Original Article

Acute Perforated Appendicitis in Adults: Management and

Complications in Lagos, Nigeria
Olanrewaju Samuel Balogun, Adedapo Osinowo1, Michael Afolayan, Thomas Olajide, Abdulrazzak Lawal, Adedoyin Adesanya
Department of Surgery, Faculty of Clinical Sciences, College of Medicine, General Surgery Unit, University of Lagos, 1Department of Surgery, Faculty of Clinical
Sciences, College of Medicine, University of Lagos, Idi‑Araba, Lagos, Nigeria

Abstract
Background: Acute perforation of the appendix is one of the complications of appendicitis that is associated with increased morbidity
and mortality and hence regarded as a surgical emergency. Risk factors for perforated appencidicits include extremes of age, male sex,
pregnancy, immunosuppression, comorbid medical conditions and previous abdominal surgery. Objectives: This study focuses on the
pattern of presentation, risk factors, morbidity and mortality of patients managed for perforated appendicitis in our centre. Subjects and
Methods: We conducted a seven-year retrospective review of consecutive adult patients who had surgery for perforated appendicitis in our
centre. Results: The perforation rate in the study was 28.5%. The peak age of presentation was between 21-30 years. Forty-two (71.1%)
of the patients under study were males. Only 3 (5.1%) of the cohorts had history of recurrent abdominal pain. Majority of the patients were
in the American Society of Anesthesiologists (ASA) II (44.1%) and III (42.4%) categories. Surgical site infections (SSI) (18.6%), wound
dehiscence (15.2%) and pelvic abscess (13.5%) were the most common complications. The Incidence of SSI was found to correlate with
male gender, (P = 0.041), co-morbidity (P = 0.037) and ASA score (0.03) at 95% confidence interval. Routine use of intraperitoneal drain
after surgery for perforated appendicitis did not appear to reduce the incidence of pelvic abscess. No mortality in the studied population.
Conclusion: Appendiceal perforation was more common in male patients with first episode of acute appendicitis. Previous abdominal
surgery and comorbid medical conditions were of lesser risk factors for appendiceal perforation in our patients. Surgical site infection was
the commonest complication after surgery.

Keywords: Appendicitis, perforation, adults, laparotomy, outcome, complications

Résumé
Contexte: La perforation aiguë de l’appendice est l’une des complications de l’appendicite associée à une augmentation de la morbidité et
de la mortalité et donc considérée comme une urgence chirurgicale. Les facteurs de risque pour les applications perforées comprennent les
extrêmes d’âge, le sexe masculin, la grossesse, l’immunosuppression, les conditions médicales concomitantes et la chirurgie abdominale
antérieure. Objectifs: Cette étude se concentre sur le schéma de présentation, les facteurs de risque, la morbidité et la mortalité des patients
pris en charge pour une appendicite perforée dans notre centre. Sujets et méthodes: Nous avons effectué une revue rétrospective sur sept ans
de patients adultes consécutifs ayant subi une chirurgie pour une appendicite perforée dans notre centre. Résultats: Le taux de perforation
dans l’étude était de 28,5%. L’âge maximal de présentation était entre 21-30 ans. Quarante-deux (71,1%) des patients étudiés étaient des
hommes. Seulement 3 (5,1%) des cohortes avaient des antécédents de douleurs abdominales récurrentes. La majorité des patients étaient dans
les catégories II (44,1%) et III (42,4%) de l’American Society of Anesthesiologist (ASA). Les infections du site opératoire (SSI) (18,6%), la
déhiscence des plaies (15,2%) et les abcès pelviens (13,5%) étaient les complications les plus fréquentes. L’incidence de SSI a été trouvée
corrélée avec le sexe masculin, (p = 0,041), la co-morbidité (p = 0,037)
et le score ASA (0,03) à intervalle de confiance de 95%. L’utilisation
Address for correspondence: Dr. Olanrewaju Samuel Balogun,
systématique d’un drain intrapéritonéal après une chirurgie pour une Department of Surgery, Faculty of Clinical Sciences, College of Medicine,
appendicite perforée ne semble pas réduire l’incidence des abcès General Surgery Unit, University of Lagos, Idi‑Araba, Lagos, Nigeria.
pelviens. Aucune mortalité dans la population étudiée. Conclusion: E‑mail: drlanrebalogun@gmail.com
La perforation appendiculaire était plus fréquente chez les patients
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DOI: How to cite this article: Balogun OS, Osinowo A, Afolayan M, Olajide T,
10.4103/aam.aam_11_18 Lawal A, Adesanya A. Acute perforated appendicitis in adults: Management
and complications in Lagos, Nigeria. Ann Afr Med 2019;18:36-41.

