Microsoft Word - GJPHM-2019- perforated appendecitis.docx 90 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo THE INCIDENCE OF PERFORATED APPENDICITIS AMONG PEDIATRIC PATIENTS IN KHARTOUM NORTH TEACHING HOSPITAL, SUDAN Ibrahim Salih Elkheir1, Mohammed Altyb Alshykh2, Ayman Gafer Mustafa3 1 Consultant of paediatric surgery, head of the department of paediatric surgery in Khartoum North Teaching Hospital and associate professor of paediatric surgery Alzaiem Alazhari University –Sudan. 2 MBBS, Alzaiem Alazhari University –Sudan. 3 MBBS, Alzaiem Alazhari University –Sudan. Corresponding author: dr.ibrahim5@hotmail.com ABSTRACT Introduction: Acute appendicitis is a common emergency condition in paediatrics with different ages. The perforated appendicitis is one of the most serious complications of acute appendicitis which may lead to peritonitis. The aim of our study is to calculate the incidence of perforated appendicitis. Methods: This is a retrospective cross-sectional study has been conducted at Khartoum north teaching hospital. The total number of patients was 214. Results: the most common age in this study are 13 years old and the mean age is 11 years, 128 of cases were male 59.8% and 86 were females 40.2%. All cases of our study presented with fever 100%, 80.8% presented with right iliac fossa pain, and anorexia 100%. 50.5% of cases came within the first day of presentation and 26.6% of cases came in 4th day of presentation, all cases presented with right iliac fossa tenderness, 15.9% of cases presented with perforated acute appendicitis, 67.29% of cases operated after 6 hours, 5.61% operated in more than 6 hours and 27.1% operated after 6 weeks. Conclusion: In this study the incidence of perforated acute appendicitis was 15.9% which is low in comparison with another study because there was no delay in appendectomy operation and the majority of patients came within the first day of the disease. Keywords: Incidence, Perforated Appendicitis, Paediatrics, Sudan. 91 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo Introduction Acute appendicitis is a common paediatrics surgical emergency, the admissions is about 1- 2% of all paediatric surgical conditions (Almaramhy, 2017) . The severity of acute appendicitis was classified as uncomplicated disease or complicated disease (perforated acute appendicitis, appendicular abscess) (Omling et al., 2019) or inflammatory mass (Guidaa et al., 2015). The diagnosis of this condition is challenging because of its symptoms are similar to another diseases such as gastroenteritis in which the patients presented with abdominal pain, vomiting nausea, diarrhea, or fever (Wang et al., 2019) . Or omental infarction(Yang, 2010) which presented with the same symptoms of acute appendicitis. The classic presentation of symptoms are not usual in children (Becker & Bachur, 2007). The children have the higher rate of perforation, rather than the adults. (Jha et al., 2017) The rate of treated perforated appendicitis about 37% among children(Turela et al., 2019). In age of less than 5 years the rate of perforation is 30%. The rate of missed and delayed diagnosis in older paediatrics about 28% to 57% (Çelik et al., 2019). The perforation is define as a fecalith in the abdomen or hole in the appendix (Peter et al., 2008 ). The delayed of treatment of acute appendicitis will lead to progression of the disease to perforation which can cause complications such as peritonitis, abscess and partial bowel obstruction and this complications increase the rate of morbidity and mortality (Ngim, 2014). The diagnosis of acute appendicitis by: 1-Clinical examination (Groselj- Grenc et al., 2007), 2-Or by using imaging ; in the case of children we request abdominal ultrasound U/S rather than computed tomography CT scan but the uses of it is less due to risk of exposure to ionizing radiation (Phalke & Das, 2018) 3-and other laboratory investigations such C- reactive protein CRP, white cell count and bilirubin (McGowan et al., 2013). The treatment of acute appendicitis are laparoscopic or open appendectomy. However, the role of laparoscopic appendectomy is controversial in management of complicated appendicitis in paediatrics (Tsai et al., 2012 ). In new study; uncomplicated acute appendicitis may treated non-operatively and the patients get the clinical recovery after received of antibiotics (Knaapen et al., 2019). Post- operatively all patients with perforated acute appendicitis must receive intravenous antibiotics for 5 days minimally. (St. Peter et al., 2008). The aim of this study is to calculate the incidence of perforated appendicitis in Khartoum North Teaching Hospital. Methods This is a retrospective cross-sectional study at Khartoum North Teaching Hospital which is the one of reference hospital in Sudan and it placed in Bahri city. We was studied 214 patients who came with acute appendicitis which is one of the most common emergency condition in the paediatric surgery department. Some of the data were collected from the record of patients who were operated and some from new patients came to us then diagnosed as acute appendicitis cases and was operated. Duration of this study from November 2018 to August 2019. When the patients come to our emergency we take the history; assess and analyse the symptoms of acute appendicitis such as periumbilical pain, Right Iliac Fossa pain (RIF), nausea, vomiting, anorexia, fever, dysuria and, changes of bowel habits and previous history of similar abdominal pain; and the duration of all this symptoms. Then we do the examination; firstly general examination such as temperature, pulse rate... etc. secondly abdominal examination searching for RIF tenderness and rebound tenderness. Then we do the investigations like Complete Blood Count CBC, Urine analysis and sometimes we need to do imaging to support our diagnosis using abdominal ultrasound or computed tomography CT scan. And we followed our patients after the operation until get well then discharged them and must be followed in refer clinic. The data have been collected by questionnaires and was analysed by SPSS application. We was consent all new patients and explained to them all the information will be kept in privacy and consent the hospital for collect the data from records. 