Appendicitis in AfricaAppendicitis in AfricaALC Jones

Oct 2010

Case Presentation 1Case Presentation 1

• 20 western male• 1 day history

progressive para-umbilical pain moving to RIF

• Rebound and percussion tenderness

• Vomiting• Rovsing’s +ve

Case Presentation – Investigation?Case Presentation – Investigation?

• Observations – pulse 93, BP 120/79, t – 37.4C

• Bloods – raised inflammatory markers

» Neutrophilia (left shift)

• Radiology? Xray, U/S, CT?• Diagnosis? - Appendicitis

» Mesenteric adenitis, terminal ileitis, Meckel’s diverticulum, lymphoma, renal colic, UTI, carcinoid, testicular torsion

Case Presentation – Management?Case Presentation – Management?

Post-operativelyPost-operatively

• Antibiotics• E&D• Follow up?

AnatomyAnatomy

AnatomyAnatomy

Aetiology and pathophysiologyAetiology and pathophysiology

• Obstruction of the appendix lumen

• Mucus production, swelling, decrease venous return,ischaemia, necrosis, perforation, peritonitis, death

• Low fibre diet – faecal stasis

Squatting HypothesisSquatting Hypothesis

• “"When the thighs are pressed against the abdominal muscles in this position, the pressure within the abdomen is greatly increased, so that the rectum is more completely emptied.

• Our toilets are not constructed according to physiological requirements. Toilet designers can do a good deal for people if they will study a little physiology and construct seats intended for proper [elimination].“ H. Aaron 1938

Case Presentation 2Case Presentation 2

• 26 male - Zulu farmer• 3 day history of ubuhlungu

in lower abdomen.• Progressively worse,

diarrhoea, anorexia• Feverish,oliguric• Lower abdomen generally

tender with peritonism.

Case Presentation 2Case Presentation 2

• Observations – pulse 120, BP 65/30, t – 39C

• Bloods – raised inflammatory markers» Cr – 230 U – 20 LFTS-NAD

• Radiology? Xray, U/S, CT?• Diagnosis? - Gangrenous/Perforated

Appendicitis» Yersinia, TB, Toxoplasmosis, Schistomiasis» UTI, Carcinoid, Testicular Torsion

Case Presentation 2 - ManagementCase Presentation 2 - Management

• Resuscitation• IV abx• How quickly to theatre?• Surgical approaches• Post-op care• ?Histology follow up

Appendicitis in AfricaAppendicitis in Africa

• Lower incidence rates in rural population compared to urban and developed countries (?but rising)

• Direct correlation between delayed presentation and perforation [2]

• Atypical history – likely suppurative appendicitis. ?higher perf rates check histology [3]

Appendicitis in AfricaAppendicitis in Africa

• Studies have shown prolonged post-op stay – higher incidence perforation+ peritonitis

• Africans have a higher DALY compared with developed countries

Case Presentation 3Case Presentation 3

• 43 female presents with 2/7 lower abdominal pain and vomiting

• BNO. Pain localising in RIF. Tender with rebound and localised guarding.

• Hb – 10.2 g/dl WCC -14 Neut – 11• Plt – 253 Cr-122 U-12

Case Presentation 3Case Presentation 3

• On examination: Mass in RIF

• Differential diagnosis?

Case Presentation 3Case Presentation 3

• Appendix Mass – management options

• 1. Conservative – IV abx and 6-8 weeks interval appendix

• 2. Immediate appendicectomy / Right hemi after several days of IV abx

• 3. Totally conservative management

SummarySummary

• Incidence of appendicitis is generally less in developing continents ie. Africa, but rising

• Treatment is more invasive as presentations are late and associated with higher rates of perforation and gangrene

• Higher DALY• Consider other differential diagnosis and

aetiology to appendicitis, hence always send for histology.

ReferencesReferences1. Jones BA, Demetriades D, Segal I, Burkitt DP (1985). "The prevalence of

appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa". Ann. Surg. 202 (1): 80–2.

2. Chamisa I (Nov 2009) A clinicopathological review of 324 appendices removed for acute appendicitis in Durban, South Africa: a retrospective analysis. Ann. RCSEng Vol 91, No 8, pp. 688-692(5)

3. Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement. Permanente Medical Journal

4. Ojo OS, Udeh SC, Odesanmi WO, Review of the histopathological findings in appendices removed for acute appendicitis in Nigerians. J R Coll Surg Edinb. 1991 Aug;36(4):245-8.

5. ES Garba, A Ahmed. (2008)Management of appendiceal mass. Ann Afr Med Vol 7 (4) p200-204

6. World Health Organisation

Don’t forget.. Order yours today!Don’t forget.. Order yours today!