36 © 2019 Annals of African Medicine | Published by Wolters Kluwer - Medknow

 Balogun, et al.: Perforated appendicitis in Adults
masculins présentant un premier épisode d’appendicite aiguë. La chirurgie abdominale antérieure et les conditions médicales comorbides
étaient des facteurs de risque moins pour la perforation appendiculaire chez nos patients. L’infection du site opératoire était la plus courante
après la chirurgie.
Mots‑clés: appendicite, perforation, adultes, laparotomie, résultat, complications
Introduction
Acute appendicitis and its complications are leading causes
of acute abdomen and indications for emergency surgical
intervention in clinical practice.
In clinical terms, acute appendicitis can be described as
simple or complicated. Complicated appendicitis includes
appendix mass, appendix abscess, and perforated appendicitis.
Most complicated appendicitis started de novo as simple
appendicitis raising the notion that it is a disease in evolution
that has become of clinical importance due to delayed or
missed diagnosis. Grossly, simple appendicitis is of two
major forms: obstructive and catarrhal appendicitis. Acute
appendicitis in adults is often obstructive in type and sequel
to some form of luminal obstruction by fecaliths, lymphoid
tissues, or rarely foreign bodies. [1] Extrinsic causes of
luminal obstruction of the appendix include periappendiceal
bands. Anatomically, appendix is a blind‑ending structure.
A closed‑loop obstruction of its lumen in severe cases result
in inflammation and transmural necrosis which eventually
lead to perforation and discharge of the luminal contents (pus
and fecaliths) and peritonitis. A prospective study by Narsule
et al.[2] on 202 children undergoing appendicectomy revealed a
linear relationship between the duration of symptoms (onset to
surgery) and risk of perforation. In their study, no perforation
was recorded in children with abdominal pain of  <12  h
duration. The perforation rate rose in a linear fashion from 10%
by 18 h to 44% by 36 h. If symptoms were present for more
than 2 days, the risk of perforation was >40%. In contrary,
Bickell et al.[3] in an earlier retrospective study of 219 adults
with appendicitis had documented a minimal perforation
risk in the first 36  h of symptom onset and remains at 5%
thereafter. However, a study has shown that in many patients
treated with antibiotics, appendicitis symptoms may resolve
without ensuing perforation; hence, medical treatment with
antibiotics has been proposed in a selected group of patients
with uncomplicated appendicitis.[4]
Table 1: Age and sex distribution of patients with perforated appendicitis (n=59)
Age (years) Male Percentage (%)
≤20 12 20.3
21-30 15 25.4
31-40 8 13.5
41-50 3 5.1
51-60 3 5.1
>60 1 1.7
Total 42 71.1
Annals of African Medicine  ¦  Volume 18  ¦  Issue 1  ¦  January-March 2019
Sequelae of appendiceal perforation have some important
economic consequences and are associated with increased
length of hospital stay, morbidity, and mortality even with
treatment.[5] These factors are important considerations in
developing countries where access to health care and resources
are limited with attendant delay in diagnosis and treatment.
Management options for perforated appendicitis range from
percutaneous drainage to laparoscopic and open appendectomy
with drainage. To the best of our knowledge, few studies
have focused on the management outcome of patients with
perforated appendicitis in our environment. This study aimed
to determine the pattern of presentation, risk factors, and
incidence of postoperative complications and mortality in
patients who had surgery for perforated appendicitis in our
institution.
Methodology
A 7‑year retrospective review of medical records of patients
aged 16  years and above who had surgery for appendiceal
perforation between July 2010 and June 2017 in our hospital
was carried out.
Approval for the study was obtained from the Lagos University
Teaching Hospital’s Health Research Ethics Committee.
Patients’ demographic characteristics, clinical presentation,
laboratory parameters, radiological features, surgical
intervention time, and postoperative complications were
entered into a structured pro forma for analysis. Data
analysis was done using IBM SPSS statistics for Windows,
Version 23 (IBM Corp., Armonk, NY, USA). Results of the
analysis were expressed in tables as simple percentages.
Relationships between patients’ gender, medical comorbidities,
duration of symptoms, preoperative American Society of
Anesthesiologists  (ASA) score, and incidence and type of
postoperative complications were tested by Chi‑square tests.
Statistical significance was set at P < 0.05.
Female Percentage (%) Frequency (subtotal) (%)
2 3.4 14 (23.7)
11 18.6 26 (44.1)
3 5.1 11 (18.6)
0 0 3 (5.1)
1 1.7 4 (6.8)
0 0 1 (1.7)
17 28.9 59 (100.0)
37
 Balogun, et al.: Perforated appendicitis in Adults