92 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo Results The most common age of cases were 13 years old which about 35.5 % and the mean age is 11 years. 59.8% of cases are male and 86 are females 40.2%, 52% of cases came from alhag yousif city. 15.9% of cases presented with perforated acute appendicitis, 18.7% presented with appendiceal abscess, 27.1% presented with appendiceal mass and 38.3% presented simply to moderately inflamed appendix (Table 1). All cases of our study presented with fever 100%, about 78% of cases presented with vomiting, 80.8% presented with right iliac fossa pain, 56.5% presented with periumbilical pain, 35.5% the pain shifted to the right iliac fossa but 64.5% of cases the pain was not shifted, 93.9% of cases have no history of similar abdominal pain. All cases presented with anorexia 100%, 31% of cases presented with diarrhoea, 7.9% came with constipation and 77% of cases presented with no change in bowel habits (Table 2). All cases presented with RIF's tenderness, 58.9% of cases presented with rebound tenderness and the mean body temperature about 37.4 (17%). 88.8% of cases were received samixone (ceftriaxone) and 6.1% of cases were received samixone and Diclofenac sodium injection. The mean TWBCS in our patients with perforated appendicitis was 18 x103/uL (5.09%), mean platelets values 324.6 x103/uL (91.65%) and mean hemoglobin value 11.5 mg/dl (3.26 %) (Table 3). 50.9% of cases have been diagnosed without imaging, 40.2% of cases have been diagnosed with the US and 8.9% of cases have been diagnosed with CT scan (Table 4). 67.29% of cases operated within the first day of admission, 5.61% operated in the second day of admission and 27.1% operated after 6 weeks which explain the percentage of appendicular mass. Table 1: Socio-demographic data of the cases and the types of acute appendicitis Variables N % Age 9 years 15 7.0 11 years 70 32.7 12 years 53 24.8 13 years 76 35.5 Gender Male 128 59.8 female 86 40.2 Types of appendicitis Simple to moderate 82 38.3 Appendiceal mass 58 27.1 Appendiceal abscess 40 18.7 93 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo Table 2: Symptoms of acute appendicitis Symptoms Yes No N % N % Anorexia 214 100% 0 0% Nausea 87 40.7% 127 59.3% Vomiting 167 78.0% 47 22.0% Fever 214 100.0% 0 0.0% Dysuria 0 0.0% 214 100.0% abdominal pain (RIF) 173 80.8% 41 19.2% periumbilical pain 121 56.5% 93 43.5% Shifting 76 35.5% 138 64.5% History of similar pain 13 6.1% 201 93.9% No history of similar pain 201 93.9% 13 6.1% Diarrhoea 31 14.5% 183 85.5% Constipation 17 7.9% 197 92.1% No change in bowel habits 166 77.6% 48 22.4% Table 3: Findings on examination specific to acute appendicitis, Antibiotics was used and investigations Variables N % Sings RIF tenderness 214 100% Rebound tenderness 126 58.9% Body temperature (mean) 37.4 C Std. deviation= 0.42465 (17%) Antibiotics Samixone (Ceftriaxone) 190 88.8% Diclofenac sodium 11 5.1% samixone and vortrine 13 6.1% Investigations TWBCs mean 18 x103/uL Std. deviation (3.70839) Haemoglobin mean 11.5 mg/dl Std. deviation (1.44201) Platelets 324.6 x103/uL Std. deviation (112.60253) 94 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo Table 4: Type of Imaging done to patients Imaging N % No imaging 109 50.9% Ultrasound scan the US 86 40.2% A computed tomography CT scan 19 8.9% Discussion Appendicitis is an acute inflammatory disease may result from obstruction of the appendix lead to inflammation, perforation and necrosis.(Veli Avci, 2019 ).It is a one of the commonest surgical emergency in adults or paediatrics.(Aneirosa et al. , 2019). We were conducted this study in Khartoum North Teaching Hospital which is a one of the reference hospital in Sudan which located in Bahri city and contain one of the referral centre of the paediatric surgery in the Sudan. Highest incidence in of acute appendicitis in our study were in males rather than females but both at the similar age 11-13 years old and the mean age 11 years ( Becker & Bachur, 2007). The symptoms of acute appendicitis in our study were RIF pain which was less in percentage than previous studies 94%(Ngim, 2014) because of some cases were came to us before shifted of the pain to RIF, the percentage of vomiting, absence of changed in bowel habits, tenderness and rebound tenderness in RIF near to percentage in previous studies (Ngim, 2014; Becker & Bachur, 2007). 50.5% of cases were came within the first day to our paediatric surgery emergency. The diagnosis of cases in our department depend on clinical examination so 50.9% diagnosed without imaging just 40.2% diagnosed by US. Another investigations that we were did; Complete Blood Count CBC and found that TWBCs was high and the mean value was 37.4 (17%) which similar to another studies ( McGowan et al., 2013) (Groselj-Grenc et al., 2007) (Yang et al., 2010). In our study 88.8% of patients received antibiotic (ceftriaxone) before and after the operation. In recent study 15.9% of cases presented with perforated acute appendicitis and it's low in compare with other study which the rate of perforation about 52% ( Ngim et al., 2014) because we operate all patients whom diagnosed with acute appendicitis without delay in time of operation and almost cases operated within the first day of admission (Papandria et al., 2013) Conclusion The incidence of perforated acute appendicitis was 15.9% which is low in our study in comparison with the previous study because there was no delayed in appendectomy operation in our department and the majority of patients come within the first day of the disease. That means the delayed operation increases the risk of perforated appendicitis. Conflict of interest No one of authors has a conflict of interest. 95 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2019, VOL 1, ISSUE 2 gggggglo References Almaramhy, H. H. ( 2017). Acute appendicitis in young children less than 5 years: review article. 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