Acute appendicitis
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Date
2013
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Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader
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•51• Chapter 5 Acute Appendicitis S.B. Naaeder, J.N. Clegg-Lamptey and J.C.B. Dakubo Introduction In 1886 Reginald H. Fitz first described appendicitis in his presentation titled “Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment” to the first meeting of the Association of American Physicians in Washington DC1 . He coined the term appendicitis to distinguish it from other inflammatory conditions in the region of the caecum such as typhilitis and perityphilitis. This was followed by Charles McBurney’s description of his classical sign in the diagnosis of acute appendicitis in 18892 . Appendicitis is now the most common intra-abdominal emergency surgical condition worldwide. It has been postulated that acute appendicitis is the first serious disease to emerge following dietary modification with the adoption of fibre-depleted diets. In 1920 Rendle Short propounded the hypothesis that the rise in the incidence of acute appendicitis in western populations was primarily due to the substitution of high-residue diets with refined low-fibre diets.3 This concept was popularized by Dennis Burkitt4 who reviewed all the available epidemiological and experimental evidence and concluded that undue refining of dietary carbohydrate was the most important causative factor of acute appendicitis, diverticular disease and large bowel cancer. He noted the rarity of these large bowel diseases in African populations who consumed diets high in fibre and the high incidence of these diseases in populations living on low fibre diets.4 The incidence of acute appendicitis is rising in Africa and this has been attributed to socio-economic advancement with its accompanying life-style changes and adoption of low-residue diets. However, current evidence suggests that low-residue diet may not be the important aetiological factor in acute appendicitis as has been postulated. This is •52• Chapter 5 because, in Africa, patients with acute appendicitis consume traditional high -residue diets and urbanization has been shown to have no effect on the dietary fibre intake and bowel function of Africans5 . Incidence There is considerable variation in the incidence of appendicitis all over the world. The disease is common in western nations but much less so in developing countries, however, this is changing. Recent reports suggest that the incidence of acute appendicitis is declining in the developed world. The reason for this decline is not clear but it has been suggested that this may be related to an increase in dietary fibre intake in these populations6 . Between 1989 and 2000 the age-standardized hospital admission rates for acute appendicitis in England was noted to have decreased by 12.5 per cent in males and 18.8 percent in females7 . In the USA the incidence of appendicitis decreased by 14.6 per cent between 1970 and 1984.6 All reports on acute appendicitis were unanimous that acute appendicitis was rare in Africa six to seven decades ago.8,9 This is no longer the situation as the incidence of the disease has been increasing progressively ever since. Adekunle O.O et al. reported a progressive increase in the annual incidence of acute appendicitis in Nigeria between 1973 and 198310 . Similar trends have been reported in both rural and urban communities in Ghana11-15 and other parts of Africa.16-17 Acute appendicitis was uncommon in Ghana in the 1940s; by 1966 the annual incidence was 2.2 per 10,000 population.12 This rose to 2.63 per 10,000 population by 197113 and currently the reported annual incidence of acute appendicitis is 3.18 per 10,000 population.14 This is still lower than the annual incidence rate of 11 per 10,000 population reported in the USA with an even higher rate (25 per 10,000 population) in the young (10-19 years).6 Acute appendicitis is now the leading cause of the acute abdomen in Africa including the West African sub-region18-21 . Aetiology of acute appendicitis The cause of appendicitis has been attributed to a number of factors. Diets low in residue have been blamed4 but studies in Ghana have disputed this notion.5,22 These studies noted that urbanization had •53• Acute Appendicitis no effect on the dietary habits of Ghanaians and that dietary fibre intake was high in patients with acute appendicitis. Gelfand found that patients admitted with acute appendicitis in Africa followed a traditional diet.23 Appendicular luminal obstruction is thought to initiate the inflammatory changes associated with acute appendicitis. The obstruction is by a faecolith in...
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Keywords
Acute appendicitis, vermiform appendix, Large bowel cancer