Results Table 2: Clinical symptoms,risk factors and total white

There were 224 cases of acute appendicitis managed during cell count in acute perforated appendicitis (n=59)
this period. Sixty‑four patients had appendiceal perforation, Nature of symptoms (n=59) Frequency of symptoms
giving the perforation rate of 28.5%. Of a total of 64 patients out of 59 patients (%)
who had surgery for acute perforated appendicitis, 5 were Abdominal pain migration 52 (88.1)
excluded from further data analysis due to incomplete records. Anorexia 33 (55.9)
Nausea and vomiting 50 (84.7)
Of 59 patients under review, there were 42 (71.1%) males and
Fever 37 (62.7)
17 (28.8%) females, giving a ratio of 2.5–1. The mean age at
Dyspepsia 4 (6.8)
presentation was 29.98 ± 2.08 (range: 16–70) years and median
Diarrhea 15 (25.4)
was 26 years. The peak age of presentation was between 21
Constipation 19 (32.2)
and 30 years, accounting for 44.1% of all cases [Table 1]. History of similar attack in the past 3 (5.1)
The mean duration for onset of abdominal pain before Previous abdominal surgery 5 (8.5)
presentation was 4.5 ± 3.42 days (range: 0.74–14 days). Comorbidities (diabetes and 5 (8.4)
hypertension)
Abdominal pain was present in all patients. Fifty‑two (88.1%)
Pregnancy 1 (1.7)
patients reported initial periumbilical pain before it became
generalized. Nausea and vomiting were present in 50 (84.7%) Total white blood cell count/mm 3
Frequency (%)
(n=53)
patients and anorexia in 33 (55.9%) patients. Five (8.4%)
<4000 4 (7.5)
of the patients had comorbid medical conditions and one
4001-10,000 15 (28.3)
was pregnant [Table 2]. Total white cell count record was
>10,000 34 (64.2)
retrieved in 53 of 59 patients [Table 2]. Of these, leukocytosis
of  >10,000/mm3 was present in 34  (64.2%) of patients.
Only 23 patients had preoperative abdominal/chest X‑ray.
The predominant finding among these patients was that of Table 3: Preoperative American Society of
Anesthesiologists (ASA) grade and hospital stay after
small bowel obstruction/ileus in 11 (47.8%) patients. Only
surgery (n=59)
3 (13%) of 23 patients evaluated with abdominal/chest X‑ray
had radiological evidence of pneumoperitoneum. Abdominal ASA grade Frequency (patients) (%)
ultrasound findings were retrieved in 38 (64.4%) patients. I 6 (10.2)
The major finding on abdominal ultrasound among these II 26 (44.1)
patients was periappendiceal fluid collection in 17 (44.7%) III 25 (42.4)
cases. IV 2 (3.4)
Total 59 (100)
Using the surgical risk classification of the ASA, the
Hospital stay (days) Frequency (days) (%)
predominant ASA groups were in classes II and III which
0-7 9 (15.3)
accounted for 44.1% and 42.4% of cases, respectively [Table 3]. 8-14 33 (55.9)
The range of hospital stay was 5–56 days [Table 3]. 15-21 10 (16.9)
Surgical site infections (SSIs), wound dehiscence, and pelvic 22-28 3 (5.1)
abscess were the most common complications at 18.3%, >28 4 (6.8)
15.2%, and 13.5%, respectively  [Table  4]. There was no Total 59 (100)
ASA=American Society of Anesthesiologists
mortality in our review.
Univariate analysis using Chi‑square test at 95%
confidence interval and significant P <  0.05 showed Table 4: Postoperative complications (n=59)
that overall complication rate is significantly related to Complication Frequency (%)
the ASA score (χ 2  =  11.22; P <  0.05). There was also Surgical site infections 11 (18.6)
a statistically significant relationship between SSI and Wound dehiscence 9 (15.2)
male sex  (P  =  0.041), comorbidity (P  =  0.037), and Pelvic abscess 8 (13.5)
ASA  (0.03) at 95% confidence interval. However, there Postoperative pyrexia 5 (8.5)
was no statistically significant association between SSI and Chest infection 2 (3.3)
age  (age group), previous attacks, and total white blood Organic brain dysfunction 1 (1.6)
cell count at presentation.
276  patients at Ilorin revealed that acute appendicitis
Discussion was the most common cause of acute abdomen and was
Acute appendicitis is a leading cause of acute abdomen responsible for 30.3% of all cases seen within the study
requiring surgery in Nigeria. A  prospective study of period.[6] However, the incidence of perforation (perforation

