Management of Appendix Mass in a Nigerian Rural District

MANAGEMENT OF APPENDIX MASS IN A NIGERIAN RURAL DISTRICT

ABSTRACT

Background

Appendcitis is a common problem. Sometimes it is complicated by formation of a mass which may be a phlegmon or an abscess .The traditional management of an appendix mass was conservative, followed by interval appendicectomy. There is now controversy as to whether interval appendicectomy is really necessary. It is against this background that we review our management of this condition in a rural area in

Nigeria, where many patients present with either perforation or a mass .

Aim:- The aim of this paper is to present our experience with the management of appendix mass as found among rural people in Nigeria, and compare it with the practice in other places.

Methods: Retrospective review of all patients presenting with appendix masses and admitted at

Jasman Hospital Udo-Ezinihitte over a 30-year period (1977-2006). Their case notes, theatre and ward registers were utilized. Information extracted included presenting symptoms, age, gender, treatment received, and outcome. Data was analyzed by descriptive statistics.

Results: Fifteen Thousand Two Hundred and Sixty Five patients were seen with complaints related to the right iliac fossa in the period under consideration. Seventy two (0.5%) of these had palpable tender masses. Seventy (97.2%) of the seventy two ,were inflammatory masses of the appendix, consisting of 13

(19%) cases of frank abscesses and 57 (81%) cases of phlegmons. The male to female ratio was 1:1.2 .Their ages ranged from 6 to 68 years with an average of 37 years. Forty nine (70%) were between 16 and 65 years. Two patients had immediate appendicectomy.The rest (68) were placed on antibiotics on admission. Thirteen (19%) had abscesses drained, right hemicolectomy was performed in 1 of 70 (1.42%) with appendix mass. Interval appendicectomy was carried out in a total of 28 out of 70 (40%) patients .

Thirty six (51.4%) patients did not return for scheduled appendicectomy. Abscesses recurred in 3 (4.3%) cases after initial drainage .

1 At interval appendicectomy, there were varying degrees of shortening of the appendix in 11 cases. There was a total disappearance in 4 (5.71%) patients, fibrosed stumps in 5 (7.1%). Two showed lesser degrees of shortening. Two specimens showed continued inflammatory response three to seven months after conservative management. There were two deaths (4.3%).

Conclusion:

In this study we found that most of the palpable inflammatory masses in the right iliac fossa originated from the appendix. Conservative treatment should be the initial line of management for appendiceal masses, but sometimes immediate appendicectomy, right hemicolectomy, or interval appendicectomy may become necessary.

Kew Words: Right iliac fossa, inflammatory mass, interval appendicectomy.

2 3 Introduction:

A local perforation of the appendix, if walled off by omentum and bowel, forms an appendix mass1.

Continued suppuration results in an abscess2. Thus an appendix mass may be a phlegmon which can resolve or an abscess which needs to be drained3 . Other lesions may mimic an inflammatory appendix mass and present as masses in the right iliac fossa. Examples are cecal cancer with underlying appendiceal abscess4, an appendiceal mucoccele5 and an inflamed necrotic appendix epiploicus.6 The diagnosis of an appendix mass may be made on the basis of presenting symptoms and signs alone, but ultrasonography and computerized tomography enhance the accuracy of diagnosis.7,8

The aim of this paper was to present our experience with the management of appendix masses at a hospital in a rural district of Nigeria.

4 Patients and Methods:

This is a retrospective review of all patients presenting with right iliac fossa masses and admitted at

Jasman Hospital Udo-Ezinihitte over a 30- year period, from November 1977 to October 2006. The case notes of all patients presenting with complaints relating to the right iliac fossa were retrieved. Those who were found to have inflammatory right iliac fossa masses on physical examination or at exploration, were included. Those who had no inflammatory masses were excluded. Also utilized were the theatre and ward registers. Information extracted consisted of their gender, age, presenting complaints and physical findings, treatment received, and outcome. Data were analysed by descriptive statistics.

5 Results:

Fifteen thousand, two hundred and sixty five patients were seen with complaints related to the right iliac fossa in the period under review. Seventy two patients who presented with masses in the right iliac fossa were studied.

