Acute appendicitis in the developing world is a morbid disease

Abstract

INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile to that in the developed world. METHODS A retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis. RESULTS A total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%.Rural patients had a longer median duration of illness (3 vs 5 days, p<0.001) as well as a more advanced disease profile associated with perforation and severe intra-abdominal sepsis (19% vs 71%, p<0.001). Female patients had a longer median duration of illness (3 vs 4 days, p<0.001), were more likely to present with severe intra-abdominal sepsis (31% vs 54%, p<0.001) and were more likely to require a laparotomy (50% vs 73%, p<0.001). The total cost of managing the entire cohort of 1,004 patients over the 4-year period was £2,060,972. CONCLUSIONS Acute appendicitis in South Africa is a serious disease associated with significant morbidity. Late presentation is common. Female and rural patients have the worst clinical outcomes, with significant cost to the health system.

The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa

“…[16] The severity of acute appendicitis in SA has been well described in the literature, and appendicitis in SA carries significantly higher morbidity and mortality than in the developed world, primarily as a result of delayed presentation and poor access to healthcare. [17][18][19] Patients generally present with more advanced disease than in HICs. Similarly, complicated peptic ulcer disease is rarely seen in HICs, where there is ready access to drug therapy and endoscopy services.…”

Incidence of complicated acute appendicitis: a single-centre retrospective study

“…Other reasons exist. First of all, delays in the diagnostics due to the additional wait before seeking medical attention by patients and their caretakers, as well as the failure to diagnose appendicitis by the primary care physicians, and lastly the delayed referral to paediatric surgery departments [19][20][21].…”

Increased anatomic severity in appendicitis is associated with outcomes in a South African population

“…The relaparotomy rate of 53% is elevated. In the South African cohort, delayed presentation with late pathology and advanced physiologic insult are much more common compared with data from the developed world (6,18). Relook laparotomy is usually broadly divided into two approaches either planned or on demand.…”

“…Due to late presentation and increased severity of intra-abdominal contamination, the threshold for relook is often much lower for this cohort. The need for repeat laparotomy in the South African setting is previously reported extensively (6–7, 18–20). Currently, the South African authors follow an on demand approach and have a low threshold for repeat surgery.…”