38 Annals of African Medicine  ¦  Volume 18  ¦  Issue 1  ¦  January-March 2019

 Balogun, et al.: Perforated appendicitis in Adults
rate) in acute appendicitis varies widely; a perforation rate
between 4.4 and 39% has been reported in the West African
Subregion.[7‑10]
A retrospective study by  Njoku et al.[7]  on 655 appendicectomies
revealed 29 cases of perforation giving a perforation rate of
4.4%. Adeyanju and Adebiyi[8]  reported perforation rate of
13  (7.2%) of 180 appendicectomies. Another retrospective
study by Edino et  al.[9] on 142 appendicectomies reported
33 cases of appendiceal perforation with a perforation rate of
23.2%. Yeboa[10]  in Ghana found 249 cases of appendiceal
perforation in 638 appendicectomies with a perforation rate
of 39%. In our study, the perforation rate was 28.5%. This is
far higher than observed by some researchers in Nigeria and
less than the quoted figure from Ghana.[7‑10] This difference
may reflect varying pattern of referral and these studies are
retrospective.
Delay in surgical intervention has been associated with increased
rate of perforation from 3% in patients operated within 24 h of
presentation to 31% in patients operated at 36 h.[11]
The incidence of perforated appendicitis is higher in the
extreme of ages .[2,5,12,13] Ahmad et al.[12] reported 46.15% in the
first decade of life and 56.61% in the elderly patients presenting
with appendicitis. Documented risk factors for appendiceal
perforation in elderly include male sex, fever ≥38°C, immune
compromise  (diabetes and steroids use) anorexia, and
duration of abdominal pain before presentation.[5] In children,
nonspecific nature of abdominal pain of acute appendicitis
leads to delayed presentation. In addition, there is a higher
rate of progression of appendicitis in children due to lack
of well‑developed omentum and abdominal fat to contain
inflammatory process.[2,4,14]
The mean age for perforated appendicitis in our study was
29.98 ± 2.08 years and the peak age at presentation was found
in the third decade of life. Of 59 patients, 26 (44.1%) were
between 21 and 30 years. An earlier retrospective review of
250 cases of appendicitis from our center had documented
the mean age of 25.7 ± 0.103 years and the peak age in the
third decade of life accounting for 42.8% of cases.[15] In
general and within the peak age group, we found a higher
incidence of perforated appendicitis in our male patients. The
exact reason why perforated appendicitis is more common
in males is not clear, but similar association has been found
in many studies.[16‑18] In our opinion, a higher incidence of
appendicitis in male patients as documented in most series
may explain why its complication is also more frequent in
the male population.
Comorbid medical conditions and immune suppressive states
are known risk factors for appendiceal perforation. Only
5  (8.4%) of our patients had comorbid medical conditions:
Four were hypertensive and one was diabetic.
Abdominal pain was present in 100% of patients, with
52  (88.1%) patients reporting classical abdominal pain
Annals of African Medicine  ¦  Volume 18  ¦  Issue 1  ¦  January-March 2019
migration from localized periumbilical to generalized
abdominal pain. Leading associated symptoms were nausea
and vomiting in 84.7% of patients and anorexia in 55.9%.
Similar findings were found by  Ohene-Yeboah and Togbe in
Ghana and Fashina et al in Nigeria.[10,15]
Leukocytosis with polymorphonuclear predominance is
helpful in the diagnosis of acute appendicitis. While a study
had documented leukocytosis of  >10,000  cells/mm 3 in
80%–85% of patients with acute appendicitis,[19] a previous
study in our institution had shown that the leukocytosis is not
a feature of acute appendicitis in our environment. Fashina
et  al.[15] reported a mean white cell count of 8538  ±  4166
mm 3 in acute appendicitis. However, in appendiceal
perforation, leukocytosis is marked. We found leukocytosis
of >10,000/ mm3 in 33 (55.9%) patients reviewed.
Electrolyte abnormalities are commonly encountered in
patients with acute abdomen due to fluid loss. In addition,
many of these patients are on nil per os while a definitive
diagnosis is being sought and in preparation for surgery. We
retrieved electrolyte panel results in 52 of 59  patients. The
