appendicitis. This suggests that an accurate clinical assessment can identify subgroups with a high likelihood of appendicitis without the use of radiological imaging. Radiological imaging is typically used in patients with an equivocal clinical diagnosis in our unit. Overall, the use of imaging was not associated with a decrease in the rate of negative appendicectomy reflecting the predominant use of ultrasound as the first line imaging modality. Pre-operative
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Table 5 – Comparison between paediatric and adult patients.
Diagnosis
Paediatric (n ¼ 105)
Adult (n ¼ 197)
32 (30) 9 (9) 36 (34) 28 (27)
58 (29) 20 (10) 42 (21) 77 (39)
22.0 2.9 4.3
23.0 3.2 7.6
22.0 3.1 6.7
4.1 19 (18) 56 (53) 41 (73) 55 (98) 15 (27) 2 (3.6)
5.8 90 (46) 128 (65) 62 (48) 103 (80) 25 (25) 11 (8.6)
5.6 119 (39) 184 (61) 103 (56) 158 (86) 40 (25) 13 (7.1)
Simple appendicitis Advanced appendicitis ANSAP Other
Median duration of pre-hospital symptoms Median emergency department delay (h) Median time from surgical assessment until decision made to operate Median time to theatre after decision made to operate Radiological investigation Operative intervention Open appendicectomy Total appendicectomy Normal appendix removed Post-operative morbidity
Total (n ¼ 302) 90 29 78 105
(30) (10) (26) (35)
p Value 0.895 0.838 0.018 0.032 0.745 0.264 0.264 0.012 <0.001 0.063 0.002 <0.001 0.705 0.350
Values in parentheses are percentages.
imaging inherently adds to the in-hospital time to operation in patients who proceed to surgery.8 The increased time from surgical assessment to operative intervention in patients with appendicitis who had pre-operative imaging was significant but was not associated with either increased morbidity or increased rates of perforated appendicitis. The group who were selected for surgery on the basis of clinical findings alone was more likely to have signs of peritonism in the right iliac fossa. This suggests that those who underwent radiological imaging were thought less likely to have appendicitis and that any resultant increase in the hospital interval could be tolerated. The finding that this group did not differ in terms of postoperative morbidity or rates of perforated appendicitis appears to justify this. While laparoscopic surgery is increasingly being used in patients with suspected appendicitis, open appendicectomy remains a commonly performed operation9 and was the operation of choice for 61% of the appendicectomies performed in our study in accordance with recent Scottish data.10 As one of three hospitals in the catchment area that receives adult surgical admissions it is possible that some readmissions were to other institutions. This limitation precludes comparison of readmission rates following open vs. laparoscopic appendicectomy in this series. The rate of perforated appendicitis reported here is similar to a recent UK publication reporting a 19% rate of significant peritoneal contamination.10 In accordance with previous reports,2,11,12,13,14 in our experience, increased duration of prehospital symptoms was the main factor associated with perforated appendicitis. After presentation to the emergency department, those with perforated appendicitis had a shorter in-hospital time to theatre compared to other patients who underwent surgery. This expedient management of patients with perforated appendicitis is reassuring from a clinical audit point of view and concurs with previous reports,14,15 undoubtedly reflecting the more florid clinical picture in those with perforated disease at presentation. Non-patient factors related to hospital organisation have been associated with differences in rates of advanced appendicitis.16 In the Irish healthcare model, patients with
private healthcare insurance and those without access emergency care through a single point of entry. No difference was observed in the rate of perforated appendicitis in relation to private healthcare insurance. Patients who attended a primary practitioner prior to attending hospital did have an increased total duration of pre-hospital symptoms compared to patients who self-presented to the emergency department. This difference cannot solely be explained by time spent attending the primary practitioner as the median time from attending the GP to presentation at hospital was just over 3 h reflecting a prompt referral from primary care. In 1985, Brender et al., found increased rates of perforated appendicitis in children whose parents had been advised by the first health professional contacted, to observe their children at home.17 We identified no significant difference in either the rate of appendicitis as final diagnosis or rates of perforated appendicitis in those who attended their primary practitioner initially. Similarly, there was no difference in duration of prehospital symptoms or rates of advanced appendicitis in patients who lived further from hospital. While rural residence has been associated with increased risk of perforated appendicitis,18 the distances involved in this current region of study are probably not substantial enough to account for differences in time to presentation or rates of perforation. In