Acute Perforated Appendicitis in Adults: Management and Complications in Lagos, Nigeria

22/9/2019 Apendicitis aguda perforada en adultos: manejo y complicaciones en Lagos, Nigeria
Ann Afr Med . 2019 enero-marzo; 18 (1): 36–41. PMCID: PMC6380116

doi: 10.4103 / aam.aam_11_18 PMID: 30729931
Idioma: Inglés | francés
Apendicitis aguda perforada en adultos: manejo y

complicaciones en Lagos, Nigeria
Olanrewaju Samuel Balogun , Adedapo Osinowo , 1 Michael Afolayan , Thomas Olajide
, Abdulrazzak Lawal ,y Adedoyin Adesanya
Department of Surgery, Faculty of Clinical Sciences, College of Medicine, General

Surgery Unit, University of Lagos, Idi-Araba, Lagos, Nigeria
1
Department of Surgery, Faculty of Clinical Sciences, College of Medicine, University of
Lagos, Idi-Araba, Lagos, Nigeria
Address for correspondence: Dr. Olanrewaju Samuel Balogun, Department of
Surgery, Faculty of Clinical Sciences, College of Medicine, General Surgery Unit,
University of Lagos, Idi-Araba, Lagos, Nigeria. E-mail: drlanrebalogun@gmail.com
Copyright : © 2019 Annals of African Medicine
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
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Resumen
Antecedentes:
La perforación aguda del apéndice es una de las complicaciones de la apendicitis
que se asocia con una mayor morbilidad y mortalidad y, por lo tanto, se considera
una emergencia quirúrgica. Los factores de riesgo para los appencidicits
perforados incluyen extremos de edad, sexo masculino, embarazo,
inmunosupresión, afecciones médicas comórbidas y cirugía abdominal previa.
Objetivos:
Este estudio se centra en el patrón de presentación, los factores de riesgo, la
morbilidad y la mortalidad de los pacientes tratados por apendicitis perforada en
nuestro centro.
Sujetos y métodos:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380116/ 1/14
Realizamos una revisión retrospectiva de siete años de pacientes adultos

consecutivos que se sometieron a cirugía por apendicitis perforada en nuestro
centro.
Resultados:
La tasa de perforación en el estudio fue del 28,5%. La edad pico de presentación

fue entre 21-30 años. Cuarenta y dos (71.1%) de los pacientes en estudio eran
hombres. Solo 3 (5,1%) de las cohortes tenían antecedentes de dolor abdominal
recurrente. La mayoría de los pacientes pertenecían a las categorías de la
Sociedad Americana de Anestesiólogos (ASA) II (44.1%) y III (42.4%). Las
infecciones del sitio quirúrgico (ISQ) (18,6%), la dehiscencia de la herida
(15,2%) y el absceso pélvico (13,5%) fueron las complicaciones más comunes.
Se encontró que la incidencia de SSI se correlaciona con el género masculino, ( P
= 0.041), comorbilidad ( P= 0.037) y puntaje ASA (0.03) en un intervalo de
confianza del 95%. El uso rutinario de drenaje intraperitoneal después de la
cirugía por apendicitis perforada no pareció reducir la incidencia de absceso
pélvico. Sin mortalidad en la población estudiada.
Conclusión:
La perforación apendicular fue más común en pacientes masculinos con el
primer episodio de apendicitis aguda. La cirugía abdominal previa y las
afecciones médicas comórbidas fueron factores de menor riesgo de perforación
apendicular en nuestros pacientes. La infección del sitio quirúrgico fue la
complicación más común después de la cirugía.
Palabras clave: apendicitis, perforación, adultos, laparotomía, resultado,

complicaciones, apendicitis, perforación, adultes, laparotomía, resultado,
complicaciones
I NTRODUCCIÓN
La apendicitis aguda y sus complicaciones son las principales causas de abdomen
agudo y las indicaciones de intervención quirúrgica de emergencia en la práctica
clínica.
En términos clínicos, la apendicitis aguda puede describirse como simple o