predominant electrolyte abnormality was hypokalemia (serum
potassium <3.5 mmol/l) which was found in 19 (36.5%) of
52 patients. This was corrected before surgery.
Plain abdominal/chest X‑ray and abdominal ultrasound are
common first‑line radiological investigations for suspected
acute abdomen in our accident and emergency.
This study confirmed the opinion that pneumoperitoneum
due to appendiceal perforation is not a common occurrence
in plain abdominal/chest X‑rays, and most cases reported in
the literature were in the form of case reports/case series.[20,21]
Some larger retrospective studies have reported findings of
pneumoperitoneum in 5%–8% of gastrointestinal perforations
due to perforated appendicitis.[22,23] In 23 patients evaluated
with abdominal/chest X‑ray, we found the frequency of
pneumoperitoneum in 3 (13%) cases. A higher value obtained
in this study may be attributed to the estimation of frequency of
pneumoperitoneum in cohorts of patients under review, rather
than the etiology of pneumoperitoneum in acute abdomen
which was evaluated in most studies.[22,23] The clinical diagnosis
and indications for surgery in most of our patients were based
mainly on the history and clinical signs of peritonitis. Positive
radiological signs of perforation such as pneumoperitoneum
were added reinforcement to our diagnosis and our decision
to operate.
In the preoperative anesthetic assessment of our patients using
the ASA physical status classification score, majority of the
patients were in ASA II (44.1%) and III (42.4%) categories.
Only two patients in the review which showed signs of severe
toxicity and peritonitis as were in ASA IV category. Ours
is a referral center and is a common practice for referring
institutions to commence antibiotics treatment for patients with
acute abdominal condition. This may have limited severity
of endotoxemia and systemic sepsis at presentation. This is
39
 Balogun, et al.: Perforated appendicitis in Adults
coupled with the fact that most of the patients in this study are
young with low rate of comorbid medical conditions. About
86.4% of our patients were <40 years.
Definitive treatment of acute appendicitis and its complications
is accomplished by the removal of appendix and other infected
foci, drainage of abscess, irrigation of the abdomen with saline,
and insertion of peritoneal drain as indicated. This can be
achieved via open or laparoscopic surgery. However, in recent
times, some authorities have advised selective antibiotic use for
perforated appendicitis and those due to phlegmon followed
by interval appendectomy in Children.[24] This approach is
still controversial due to its high failure rate and may not be
applicable to adult scenarios. Our treatment of choice for acute
simple and complicated appendicitis is appendicectomy. We
use Lanz incision where the peritoneal signs are localized or
a laparotomy in case of generalized peritonitis.
SSIs  (18.6%), wound dehiscence  (15.2%), and pelvic
abscess  (13.5%) were the common complications we
encountered in this study. In our practice, we routinely
leave a peritoneal drain for all patients after exploratory
laparotomy for viscus perforation and remove drain when
it is no longer active  (<50  ml/day). We also administer
broad‑spectrum antibiotics from admission for about 1 week
after surgery. There are some concerns regarding the benefit
of this approach as it has not been shown to reduce post‑op
septic complications. Levin and Walter [25] reported that
perforated appendicitis is a single predisposing factor for the
development of postappendectomy intra‑abdominal abscess.
They found that technique of stump closure, routine saline
peritoneal lavage, and drain placement did not decrease the
risk of intra‑abdominal abscess in perforated and nonperforated
appendicitis. In this study, 8 (13.5%) of the patients had pelvic
abscess, and in our experience, routine use of peritoneal drain
after surgery for perforated appendicitis did not appear to
reduce the incidence of pelvic abscess. A  recent Cochrane
review has shown that the effect of abdominal drainage on
prevention of intraperitoneal abscess or wound infection after
open appendectomy is uncertain for patients with complicated
appendicitis.[26]