our own institution, the lack of a dedicated emergency operating theatre adds to the in-hospital time to operation in patients with suspected appendicitis. In those with appendicitis, the median time taken to reach theatre after the decision to operate had been made and communicated to theatre staff was 5 h representing one third of the total pre-operative time. While our figures for in-hospital time to theatre compare with those reported in Ireland, this in-hospital pre-operative time is significantly greater than reports from the United States. Recent retrospective reviews of patients undergoing appendicectomy in community centres in the United States report mean times to theatre from 7.1 h to 11.5 h3,15 which is facilitated by the well developed infrastructure that supports the speciality of emergency surgery in the United States.19 However, with the consistent finding that increased duration of pre-hospital symptoms is the main factor associated with
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perforated appendicitis, do the lower rates of perforated appendicitis reported from the United States reflect the benefit of reduced in-hospital time to surgery or merely that a greater percentage of US patients will present earlier in their disease course? We have demonstrated in this prospective observational study that the majority of patients presenting to hospital with RIF pain did not have appendicitis. Delay in accessing the operating theatre was not associated with perforated appendicitis or post-operative morbidity. This study confirms, in a prospective fashion, that increased duration of pre-hospital symptoms is the main factor associated with perforated appendicitis. The use of pre-operative imaging adds significantly to the delay in reaching theatre and while this delay is not associated with increased morbidity, it was not helpful in reducing the number of unnecessary operations in this study. In assessing all patients with acute RIF pain, clinical history and physical examination are useful in identifying patients with a high probability of appendicitis and whose definitive management remains operative and is unlikely to be altered by radiological imaging.
references
1. Luckmann R. Incidence and case fatality rates for acute appendicitis in California. A population-based study of the effects of age. Am J Epidemiol 1989;129:905–18. 2. Pittman-Waller V, Myers J, Stewart R, Dent D, Page C, Gray G, et al. Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 2000;66:548–54. 3. Clyde C, Bax T, Merg A, MacFarlane M, Lin P, Beyersdorf S, et al. Timing of intervention does not affect outcome in acute appendicitis in a large community practice. Am J Surg 2008; 195:590–3. 4. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244(5):656–60. 5. Andersson RE, Hugander A, Ravn H, Offenbartl K, Gahzi SH, Nystrom PO, et al. Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000;24:479–85.
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6. Rennie AT, Tytherleigh MG, Theodoroupolou K, Farouk R. A prospective audit of 300 consecutive young women with an acute presentation of right iliac fossa pain. Ann Roy Coll Surg Engl 2006;88:140–3. 7. Korner H, Sondenaa K, Soreide JA, Nysted A, Vatten L. The history is important in patients with suspected acute appendicitis. Dig Surg 2000;17:364–9. 8. Lee CC, Golub R, Singer AJ, Cantu Jr R, Levinson H. Routine versus selective abdominal computed tomography scan in the evaluation of right lower quadrant pain: a randomized controlled trial. Acad Emerg Med 2007 Feb;14(2):117–22. 9. Ng S, Fleming FJ, Drumm J, Waldron D, Grace PA. Current trends in the management of acute appendicitis. Ir J Med Sci. 2008 Jun;177(2):121–5. 10. Paterson HM, Qadan M, de Luca SM, Nixon SJ, PatersonBrown S. Changing trends in surgery for acute appendicitis. Br J Surg 2008 Mar;95(3):363–8. 11. Kearney D, Cahill R, O Brien E, Kirwan W, Redmond H. Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum; 2008. 12. Raman SS, Osuagwu FC, Kadell B, Cryer H, Sayre J, Lu DS. Effect of CT on false positive diagnosis of appendicitis and perforation. N Engl J Med 2008;358(9):972–3. 13. Eldar S, Nash E, Sabo E, Matter I, Kunin J, Mogilner JG, et al. Delay of surgery in acute appendicitis. Am J Surg 1997;173: 194–8. 14. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995; 221(3):278–81. 15. Piper HG, Rusnak C, Orrom W, Hayashi A, Cunningham J. Current management of appendicitis at a community center– how can we improve? Am J Surg 2008 May;195(5):585–8. Discussion 8–9. 16. Sicard N, Tousignant P, Pineault R, Dube S. Non-patient factors related to rates of ruptured appendicitis. Br J Surg 2007; 94:214–21. 17. Brender JD, Marcuse EK, Koepsell TD, Hatch EI. Childhood appendicitis: factors associated with perforation. Pediatrics 1985 Aug;76(2):301–6. 18. Penfold R, Chisolm D, Nwomeh B, Kelleher K. Geographic disparities in the risk of perforated appendicitis among children in Ohio: 2001–2003. Int J Health Geogr 2008;7(56):1–9. 19. Ekeh A, Monson B, Wozniak C, Armstrong M, McCarthy M. Management of acute appendicitis by an acute care surgery service: is operative intervention timely? J Am Coll Surg 2008; 207(1):43–8.
