Original article

Clinical correlation of acute appendicitis with histopathological diagnosis: a prospective study

Joshi B R*, Manandhar K**,

Abstract
Background: Acute appendicitis is one of the commonest causes of acute abdomen in ER, which is mainly diagnosed in clinical ground. The objective of the study was to determine the diagnostic accuracy in patient of acute appendicitis. Material and Method: A prospective study conducted at NAMS, Bir hospital; with 100 subjects presented with acute abdomen and clinically diagnosed as acute appendicitis. Emergency appendectomy was done in all consecutive subjects and intra operative finding along with histopathological reports were compared with clinical diagnosis. Results: On the basis of histopathological report, 86% were found to have acute appendicitis with misdiagnosis in rest of the subjects requiring unnecessary explorations. Conclusion: Clinical surgical skill is good enough to diagnose acute appendicitis when auxiliary diagnostic tools are not available to elevate the diagnostic accuracy. Key words: acute appendicitis, clinical diagnosis, negative exploration

Introduction
Acute appendicitis is still one of the commonest causes of acute abdomen with surgical emergencies in emergency department. Though the surgeons have been confronting the acute appendicitis since its first described in 1886 by R H Fits1, its diagnosis is still remains a dilemma to almost all of the surgeons, at least some point in their practice. Since observations is not an ideal option once the cause of acute abdomen is due to the inflamed appendix, as it can be followed by various serious complications hindering the morbidity and mortality rate, the surgeons prefer to proceed either to observe the subject until the signs and symptoms make the diagnosis confidently clear or by immediate operation as soon as the diagnosis of acute appendicitis is made. To overcome with the problem of misdiagnosis resulting to complications like perforation and sepsis; and unnecessary surgical interventions as well, superior clinical judgment got no alternatives. With objectives of improving the clinical judgments, various clinical scoring systems along with some computer assisted diagnostic tools have also been invented till this date, but none of them seem accurate enough to rely on. Nevertheless, these tools definitely helped to junior surgeons, whos diagnostic accuracy reported to be increased from 58% up to 71%.2 These supplementary diagnostic tools, which are never 100% accurate, though can help in diagnosing the case may not always be available, specially

*Unit chief, Urology Unit, NAMS, Bir Hospital **Registrar, Urology Unit, NAMS, Bir Hospital

at night time and district hospitals. In addition to that, the vagaries of its presentation and the variability of signs are such that even the most experienced surgeons may remove normal appendixes or sit on those that have perforated, always making them less than perfect in their entire carrier. Therefore, this prospective study was conducted to analyze the accuracy of clinical diagnosis made by surgeons without relying on supplementary tools in acute appendicitis.

appendectomy was taken for the study proper and emergency appendectomy was done by surgical team on duty. Intra operative findings like location, morphology, perforation status of the appendix etc. were recorded and appendix was removed and sent for HPE in all the study subjects, including clinically normal looking appendix. HPE report, which was taken as final diagnosis, once was made available, result s were compared wit h clinical presentation and intra operative findings and study was analyzed.

Methods
The entire patient presented to emergency department, NAMS from January July 2007, consulting for acute abdomen and admitted to surgical department with provisional diagnosis of acute appendicitis were included in the study. A good clinical history and proper physical examination was performed on all the subjects admitted. Clinical history focusing on describing the abdominal pain, nausea/vomiting and anorexia and fever were made. History of similar pain in the past and LMP in female subjects were also extracted. Physical examination was started from vital signs including temperature and detailed abdominal examination was carried our giving special attention to right lower quadrant, point of maximum tenderness, rebound tenderness and muscle guarding. Sings like Dumphys sign, Psoas sign, Obturator sign and Rovsing signs were also evaluated and systematically recorded in a performa. Some subjects requiring additional period of observation were reevaluated frequently and finding were recorded accordingly. No any additional diagnostic tools were done unless indicated for other medical purposes other than diagnosing for acute appendicitis. All the patient who finally diagnosed clinically as having acute appendicitis were planned for emergency open appendectomy and patient counseling was carried out. All subjects were explained clearly beforehand for the least possibility of misdiagnosis resulting to negative exploration and other differentials as a universal rule in acute appendicitis. Consent was secured and one hundred consecutive subjects giving consent for emergency

Results
Total of one hundred subjects were studied. Out of which, 68% were male of mean age 2710.2 and 32% were female of mean age 30.211, with their age ranges from 16 to 62 years (mean age of 2810.5). Since this hospital has no pediatric surgery department, no pediatric subjects were included in this study. On gross examination of the specimen intra operatively, 9% was diagnosed to have normal appendix, with 91% grossly looking appendicitis at their various stages of inflammation like acutely inflamed (70%), gangrenous (19%) and perforated (2%). On the basis of gross examination of the specimen intra-operatively, the rate of negative exploration for the cases of acute appendicitis seems only 9%. Diagram No. 1: Intra operative diagnosis of the patients with clinical features of acute appendicitis

However, according to the histopathological examination report of the specimen, which is considered as the final definitive diagnosis, 14 % found to have normal appendix with 86% of appendicitis at their various stages of inflammation.

