PREVALENCEANDOUTCOMEOFPERFORATEDAPPENDI

XAMONGCASES
OFOPERATEDAPPENDI
CITI
SATJUSH,
FROM 2012-
2015.

ByGemechuLemi(
M.D)

A THESI
S TO BE SUBMI
TTED TO JI
MMA UNI
VERSI
TY,COLLEGE OF
MEDI
CAL AND HEALTH SCI
ENCES,DEPARTMENT OF SURGERY;I
N
PARTI
ALFULFI
LLMENT FOR THEREQUI
REMENTS OFCERTI
FICATEI
N
GENERALSURGERY.

DECEMBER2015

JI
MMA,
ETHI
OPI
A

PREVALENCEANDOUTCOMEOFPERFORATEDAPPENDI
XAMONGCASES

1|Page
OFOPERATEDAPPENDI
CITI
SATJUSH,
FROM 2012-
2015.

ByGemechuLemi(
M.D)

ADVI
SORS

YonasYi
lma(
M.D,
Assi
stantPr
ofessorofsur
ger
y)

LemesaDube(
BSC,
MPH)

DECEMBER2015

JI
MMA,
ETHI
OPI
A

Summer
y
2|Page
Backgr
ound: Appendi
cit
isi
srecogni
zed wor
ldwi
de as t
he commonestsur
gical
emer
gencyandappendect
omyi
sthecommonestemer
gencysur
gicalpr
ocedur
e.I
ts
managementbecomesmor
echal
lengi
ngwhent
hepat
ientpr
esent
swi
thper
for
ated
appendi
cit
is.Thedi
ff
icul
tyi
ndi
sti
ngui
shi
ngappendi
cit
isf
rom ot
hercommon causes
ofabdomi
nal pai
n and t
hei
ncr
ease i
n mor
bidi
tyand mor
tal
it
yaccompanyi
ng
per
for
atedappendi
xmakesi
tani
mpor
tantconcer
nforphysi
cians.
Unr
ecogni
zedper
for
atedappendi
xleadi
ngt
oli
fet
hreat
eni
ngcondi
ti
oni
scommoni
n
devel
opi
ngcount
ri
es,especi
all
yinSub-
sahar
ancount
ri
esi
ncl
udi
ngEt
hiopi
a. The
bur
denofappendi
cit
isi
nEt
hiopi
aisnotcl
ear
lyknownbutsomehospi
talst
udi
eshave
shownt
hati
tisani
mpor
tantcauseofmor
bidi
tyandmor
tal
it
y.

Obj
ect
ive:pur
poseoft
hisst
udyi
stoassesst
hepr
eval
enceandout
comeofper
for
ated
appendi
xoper
atedi
nJUSH.

Method:Ret
rospecti
verecordreview fr
om ORl og-books,admissi
onrecordsandcardsof
subj
ectswhounder wentoperati
onandi nt r
a-oper
ativel
yfoundtohaveper f
orat
edappendixi
n
JUSHbetweenSept ember1/2013t oSept ember1/2015wasdone.Thr eedat acoll
ectors
wererecrui
ted,tr
ainedandpar tici
patedi nthedat acoll
ecti
on.Thedat awereenter
edand
anal
yzedusingSPSSver si
on20- comput ersoft
ware.Descri
pti
vestat
ist
icsli
kefr
equency,
measuresofcentr
altendencywer ecomput edandpr esent
edusing t
ables.

Results:Recordsof184pat ient swer eavail

abl
eandi ncludedint hest udy.Inthi
sst udyMal e
consti
tutedthemaj or
ity130( 70.7%)andf emale54( 29.
3).Outof54f emal es5oft hem were
pregnantand49wer enot.Theager angesfrom 5-76yearswithmeanageof26. 40year s.Most
ofthecaseswer efrom rural128( 69.6%)thanurban56( 30.4%)
.Accor dingtot hi
sstudy,there
areseveralvari
ablesthatarepr edict
iveofpooroutcomei npatientswi t
happendi cit
is.Late
presentati
on,extr
emisofages, pr eoperati
vetr
eatmentwi thantibiot
icsduet owrongdi agnosi
s,
presentati
onwi t
hgener al
izedper i
tonit
isandpresenceofcomor bidcondi t
ionli
ket ypetwoDM
andHI V/AIDSarethemostpr edicti
veofdeath.

3|Page
Acknowl
edgement
Aboveal
l,Iwoul
dli
ket
othankt
heal
might
yGodf
oral
lreasons.Iwoul
dal
sot
hank
Ji
mmaUni
ver
sit
yforcr
eat
ingt
heoppor
tuni
ty.Depar
tmentofsur
ger
ydeser
vesspeci
al
t
hanki
ngf
ort
heowner
shi
pandcoor
dinat
ionoft
hepr
ogr
am.Mygr
ati
tudegoest
omy
advi
sor
sDr
.YonasYi
lma and Mr
.Lemessa Dube f
ort
hei
rinval
uabl
egui
dance,
comment
sandsuggest
ionsaswel
lasf
ort
hei
rswi
ftr
esponsest
omyr
equest
s.

4|Page
Tabl
eofCont
ent
s Page

Resear
chSummar
y…………………………………………………………3

Acknowl
edgment
……………………………………………………………4

Tableofcont
ent
s--
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
-
---
5

Abbr
evi
ati
ons…………………………………………………………………7

Chapt
er1.I
ntr
oduct
ion

1.
1Backgr
oundI
nfor
mat
ion…………………………………………8

1.
2St
atementoft
hepr
obl
em…………………………………………10

1.
3.Si
gni
fi
canceoft
hest
udy………………………………………-
--11

Chapt
er2.Li
ter
atur
eRevi
ew…………………………………………………12

Chapt
er3.Obj
ect
ives…………………………………………………………18

3.
1.Gener
alObj
ect
ive…………………………………………………18

3.
2.Speci
fi
cObj
ect
ives…………………………………………………18

Chapt
er4.Met
hodsandMat
eri
als………………………………………………19

4.
1.St
udyAr
ea…………………………………………………………19

4.
2.St
udyDesi
gnandSt
udyPer
iod……………………………………20

4.
3.Popul
ati
on……………………………………………………………21

4.
3.1Sour
cePopul
ati
on ……………………………………21

4.
3.2.
StudyPopul
ati
on………………………………………….
21

4.
4.I
ncl
usi
onandExcl
usi
onCr
it
eri
a……………………………………21

4.
5.Sampl
eSi
zeandSampl
ingTechni
que ……………………………21

4.
6.Dat
acol
lect
ors………………………………………………………21

5|Page
 4.
7Var
iabl
es……………………………………………………………-
21

4.
8.1DependentVar
iabl
es……………………………………….
.21

4.
8.2I
ndependentVar
iabl
es…………………………………….
.22

4.
9.Dat
aAnal
ysi
s,Pr
ocessi
ng,
andI
nter
pret
ati
on………………………. 22

4.
10.Dat
aQual
it
yAssur
ance…………………………………………… 22

4.
11.Et
hicalConsi
der
ati
on ………………………………………… 22

4.
12.Di
ssemi
nat
ionPl
an………………………………………………… 22

4.
13.
Oper
ati
onaldef
ini
ti
ons……………………………………………… 22

Chapt
er5.Resul
tsandDi
scusi
on……………………………………………………23

Chapt
er6.concl
usi
onandRecommendat
ion………………………………………31

Ref
erences……………………………………………………………………………32

6|Page
Acr
onyms&Abbr
evi
ati
ons
JUSH-Ji
mmauni
ver
sit
yspeci
ali
zedHospi
tal

SSI
-Sur
gicalsi
tei
nfect
ion

CBC-compl
eteBl
oodCount

U/
A–ur
ineanal
ysi
s

7|Page
Chapt
erone:I
ntr
oduct
ion
1.
1.Backgr
ound:

Appendi
cit
isi
s def
ined as t
he i
nfl
ammat
ion ofappendi
x. Ther
eis no uni
fyi
ng
hypot
hesi
sregar
dingt
heet
iol
ogyofacut
eappendi
cit
is.Butt
heObst
ruct
ionoft
he
appendi
ceall
umenwi
thf
aecol
it
h,st
ri
ctur
e,t
umour,
I
ntest
inalpar
asi
tes,
Lymphoi
d
hyper
plasi
a,et
c.seemst
obeessent
ialf
orbact
eri
alover
growt
hint
hel
umenandt
he
devel
opmentofappendi
cealgangr
eneandper
for
ati
on.Whi
leappendi
cit
isi
scl
ear
ly
associ
ated wi
th bact
eri
alpr
oli
fer
ati
on wi
thi
ntheappendi
x,no si
ngl
eor
gani
sm i
s
r
esponsi
ble.A pol
ymi
crobi
ali
nfect
ionwi
thmi
xedgr
owt
hofaer
obi
candanaer
obi
c
or
gani
smsi
susual(
1).