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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
The management of right iliac fossa pain – Is timing everything? D.P. McCartan, F.J. Fleming, P.A. Grace* Department of Surgery, Mid-Western Regional Hospital, University of Limerick, Limerick, Ireland
article info
abstract
Article history:
Background: Right iliac fossa (RIF) pain remains the commonest clinical dilemma encoun-
Received 30 November 2009
tered by general surgeons. We prospectively audited the management of acute RIF pain,
Accepted 30 November 2009
examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.
Keywords:
Methods: Over a six-month period, 302 patients, median age 18 years, 59% female, were
Right iliac fossa pain
admitted with RIF pain. Symptoms, clinical findings and laboratory results were docu-
Acute appendicitis
mented. Patient management, timing of radiological investigations and operations, and
Diagnosis
outcome were recorded prospectively. Results: Non-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n ¼ 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) ( p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis. Conclusion: The majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity. ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Appendicitis remains the most common general surgical emergency in developed countries. However, appendicitis can simulate other benign causes of acute abdominal pain and is frequently imitated by other pathologies, thus it presents a significant diagnostic challenge to the assessing surgeon. Traditional management of patients with suspected appendicitis has focused on early surgical intervention with
the aim of preventing disease progression, as it is well recognised that advanced appendicitis carries a higher rate of both morbidity and mortality.1,2 The impact of in-hospital assessment time after presentation to hospital on outcomes in appendicitis remains unclear. Clyde et al., in a recent retrospective review of 1200 patients from a large community surgical practice concluded that short delays, the average time to surgical intervention was 7.1 h after seeking medical attention, in surgical intervention for acute appendicitis are
* Corresponding author. Tel.: þ353 (0) 61 482121; fax: þ353 (0) 61 482122. E-mail address: [email protected] (P.A. Grace). 1479-666X/$ – see front matter ª 2009 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2009.11.008
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Age/Sex Prolife Nu m b er of P a t ien t s
80 70
Male
60
Female
50 40 30 20 10 0 <15
15-25
25-35
35-45
45-55
>55
Age (years) Fig. 1 – Patient demographics.
well tolerated.3 In contrast, a similarly powered retrospective review from Connecticut concluded that hospital interval was associated with advanced grade of appendicitis.4 A fundamental limitation of these studies, acknowledged by the authors in both cases, is that they are retrospective and only examine patients who undergo appendicectomy, thus there is a paucity of prospective studies examining all patients who present with right iliac fossa (RIF) pain. The objectives of this study were to prospectively evaluate the assessment and management of all patients presenting to our hospital with acute right iliac fossa pain. We aimed to examine the relationship between presenting symptoms and clinical signs, the use of pre-operative radiological imaging and type of operative intervention on patient management and outcome.
Methods Over a six-month period, all patients referred to the General Surgical team on-call with acute RIF pain were included. Our hospital has an immediate catchment population of 185,000 and is the regional paediatric unit for a population of 361,000. The hospital does not have a dedicated emergency operating theatre. The General Surgical on-call rota is shared between seven surgeons with a range of sub-specialist interests including breast surgery, vascular surgery, colorectal surgery and urology. All data were collected prospectively on a specifically designed proforma that was completed by the General Surgical Senior House Officer (Surgical Trainee Year 1 or 2) who assessed the patient in the Emergency Department. Recorded information included details on symptom type, duration and associated symptoms such as nausea. Findings on clinical examination including assessment of the abdomen were documented. Results of the serum white cell count and urinalysis at time of initial assessment were recorded. Both adult and paediatric patients, defined as patients aged under 14 years of age, were eligible for inclusion. Further details on patient management were recorded with the knowledge of the clinical team. As the aim of this study was to evaluate current management of RIF pain rather than implement a change of practice, the decision to proceed with either a radiological investigation or with surgery was left to