The overall complication rate in our study was 43.1%. However,
some patients had more than one type of complications.
Preoperative ASA score was found to be associated with
the incidence of complications after surgery for perforated
appendicitis (χ2 = 11.22; P < 0.05). The study also showed
some association between incidence of SSI and male
gender (P = 0.041), comorbidity (P = 0.037), and ASA (0.03)
at 95% confidence interval. However, there is no statistically
significant association between SSI and age  (age group),
previous attacks, total white blood cell count at presentation,
and time to surgical intervention.
Conclusion
Perforated appendicitis is a common complication of
acute appendicitis occurring in a young population in our
40
environment. Significant risk factors for appendiceal perforation
in this study were first episode of abdominal pain and male sex.
A history of recurrent acute appendicitis predating perforation
was found in minority of our patients. In addition, previous
abdominal surgery and comorbid medical conditions were less
contributing factors in our patients. SSI was the most common
complication after surgery. Routine use of intraperitoneal drain
had little effect on the incidence of pelvic abscess. The overall
prognosis is good with early surgical intervention.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Ramdass  MJ, Young Sing  Q, Milne  D, Mooteeram  J, Barrow  S.
Association between the appendix and the fecalith in adults. Can J Surg
2015;58:10‑4.
2. Narsule CK, Kahle EJ, Kim DS, Anderson AC, Luks FI. Effect of delay
in presentation on rate of perforation in children with appendicitis. Am J
Emerg Med 2011;29:890‑3.
3. Bickell NA, Aufses AH Jr., Rojas M, Bodian C. How time affects the
risk of rupture in appendicitis. J Am Coll Surg 2006;202:401‑6.
4. Salminen  P, Paajanen  H, Rautio  T, Nordström P, Aarnio  M,
Rantanen  T, et al. Antibiotic therapy vs. appendectomy for treatment
of uncomplicated acute appendicitis: The APPAC randomized clinical
trial. JAMA 2015;313:2340‑8.
5. Sirikurnpiboon  S, Amornpornchareon  S. Factors associated with
perforated appendicitis in elderly patients in a tertiary care hospital.
Surg Res Pract 2015;2015:847681.
6. Agboola  JO, Olatoke  SA, Rahman  GA. Pattern and presentation
of acute abdomen in a Nigerian teaching hospital. Niger Med J
2014;55:266‑70.
7. Njoku  TA, Okobia  MN. Perforated appendicitis: Risk factors and
outcomes of management. Niger J Surg Sci 2006;16:76‑7.
8. Adeyanju MA, Adebiyi A. An audit of appendicitis at a tertiary centre in
Lagos, Nigeria. J Sci Res Stud Nigerian 2015;2:126‑34.
9. Edino  ST, Mohammed  AZ, Ochichia  O, Anumah  M. Appendcitis in
Kano, Nigeria: A 5 year review of pattern, morbidity and mortality. Ann
Afr Med 2004;3:38‑41.
10. Ohene‑Yeboah M, Togbe B. An audit of appendicitis and appendicectomy
in Kumasi, Ghana. West Afr J Med 2006;25:138‑43.
11. Koyuncu A, Yavuz A, Bulus H, Dogan M. Association between delay
in surgical treatment and perforation in acute appendicitis. J Surg Oper
Care 2016;1:205.
12. Ahmad T, Alli Z, Alli A, Anjum S. Perforated appendix: Contributing
factors. J Univ Med Dent Coll 2010;1:11‑6.
13. Omari AH, Khammash MR, Qasaimeh GR, Shammari AK, Yaseen MK,
Hammori SK, et al. Acute appendicitis in the elderly: Risk factors for
perforation. World J Emerg Surg 2014;9:6.
14. Nance  ML, Adamson  WT, Hedrick  HL. Appendicitis in the young
child: A  continuing diagnostic challenge. Pediatr Emerg Care
2000;16:160‑2.
15. Fashina  IB, Adesanya AA, Atoyebi  OA, Osinowo  OO, Atimomo  CJ.
Acute appendicitis in Lagos: A review of 250 cases. Niger Postgrad Med
J 2009;16:268‑73.
16. Andersson  RE, Hugander  A, Thulin  AJ. Diagnostic accuracy and
perforation rate in appendicitis: Association with age and sex of the
patient and with appendicectomy rate. Eur J Surg 1992;158:37‑41.
17. Augustin  T, Cagir  B, Vandermeer  TJ. Characteristics of perforated
appendicitis: Effect of delay is confounded by age and gender.
J Gastrointest Surg 2011;15:1223‑31.
18. Lin  KB, Lai  KR, Yang  NP, Chan  CL, Liu  YH, Pan  RH, et al.
Epidemiology and socioeconomic features of appendicitis in Taiwan:
Annals of African Medicine  ¦  Volume 18  ¦  Issue 1  ¦  January-March 2019
 Balogun, et al.: Perforated appendicitis in Adults

