Acute Appendicits : Still a Missed Diagnosis in

Acute Appendicits: Still a Missed Diagnosis in El Obeid, Western Sudan Doumi E A , Abdelrahman I H 2 Abstract Patients and Methods: One hundred and one patients with appendicitis were admitted to the emergency wards of the University Surgical Unit in El Obeid Teaching Hospital, Western Sudan during the period from July 2005 to June 2006. There were 64 males and 37 females. Results: The mean age was 20.8 years ± S.D. 12.8. 34 patients had appendicular mass, four patients had appendicular abscess and five patients had generalized peritonitis presenting with acute abdomen. Out of the 58 patients admitted as acute appendicitis, 15 patients were found to have perforated appendices at operation and the rest inflamed oedematous appendices, with a negative appendicectomy rate of zero per cent. Conclusion: These findings reflect the poor awareness about acute appendicitis and its seriousness in this area. It is the problem of late diagnosis rather than late presentation as all patients were misdiagnosed and put under treatment for other medical conditions before being admitted to the surgical wards.


Introduction
Appendicitis is the inflammation of the appendix.The inflamed appendix if not treated can burst causing local and/or generalized peritonitis, septicaemia or death.The first patient to survive appendicectomy was described by Claudius Amyand in 1736.The term appendicitis was suggested in 1886 1 .
Burkett more than 40 years ago, stated that the epidemic of appendicitis is the result of dietary change, i.e. decreased fibres and increased refined food 1 .The disease, which was thought to be a Western entity, became ubiquitous all over the world 2 .Patients with unrecognized appendicitis, leading to life threatening complications were reported from the Sudan and else where in the region [3][4][5][6] .
In this study we report our local experience in El Obeid Teaching Hospital, Western Sudan where the society is developing fast and social habits including diet are changing towards modernization.

Patients and Methods
The study population consisted of 104 patients, admitted to the wards of the University Surgical Unit in El Obeid Teaching Hospital during the period from July 2005 to June 2006.
The data was retrieved from the patients' files.The files of three patients were deficient so they were excluded.The records of the remaining Email: elbushradoumi@hotmail.com101 patients were retrospectively analyzed using the SPSS computer package system.

Results
Among the 101 patients, there were 64 males and 37 females.The mean age was 20.83 years ± S.D. 12.83.
The clinical diagnosis on admission is shown on table 1.All patients had some sort of medical treatment before admission, 72 had antimalarial drugs, 14 had anti-amoebiasis, eight treated for colitis and the rest were treated for pelvic inflammatory disease and urinary tract infection.Nearly 34% of the patients were diagnosed as appendicular mass, they were treated conservatively and offered elective appendicectomy later.Four patients were diagnosed to have appendicular abscesses and another five had acute abdomen with generalized peritonitis.Laparotomies were done for all nine patients (8.8%)where drainage of the local or generalized abscess was done and the appendices were removed.

Discussion
Acute appendicitis is a common surgical emergency, world wide 2 .It is estimated that about 10% of the population will develop acute appendicitis 7,8 .Appendicitis is the commonest condition requiring emergency operation among the African children 2 .In Sudan, previous published reports indicated that the condition is common and that delayed diagnosis was associated with increased morbidity and mortality 3,4 .Reports from this hospital emphasized a similar pattern more than a decade ago.Despite being a common disease all our patients were misdiagnosed and treated initially for other pathology.Similar lack of awareness and diagnostic failure in African society was reported before 2,9 .
In this study, the number of patients analyzed accounted for all cases diagnosed as appendicitis found among the emergency surgical admissions in this hospital during the period from July 2005 to June 2006 indicating a case of appendicitis is probably seen every 3-4 days.
The age distribution in this series was in line with other reports 3,10 , showing a peak frequency around the end of the 2 nd decade and the beginning the 3 rd decade of life (20±12 years).The gender pattern with M: F ratio of 1.7: 1 is also similar to the findings in other studies 3,9 .
Out of the 58 patients who were admitted with the clinical diagnosis of acute appendicitis 15 patients were found to have perforated appendices at operation.The remaining 43 cases were described to have oedematous inflamed appendices i.e. with a negative appendicectomy rate of zero per cent.This is not keeping with reports from the literature [11][12][13] .Word wide, 15-30% of laparotomies for suspected appendicitis yielded negative findings 14 .
There was no mortality among the study group, but 11 patients (10.9%) had wound infection with prolonged hospital stay and two patients (1.9%) were re-admitted with adhesive intestinal obstruction which was managed conservatively.This is consistent with other's findings 11,15 .
The overall number of complicated appendicitis in this study was 58 patients (57.4%).

Conclusion
The findings in this study reflected the poor awareness of acute appendicitis and its seriousness in spite of its common frequency in this area.Our big problem is the late diagnosis rather than late presentation.