the discretion of the consultant surgeon in care of the patient and not determined by criteria defined by the study. The timing, results and influence on clinical decisions of any radiological investigations were documented. The decision to proceed to surgery was taken in conjunction with the consultant in charge in each case and the choice of surgical approach was at the discretion of the consultant surgeon. The level of surgeon performing the operation varied between clinical teams. Any operation performed by a trainee, with the exception of two senior registrars, was supervised by a consultant. It is departmental policy that at laparoscopy, if no other cause for the patient’s symptoms can be identified, an appendicectomy is performed even if macroscopically normal. Patients were assessed for post-operative morbidity at a once off out patient visit six weeks post-discharge as well as for readmission with similar symptoms. Patients who did not undergo surgery were not followed up as out patients as a matter of routine but only if further investigations were deemed necessary. A diagnosis of appendicitis was based on histological findings. Classification of perforated appendicitis, i.e. perforation or abscess formation, was based on macroscopic findings at operation. Other diagnoses considered included acute non-specific abdominal pain (ANSAP), defined as acute abdominal pain of under 7 days’ duration and for which there is no diagnosis after examination and baseline investigations. This included patients who had a histologically normal appendix removed in the absence of other pathology. A gynaecological cause for RIF pain was attributed to females with the finding of a gynaecological abnormality on radiological imaging or at surgery. Mesenteric adenitis was considered as a diagnosis in patients aged less than 14 years of age with evidence of a concomitant viral respiratory tract infection with associated pyrexia, whose clinical condition improved with non-operative management. Statistical analysis was performed using SPSS statistical software, version 12.0 (SPSS Inc, Chicago, IL, USA). Stepwise logistic regression analysis was used to predict acute appendicitis with regard to a number of variables. Categorical variables were assessed using Fisher’s exact test. Continuous variables were examined using either the Kruskall–Wallis test or the Mann–Whitney test for non-parametric data.
Results Over the six-month period, a total of 302 patients were referred to the general surgical team with acute RIF pain. More females presented with RIF pain than males (Fig. 1). Twentythree (13%) of the female cohort had attended the emergency department within the previous 12 months with similar symptoms compared to seven (6%) of the male patients. Appendicitis was the final diagnosis in 119 patients (39%) admitted with RIF pain (Table 1). More males than females had appendicitis (57% vs. 27%, p < 0.001). There was no difference between the sexes in rate of perforated appendicitis (24% male vs. 25% female, p ¼ 1.00). Of 105 females aged between 15 and 50 years at admission, a gynaecological cause for their RIF pain was identified in 53 patients (50%) with 25 patients (24%) having appendicitis. Twenty-nine of the 65 females with
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Table 1 – Breakdown of final diagnosis in all patients admitted with right iliac fossa pain.
Simple appendicitis Perforated appendicitis Acute non-specific abdominal pain Gynaecological cause Mesenteric adenitis Other Total
Female
Male
Total
36 (20) 12 (7) 40 (23)
54 (43) 17 (14) 38 (21)
119 (39)
65 (37) 8 (5) 16 (9)
–
177
78 (26)
6 (5) 10 (8)
65 (22) 14 (5) 26 (9)
125
302
Values in parentheses are percentages.
a gynaecological diagnosis underwent surgery and in all of these cases, ovarian pathology was identified in the form of ovarian cysts. The remaining 36 gynaecological diagnoses were established on pelvic ultrasound demonstrating a range of abnormalities from simple ovarian cysts (n ¼ 21), ovarian malignancy (n ¼ 2), fibroids (n ¼ 1) and free pelvic fluid suggestive of a ruptured cyst with a normal ovary visualised (n ¼ 12). Of the 23 female patients who had attended the emergency department within the previous 12 months, 10 were found to have a gynaecological cause for their pain on ultrasound and five had acute appendicitis. No cause for the pain could be identified in the remaining seven, all of whom had normal ultrasound scans. Of the 78 patients with a diagnosis of acute non-specific abdominal pain (ANSAP), 22 (28%) had a normal ultrasound. A further 28 patients (36%) proceeded to surgery and all of these had a histologically normal appendix removed in the absence of any other visible pathology. Ten of the 78 patients with ANSAP were readmitted in the 6 months post-surgery with a similar type of pain at a median time of 43 days post-surgery. Other causes for RIF pain were identified in 26 patients (9%). These included urinary tract infection (six), chronic RIF pain on further assessment (six), gastroenteritis (five), small bowel obstruction (three), acute diverticulitis (two), terminal ileitis (two) and a patient with a benign leiomyoma of the small bowel. A history of anorexia was the only significant symptom that proved helpful in discriminating between appendicitis and other diagnoses (Table 2). On clinical examination the