complicada. La apendicitis complicada incluye la masa del apéndice, el absceso
del apéndice y la apendicitis perforada. La apendicitis más complicada comenzó
de novo como una simple apendicitis que plantea la noción de que es una
enfermedad en evolución que ha adquirido importancia clínica debido a un
diagnóstico retrasado o perdido. En términos generales, la apendicitis simple
tiene dos formas principales: apendicitis obstructiva y catarral. La apendicitis
aguda en adultos a menudo es de tipo obstructivo y secuela de alguna forma de
obstrucción luminal por fecalitos, tejidos linfoides o raramente cuerpos extraños.
[ 1Las causas extrínsecas de obstrucción luminal del apéndice incluyen bandas

periapendiculares. Anatómicamente, el apéndice es una estructura de final ciego.
Una obstrucción de circuito cerrado de su luz en casos severos produce
inflamación y necrosis transmural que eventualmente conduce a la perforación y
descarga de los contenidos luminales (pus y fecalitos) y peritonitis. Un estudio
prospectivo de Narsule et al . [ 2] en 202 niños sometidos a apendicectomía
reveló una relación lineal entre la duración de los síntomas (inicio de la cirugía)
y el riesgo de perforación. En su estudio, no se registró perforación en niños con
dolor abdominal de <12 h de duración. La tasa de perforación aumentó de
manera lineal del 10% en 18 h al 44% en 36 h. Si los síntomas estuvieron
presentes por más de 2 días, el riesgo de perforación fue> 40%. Por el contrario,
Bickell et al . [ 3] en un estudio retrospectivo anterior de 219 adultos con
apendicitis había documentado un riesgo mínimo de perforación en las primeras
36 h de aparición de síntomas y se mantiene en 5% a partir de entonces. Sin
embargo, un estudio ha demostrado que en muchos pacientes tratados con
antibióticos, los síntomas de apendicitis pueden resolverse sin la consiguiente
perforación; por lo tanto, se ha propuesto un tratamiento médico con antibióticos
en un grupo seleccionado de pacientes con apendicitis no complicada. [ 4 ]
Sequelae of appendiceal perforation have some important economic

consequences and are associated with increased length of hospital stay,
morbidity, and mortality even with treatment.[5] These factors are important
considerations in developing countries where access to health care and resources
are limited with attendant delay in diagnosis and treatment.
Management options for perforated appendicitis range from percutaneous

drainage to laparoscopic and open appendectomy with drainage. To the best of
our knowledge, few studies have focused on the management outcome of
patients with perforated appendicitis in our environment. This study aimed to
determine the pattern of presentation, risk factors, and incidence of postoperative
complications and mortality in patients who had surgery for perforated
appendicitis in our institution.
METHODOLOGY
A 7-year retrospective review of medical records of patients aged 16 years and
above who had surgery for appendiceal perforation between July 2010 and June
2017 in our hospital was carried out.
Approval for the study was obtained from the Lagos University Teaching
Hospital's Health Research Ethics Committee.
Patients’ demographic characteristics, clinical presentation, laboratory

parameters, radiological features, surgical intervention time, and postoperative
complications were entered into a structured pro forma for analysis. Data
analysis was done using IBM SPSS statistics for Windows, Version 23 (IBM
Corp., Armonk, NY, USA). Results of the analysis were expressed in tables as
simple percentages. Relationships between patients’ gender, medical
comorbidities, duration of symptoms, preoperative American Society of
Anesthesiologists (ASA) score, and incidence and type of postoperative
complications were tested by Chi-square tests. Statistical significance was set at
P < 0.05.
RESULTS
There were 224 cases of acute appendicitis managed during this period. Sixty-
four patients had appendiceal perforation, giving the perforation rate of 28.5%.
Of a total of 64 patients who had surgery for acute perforated appendicitis, 5
were excluded from further data analysis due to incomplete records.
Of 59 patients under review, there were 42 (71.1%) males and 17 (28.8%)

females, giving a ratio of 2.5–1. The mean age at presentation was 29.98 ± 2.08
(range: 16–70) years and median was 26 years. The peak age of presentation was
between 21 and 30 years, accounting for 44.1% of all cases [Table 1].
Table 1
Age and sex distribution of patients with perforated appendicitis (n=59)
Age Male Percentage Female Percentage Frequency (subtotal)