Appendi
cit
isi
srel
ati
vel
yrar
eini
nfant
s,and becomes i
ncr
easi
ngl
y common i
n
chi
ldhoodandear
lyadul
tli
fe,r
eachi
ngapeaki
nci
dencei
nthet
eensandear
ly20s.
Af
termi
ddl
eage,t
her
iskofdevel
opi
ngappendi
cit
isi
squi
tesmal
l.Thei
nci
denceof
appendi
cit
isi
sequalamongmal
esandf
emal
es(
1,2,
3).

The cl
assi
calf
eat
ures ofacut
e appendi
cit
is begi
n wi
th poor
lyl
ocal
ized col
icky
abdomi
nalpai
n.Thepai
nisf
requent
lyf
ir
stnot
icedi
ntheper
i-umbi
li
calr
egi
on.Cent
ral
abdomi
nalpai
nisassoci
atedwi
thanor
exi
a,nauseaandusual
lyoneort
woepi
sodesof
vomi
ti
ngt
hatf
oll
ow t
heonsetofpai
n. Anor
exi
aisausef
ulandconst
antcl
ini
cal
f
eat
ure,par
ti
cul
arl
yinchi
ldr
en.Wi
thpr
ogr
essi
vei
nfl
ammat
ionoft
heappendi
x,t
he
par
iet
alper
it
oneum i
nther
ighti
li
acf
ossabecomesi
rr
it
ated,pr
oduci
ngmor
eint
ense,
const
antandl
ocal
isedsomat
icpai
nthatbegi
nst
opr
edomi
nat
e.Pat
ient
sof
tenr
epor
t

8|Page
t
hisasanabdomi
nalpai
nthathasshi
ft
edandchangedi
nchar
act
er. Typi
cal
ly,
coughi
ngorsuddenmovementexacer
bat
est
her
ighti
li
acf
ossapai
n.Thecar
dinal
si
gns ar
ethose ofan unwel
lpat
ientwi
thl
ow-
grade f
ever
,local
ized abdomi
nal
t
ender
ness,muscl
e guar
ding and r
ebound t
ender
ness.Al
so pal
pabl
e mass and
t
ender
ness al
lover t
he abdomen i
n cases of compl
icat
ed appendi
cit
is wi
th
appendi
cealmassandgener
ali
zedper
it
oni
ti
srespect
ivel
y(1,
2,
4-7)
.

Thedi
agnosi
sofappendi
cit
isr
est
smor
eont
hor
oughcl
ini
calexami
nat
iont
hanonany
aspectofi
nvest
igat
ion.I
nvest
igat
ions l
ike CBC ,
U/A,ul
tr
asonogr
aphy,comput
ed
t
omogr
aphy(
CT)
,et
c.ar
ecommonl
ydonet
osuppor
tthedi
agnosi
sand/
orexcl
udei
t.
Despi
tet
he i
ncr
eased use oful
tr
asonogr
aphy,comput
ed t
omogr
aphy (
CT)
,and
l
apar
oscopy,t
her
ateofmi
sdi
agnosi
sofappendi
cit
ishasr
emai
nedconst
ant(
15.
3%)
,
ashast
her
ateofappendi
cealr
upt
ure(
2,4,
5.)

Onceappendi
cit
isi
sdi
agnosed ,
sur
gicalt
reat
menti
sindi
cat
ed whi
ch i
ssur
gical
r
emoval of t
he i
nfl
amed appendi
x cal
led appendect
omy. Appendect
omy f
or
appendi
cit
isi
sthemostcommonl
yper
for
medemer
gencyoper
ati
oni
nthewor
ld.But
some epi
sodes ofacut
e appendi
cit
is appar
ent
ly subsi
de spont
aneousl
y orwi
th
ant
ibi
oti
cs.Ther
epor
tedassoci
atedmor
tal
it
yrat
eofappendi
cit
isi
s atl
east67%
wi
thoutsur
gicalt
her
apy.Cur
rent
ly,t
he mor
tal
it
yrat
eforacut
e appendi
cit
is wi
th
pr
omptsur
gicali
nter
vent
ion i
sless t
han 1% .So t
he nat
uralhi
stor
y ofacut
e
appendi
cit
iswi
thoutsur
gicali
nter
vent
ioni
s:r
esol
uti
oni
nsomepat
ient
sbuti
not
her
s
f
ormat
ionofappendi
cealmass,per
for
ati
onwi
thl
ocal
izedabscessorper
for
ati
onwi
th
gener
ali
zedper
it
oni
ti
s(1,
2).

9|Page
 1.
2.St
atementoft
hepr
obl
em :

Appendi
cit
isi
soneoft
hel
eadi
ng causeofacut
eabdomeni
nal
lage gr
oups
i
ncl
udi
ng chi
ldhood and appendect
omy f
orappendi
cit
isi
sthe mostcommonl
y
per
for
medemer
gencyoper
ati
oni
nthewor
ld(
2).

Despi
te a hi
gh pr
eval
ence ofacut
e appendi
cit
is as wel
las per
for
ated appendi
x
r
epor
tedi
n sever
alAf
ri
cancount
ri
es,ver
yfew ornor
esear
chi
sdoneaboutt
he
pr
eval
ence and out
come of per
for
ated appendi
xint
he East
ern Af
ri
can count
ry
i
ncl
udi
ngEt
hiopi
a(6-
9).

I
fthei
nfl
amedappendi
xisnotat
tendedt
our
gent
ly,i
twi
llpr
oceedt
o gangr
ene and
per
for
ati
on,
andr
esul
tinper
it
oni
ti
sorabscessf
ormat
ion.

Whi
leacut
eappendi
cit
isi
spr
imar
il
yadi
seaseoft
heyoungerpopul
ati
on,wi
thonl
y
5–10% ofcasesoccur
ri
ngi
nel
der
lyper
sons,t
hei
nci
dence ofappendi
cit
isi
nol
der
pat
ient
sseemst
obei
ncr
easi
ngwi
thani
ncr
easei
nli
feexpect
ancy.

Mor
bidi
tyandmor
tal
it
yrat
esar
egr
eat
eri
nol
derpat
ient
swhoof
tenhavedel
ayedand
at
ypi
calpr
esent
ati
ons,l
eadi
ng t
oincr
eased f
requency ofper
for
ati
on and i
ntr
a-
abdomi
nali
nfect
ion (
3,4)
.Fact
orst
hati
ncr
ease appendi
cealper
for
ati
on i
ncl
ude:
ext
remesofage,l
atepr
esent
ati
on,i
mmunosuppr
essi
on,di
abet
esmel
li
tus,f
aecol
it
h
obst
ruct
ion oft
he appendi
xlumen,a f
ree-
lyi
ng pel
vic appendi
x and pr
evi
ous
abdomi
nalsur
ger
ythatl
imi
tst
heabi
li
tyoft
hegr
eat
eroment
um t
owal
lof
fthespr
ead
ofper
it
onealcont
ami
nat
ion(
1,2,
8-10)
.

Li
kemanyr
esour
ce-
poorset
ti
ngs,acut
elyi
llpat
ient
sinEt
hiopi
aof
tenpr
esentl
atei
n
t
hedi
seasepr
ocessandt
her
eisf
requent
lyl
imi
tedt
imef
ordi
agnost
icst
udi
esandl
ack

10|Page
ofwel
ltr
ainedmanpowerpr
iort
odef
ini
ti
vet
her
apy.

Par
ti
cul
art
oappendi
cit
is,
ther
eisaknowl
edgegapr
egar
dingl
evelofl
atepr
esent
ati
on
andt
heef
fectofl
atepr
esent
ati
onont
hepr
ognosi
soft
hedi
seasesi
nlow i
ncome
set
ti
ng(
6,7,
8).

Ther
efor
e,t
hegoal
soft
hisst
udyi
stobet
terel
uci
dat
ethepr
eval
enceandout
comeof
per
for
atedappendi
xatJi
mmaUni
ver
sit
ySpeci
ali
zedhospi
tal
,Ji
mma,
Ethi
opi
a.

1.
3.Si
gni
fi
canceoft
hest
udy

Ther
esul
tofst
udywi
llhel
p;

Pol
icymaker
stogai
ninsi
ghtont
her
oleofheal
theducat
ionf
ori
mpr
ovementof
ear
lypr
esent
ati
on ofpat
ient
sto hospi
talwhen t
heygotser
iousabdomi
nal
i
ll
ness.

Sur
gicalt
eams and ot
herheal
th wor
ker
s a bet
terunder
standi
ng on t
he
pr
eval
enceandout
comeofper
for
atedappendi
x.

Ther
esul
toft
hisst
udywi
llhel
pheal
thcar
epr
ovi
der
stogi
vemor
eemphasi
sfor
pat
ient
s who have f
act
orst
hatcoul
d wor
sen t
he out
come ofper
for
ated
appendi
x.

Theout
comeoft
hest
udywi
llal
souseasbasel
inef
orot
herr
esear
cher
s.