finding of either a tachycardia of greater than 100 beats per minute or rebound tenderness in the right iliac fossa on examination was significantly associated with an ultimate diagnosis of appendicitis. Of the 25 patients who were tachycardic, pyrexial and had right iliac fossa guarding on examination, 23 (92%) turned out to have a final diagnosis of appendicitis. All of these patients had an elevated serum white cell count of greater than 11.0 109/L. The sensitivity of an elevated white cell count for acute appendicitis was 0.81 with a specificity of only 0.63. When the overall patient-timeline, from development of symptoms to surgery is examined (Fig. 2), it is clear that those with perforated appendicitis had a significantly longer duration of pre-hospital symptoms (median 50.0 h) compared to those patients with simple appendicitis (median 16.5 h) or other diagnosis (median 22.0 h) ( p < 0.001). Patients who presented to a primary practitioner (n ¼ 211, 70%) prior to attending hospital, had a significantly longer duration of prehospital symptoms (median 24.1 h) than those who self-presented to the Emergency Department (15.2 h) ( p < 0.001). The median time from attending a primary practitioner to presentation at hospital was 3.3 h. However, the patients who attended a primary practitioner were as likely to have an ultimate diagnosis of appendicitis as those who presented straight to the emergency department (40% vs. 37%) ( p ¼ 0.508). The rate of perforated appendicitis did not differ in patients with private health insurance and those without (26% vs. 23%) ( p ¼ 0.732). Ninety-four patients (31%) lived greater than 20 miles from the hospital however, this group did not significantly differ in duration of pre-hospital symptoms (median 24.0 h vs. 21.0 h, p ¼ 0.068) or in rate of advanced appendicitis (26% vs. 24%) ( p ¼ 0.820) compared to those that lived within 20 miles of the hospital. A major difference in management after initial surgical assessment was that the time taken to decide to operate was significantly shorter in patients with both simple (median 4.7 h) and perforated (median 2.0 h) appendicitis when compared to those with another diagnosis (median 14.9 h) ( p < 0.001). This suggests that clinical indecision is of shorter duration for those with acute appendicitis than in those in whom the clinical picture is not one of acute appendicitis. One hundred and nine patients were listed for theatre after initial clinical assessment. Radiological imaging was used as an
Table 2 – Clinical assessment. Other diagnosis
Acute appendicitis
Odds ratio (95% CI)
p Value
Sex (male) Nausea Vomiting Anorexia Temperature >37.5 C Tachycardia Rebound tenderness RIF Elevated WCC
54 (30%) 131 (72%) 72 (39%) 73 (40%) 23 (13%) 24 (13%) 35 (19%) 68 (37%)
71 (60%) 97 (82%) 77 (65%) 87 (73%) 36 (30%) 45 (38%) 64 (54%) 96 (81%)
4.70 (2.50, 8.82) 0.79 (0.36, 1.77) 1.20 (0.62, 2.34) 3.97 (2.12, 7.44) 1.26 (0.56, 2.84) 2.42 (1.11, 5.27) 2.47 (1.32, 4.62) 5.51 (2.93, 10.35)
<0.001 0.570 0.584 <0.001 0.576 0.027 0.005 <0.001
Total
183 (61%)
119 (39%)
Values in parentheses in both the ‘other diagnosis’ and ‘acute appendicitis’ columns are percentages, with those in the ‘Odds ratio’ column representing 95% confidence intervals.
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Duration of Pre Hospital Symptoms (hrs)
140 120 100 80 60 40 20 0
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Other Diagnosis
Simple Appendicitis
Advanced Appendicitis
Time to decision to operate after surgical assessment (hrs)
Emergency Department Assessment (hrs)
10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0
40 35 30 25 20 15 10 5
12 10 8
(hrs)
Time to theatre after decision to operate
0
6 4 2 0
Fig. 2 – Relationship between final diagnosis and prehospital symptom duration, emergency department delay, delay in decision to operate and time to theatre. Data are expressed as medians with bars representing 25th and 75th percentile.
adjunct in 109 of the remaining 193 patients of whom 48 proceeded to theatre along with an additional 27 patients who were listed for surgery based on repeated clinical examination alone. Fifty-seven patients did not have surgery or radiological imaging with repeated clinical assessment alone determining management. Radiological imaging was more frequently used in females (Table 3). Ultrasound was the most commonly utilised imaging modality for patients presenting with RIF pain. Of the 54 patients who had a normal ultrasound scan, five had a subsequent CT scan with appendicitis diagnosed on four of these scans. Twenty-five patients with a normal ultrasound scan proceeded to surgery with the resultant finding of appendicitis in five patients and a gynaecological abnormality in 11 patients. CT was used in the assessment of 22 patients with appendicitis with the sensitivity of CT for appendicitis in this small group 0.92 and a specificity of 1.00. The use of pre-operative imaging did not result in a significant decrease in the rate of negative appendicectomy.
