1. Appendicitis in Africa ALC Jones Oct 2010

2. Case Presentation 1 20 western male 1 day history progressive para- umbilical pain moving to RIF Rebound and percussion tenderness Vomiting Rovsing’s +ve

3. Case Presentation – Investigation? Observations – pulse 93, BP 120/79, t – 37.4C Bloods – raised inflammatory markers »Neutrophilia (left shift) Radiology? Xray, U/S, CT? Diagnosis? - Appendicitis »Mesenteric adenitis, terminal ileitis, Meckel’s diverticulum, lymphoma, renal colic, UTI, carcinoid, testicular torsion

4. Case Presentation – Management?

5. Post-operatively Antibiotics E&D Follow up?

6. Anatomy

8. Aetiology and pathophysiology Obstruction of the appendix lumen Mucus production, swelling, decrease venous return,ischaemia, necrosis, perforation, peritonitis, death Low fibre diet – faecal stasis

9. Squatting Hypothesis “"When the thighs are pressed against the abdominal muscles in this position, the pressure within the abdomen is greatly increased, so that the rectum is more completely emptied. Our toilets are not constructed according to physiological requirements. Toilet designers can do a good deal for people if they will study a little physiology and construct seats intended for proper [elimination].“ H. Aaron 1938

10. Case Presentation 2 26 male - Zulu farmer 3 day history of ubuhlungu in lower abdomen. Progressively worse, diarrhoea, anorexia Feverish,oliguric Lower abdomen generally tender with peritonism.

11. Case Presentation 2 Observations – pulse 120, BP 65/30, t – 39C Bloods – raised inflammatory markers »Cr – 230 U – 20LFTS-NAD Radiology? Xray, U/S, CT? Diagnosis? - Gangrenous/Perforated Appendicitis »Yersinia, TB, Toxoplasmosis, Schistomiasis »UTI, Carcinoid, Testicular Torsion

12. Case Presentation 2 - Management Resuscitation IV abx How quickly to theatre? Surgical approaches Post-op care ?Histology follow up

13. Appendicitis in Africa Lower incidence rates in rural population compared to urban and developed countries (?but rising) Direct correlation between delayed presentation and perforation [2] Atypical history – likely suppurative appendicitis. ?higher perf rates check histology [3]

14. Appendicitis in Africa Studies have shown prolonged post-op stay – higher incidence perforation+ peritonitis Africans have a higher DALY compared with developed countries

15. Case Presentation 3 43 female presents with 2/7 lower abdominal pain and vomiting BNO. Pain localising in RIF. Tender with rebound and localised guarding. Hb – 10.2 g/dl WCC -14 Neut – 11 Plt – 253Cr-122 U-12

16. Case Presentation 3 On examination: Mass in RIF Differential diagnosis?

17. Case Presentation 3 Appendix Mass – management options 1. Conservative – IV abx and 6-8 weeks interval appendix 2. Immediate appendicectomy / Right hemi after several days of IV abx 3. Totally conservative management

18. Summary Incidence of appendicitis is generally less in developing continents ie. Africa, but rising Treatment is more invasive as presentations are late and associated with higher rates of perforation and gangrene Higher DALY Consider other differential diagnosis and aetiology to appendicitis, hence always send for histology.

19. References 1.Jones BA, Demetriades D, Segal I, Burkitt DP (1985). "The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa". Ann. Surg. 202 (1): 80–2. 2.Chamisa I (Nov 2009) A clinicopathological review of 324 appendices removed for acute appendicitis in Durban, South Africa: a retrospective analysis. Ann. RCSEng Vol 91, No 8, pp. 688-692(5) 3.Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement. Permanente Medical Journal 4.Ojo OS, Udeh SC, Odesanmi WO, Review of the histopathological findings in appendices removed for acute appendicitis in Nigerians. J R Coll Surg Edinb. 1991 Aug;36(4):245-8. 5.ES Garba, A Ahmed. (2008)Management of appendiceal mass. Ann Afr Med Vol 7 (4) p200-204 6.World Health Organisation

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