(years) (%) (%) (%)
≤20 12 20.3 2 3.4 14 (23.7)
21-30 15 25.4 11 18.6 26 (44.1)
31-40 8 13.5 3 5.1 11 (18.6)
41-50 3 5.1 0 0 3 (5.1)
51-60 3 5.1 1 1.7 4 (6.8)
>60 1 1.7 0 0 1 (1.7)
Total 42 71.1 17 28.9 59 (100.0)
The mean duration for onset of abdominal pain before presentation was 4.5 ±
3.42 days (range: 0.74–14 days). Abdominal pain was present in all patients.
Fifty-two (88.1%) patients reported initial periumbilical pain before it became
generalized. Nausea and vomiting were present in 50 (84.7%) patients and
anorexia in 33 (55.9%) patients. Five (8.4%) of the patients had comorbid
medical conditions and one was pregnant [Table 2]. Total white cell count record
was retrieved in 53 of 59 patients [Table 2]. Of these, leukocytosis of

>10,000/mm3 was present in 34 (64.2%) of patients. Only 23 patients had
preoperative abdominal/chest X-ray. The predominant finding among these
patients was that of small bowel obstruction/ileus in 11 (47.8%) patients. Only 3
(13%) of 23 patients evaluated with abdominal/chest X-ray had radiological
evidence of pneumoperitoneum. Abdominal ultrasound findings were retrieved
in 38 (64.4%) patients. The major finding on abdominal ultrasound among these
patients was periappendiceal fluid collection in 17 (44.7%) cases.
Table 2
Clinical symptoms,risk factors and total white cell count in acute
perforated appendicitis (n=59)
Nature of symptoms (n=59) Frequency of symptoms out of 59 patients

(%)
Abdominal pain migration 52 (88.1)
Anorexia 33 (55.9)
Nausea and vomiting 50 (84.7)
Fever 37 (62.7)
Dyspepsia 4 (6.8)
Diarrhea 15 (25.4)
Constipation 19 (32.2)
History of similar attack in the past 3 (5.1)
Previous abdominal surgery 5 (8.5)
Comorbidities (diabetes and 5 (8.4)
hypertension)
Pregnancy 1 (1.7)
Total white blood cell count/mm3 Frequency (%)

(n=53)
<4000 4 (7.5)
4001-10,000 15 (28.3)
>10,000 34 (64.2)
Open in a separate window
Using the surgical risk classification of the ASA, the predominant ASA groups
were in classes II and III which accounted for 44.1% and 42.4% of cases,
respectively [Table 3]. The range of hospital stay was 5–56 days [Table 3].
Table 3
Preoperative American Society of Anesthesiologists (ASA) grade and
hospital stay after surgery (n=59)
ASA grade Frequency (patients) (%)

I 6 (10.2)
II 26 (44.1)
III 25 (42.4)
IV 2 (3.4)
Total 59 (100)
Hospital stay (days) Frequency (days) (%)
0-7 9 (15.3)
8-14 33 (55.9)
15-21 10 (16.9)
22-28 3 (5.1)
>28 4 (6.8)
Total 59 (100)
Open in a separate window
ASA=American Society of Anesthesiologists
Surgical site infections (SSIs), wound dehiscence, and pelvic abscess were the
most common complications at 18.3%, 15.2%, and 13.5%, respectively [Table 4
]. There was no mortality in our review.
Table 4
Postoperative complications (n=59)
Complication Frequency (%)