The use of pre-operative radiological imaging was associated with a significantly increased time to operative intervention in patients with appendicitis. Those with appendicitis who did not have pre-operative imaging (n ¼ 96) reached the operating theatre at a median time of 9.4 h from initial assessment by the surgical team compared to 21.4 h in those who did have pre-operative imaging (n ¼ 21) ( p < 0.001). However, this increased time to surgery was not associated with an increased rate of perforated appendicitis ( p ¼ 0.326) or increased post-operative morbidity ( p ¼ 0.520). Patients who proceeded to surgery without radiological imaging were more likely to have rebound tenderness in the RIF on examination than those who were imaged (49% vs. 21% p ¼ 0.001). They were also more likely to have a raised serum white cell count (68% vs. 44%, p ¼ 0.006) and were ultimately more likely to have a final diagnosis of acute appendicitis (56% vs. 27%, p ¼ 0.002) but the rates of perforated appendicitis did not differ in the two groups. One hundred and eighty four patients (61%) proceeded to surgery during their admission (Table 4). Four patients had pathology identified on pre-operative imaging that was not acute appendicitis but required surgery. The remaining patients proceeded to operative intervention for suspected appendicitis with a laparoscopic approach adopted in 43% of patients. Patients aged under 14 were less likely to undergo a laparoscopic procedure (27% vs. 48%, p ¼ 0.009). Conversion from laparoscopy to an open procedure occurred in 11 cases (14%) due to surgeon preference for managing perforated appendicitis, when identified at laparoscopy, via an open procedure. Of the 158 appendices removed, 40 (25%) were normal on histological examination. The rate of normal appendicectomy was higher in patients undergoing a laparoscopic procedure (37%) than an open appendicectomy (19%) ( p ¼ 0.021). There was no post-operative morbidity in any of the 40 patients who had a normal appendix removed, however five were readmitted within six months of discharge with a similar pain. There was no post-operative mortality. Post-operative morbidity was 7.1% for all patients undergoing operative intervention. The complication rate was comparable between open (6.5%) and laparoscopic procedures (7.8%) ( p ¼ 0.785). The complication rate was higher in patients with perforated appendicitis (21%) when compared to patients with either simple appendicitis (7%) or another diagnosis (3%) who underwent surgery ( p < 0.001). In-hospital time to theatre did not differ between patients who developed a post-operative complication (median 15.8 h) and those who did not (median 17.9 h) ( p ¼ 0.591). There were six localised infectious complications; five wound infections and one pelvic abscess. One patient developed septic shock in the early post-operative period and one patient had a prolonged post-operative pyrexia, yet no pelvic collection was demonstrable on imaging. The significant non-infectious complication was one case of a pulmonary embolus in spite of adequate prophylaxis. The remaining complications were acute urinary retention, prolonged post-operative paralytic ileus, and two cases of chest pain, neither of which had biochemical or electrocardiograph evidence of myocardial ischaemia. One hundred and twenty three patients did not undergo operative intervention during their admission to hospital. Of
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Table 3 – Use of radiological imaging in establishing a diagnosis. Female (n ¼ 177) Radiological investigation 1st investigation: ultrasound 1st investigation: computed tomography Time from surgical assessment to investigation report (h)* Median (Range) Mean (S.D.) Normal investigation Further radiological imaging Subsequent operation Final diagnosis of appendicitis
Male (n ¼ 125)
94 (53%) 87 (49%) 7 (4%)
15 (12%) 10 (8%) 5 (4%)
15.6 (1–68) 20.0 (15.4) 45 (48%) 10 (11%) 39 (41%) 18 (19%)
17.1 (4–61) 23.0 (15.0) 9 (60%) 2 (13%) 9 (60%) 5 (33%)
Time from surgical review to theatre in those with appendicitis and pre-operative imaging (h)* Median (Range) 25.7 (7–61) 17.1 (6–53) Mean (S.D.) 32.1 (26.1) 24.2 (19.7) Post-operative morbidity 0 2 (22%)
Total (n ¼ 302) 109 (36%) 97 (32%) 12 (4%)
15.9 20.4 54 12 48 23
(1–68) (15.3) (50%) (11%) (44%) (21%)
21.5 (6–61) 30.2 (24.7) 2 (4%)
Values in parentheses are percentages unless indicated otherwise. * (h) = hours
these, 19 (15%) were readmitted with a similar presentation within six months, with a median time from discharge to readmission of 29 days (range 2–165 days). Upon readmission, six patients had a radiological investigation with ovarian pathology identified in four female patients. None of the patients readmitted were diagnosed with appendicitis on the second admission. Radiological imaging was less frequently used in patients under 14 years of age when compared to adult patients (18% vs. 46%, p < 0.001) (Table 5). There was no difference in prehospital symptom duration, emergency department delay or time to decision made to operate between adult and paediatric patients although paediatric patients did reach theatre more quickly than their adult counterparts. Paediatric patients were also more likely to undergo open appendicectomy.