11|Page
Chapt
erTwo–Li
ter
atur
eRevi
ew

Appendi
cit
is-
def
ined ast
hei
nfl
ammat
ion ofappendi
xduet
o di
ff
erentcausesof
l
umi
nalobst
ruct
ionandsecondar
il
ybact
eri
alpr
oli
fer
ati
oni
sthel
eadi
ngcauseofacut
e
abdomeni
nal
lagegr
oupsandappendect
omyf
orappendi
cit
isi
sthemostcommonl
y
per
for
medemer
gencyoper
ati
oni
nthewor
ld(
1,2)
.Thel
if
eti
mer
ateofappendect
omy
i
s12% f
ormenand25% f
orwomen,wi
thappr
oxi
mat
ely7% ofal
lpeopl
eunder
goi
ng
appendect
omyf
oracut
eappendi
cit
isdur
ingt
hei
rli
fet
ime(
1).

Event
hought
hepeaki
nci
denceofacut
eappendi
cit
isi
sint
het
eensandear
ly20s,
cases ofcompl
icat
ed appendi
cit
isl
ike per
for
ated appendi
x ar
e becomi
ng mor
e
commont
hanbef
orei
nbot
hext
remesofages.

Appendi
cit
isi
ntheel
der
lyi
sbecomi
ngani
ncr
easi
ngl
yfr
equentcl
ini
calencount
erdue
t
othe i
ncr
eased l
if
e expect
ancy i
nthe human r
ace overt
he l
asthal
f-cent
ury.
Appendi
cit
isi
nthi
sagegr
ouphas,t
her
efor
e,becomer
elat
ivel
ymor
ecommonwi
than
at
ypi
calpr
esent
ati
onandcompl
icat
iont
hati
ncur
sdel
ayi
ndi
agnosi
swi
that
tendant

12|Page
mor
bidi
tyandmor
tal
it
y.I
naddi
ti
on,
thepat
ientpr
esent
edwi
thot
hercomor
bidi
ti
est
hat
coul
ddet
ractf
rom adi
agnosi
sofappendi
cit
ist
otheunwar
y(2,
3,
6).Fi
ndi
ngsf
rom case
r
epor
tsf
rom Depar
tmentofSur
ger
y,Dr
umhel
lerHospi
tal
,Canadashowedt
hatt
he
i
ncr
easedl
if
eexpect
ancyt
hatcameaboutdur
ingt
hel
ate20t
handt
hef
ir
stdecadeof
he 21st cent
t uri
es has compel
led sur
geons and physi
cians t
o under
take medi
cal
pr
ocedur
es i
nincr
easi
ngl
y ol
derpat
ient
s.The mostcommon emer
gentsur
gical
oper
ati
on,appendi
cit
is,pr
evi
ousl
yregar
dedasapedi
atr
icoper
ati
on,i
sincr
easi
ngl
y
bei
ngseeni
nol
derpat
ient
s(6)
.

Theger
iat
ri
cpat
ientwi
thappendi
cit
is,however
,pr
esent
sremar
kabl
ydi
ff
erent
lyf
rom
hi
spedi
atr
iccount
erpar
t,l
argel
yduet
othechangesi
nthebody’
sphysi
ologi
creser
ves
anddi
seasemani
fest
ati
on.Thus,st
ereot
ypi
ngoft
hepr
esent
ati
onsofappendi
cit
is
coul
d putel
der
ly pat
ient
s pr
esent
ing wi
thi
tatr
isk ofmor
bidi
ty and del
ayed
i
mpl
ement
ati
onoft
reat
mentduet
odel
ayi
nmaki
ngt
hedi
agnosi
s.Thedi
ff
icul
tyi
n
est
abl
ishi
ngt
hedi
agnosi
sear
lycanbeat
tr
ibut
edt
osever
alf
act
ors.El
der
lypat
ient
s
t
endt
oseekhel
prel
ati
vel
ylat
efr
om t
heonsetofsympt
oms.Whent
heydo,
inasi
zabl
e
pr
opor
ti
on,
thepr
esent
ingf
eat
uresar
eat
ypi
cal
.

Cl
ini
calandl
abor
ator
yfeat
uresofi
nfl
ammat
ionl
ikepai
n,vomi
ti
ng,andl
eukocyt
osi
s
maybegr
eat
lyat
tenuat
ed,
presumabl
yduet
oanagei
ngi
mmuneandneur
alsyst
ems.
Fort
hisr
eason,
appendect
omyshoul
dnotbedel
ayedi
ntheel
der
ly(
3,6,
7).

St
udydonei
n Mansour
aFacul
tyofMedi
cine,
Mansour
aUni
ver
sit
y,Egyptshowedal
so
Appendi
cit
isi
ntheel
der
lycont
inuest
obeachal
lengi
ngsur
gicalpr
obl
em.
Pat
ient
scont
inuedt
opr
esentl
atewi
that
ypi
calpr
esent
ati
ons.Themedi
calr
ecor
dsof
el
der
lypat
ient
s(aged>60year
s)whounder
wentappendect
omyf
oracut
eappendi
cit
is
att
hathospi
talwer
erevi
ewed.Var
iabl
essel
ect
ed f
oranal
ysi
sincl
uded age,sex,
pr
esent
ing sympt
oms, oper
ati
ve appr
oach, oper
ati
ve f
indi
ngs,
dur
ati
on of
hospi
tal
izat
ion.
Pat
ient
swer
ecompar
edt
oacont
rolgr
oup,l
esst
han31year
sadmi
tt
eddur
ingt
he
sameper
iod.Accor
dingl
y,
Twent
y-t
hreepat
ient
s’r
ecor
dsaged>60year
swi
thacut
e

13|Page
appendi
cit
iswer
ecompar
edt
oagr
oupof40pat
ient
saged<30year
s(7)
.
Al
lyoungpat
ient
sgr
ouphadanunevent
fulpost
oper
ati
ver
ecover
yonl
ytwocases(
5%)
hadwoundi
nfect
ion.Ther
ewasonedeat
hint
heel
der
lygr
oupt
husmor
tal
it
yrat
ewas
4.
3%.
Theset
wogr
oupsofpat
ient
sshowedal
sosi
gni
fi
cantdi
ff
erencesi
nrel
ati
ont
othe
st
age ofdi
sease atoper
ati
on and post
oper
ati
ve compl
icat
ions.El
der
ly gr
oup of
pat
ient
shadper
for
atedappendi
xin16cases(
69.
5%)whi
lei
ngr
oupI
Ipat
ient
sei
ght
cases(
20%)hadper
for
atedappendi
x.El
der
lypeopl
eof
tenpr
esentt
ohospi
tal
sinan
advancedst
ageoft
hedi
sease.
I
nyoungpeopl
e,t
heper
for
ati
onr
ateofacut
eappendi
cit
isi
slesst
han20%whi
let
his
canbe70%orevenashi
ghas90%i
nel
der
lypeopl
e.Ther
easonsbehi
ndt
hiscoul
dbe
expl
ained by l
ate pr
esent
ati
on, age-
speci
fi
c physi
ologi
cal al
ter
ati
on, at
ypi
cal
pr
esent
ati
onanddel
ayi
ndi
agnosi
s.I
nthe ser
ies,el
der
lygr
oupofpat
ient
shad
per
for
atedappendi
xin16cases(
69.
5%)whi
lei
ngr
oupI
Ipat
ient
sei
ghtcases(
20%)
hadper
for
atedappendi
xatar
atewhi
chi
ssi
mil
art
owhati
sfoundi
nli
ter
atur
es(
13)
.
Theover
allcompl
icat
ionr
ateof15.
9% i
ntheser
iesi
sal
it
tl
ebi
tlowert
hanpr
evi
ous
r
epor
tsof28–60%(
6,7)
.
Themor
tal
it
yrat
einel
der
lypat
ient
swi
thacut
eappendi
cit
isi
sbet
ween4%and10%.
Deat
hisof
tendi
rect
lyr
elat
edt
oint
ra-
abdomi
nalsepsi
sandi
nmostcasest
osept
ic
compl
icat
ionsf
rom per
for
ati
onaugment
edbyassoci
atedsever
ecomor
bidi
ti
es.
I
ntheser
ies,t
hemor
tal
it
yrat
ewas4.
3% duet
osept
iccompl
icat
ionsandmul
ti
ple
or
ganf
ail
ure(
13)
.
I
nconcl
usi
on,acut
eappendi
cit
isi
ntheel
der
lyr
emai
nsachal
lengef
orpr
act
ici
ng
sur
geonsandcont
inuest
obeassoci
atedwi
thhi
ghmor
bidi
tyandmor
tal
it
y.Wi
th
i
ncr
easi
ngl
if
eexpect
ancy,
mor
esuchcasesar
eli
kel
ytobeencount
eredi
nthef
utur
e.
Resul
tsmi
ghti
mpr
ovewi
thear
li
erconsi
der
ati
onoft
heuseofCTabdomeni
nthe
di
agnosi
s ofel
der
ly pat
ient
s wi
th abdomi
nalpai
n,f
oll
owed by pr
omptsur
gical
oper
ati
on(
3,6,
13)
.

