Appendicitis in Africa

ALC Jones

Oct 2010

Case 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?

• 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’sdiverticulum, lymphoma, renal colic, UTI, carcinoid, testicular torsion

Case Presentation – Management?

Post-operatively

• Antibiotics

• E&D

• Follow up?

Anatomy

Anatomy

Aetiology and pathophysiology

• Obstruction of the appendix lumen

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

• Low fibre diet – faecal stasis

Squatting 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 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 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 - Management

• Resuscitation

• IV abx

• How quickly to theatre?

• Surgical approaches

• Post-op care

• ?Histology follow up

Appendicitis 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 Africa

• Studies have shown prolonged post-op

stay – higher incidence perforation+

peritonitis

• Africans have a higher DALY compared

with developed countries

Case 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 3

• On examination: Mass in RIF

• Differential diagnosis?

Case 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

Summary

• 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.

References

1. 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 histopathologicalfindings 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

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