Surgical site infections 11 (18.6)
Wound dehiscence 9 (15.2)
Pelvic abscess 8 (13.5)
Postoperative pyrexia 5 (8.5)
Chest infection 2 (3.3)
Organic brain dysfunction 1 (1.6)
Univariate analysis using Chi-square test at 95% confidence interval and

significant P < 0.05 showed that overall complication rate is significantly related
to the ASA score (χ2 = 11.22; P < 0.05). There was also a statistically significant
relationship between SSI and male sex (P = 0.041), comorbidity (P = 0.037), and
ASA (0.03) at 95% confidence interval. However, there was no statistically
significant association between SSI and age (age group), previous attacks, and
total white blood cell count at presentation.
DISCUSSION
Acute appendicitis is a leading cause of acute abdomen requiring surgery in
Nigeria. A prospective study of 276 patients at Ilorin revealed that acute
appendicitis was the most common cause of acute abdomen and was responsible
for 30.3% of all cases seen within the study period.[6] However, the incidence of
perforation (perforation rate) in acute appendicitis varies widely; a perforation
rate between 4.4 and 39% has been reported in the West African Subregion.
[7,8,9,10]
A retrospective study by Njoku et al.[7] on 655 appendicectomies revealed 29

cases of perforation giving a perforation rate of 4.4%. Adeyanju and Adebiyi[8]
reported perforation rate of 13 (7.2%) of 180 appendicectomies. Another
retrospective study by Edino et al.[9] on 142 appendicectomies reported 33 cases
of appendiceal perforation with a perforation rate of 23.2%. Yeboa[10] in Ghana
found 249 cases of appendiceal perforation in 638 appendicectomies with a
perforation rate of 39%. In our study, the perforation rate was 28.5%. This is far
higher than observed by some researchers in Nigeria and less than the quoted
figure from Ghana.[7,8,9,10] This difference may reflect varying pattern of
referral and these studies are retrospective.
Delay in surgical intervention has been associated with increased rate of

perforation from 3% in patients operated within 24 h of presentation to 31% in
patients operated at 36 h.[11]
The incidence of perforated appendicitis is higher in the extreme of ages.

[2,5,12,13] Ahmad et al.[12] reported 46.15% in the first decade of life and
56.61% in the elderly patients presenting with appendicitis. Documented risk
factors for appendiceal perforation in elderly include male sex, fever ≥38°C,
immune compromise (diabetes and steroids use) anorexia, and duration of
abdominal pain before presentation.[5] In children, nonspecific nature of
abdominal pain of acute appendicitis leads to delayed presentation. In addition,
there is a higher rate of progression of appendicitis in children due to lack of
well-developed omentum and abdominal fat to contain inflammatory process.
[2,4,14]
The mean age for perforated appendicitis in our study was 29.98 ± 2.08 years
and the peak age at presentation was found in the third decade of life. Of 59
patients, 26 (44.1%) were between 21 and 30 years. An earlier retrospective
review of 250 cases of appendicitis from our center had documented the mean
age of 25.7 ± 0.103 years and the peak age in the third decade of life accounting
for 42.8% of cases.[15] In general and within the peak age group, we found a
higher incidence of perforated appendicitis in our male patients. The exact reason
why perforated appendicitis is more common in males is not clear, but similar
association has been found in many studies.[16,17,18] In our opinion, a higher
incidence of appendicitis in male patients as documented in most series may
explain why its complication is also more frequent in the male population.
Comorbid medical conditions and immune suppressive states are known risk
factors for appendiceal perforation. Only 5 (8.4%) of our patients had comorbid
medical conditions: Four were hypertensive and one was diabetic.
Abdominal pain was present in 100% of patients, with 52 (88.1%) patients

reporting classical abdominal pain migration from localized periumbilical to
generalized abdominal pain. Leading associated symptoms were nausea and
vomiting in 84.7% of patients and anorexia in 55.9%. Similar findings were
found by Ohene-Yeboah and Togbe in Ghana and Fashina et al in Nigeria.[10,15]
Leukocytosis with polymorphonuclear predominance is helpful in the diagnosis