Onot
herhands,t
her
eisal
soi
ncr
easedf
indi
ngofcompl
icat
edcasesofappendi
cit
is

14|Page
l
ikeper
for
ati
onwi
thgener
ali
zedper
it
oni
ti
sinundert
enchi
ldr
en.Cl
ini
calpr
ofi
leand
r
iskf
act
orsassoci
atedwi
thper
for
ati
onofappendi
xinchi
ldr
enunder13year
sofage
wasst
udi
edatDepar
tmentofPaedi
atr
icsandChi
ldHeal
th,Addi
sAbabaUni
ver
sit
y
,
Facul
tyofMedi
cine(
6).

Accor
dingl
y at
otalof147caseswer
eanal
yzed.The meanagewas9.
3year
sand
appendi
cit
is occur
red mor
e commonl
y among mal
es.Atoper
ati
on ,per
for
ated
appendi
xwasf
oundi
n54.
4%andphl
egmonousappendi
xint
her
est(
45.
6%)
.Ther
ate
ofper
for
ati
oni
smor
ecommoni
nthosepat
ient
sbel
owt
enyear
sofage;97outof147
pat
ient
swer
ebel
owt
enyear
sofagehadper
for
atedappendi
cit
isascompar
edt
othose
abovet
enyear
swhi
chi
s53onl
y(p<0.
05)
.Ther
ateofper
for
ati
oni
nthi
sser
iesi
s
si
mil
arwi
thanear
li
err
epor
tfr
om t
hesamehospi
tal(
6),
fr
om Yi
rgal
em Hospi
tal(
9)
andf
rom Gonder(
7).

ButSudanesest
udyshowedaper
for
ati
onr
ateof13.
2% whi
chi
slowert
hant
hat
obser
vedi
nourcount
ry(
10)
.

Fact
orsi
ndependent
lyf
oundt
obepr
edi
ctor
sofper
for
ati
onbyuni
var
iat
eanal
ysi
swer
e:
age<10year
s,dur
ati
onofi
ll
nessf
orover24hour
s,hi
stor
yoft
reat
mentel
sewher
e
bef
orear
ri
valt
otheHospi
tal,gener
ali
zedabdomi
nalt
ender
ness,r
eboundt
ender
ness,
and/
orr
igi
dit
y,hypoact
iveand/
orabsentbowelsound,RLQmass,l
eukocyt
osi
swi
th
neut
rophi
li
aand pr
esenceofcompl
icat
ion(
6).
Oft
hesef
act
orsdel
ayi
nint
ervent
ion
duet
olat
epr
esent
ati
ont
ohospi
tali
sani
mpor
tantpr
event
abl
efact
or.
Compl
icat
ion
occur
red i
n 25-
30% ofchi
ldr
en wi
th appendi
cit
is pr
imar
il
y among t
hose wi
th
per
for
ati
on.

The compl
icat
ion i
ncl
udes wound i
nfect
ion(
8.16 %) ,
i
ntr
a-abdomi
nal
abscess(
9.52%)
,i
ntest
inalobst
ruct
ion(
2.72%)andent
ero-
cut
aneousf
ist
ula(
1.36%)
.Out
of147cases,
24(
16.
33%)pat
ient
shadcompl
icat
ionand21oft
hem wer
eint
hegr
oup
wi
thper
for
ati
onsuggest
ingt
hatt
heoccur
renceofcompl
icat
ioni
shi
ghl
ypr
edi
cti
veofa
per
for
atedappendi
x(p<0.
05)
.Ther
ewasonedeat
h(0.
68%)(
4).

APr
ospect
iveRandomi
zedCont
rol
ledSt
udyofPer
it
onealDr
ainsi
nthemanagementof

15|Page
Per
for
atedAppendi
cit
iswi
thoutPer
it
oni
ti
swasunder
takeni
nDept
.ofSur
ger
y,Col
lege
ofHeal
thSci
ences,Uni
ver
sit
yofNai
robi
,Kenya.Oft
he216pat
ient
sdi
agnosedwi
th
acut
eappendi
cit
is,117pat
ient
shadsi
mpl
eacut
eappendi
cit
iswi
thoutper
for
ati
onand
wer
ether
efor
eexcl
udedf
rom t
hest
udy(
12)
.
Ni
net
ysevenpat
ient
shadvar
iousst
agesofadvancedappendi
cul
arpat
hol
ogy.Seven
had gener
ali
zed per
it
oni
ti
s and wer
e al
so excl
uded.The r
emai
ning 90 pat
ient
s
const
it
utedourst
udypopul
ati
on.Thesewer
eequal
lyr
andomi
zedt
otwogr
oups.For
ty
f
ivehadt
hecl
osedsyst
em oft
ubedr
ainagepr
ovi
ded(
wit
houtsuct
ion)whi
let
he
r
emai
ning45hadnodr
aini
nser
ted.
Al
loft
he90pat
ient
sincl
udedi
nthest
udyhadhi
stol
ogi
calconf
ir
mat
ionofani
nfl
amed
per
for
atedappendi
x.Post
oper
ati
vel
y,18pat
ient
shadwoundsepsi
sand6pat
ient
shad
ot
hercompl
icat
ionsi
ncl
udi
ngf
aecalf
ist
ula,
abdomi
nalabscess,
andpar
alyt
ic
i
leus.Outoft
hosewi
thwoundsepsi
s,t
hemaj
ori
ty(
83%)wer
eint
hedr
aingr
oup.Al
l
pat
ient
swi
thot
hercompl
icat
ionsbel
ongedt
othedr
aingr
oup.Thepat
ient
sint
hedr
ain
gr
ouphadsi
gni
fi
cant
lyl
ongerdur
ati
onofant
ibi
oti
cuseandhospi
talst
ay(
12)
.
Al
l90pat
ient
sint
hest
udyr
ecei
vedpar
ent
eralant
ibi
oti
cscover
inganaer
obi
caswel
l
asaer
obi
cgr
am posi
ti
veandgr
am negat
iveor
gani
sm.Par
ent
eralant
ibi
oti
cswer
e
st
opedoncepyr
exi
aresol
vedandt
hepat
ient
swer
efeedi
ngwel
l.For
tysi
xpat
ient
s
usedi
ntr
avenousant
ibi
oti
csf
orupt
o3dayspost
oper
ati
vel
y;24pat
ient
sfor4days,
20
pat
ient
sfor5daysormor
e.85% oft
hosewhower
eonant
ibi
oti
csf
orl
ongert
han5
daysi
nthehospi
talhaddr
ainswhi
le15%di
dnothavedr
ains.I
naddi
ti
onal
lpat
ient
s
wer
edi
schar
gedhomeonor
alant
ibi
oti
csf
oraper
iodof5days.Over
all
,pat
ient
sint
he
dr
aingr
ouphadl
ongeruseofi
n-hospi
talant
ibi
oti
cs(
12)
.
Ther
ewassi
gni
fi
cantdi
ff
erencei
nlengt
hofhospi
talst
ay.Pat
ient
sint
hedr
aingr
oup
hadanaver
ageof6.
1daysi
nhospi
tal
,andt
heycont
inuedt
heuseofant
ibi
oti
cs.I
twas
acommonobser
vat
iont
hatonr
emovaloft
hedr
ain,t
her
ewasasel
fli
mit
ingser
ous
exudat
ionf
rom t
hedr
ainsi
teandpai
ninmostoft
hepat
ient
s.
Somet
imesast
eri
ledr
essi
ngwaspl
acedont
hesi
tef
oranext
radayorso.I
fthe
t
reat
ingt
eam di
schar
gedt
hepat
ienti
nthi
sst
ate,mostpat
ient
swoul
dnotl
eaveand
t
he nur
sing t
eam woul
d cont
inue wi
tht
he ant
ibi
oti
cs.Thi
s pr
act
ice;t
hough not
cont
est
ed,cont
ri
but
edt
othel
engt
hofhospi
talst
ayi
npat
ient
swi
thdr
ainswi
thout

16|Page
ot
hersept
iccompl
icat
ions.Pat
ient
swhost
ayl
ongeri
nthehospi
talhavel
ongerdel
ay
t
oret
urnt
owor
korschool
.Thest
udyr
eveal
shi
ghoddsr
ati
ofori
ncr
easedhospi
tal
st
ayanduseofi
n-hospi
talant
ibi
oti
cssuggest
ingt
hatuseofdr
ainsi
nthesepat
ient
s
addst
othepat
ient
’sdi
seasebur
den and del
ayst
hei
rret
urnt
o nor
malact
ivi
ti
es.
Per
for
ated appendi
cit
is and i
ts compl
icat
ions i
s common among pat
i s wi
ent th acut
e
appendi
cit
isi
noursetup,
cont
ri
but
ing43%ofpat
ient
swi
thappendi
cit
isi
nthepastone
year
.Mor
emal
est
hanf
emal
eswer
einvol
vedandt
hemaj
ori
tywer
eint
heyoungage
gr
oup.Passi
vepr
ophyl
act
icdr
ainsi
nser
tedi
ntot
heper
it
onealcavi
tyaf
teroper
ati
onf
or
per
for
atedappendi
xdonotf
unct
ionasi
ntendedsi
ncet
hevol
umesofef
fl
uentdr
ained
ar
e negl
igi
ble. The use of per
it
oneal dr
ainage post appendect
omy i
n advanced
appendi
cit
is,
wher
e a per
for
ati
on associ
ated i
nfl
ammat
oryt
urbi
d exudat
es;ora l
ocal
ized
abscess,orappendi
cul
arphl
egmon,ar
efound;i
sassoci
atedwi
thhi
gherpostoper
ati
vesept
ic
compl
icat
ions,pr
olongeduseofant
ibi
oti
csandl
ongerhospi
talst
ay.The f
indi
ngssuggest
t
hatuseofapr
ophyl
act
icdr
ainpostappendect
omyi
ncr
easespat
ientmor
bidi
tyandcostof
heal
thcar
e(12)
.