Discussion The current study is unique in the modern setting, in prospectively examining all patients presenting with acute RIF
Table 4 – Operative intervention.
Open appendicectomy Laparoscopic appendicectomy Laparoscopy: convert to open appendicectomy Diagnostic laparoscopy Laparotomy Other Total appendicectomy Normal appendices removed Total operative intervention
Female
Male
Total
28 (30) 33 (35) 7 (8)
69 (76) 10 (11) 4 (4)
97 (53) 43 (23) 11 (6)
22 1 2 70 23 93
1 (1) 6 (7) 1 (1) 88 (70) 17 (19) 91 (73)
23 (13) 7 (4) 3 (2) 158 (52) 40 (25) 184 (61)
(24) (1) (2) (40) (33) (53)
Values in parentheses are percentages. The percentage values for specific procedures are a percentage of total operative intervention for each group.
pain. In adopting this approach, the aim was to evaluate the overall outcome of what is a heterogeneous patient cohort not only in terms of final diagnosis but also in terms of management strategy and presenting signs and symptoms. The incidence of acute appendicitis in patients presenting with RIF pain is not commonly reported. In our study, acute appendicitis accounted for the final diagnosis in 39% of the patients, with appendicitis being more common in men in accordance with a previous study by Andersson et al.5 The most common final diagnosis in female patients aged between 15 and 50 years was gynaecological in contrast to a previous study of women of child bearing age that established appendicitis as the most common diagnosis.6 In our unit, all female patients presenting with acute RIF pain are admitted under the general surgical service, which may explain the high proportion of patients with a gynaecological abnormality. An accurate history and physical examination are integral to the clinical management of patients presenting with RIF pain. A study by Korner et al., found a history of migratory pain and a history of nausea or vomiting, to be significant predictors of appendicitis.7 In contrast to our study where the finding of either a tachycardia or rebound tenderness were significant predictors of acute appendicitis, physical signs were of no predictive value in the Korner study, probably reflecting the fact that patients included all underwent operative intervention for suspected appendicitis and thus, were more likely to have physical signs. Ninety two percent of patients in our study who were pyrexial, tachycardic, had RIF guarding on examination and had a raised serum white cell count at initial assessment had a histological diagnosis of appendicitis. This suggests that an accurate clinical assessment can identify subgroups with a high likelihood of appendicitis without the use of radiological imaging. Radiological imaging is typically used in patients with an equivocal clinical diagnosis in our unit. Overall, the use of imaging was not associated with a decrease in the rate of negative appendicectomy reflecting the predominant use of ultrasound as the first line imaging modality. Pre-operative
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the surgeon 8 (2010) 211–217
Table 5 – Comparison between paediatric and adult patients.
Diagnosis
Paediatric (n ¼ 105)
Adult (n ¼ 197)
32 (30) 9 (9) 36 (34) 28 (27)
58 (29) 20 (10) 42 (21) 77 (39)
22.0 2.9 4.3
23.0 3.2 7.6
22.0 3.1 6.7
4.1 19 (18) 56 (53) 41 (73) 55 (98) 15 (27) 2 (3.6)
5.8 90 (46) 128 (65) 62 (48) 103 (80) 25 (25) 11 (8.6)
5.6 119 (39) 184 (61) 103 (56) 158 (86) 40 (25) 13 (7.1)
Simple appendicitis Advanced appendicitis ANSAP Other
Median duration of pre-hospital symptoms Median emergency department delay (h) Median time from surgical assessment until decision made to operate Median time to theatre after decision made to operate Radiological investigation Operative intervention Open appendicectomy Total appendicectomy Normal appendix removed Post-operative morbidity
Total (n ¼ 302) 90 29 78 105
(30) (10) (26) (35)
p Value 0.895 0.838 0.018 0.032 0.745 0.264 0.264 0.012 <0.001 0.063 0.002 <0.001 0.705 0.350
Values in parentheses are percentages.