of acute appendicitis. While a study had documented leukocytosis of >10,000
cells/mm3 in 80%–85% of patients with acute appendicitis,[19] a previous study
in our institution had shown that the leukocytosis is not a feature of acute
appendicitis in our environment. Fashina et al.[15] reported a mean white cell
count of 8538 ± 4166 mm3 in acute appendicitis. However, in appendiceal

perforation, leukocytosis is marked. We found leukocytosis of >10,000/ mm3 in
33 (55.9%) patients reviewed.
Electrolyte abnormalities are commonly encountered in patients with acute

abdomen due to fluid loss. In addition, many of these patients are on nil per os
while a definitive diagnosis is being sought and in preparation for surgery. We
retrieved electrolyte panel results in 52 of 59 patients. The predominant
electrolyte abnormality was hypokalemia (serum potassium <3.5 mmol/l) which
was found in 19 (36.5%) of 52 patients. This was corrected before surgery.
Plain abdominal/chest X-ray and abdominal ultrasound are common first-line

radiological investigations for suspected acute abdomen in our accident and
emergency.
This study confirmed the opinion that pneumoperitoneum due to appendiceal

perforation is not a common occurrence in plain abdominal/chest X-rays, and
most cases reported in the literature were in the form of case reports/case series.
[20,21] Some larger retrospective studies have reported findings of
pneumoperitoneum in 5%–8% of gastrointestinal perforations due to perforated
appendicitis.[22,23] In 23 patients evaluated with abdominal/chest X-ray, we
found the frequency of pneumoperitoneum in 3 (13%) cases. A higher value
obtained in this study may be attributed to the estimation of frequency of
pneumoperitoneum in cohorts of patients under review, rather than the etiology
of pneumoperitoneum in acute abdomen which was evaluated in most studies.
[22,23] The clinical diagnosis and indications for surgery in most of our patients
were based mainly on the history and clinical signs of peritonitis. Positive
radiological signs of perforation such as pneumoperitoneum were added
reinforcement to our diagnosis and our decision to operate.
In the preoperative anesthetic assessment of our patients using the ASA physical
status classification score, majority of the patients were in ASA II (44.1%) and
III (42.4%) categories. Only two patients in the review which showed signs of
severe toxicity and peritonitis as were in ASA IV category. Ours is a referral
center and is a common practice for referring institutions to commence
antibiotics treatment for patients with acute abdominal condition. This may have
limited severity of endotoxemia and systemic sepsis at presentation. This is
coupled with the fact that most of the patients in this study are young with low
rate of comorbid medical conditions. About 86.4% of our patients were <40
years.
Definitive treatment of acute appendicitis and its complications is accomplished