Quant
if
yingt
hedi
spar
it
yinout
comebet
weenur
banandr
uralpat
ient
swi
thacut
e
appendi
cit
iswasassessedi
nDepar
tmentofSur
ger
y,Nel
sonR Mandel
aSchoolof
Medi
cine,
Dur
ban,
Sout
hAf
ri
ca.Tocompar
eout
comesofur
banandr
uralpat
ient
sand
t
o det
ermi
ne whet
hert
her
e ar
e di
spar
it
ies i
n out
come ,
a pr
ospect
ive st
udywas
conduct
edi
ncl
udi
ngal
lpat
ient
swhopr
esent
edwi
thacut
eappendi
cit
isf
rom bot
h
ur
ban and r
uralar
eas.Accor
dingl
y,t
otalof500pat
ient
swer
eincl
uded,wi
th 200
pat
ient
sint
her
uralgr
oupand300i
ntheur
bangr
oup.Thosef
rom t
her
uralgr
ouphad
asi
gni
fi
cant
lyl
ongerdur
ati
onofsympt
omspr
iort
opr
esent
ati
on.Al
lsept
icpar
amet
ers
wer
esi
gni
fi
cant
lywor
sei
nther
uralgr
oup.Si
gni
fi
cant
lymor
epat
ient
sfr
om t
her
ural
gr
oupr
equi
redal
apar
otomy(
77%v.51%ur
ban;p<0.
001)
(13)
.
I
nfl
amed,non-
per
for
atedappendi
cit
iswasmor
ecommonl
yseeni
ntheur
bangr
oup
(
52.
3%v.21%r
ural
;p<0.
001)
,whi
leper
for
atedappendi
cit
iswasmuchmor
ecommon
i
nther
uralgr
oup(
79%v.47.
7%ur
ban;p<0.
001)
(13)
.

Per
for
ati
onassoci
atedwi
thgener
ali
sed,f
our
-quadr
anti
ntr
a-abdomi
nalcont
ami
nat
ion

17|Page
wassi
gni
fi
cant
lyhi
gheri
nther
uralgr
oup t
han t
heur
ban gr
oup (
60.
5% v.21%,
r
espect
ivel
y;p<0.
05)
.Si
gni
fi
cant
lymor
epat
ient
sfr
om t
her
uralgr
oupr
equi
redanopen
abdomen(
46%v.12%ur
ban;p<0.
001)and≥1r
e-l
apar
otomi
est
ocont
rolsever
eint
ra-
abdomi
nalsepsi
s(60.
5%v.23.
3%ur
ban;p<0.
001)
.Sor
uralor
igi
nwasi
dent
if
iedasan
i
ndependenti
ndi
cat
orofpoorout
come.Possi
bler
easonsmayi
ncl
udedi
ff
icul
tyi
n
accessi
ngt
heheal
thsyst
em ordel
ayi
ntr
ansf
ert
oar
egi
onalhospi
tal(
13)
.
Theover
allcompl
icat
ionr
atewassi
gni
fi
cant
lyhi
gheri
nther
uralgr
oup(
35% v.11%
ur
ban;p<0.
001)
.Consi
der
edsepar
atel
y,eachoft
hef
oll
owi
ngwassi
gni
fi
cant
lyhi
gher
i
nther
uralgr
oup(
rur
alv.ur
ban,r
espect
ivel
y):hospi
tal
-acqui
redpneumoni
a(21.
5%v.
5%;p<0.
001)
,renalf
ail
ure(
14% v.0.
7%;p<0.
001)
,wound sepsi
s(22.
5% v.6.
7%;
p<0.
001)andot
hermi
scel
laneouscondi
ti
ons(
5.5% v.0.
3%;p<0.
001)
. Theover
all
mor
tal
it
y was si
gni
fi
cant
ly hi
gheramong r
ural
-based pat
ient
sthan ur
ban-
based
pat
ient
s(3.
5%v.0.
3%,r
espect
ivel
y;p=0.
008)
(13)
.Thi
ssur
veyi
dent
if
iesr
uralor
igi
nasan
i
ndependentr
iskf
act
orf
orappendi
cul
arr
upt
ureandapoorcl
ini
calcour
se.Rur
alpat
ient
shave
maj
ordel
aysbet
weent
heonsetofsympt
omsanddef
ini
ti
vesur
ger
ycompar
edwi
thur
ban
pat
ient
s(13)
.

The exactr
easons f
ort
hese del
ays r
equi
ref
urt
heri
nvest
igat
ion.Heal
th-
seeki
ng
behavi
ouri
scompl
exandi
sinf
luencedbyr
uralpover
tyandr
emot
enessaswel
las
cul
tur
ali
ssuessuchast
her
eli
anceont
radi
ti
onalheal
ersasapr
imar
ysour
ceofcar
e
andheal
thadvi
ce.
However
,f
ail
ureofcl
ini
calr
ecogni
ti
ononcecont
actwi
tht
heheal
thsyst
em hasbeen
madef
oll
owedbydel
aysi
ntr
ansf
erf
orsur
ger
ytot
her
egi
onalhospi
talar
efai
li
ngsof
t
heheal
thsyst
em (
13)
.

18|Page
Chapt
erThr
ee:Obj
ect
ives

3.
1.Gener
alobj
ect
ive

• Toassesspr
eval
enceandout
comeofper
for
atedappendi
xamongcases
ofoper
atedappendi
cit
isi
nJUSH,
Sout
hwestEt
hiopi
a
3.
2.Speci
fi
cobj
ect
ives

• To det
ermi
ne pr
eval
ence ofper
for
ated appendi
x among cases of
oper
atedappendi
cit
isi
nJUSH.
• Toi
dent
if
yfact
orsassoci
atedwi
thper
for
atedappendi
xamongcasesof
oper
atedappendi
cit
isi
nJUSH.
• Toassessout
comeofper
for
atedappendi
x
• Todet
ermi
ner
ateofcompl
icat
ion

19|Page
Chapt
erf
our
:Met
hodsandMat
eri
als

4.
1St
udyAr
eaandper
iod

Thedat
aext
ract
ionf
rom pat
ient
’sr
ecor
dswhower
eoper
atedf
orappendi
cit
isf
rom
Sept
ember1/
2013t
oSept
ember
1/2015wasconduct
edf
rom Oct
ober1-
30/
2015i
n
Ji
mmaUni
ver
sit
yspeci
ali
zedHospi
tal
.

Ji
mmazonecompr
isesJi
mmat
ownandi
tsnear
bywor
edas.I
tisl
ocat
edi
nSout
h
WestofEt
hiopi
a,Or
omi
aregi
onalst
ate,wi
thest
imat
edpopul
ati
onof2,
486,
155.The
t
owni
slocat
ed350Ki
lomet
ersf
rom t
hecapi
tal
,Addi
sAbaba.

Ji
mmaUni
ver
sit
yisoneoft
hel
argestUni
ver
sit
iesi
nthecount
ri
eswhi
chr
unsbot
h
under
graduat
eandgr
aduat
epr
ogr
ammesi
nsever
aldi
sci
pli
nes.

Ji
mmaUni
ver
sit
ySpeci
ali
zedHospi
tal(
JUSH)i
soneoft
eachi
nghospi
tal
sint
he
count
ry.

Thehospi
talgi
vesheal
thser
viceati
npat
ientandout
pat
ientl
evelasar
efer
ralHospi
tal
f
orabout15mi
ll
ionpopul
ati
oni
ntheSout
hWestoft
hecount
ry.

Thehospi
talhasI
nter
nalMedi
cine,Pedi
atr
ics,OB/
GYN,Sur
ger
y,Dent
al,Radi
ology,
Opht
hal
mol
ogy,
Anest
hesi
ologyandPsychi
atr
ydepar
tment
s.