imaging inherently adds to the in-hospital time to operation in patients who proceed to surgery.8 The increased time from surgical assessment to operative intervention in patients with appendicitis who had pre-operative imaging was significant but was not associated with either increased morbidity or increased rates of perforated appendicitis. The group who were selected for surgery on the basis of clinical findings alone was more likely to have signs of peritonism in the right iliac fossa. This suggests that those who underwent radiological imaging were thought less likely to have appendicitis and that any resultant increase in the hospital interval could be tolerated. The finding that this group did not differ in terms of postoperative morbidity or rates of perforated appendicitis appears to justify this. While laparoscopic surgery is increasingly being used in patients with suspected appendicitis, open appendicectomy remains a commonly performed operation9 and was the operation of choice for 61% of the appendicectomies performed in our study in accordance with recent Scottish data.10 As one of three hospitals in the catchment area that receives adult surgical admissions it is possible that some readmissions were to other institutions. This limitation precludes comparison of readmission rates following open vs. laparoscopic appendicectomy in this series. The rate of perforated appendicitis reported here is similar to a recent UK publication reporting a 19% rate of significant peritoneal contamination.10 In accordance with previous reports,2,11,12,13,14 in our experience, increased duration of prehospital symptoms was the main factor associated with perforated appendicitis. After presentation to the emergency department, those with perforated appendicitis had a shorter in-hospital time to theatre compared to other patients who underwent surgery. This expedient management of patients with perforated appendicitis is reassuring from a clinical audit point of view and concurs with previous reports,14,15 undoubtedly reflecting the more florid clinical picture in those with perforated disease at presentation. Non-patient factors related to hospital organisation have been associated with differences in rates of advanced appendicitis.16 In the Irish healthcare model, patients with
private healthcare insurance and those without access emergency care through a single point of entry. No difference was observed in the rate of perforated appendicitis in relation to private healthcare insurance. Patients who attended a primary practitioner prior to attending hospital did have an increased total duration of pre-hospital symptoms compared to patients who self-presented to the emergency department. This difference cannot solely be explained by time spent attending the primary practitioner as the median time from attending the GP to presentation at hospital was just over 3 h reflecting a prompt referral from primary care. In 1985, Brender et al., found increased rates of perforated appendicitis in children whose parents had been advised by the first health professional contacted, to observe their children at home.17 We identified no significant difference in either the rate of appendicitis as final diagnosis or rates of perforated appendicitis in those who attended their primary practitioner initially. Similarly, there was no difference in duration of prehospital symptoms or rates of advanced appendicitis in patients who lived further from hospital. While rural residence has been associated with increased risk of perforated appendicitis,18 the distances involved in this current region of study are probably not substantial enough to account for differences in time to presentation or rates of perforation. In our own institution, the lack of a dedicated emergency operating theatre adds to the in-hospital time to operation in patients with suspected appendicitis. In those with appendicitis, the median time taken to reach theatre after the decision to operate had been made and communicated to theatre staff was 5 h representing one third of the total pre-operative time. While our figures for in-hospital time to theatre compare with those reported in Ireland, this in-hospital pre-operative time is significantly greater than reports from the United States. Recent retrospective reviews of patients undergoing appendicectomy in community centres in the United States report mean times to theatre from 7.1 h to 11.5 h3,15 which is facilitated by the well developed infrastructure that supports the speciality of emergency surgery in the United States.19 However, with the consistent finding that increased duration of pre-hospital symptoms is the main factor associated with
the surgeon 8 (2010) 211–217
perforated appendicitis, do the lower rates of perforated appendicitis reported from the United States reflect the benefit of reduced in-hospital time to surgery or merely that a greater percentage of US patients will present earlier in their disease course? We have demonstrated in this prospective observational study that the majority of patients presenting to hospital with RIF pain did not have appendicitis. Delay in accessing the operating theatre was not associated with perforated appendicitis or post-operative morbidity. This study confirms, in a prospective fashion, that increased duration of pre-hospital symptoms is the main factor associated with perforated appendicitis. The use of pre-operative imaging adds significantly to the delay in reaching theatre and while this delay is not associated with increased morbidity, it was not helpful in reducing the number of unnecessary operations in this study. In assessing all patients with acute RIF pain, clinical history and physical examination are useful in identifying patients with a high probability of appendicitis and whose definitive management remains operative and is unlikely to be altered by radiological imaging.
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