by the removal of appendix and other infected foci, drainage of abscess,
irrigation of the abdomen with saline, and insertion of peritoneal drain as
indicated. This can be achieved via open or laparoscopic surgery. However, in
recent times, some authorities have advised selective antibiotic use for perforated
appendicitis and those due to phlegmon followed by interval appendectomy in
Children.[24] This approach is still controversial due to its high failure rate and
may not be applicable to adult scenarios. Our treatment of choice for acute
simple and complicated appendicitis is appendicectomy. We use Lanz incision
where the peritoneal signs are localized or a laparotomy in case of generalized
peritonitis.
SSIs (18.6%), wound dehiscence (15.2%), and pelvic abscess (13.5%) were the
common complications we encountered in this study. In our practice, we
routinely leave a peritoneal drain for all patients after exploratory laparotomy for
viscus perforation and remove drain when it is no longer active (<50 ml/day). We
also administer broad-spectrum antibiotics from admission for about 1 week after
surgery. There are some concerns regarding the benefit of this approach as it has
not been shown to reduce post-op septic complications. Levin and Walter[25]
reported that perforated appendicitis is a single predisposing factor for the
development of postappendectomy intra-abdominal abscess. They found that
technique of stump closure, routine saline peritoneal lavage, and drain placement
did not decrease the risk of intra-abdominal abscess in perforated and
nonperforated appendicitis. In this study, 8 (13.5%) of the patients had pelvic
abscess, and in our experience, routine use of peritoneal drain after surgery for
perforated appendicitis did not appear to reduce the incidence of pelvic abscess.
A recent Cochrane review has shown that the effect of abdominal drainage on
prevention of intraperitoneal abscess or wound infection after open
appendectomy is uncertain for patients with complicated appendicitis.[26]
The overall complication rate in our study was 43.1%. However, some patients
had more than one type of complications. Preoperative ASA score was found to
be associated with the incidence of complications after surgery for perforated
appendicitis (χ2 = 11.22; P < 0.05). The study also showed some association
between incidence of SSI and male gender (P = 0.041), comorbidity (P = 0.037),
and ASA (0.03) at 95% confidence interval. However, there is no statistically
significant association between SSI and age (age group), previous attacks, total
white blood cell count at presentation, and time to surgical intervention.
CONCLUSION
Perforated appendicitis is a common complication of acute appendicitis
occurring in a young population in our environment. Significant risk factors for
appendiceal perforation in this study were first episode of abdominal pain and
male sex. A history of recurrent acute appendicitis predating perforation was
found in minority of our patients. In addition, previous abdominal surgery and
comorbid medical conditions were less contributing factors in our patients. SSI
was the most common complication after surgery. Routine use of intraperitoneal
drain had little effect on the incidence of pelvic abscess. The overall prognosis is
good with early surgical intervention.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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22/9/2019 Apendicitis aguda perforada en adultos: manejo y complicaciones en Lagos, Nigeria

Ann Afr Med . 2019 enero-marzo; 18 (1): 36–41. PMCID: PMC6380116

Idioma: Inglés | francés

Apendicitis aguda perforada en adultos: manejo y

Department of Surgery, Faculty of Clinical Sciences, College of Medicine, General

Copyright : © 2019 Annals of African Medicine

Realizamos una revisión retrospectiva de siete años de pacientes adultos

La tasa de perforación en el estudio fue del 28,5%. La edad pico de presentación

Palabras clave: apendicitis, perforación, adultos, laparotomía, resultado,

En términos clínicos, la apendicitis aguda puede describirse como simple o

[ 1Las causas extrínsecas de obstrucción luminal del apéndice incluyen bandas

Sequelae of appendiceal perforation have some important economic

Management options for perforated appendicitis range from percutaneous

Patients’ demographic characteristics, clinical presentation, laboratory

Of 59 patients under review, there were 42 (71.1%) males and 17 (28.8%)

Age and sex distribution of patients with perforated appendicitis (n=59)

Age Male Percentage Female Percentage Frequency (subtotal)

was retrieved in 53 of 59 patients [Table 2]. Of these, leukocytosis of

Nature of symptoms (n=59) Frequency of symptoms out of 59 patients

Total white blood cell count/mm3 Frequency (%)

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ASA grade Frequency (patients) (%)

Hospital stay (days) Frequency (days) (%)

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ASA=American Society of Anesthesiologists

Complication Frequency (%)

Univariate analysis using Chi-square test at 95% confidence interval and

A retrospective study by Njoku et al.[7] on 655 appendicectomies revealed 29

Delay in surgical intervention has been associated with increased rate of

The incidence of perforated appendicitis is higher in the extreme of ages.

Abdominal pain was present in 100% of patients, with 52 (88.1%) patients

Leukocytosis with polymorphonuclear predominance is helpful in the diagnosis

count of 8538 ± 4166 mm3 in acute appendicitis. However, in appendiceal

Electrolyte abnormalities are commonly encountered in patients with acute

Plain abdominal/chest X-ray and abdominal ultrasound are common first-line

This study confirmed the opinion that pneumoperitoneum due to appendiceal

Definitive treatment of acute appendicitis and its complications is accomplished

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