Thedepar
tmentofsur
ger
yhasemer
gencysur
gicalOPDwi
th6beds,
twoCol
dsur
gical
OPDandt
hreewar
dsf
ori
npat
ientt
reat
ment(
Sur
gicalA,
B,andC)wi
tht
otal123beds
andabout3240annualadmi
ssi
on(
incl
udesbot
hEmer
gencyandEl
ect
iveadmi
ssi
on)
.

Thedepar
tmenthasRef
err
al cl
ini
cwhi
chgi
vesanout
pat
ientser
vicef
orGener
al
Sur
gicalpat
ient
stwi
ceaweekandf
orOr
thopedi
csur
gicalpat
ient
sonceaweek.

Al
sot
heDepar
tmentowns Mi
norORwi
th2t
abl
esf
ormi
norsur
ger
yand Maj
orOR

20|Page
wi
th3t
abl
eswhi
chgi
veser
vicef
orbot
hEl
ect
iveandEmer
gencymaj
orOper
ati
on.

4.
2St
udydesi
gn
Ar
etr
ospect
iver
ecor
drevi
ewwasconduct
edf
rom Oct
ober1-
30/
2015

4.
3Popul
ati
on

4.
3.1Sour
cepopul
ati
on
Al
lappendi
cit
iscasesoper
atedi
nJUSHwer
ethesour
cepopul
ati
on

4.
3.2St
udypopul
ati
on

Al
lappendi
cit
iscasesoper
atedi
nJUSHdur
ingt
hest
udyper
iodofSept
ember1/
2013-
Sept
ember1/
2015.

4.
4Incl
usi
onandexcl
usi
oncr
it
eri
a
4.
4.1I
ncl
usi
oncr
it
eri
a

Al
lcases of oper
ated appendi
cit
is wi
thi
ntr
a oper
ati
ve conf
ir
mat
ion of
i
nfl
ammat
ion and/
orper
for
ated appendi
x dur
ing t
he st
udy per
iod wi
llbe
i
ncl
uded.

4.
4.2 Excl
usi
oncr
it
eri
a
Pat
ient
swi
thappendi
cit
iswhower
enotoper
atedf
oranyr
eason.
I
ncompl
eter
ecor
dwer
eal
sobeexcl
udedf
rom t
hest
udy.
4.
5.Sampl
esi
zeandSampl
ingt
echni
que

Al
loper
atedappendi
cit
iscasesdur
ingt
hest
udyper
iodwer
eincl
uded.

4.
5st
udyvar
iabl
es
Dependentvar
iabl
e

Per
for
atedappendi
cit
is(
yesorNo)

21|Page
I
ndependentvar
iabl
es

Age,sex,addr
ess,dur
ati
on ofi
ll
ness,pr
eoper
ati
ve t
reat
ment
,under
lyi
ng medi
cal
i
ll
ness,
previ
ousabdomi
nalsur
ger
y,pr
esenceoff
aecol
it
h.

4.
7.Oper
ati
onaldef
ini
ti
on

Dur
ati
onofi
ll
ness-
timei
nter
valbet
weent
heonsetofsympt
omsoft
hedi
seaseand
oper
ati
vei
nter
vent
ion

Lat
epr
esent
ati
on-casesofpat
ient
swhocamet
othehospi
talaf
ter48hour
sofonset
ofi
ll
ness.

4.
8Dat
acol
lect
ionpr
ocedur
eandt
ool

4.
8.1Dat
acol
lect
ion

Fi
rst
,thet
heat
reoper
ati
onandwar
dadmi
ssi
onr
ecor
dswer
erevi
ewedt
odevel
opl
ist
s
ofappendi
cit
iscasesorpat
ient
spr
esent
edandoper
ateddur
ingt
hest
udyper
iod.Then,
usi
ngt
hepat
ient
’scar
dnumberont
heoper
ati
onoradmi
ssi
onr
ecor
d,pat
ient
’scar
d
was soughtf
rom t
he hospi
tal
’s car
d of
fi
ce orr
oom.Fi
nal
ly,dat
a was col
lect
ed
(
ext
ract
ed)f
rom pat
ient
’scar
d,oper
ati
onr
ecor
dandadmi
ssi
onr
ecor
dusi
ngcheckl
ist
devel
opedf
ort
hispur
pose.

4.
8.2Dat
acol
lect
ors

Dat
acol
lect
ionwasunder
takenbyone1styearsur
gicalr
esi
dent
,onemedi
cali
nter
n
andoneBSCnur
seaf
tert
heywer
etr
ainedf
oronedayaboutcl
ini
calpr
esent
ati
on,

22|Page
compl
icat
ionandout
comeofappendi
cit
is,obj
ect
iveoft
hest
udy,var
iabl
esont
he
quest
ionnai
reandi
tsi
mpl
icat
ion.Then,t
heywer
eassi
gnedt
ofi
llt
hedat
acol
lect
ion
checkl
ist
.Al
ldat
acol
lect
ionact
ivi
ti
eswer
esuper
visedbyt
rai
nedsur
gicalr
esi
dent
s
andpr
imar
yinvest
igat
or.

4.
9.Dat
aqual
it
ycont
rol

Adequat
etr
aini
ngwaspr
ovi
dedf
ordat
acol
lect
ors,andt
hecompi
lat
ionf
ormatwas
pr
epar
edi
nsi
mpl
eEngl
isht
omai
ntai
ncl
ari
tyandeasi
erunder
standi
ngbyt
hosedat
a
col
lect
ors.

Dat
a waschecked f
orcompl
etenessand somer
epr
esent
ati
vecar
dswer
ecr
oss-
checkedbysuper
visorand/
orpr
inci
pali
nvest
igat
orf
orappr
opr
iat
eness.

4.
10.Dat
apr
ocessi
ngandanal
ysi
s

Thecol
lect
eddat
awaschecked,edi
ted,codedandent
eredi
ntoSPSSver
sion20.
0
sof
twar
eto be anal
yzed.SPSS dat
a was checked f
orer
rorand mi
ssi
ng val
ue.
Descr
ipt
ivest
ati
sti
csl
ikemeasur
eofcent
ralt
endencyandpr
opor
ti
onwer
ecomput
ed.
Fi
nal
lyt
heResul
tswaspr
esent
edi
nwr
it
tenf
orm,t
abul
ati
on&f
igur
ati
vepr
esent
ati
ons
f
rom whi
chconcl
usi
onandr
ecommendat
ionwer
emade.Resul
tswer
eal
socompar
ed
wi
thot
herst
udi
es&di
scussed.

4.
11Di
ssemi
nat
ionpl
an

Af
terr
esear
chcompl
eti
onandf
inal
izi
ngt
her
epor
t,t
hef
indi
ngoft
hest
udywi
llbe
di
ssemi
nat
edt
oal
lrel
evantst
akehol
der
sthr
oughPr
esent
ati
onandpubl
icat
ion.Copi
es
oft
her
esear
chwi
llbesubmi
tt
edt
oJi
mmaUni
ver
sit
y,JUSH,f
rom whi
chdat
awer
e
col
lect
ed,t
hemi
nist
ryofheal
thandot
herconcer
nedi
nst
it
uti
onsandst
akehol
der
sfor
possi
bleappl
icat
ionsoft
hest
udy.Theext
ractoft
her
esul
twi
llbepr
esent
edonannual
r
esear
chconf
erencesandpubl
ishedonsci
ent
if
icj
our
nal
sandr
esear
chpr
oceedi
ng

23|Page
4.
12Et
hicalconsi
der
ati
on

Ther
esear
chpr
oposalwassubmi
tt
edt
oJi
mmaUni
ver
sit
yEt
hicalRevi
ew Boar
dto
obt
ain et
hicalcl
ear
ance,and t
hen dat
a col
lect
ion was i
nit
iat
ed af
tera l
ett
erof
per
missi
on wasobt
ained f
rom t
heabover
esponsi
bleof
fi
cet
othehead ofeach
sur
gicalwar
d,Oper
ati
onr
oom headandRecor
dof
fi
ce.Thei
nfor
mat
iongat
her
edabout
t
hepat
ientwaskeptconf
ident
ial
.

Chapt
erf
ive:Resul
tsandDi
scussi
on

Resul
ts
Therewereat ot
alof246casesofappendi ci
ti
soper atedintheHospitalduri
ngthe
studyperi
odfrom September1/ 2012-sept ember 1/2015.From this,
recordsof184
pati
entswereavail
ableandi ncludedi nthestudy.InthisstudyMal econsti
tut
edthe
majori
ty130(70.
7%)andf emal e54( 29.3).Outof54f emales5oft hem werepregnant
and49wer enot.Theager angesf rom 5- 76yearswithmeanageof26. 40years.Most
ofthecaseswerefrom rur
al128( 69.6%)t hanurban56( 30.4%).

Tabl
e1.
Pat
ter
nofappendi
cit
isaccor
dingt
oage&sex

sex Tot
al
mal
e f
emal
e
1-10 14 16 30
Agei
nyear
s 11-60 106 36 142
>60 10 2 12
Tot
al 130 54 184

24|Page
Tabl
e2:Agedi
str
ibut
ionofcompl
icat
ionsamongt
hest
udyGr
oups.