Diagram No. 2: Histopathological diagnosis of the patients with clinical features of acute appendicitis

Among the patients who underwent to negative exploration for acute appendicitis, no other surgical problems requiring immediate intervention was encountered and were treated accordingly following the appendectomy. In comparing the intra-operative diagnosis with the histopathological diagnosis, there is a good correlation in between (p=0.0002), where the accuracy rate in diagnosing the acute appendicitis by examining the gross specimen intra operatively is 91%. Table No. 2: Correlation between intra operative and HPE diagnosis
Intra operatively Acute appendicitis Normal appendix Total Histopathology Acute Normal appendicitis appendix 84 7 2 7 86 14 Total 91 9 100

Most of the cases of acute appendicitis belonged to the adolescent age group i.e. 15 25 years, for both the sexes. Though the negative exploration was found in various age groups in both gender, mostly female subject of child bearing age (21 35 years) were subjected the most. The sex distribution of the acute appendicitis seems higher in male in compare to female, with male to female ratio of 2.9: 1. But, statistically, gender has no significant predilection to the acute appendicitis. Since all of the subjects studied were initially diagnosed as the case of acute appendicitis, the over all negative appendectomies in male gender was found to be 6% (4/64) and that was relatively high in female subjects (10/22), comprising of 31%. Therefore, the diagnostic accuracy in case of male subjects seems to be highly significant in compare to that in female subjects (p=0.001) Table No. 1: Age and Sex distribution of the patients diagnosed as normal appendix and acute appendicitis by HPE
Age 15-20 years 21 25 years 26 30 years 31 35 years 36 40 years 41 45 years 46 50 years 51 55 years 56 60 years > 60 years Normal Appendix by HPE Male Female 1 0 0 2 0 2 0 3 1 0 1 0 0 1 0 2 0 0 1 0 Appendicitis by HPE Male Female 20 7 20 4 5 3 12 5 3 0 0 0 3 3 0 0 0 0 1 0

OR = 42.0, 95% CI (5.97, 447.67), p<0.0001, sn= 97.7, 91.1, 99.6, sp= 50.0, 24.0, 76.0 ppv= 92.3, 84.3, 96.6, pv=77.8 ,40.2, 96.1 False positive rate = 50.0%, False negative rate = 2.3% Accuracy rate = 91.0% Discussion Out of one hundred subjects clinically diagnosed as acute appendicitis and explored, 86% were confirmed histopathologically giving our clinical diagnostic accuracy rate of 86%. The negative exploration rate of 14% determined in this study is in accordance with other studies showing the ranges from 15 30 %.3 Since the diagnosis of acute appendicitis was made purely in clinical ground, its accuracy varies according to the patient population as well as the experience of surgeons. The accuracy further improves in young adult males but considerably poor at the extreme of ages. The achievement of significantly high diagnostic accuracy rate in the present study is mostly due to covering adult population rather than subjects from extreme of ages. In this study, most of the subjects belong to the adolescent age group of 15 25 years (59%), indicating its higher prevalence in young adults. In comparative international studies,

up to 90% of the cases were belong to the age group of 10-30 years.4,5,6 The male to female ration in the present study is 2.9:1, which is in accordance with the other similar studies.7,8,9,10,11 The exact cause of male preponderance in these studies is not known. It has also been proven that, though the prevalence of acute appendicitis in adult females is less, there will be a greatest diagnostic challenge at their child bearing age, especially in the mid portion of menstrual cycle.12 Because of the various additional possible pathological states that mimic acute appendicitis in female, the rate of negative exploration also suits high. All these facts therefore ultimately provide higher diagnostic accuracy in male subjects than to its counter part. In the present study also, as all of the subjects operated had already been diagnosed clinically as acute appendicitis and final diagnosis was obtained from pathological specimen, the clinical diagnostic accuracy in male subjects 94% (64/68) seem to be highly significant (p=0.001) in compare to that of female 69% (22/32) subjects. Therefore, the normal appendicectomy rate in the present study was found to be higher in females (31.0%) in compare to that in males (6.0%), which is in agreement with the study done by Anderson et al 13, where the rate of normal appendix being removed was twice (24%) higher in women than in men 12%. In reducing the rate o f negative exploration, it is important for an operating surgeons to diagnose the case of acute appendicitis clinically as well as intra operatively. Surgeon can only be fully satisfied when the inflamed appendix was found to be the cause for the patients symptoms. If not other intra abdominal pathology should be explored for, unnecessarily elevating the degree of morbidity and mortality. Therefore, the association in between the intra operative diagnosis for acute appendicitis with the histopathological report was also evaluated, which was found to be statistically significant (p=0.0002). The accuracy of intra operative diagnosis in this study is 91%, with sensitivity

and specificity of 97.7% and 50% respectively, which is superior in compare to the similar studies done by Tiwari A et al 14 and Shum CH15, where it was only 76% and 85% respectively.

Conclusion
Diagnosis of acute appendicitis is primarily clinical and should be made confidently with proper history and thorough physical examination on the basis of clinical symptoms and signs. Though, there are v ario us supplementary laboratory investigations and diagnostic tools to aid in its diagnosis, none of them seems accurate enough and might not be available all the time as well. If the diagnosis is made on the basis of good clinical history and thorough physical examination, with repetition if necessary, satisfactory result of international standard can be achieved. Therefore, none of the diagnostics laboratory tests available at present day seem can replace the clinical skills of an experienced surgeon. References 1. G Rainey Williams. Presidential address: A history of appendicitis. Annals of Surgery; 1983;197 (5): 495-506. 2. McAdam WA, Brock BM, Armitage T, et al. Twelve years experience of computer aided diagnosis in a district general hospital. Ann R Coll Surg 1990; 72: 140 146. JuanCarlosRodrguez-Sanjun, Martn-P, IsabelS, LuisG and AngelN. C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children. Diseases of the Colon & Rectum 1999; 42(10):325-132. Adesunkanmi AR. Acute appendicitis: a prospective study of 54 cases. West Afr J Med 1993; 12(4): 197-200. Amir M, Shami IH. Analysis of early appendicectomies for suspected acute appendicitis. A prospective study. J Surg PIMS 1992; 3-4: 25-28.

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