A 12‑year population‑based study. World J Emerg Surg 2015;10:42.
19. Bener A, Suwaidi MH, Ghazawi IE. Diagnosis of appendicitis. Can J
Rural Med 2002;7:26-9.
20. Campos Canelas  AL, Fernandez  HM, Crociati Meguins  L, Silva
Barros S, Crociati Meguins EM, Ishak G, et al. Pneumoperitoneum in
association with perforated appendicitis in a Brazilian amazon woman.
Case report. G Chir 2010;31:80‑2.
21. ŞSahin  S, ÇCavusolu  T, Kubat  M, ÇCalisş H. A  rare cause of
pneumoperitoneum: Perforated appendicitis. J  Ayub Med Coll
Abbottabad 2016;28:415‑6.
22. Kumar  A, Muir  MT, Cohn  SM, Salhanick  MA, Lankford  DB,
Katabathina VS. The etiology of pneumoperitoneum in the 21st century.
J Trauma Acute Care Surg 2012;73:542‑8.
23. Ahmed M M. The Pattern of Causes of Pneumoperitoneum-induced
Peritonitis: Results of an Empirical Study. J Microsc Ultrastruct
2017;5:28-31.
24. Emil  S, Duong  S. Antibiotic therapy and interval appendectomy for
perforated appendicitis in children: A  selective approach. Am Surg
2007;73:917‑22.
25. Levin  DE, Walter P Jr. Abscess after appendectomy. Adv Surg
2015;40:263‑80.
26. Li Z, Zhao L, Cheng Y, Cheng N, Deng Y. Abdominal drainage to prevent
intra‑peritoneal abscess after open appendectomy for complicated
appendicitis. Cochrane Database Syst Rev 2018;5: CD010168.

Annals of African Medicine  ¦  Volume 18  ¦  Issue 1  ¦  January-March 2019 41

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