Compl
icat
ions Tot
al

pneumoni
a at
elect
asi
s SSI i
ntra-
abdominal
coll
ecti
on

1-10 4 4 4 2 14
Ageina
11-60 7 1 21 1 30
year
61-76 3 0 1 5 9

Tot
al 14 5 26 8 53

Outof184cases26( 14.
1%)hadhi st
oryofpreviousabdomi nalsurger
ybutf ortherest
158(85.9%)thi
swast heirfir
stsurger
y.Theti
met akenbyt hepat i
entsbetweenonsetof
symptom andpr esentat
iont ohospit
alwaslesst hanorequalt o48hour sin79(42.9%)
cases,andgr eaterthan48hour s in105( 57.1%)cases.Thel eadi
ngpr e-operati
ve
diagnosiswassi mpleacuteappendicit
is104(56.5%)followedbyappendi cealabscess
29(15.8%),therestareper f
oratedappendi
xandgener ali
zedper it
oni
tissecondar yto
appendicit
isaccounti
ngf or28(15.
2%)and23( 12.5%)respectivel
y

Tabl
e3:Pr
e-oper
ati
vedi
agnosi
sasperdur
ati
onofi
ll
ness

pr
e- oper
ati
vediagnosis Tot
al
General
ized Acute Appendiceal Per
for
ated
per
it
oniti
s appendici
ti
s abscess appendix
=/<4
Durat
ionof 0 76 3 0 79
8
i
ll
nessinhour
>48 23 28 26 28 105
Tot
al 23 104 29 28 184

25|Page
Moret han halfoft he cases 99( 53.8%)had t aken pre-oper
at i
ve treatmentwi t
h
anti
biot
ics.91.8% ofthecasest ookpr ophylact
icant i
bioti
cs.Intraoper ati
vefindi
ng
i
ncludesi nfl
amedappendi x90( 48. 9%),per
foratedappendi x42( 22.8%),appendiceal
abscess29( 15.
8%)andgener al
izedper it
onit
issecondar yt oappendi citi
s23(12.5%).
Themaj ori
tyofthepat ient
s182( 98.9%)had taken postoper ati
vet r
eatmentwi t
h
anti
biot
ics.Onehundr edsixtyfi
vecaseswer estayedint hehospi talforlessthanor
equaltosevendaysther estni
neteenst ayedformor ethansevendays.

Outofonehundr
edei
ght
yfourcases,
fif
tyt
hreecasesdevel
opedcompl
icat
ion.Fr
om
t
hist
hel
eadi
ngcompl
icat
ionwer
esur
gicalsi
tei
nfect
ion26cases,
fol
lowedby
pneumoni
a14cases,
int
ra-
abdomi
nalcol
lect
ion8casesandat
elect
asi
s5cases.Ten
(
5.4%)casesdi
eddur
ingt
hepost
-oper
ati
veper
iodwhi
let
her
est174(
94.
6%)wer
e
di
schar
gei
mpr
oved.

Tabl
e3:Out
comedi
str
ibut
ionaspercompl
icat
ions

Out
come Tot
al
di
schar
ged di
ed
i
mpr
oved
Pneumoni
a 14 0 14

At
elect
asi
s 3 2 5
Compl
icat
ions
SSI 25 1 26

I
ntr
a-abdomi
nalcol
lect
ion1 7 8

Tot
al 43 10 53

26|Page
 Tabl
e4:
Dist
ri
but
ionofDur
ati
onofi
ll
nessvscompl
icat
ions

compl
icat
ions Tot
al
pneumoni
a At
elect
asi SSI i
ntra-
s abdominal
coll
ecti
on
Durat
ionof </=48 3 0 4 0 7
i
ll
nessinahour >48 11 5 22 8 46
Tot
al 14 5 26 8 53

Tabl
e5:Out
comeasperdur
ati
onofi
ll
ness

out
come Tot
al
di
scharged di
ed
i
mproved
=/<
Dur
ati
onofi
ll
nessi
n 48hr 79 0 79
s
ahour
>48hrs 95 10 105
Tot
al 174 10 184

Tabl
e6:Di
str
ibut
ionofagevsoutcome

out
come Tot
al
di
schar
gedi
mproved di
ed

1-10 26 4 30
nayear 11-60
agei 141 1 142
61-76 7 5 12
Tot
al 174 10 184

27|Page
Tabl
e7:P-
val
ueandX2ofvar
iabl
esassoci
atedwi
thout
come.

Var
iabl
e Out
come X2 p-
val
ue Df

I
mpr
oved Di
ed

sex mal
e 123 7 0.
002 0.
963 1

f
emal
e 51 3

pr
egnancy yes 5 0 0.
324 1
0.
569
No 46 3

Age 1-
10 26 4 40.
476 0.
000 2

11-
60 141 1

>60 7 5

Durat
ionof =/<48 79 0 7.
956 0.
005 1
i
ll
ness
>48 95 10

compl
icat
io yes 43 10 26.
137 0.
000 1
n
No 131 0

28|Page
Pre-op Yes 89 10 9.
079 0.
003 1
anti
biot
ics
No 85 0

Int
ra- Inf
lamed 90 0 58.
413 0.
001 3
operat
ive appendi
x
fi
nding
Perf
orat
ed 41 1
appendi
x

Appendice 29 0
alabscess

Gener
ali
ze 14 9
d
per
it
onit
is

Co- DM 4 3 24.
954 0.
001 2
morbi
dit
y
HI
V/AI
DS 2 1

No 168 6
comor bi
dit
yil
lness

Di
scussi
on

Appendici
tisi
sr ecognizedworldwi deast hecommonestsurgicalemergency.Prompt
decisi
onandur gentsur gi
cali
ntervent i
onprevent
scompl i
cat
ionanddeat h.Thepresent
studyanal
yzedt hethreeyearspr evalenceandoutcomeofper f
oratedappendixat
JimmaUni ver
sityspeciali
zedhospi tal.Ther
ewereat ot
alof246casesofappendi ci
ti
s
operat
edintheHospi talduri
ngt hest udyperi
odfrom Sept
ember1/ 2012-september1
/2015.Fr
om this,recordsof184pat ientswereavail
ableandincl
udedi nt
hest udy.

I
nthi
sst
udyMal
econst
it
utedt
hemaj
ori
ty130(
70.
7%)andf
emal
e54(
29.
3).Outof54

29|Page
females5ofthem werepregnantand49werenot
.Theagerangesfrom 5-76year
s
withmeanageof26. 40years.Mostoft
hecaseswer
efrom r
ural128(69.
6%)than
urban56(30.
4%).

Appendici
tisisf
oundi nallagegroupswhi chisinagr eementwithot herstudi
es.Inthe
studybySaundaRBandOmarEi nSeptuangenar ian(3)t heagedistri
butionranges
from 3t
o78year sandt hemeanwas17. 2year s.Simi l
arl
ystudydonei nourcountryby
Zelal
em A(6)inYir
galem Hospi t
alsout
her npar tofEthiopiashowst hattheager ange
was4t o69years,themeanbei ng8year s.Accor dingt othi
sstudyappendi cit
isis
foundtohavehighestincidenceinmales( 70.7%)whi chisconsist
entwi t
hmany
studi
es(3,
4and7)showi ngmalepredomi nancef orwhi chnoappar entexplanati
on
couldbegiven.

Outof184cases26( 14.1%)hadhi st
oryofpreviousabdominalsur ger
ybutf ort
her est
158( 85.
9%)thiswast heirfi
rstsur
gery.Theti
met akenbythepatientsbetweenonsetof
sympt om andpr esentati
ontohospi t
alwaslesst hanorequalto48hour si n79(42.
9%)
cases,andgr eaterthan48hour si n105(57.1%)casessi milarwi t
hst udydonei n
EthiopiabyBi r
hanuK. (
7)wher ethemajori
ty(68.2%)ofpatient
scamet ot heHospit al
within48hour sofonsetofsympt oms.Otherst udiesdoneinot herpartofAfri
caal so
showedsi milarresult
s(3,9and11) .

The leading pr
e-oper
ati
ve di
agnosisi nthis st
udywas simple acute appendi
citi
s
104(56.5%)foll
owed by appendicealabscess 29(15.
8%),the restare perfor
ated
appendix and general
ized per
it
oniti
s secondaryt o appendi
cit
is accounti
ng for
28(15.2%)and23( 12.
5%)respect
ivelywhichshowedhi gherrat
eofper f
orat
ionand
peri
toniti
sinthi
sstudycompari
ngt ootherst
udies(
1,24and6).

Moret han hal

foft he cases 99(53.
8%)had t
aken pr
e-operat
ive t
reat
mentwi th
ant
ibi
oticsf
ordiagnosi
sothert
hanappendixatHeal
thCent
erand/orDi st
ri
ctHospit
al
whichisincontrastt
ootherstudieswher
emisdi
agnosi
swasl essthan20%(1,2,3,
6,
and8).

Intr
aoperativefindingincludesinf
lamedappendi
x90(48.9%),perf
oratedappendi
x
42(22.
8%),appendi cealabscess29(15.
8%)andgener
ali
zedper i
toni
ti
ssecondaryto
appendici
ti
s23( 12.5%),
whichshowedhigherr
ateofper
forat
ionandper i
toni
ti
sinthi
s
studycompar i
ngt ootherstudi
es(
1,24and6).

Almostallpati
ents182(
98.9%)hadtakenpostoper
ati
vet
reat
mentwi
thant
ibi
oti
cs
whichwasalsorout
inei
notherst
udi
es(1,2,
3,
5,
7and11).

30|Page
Outofonehundr
edei
ght
yfourcases,
fif
tyt
hreecases(
26.
5%)devel
opedcompl
icat
ion
whi
chi
shi
ghert
hancompl
icat
ionobser
vedi
not
herst
udi
esdonei
nthecount
ryand
abr
oad(
3,5,
6).Fr
om t
hist
hel
eadi
ngcompl
icat
ionwer
esur
gicalsi
tei
nfect
ion26
cases,
fol
lowedbypneumoni
a14cases,
int
ra-
abdomi
nalcol
lect
ion8casesand
at
elect
asi
s5cases.Ei
ght
ysi
xpoi
ntei
ghtper
cent(
86.
8%)ofcompl
icat
ionoccur
redi
n
t
hosepat
ient
swhocamel
ate(
aft
er48hour
sofonsetofsympt
oms)andi
nthet
wo
ext
remesofage(
lesst
han10year
sandgr
eat
ert
hansi
xtyyear
sofage)
,si
mil
arf
indi
ng
accor
dingt
othest
udydonebyBi
rhanuK.i
nBl
ackLi
onHospi
tal
,Et
hiopi
a(7)
.
Ten(
5.4%)casesdi
eddur
ingt
hepost
-oper
ati
veper
iodwhi
let
her
est174(
94.
6%)wer
e
di
schar
gei
mpr
oved.Themor
tal
it
yrat
eobser
vedi
nthi
sst
udyi
sal
mostsi
mil
arwi
th
t
hatofst
udydonebyZel
alem A.
(5.
2%)whi
chwasdonei
nYi
rgal
em Hospi
tal,
sout
her
n
Et
hiopi
a(6)
.Buti
tishi
ghert
hant
hemor
tal
it
yobser
vedi
not
herst
udi
esdonei
nthe
count
ryaswel
lasot
herpar
tsofAf
ri
ca(
1,2,
3,
4and9)
.Al
lthedeat
hoccur
redi
npat
ient
s
whocameaf
ter48hour
sofi
ll
nessand90%occur
redi
nthet
woext
remesofage(
40%
i
nunder10year
sand50%i
npat
ient
sol
dert
han60year
s)maki
ngl
atepr
esent
ati
on
andext
remesofagei
ndependentr
iskf
act
orf
ordeat
h.Thesamei
str
ueaccor
dingt
o
t
hef
indi
ngofSaudaRB,
OmarE,
studydonei
nsept
uagenar
ian(
3).

Ther
eissi
gni
fi
cantassoci
ati
onbet
weenage,
dur
ati
onofi
ll
ness,
preoper
ati
ve
t
reat
mentwi
thant
ibi
oti
cs,
int
raoper
ati
vef
indi
ng,
co-
mor
bidi
tyandout
comeaccor
ding
t
othi
sst
udy.Agehasst
rongassoci
ati
onwi
thout
come(
X-squar
e40.
476,
P-val
ueof
0.
000andDf2)
.Thi
sisi
nconsi
stentwi
thst
udydonei
nSudanbyAhmedM (
10)
.
Dur
ati
onofi
ll
nesshasal
sost
rongassoci
ati
onwi
thoutcome(
X-squar
e7.
956,
P-val
ue
0.
005andDf1)
.Int
hisst
udyal
lthemor
tal
it
ywer
einpat
ient
swhocamel
ate(
aft
er48
hour
s)whi
chwasal
soobser
vedi
not
herst
udi
esdonei
nthecount
ry(
3,4,
5,
6).Pr
e
oper
ati
vet
reat
mentwi
thant
ibi
oti
csduet
omi
sdi
agnosi
satHeal
thcent
erand/Di
str
ict
Hospi
tali
sot
hervar
iabl
esi
gni
fi
cant
lyassoci
atedwi
thout
come(
X-squar
e9.
079,
P-
val
ue0.003andDf1)
Inthi
sst udyi
ntr
aoper
ati
vef
indi
ngobser
vedwer
einf
lamedappendi
x90(
48.
9%)
,
per
for
ated appendi
x 42(
22.
8%)
,appendi
cealabscess 29(
15.
8%)and gener
ali
zed
per
it
oni
ti
ssecondar
ytoappendi
cit
isandt
her
ewassi
gni
fi
cantst
ati
sti
calassoci
ati
on
bet
weeni
ntr
aoper
ati
vef
indi
ngsandout
come(X-
squar
e58.
413,
P-val
ue0.
003andDf

31|Page
1)
.Themaj
ori
tyofdeat
hswer
ein pat
ient
spr
esent
ed wi
th gener
ali
zed per
it
oni
ti
s
secondar
ytoper
for
atedappendi
x,casesal
soobser
vedi
not
herst
udi
es(
8,9,
12)
.

Themaj
orco-
mor
bidi
tyobser
vedi
npat
ient
swhower
eunder
goneoper
ati
onf
orcases
ofappendi
cit
iswer
etypeI
IDM andHI
V/AI
DSwi
thst
rongassoci
ati
ononout
comeof
t
hepat
ient
s(X-
squar
e24.
954,P-
val
ue0.
001andDf2)
.Thr
eeoutoft
het
endeat
hs
occur
redi
nthosewi
thco-
mor
biddi
sease.

Chapt
ersi
x:Concl
usi
onandRecommendat
ion

Concl
usi
on
Acut
eappendi
cit
isi
scommoni
nourl
ocal
it
y,t
hepr
esent
ati
onandout
comei
snot

32|Page
di
fferentfrom theobservationofot
herresear
chersi
nthedevelopingworld,
butlate
presentati
on,hi gherr
atesofcomplicat
ionsanddeathsar
eobser vedinourarea.
Accor di
ngt othisstudy,therear
esever
alvari
ablest
hatarepredicti
veofpooroutcome
i
npat ientswithappendi cit
is.

Latepresent
ati
on,extr
emisofages,pr
eoperat
ivet
reatmentwithanti
biot
icsdueto
wrongdiagnosis,
present
ati
onwithgener
ali
zedperi
tonit
isandpresenceofcomorbid
condit
ionli
ketypetwoDM andHI V/
AIDSarethemostpr edi
cti
veofdeath(p<0.05for
each).

Theexactr easonsforthesedelaysrequi
ref
urtherinvesti
gat
ion.Heal
th-seeki
ng
behaviouriscompl exandisinfl
uencedbyruralpovertyandremotenessaswel las
cul
turalissuessuchast hereli
anceont r
adi
ti
onalheal er
sasapr i
marysour ceofcare
andheal thadvice.

However ,f
ail
ureofcl
inicalr
ecognit
iononcecontactwitht
hehealthsystem hasbeen
madef oll
owedbydel aysintransf
erforsurger
ytotheregi
onalhospi
talarefai
li
ngsof
thehealthsystem.I
ntervent
ionisurgentl
yneededtoimprovetheoutcomesofacut e
appendicit
is.

33|Page
Recommendat
ions

Ist
rongl
yrecommendt
hef
oll
owi
ngt
otheconcer
nedbodi
es:

Allhealt
hprofessi
onalswor ki
ngathealt
hcenter
s,pri
vatecl
inicsand/orpri
mary
hospital
stohavehi ghindexofsuspi
cionofacuteappendi
cit
isinallpat
ient
spresent
ed
withacuteabdomi nalpainandtoref
erthem ur
gentl
yforsurgeonsopinionift
he
di
agnosi sofacuteappendicit
isi
sli
kel
y.

JimmaUni ver
sit
y,col
legeofMedicalandHealt
hscienceincoll
abot
ionwithj
imma
zonalhealt
hBureaustoarrangetr
aini
ngonhowt oapproachtopati
entswith
suspectedappendi
cit
isforheal
thworkerspr
acti
cingintheheal
thcenter
sandpri
mar
y
hospit
als.

Oromiaheal
thBureausincol
labot
ionwit
hJimmazonalheal
thbur
eaustoincr
ease
heal
thseeki
ngbehavioroft
hepopulat
ionbycr
eat
ingawarenesst
hroughusi
ngsocial
mediasl
ikeFM Radio.

34|Page
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atedAppendi
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it
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ri
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kD.
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if
yingt
hedi
spar
it
yinout
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ient
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thacut
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cit
isi
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hAf
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i rMedJ2013;
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:742-
745.

35|Page
36|Page