Seventy (97.20) of these were inflammatory masses of the appendix. The other two were cecal tumors obstucting the appendix. Presenting features were abdominal pain, right iliac fossa mass, and tenderness. There were 32 (46%) males and 38 females (54%) with male to female ratio of 1.1.2. Patients’ ages ranged from 6 years to 68 years with an average of 37 years. Forty nine (70%) were between 16 and 65 years. Excluded were two patients with cecal tumors. Two patients (3%) had immediate appendicectomy, sixty eight (97%) patients were commenced on conservative treatment with antibiotics and intravenous fluids. Twenty eight (40%) patients had scheduled interval appendicectomy after resolution of their masses on conservative management. Thirty six(51%) patients did not return for their scheduled interval appendicectomy. Thirteen (19%) patients had abscesses drained, and abscesses recurred in three (4.3%) cases after initial resolution. One (1.42%) patient had right hemicolectomy for bowel injury during immediate appendicectomy. Findings at interval appendicectomy included intraperitoneal adhesions, 11 (16%) patients in whom the appendix was shortened to varying degrees , including total disappearance in four 4(6%),fibrosed stumps in five (7.1%),and two showing lesser degrees of shortening. In six (9%) patients the appendix was large and thickened while in four (6%),, it was of normal appearance.Macroscopically,the appendiceal epithelium showed varying degrees of denudation, ulceration, haemorrhages, and patchy regeneration. No histological report was available. Some appendices showed continued inflammatory response three to seven months after conservative treatment.Two (3%) patients died.

6 Discussion:

The commonest presenting features are abdominal pains, classically starting at the periumbilical area and localizing in the right iliac fossa, fevers (sometimes absent), a right iliac fossa tender mass associated with guarding and less commonly, nausea, vomiting, and diarrhea. The mass may only be evident on exploration for what was presumed to be just acute appendicitis.

The traditional management of the appendix mass has been conservative, followed with interval appendicectomy six to twelve weeks after resolution of mass.9 This method has now been called to question by advocates of purely conservative management without interval appendicectomy, 10-12 surgery being resorted to only if there is worsening response or recurrent attacks of appendicitis after resolution.Some surgeons advocate immediate appendicectomy,13,14 or ileocaecectomy or right hemicolectomy.4,15

The incidence of appendix mass in all masses found in the right iliac fossa in this study is 0.0.46% (70 of

15265). Other workers have quoted figures ranging from 2-6%, 3.8%, 16. 6.5%.17. Our figure is comparatively low and may reflect the inclusion of all patients some of them found later to have only fecoliths and limited inflammation at operation.

The age range was 6 to 68 years with a preponderance in the 16-65 years age bracket. Okafor etal, 18 working in the same geographical zone as we, had patients aged 15 to 60 years, with a preponderance in the 40-49 years age bracket Rajatapiti and Chittmittrapap 19.reported a range of 3 to 87 years, while Guo and Greeson 20. Reported a mean of 13 years. The implication is that the phenomenon of the appendix mass transcends all age and all sexes are affected. In our study, females out numbered males in a ratio of

1.2:1. This is at variance with that of Okafor etal 18 who worked in the same geographical zone.

Patients were diagnosed on physical examination alone or an exploratory laparotomy when a definite mass was found. This underscores the usefulness of ultrasonography, and computed tomography (CT scan) in

7 providing a higher positive preoperative diagnosis.7,8 We did not have the advantage of these advanced methods of diagnosis in our rural environment.

The treatment of appendix mass has become the subject of controversy. Obvious abscesses are drained.

In our work we drained all abscesses by the open extra-or intraperitoneal route but where available, ultrasonographic or computed needle- guided percutaneous drainage is preferable.13,21

The traditional management of the appendix mass has been conservative with intravenous fluid and antibiotics initially, and appendicectomy after an interval of six to twelve weeks when there has been a resolution of the mass.1,12,22 This approach gained wide acceptance and is still practiced by many surgeons9,23. Our current practice is still the same, sixty eight (97%) of our patients were initially put on conservative management with antibiotics, Of these only 28 (40%) returned for interval appendicectomy after resolution of the mass. In our locality, when patients are treated and discharged home, they rarely come back for review except when they have complaints. However, our observation revealed evidence of continuing inflammation up to three months in one patient and seven months in another, Gillick et al 24 found evidence of continuing inflammation in 50% of histological specimens, showing the long time risk of recurrence after conservative management.

The proponents of interval appendicectomy argue that it is safe, with low complication rates, allows the infection to be contained and not disseminated, and cures the patients. 24 Interval appendicectomy is also said to allow for the detection of pathologies that could not be detected on purely conservative treatment alone.2,22,26 This practice has however been questioned.1,2,2 Antagonists argue that interval appendicectomy is unnecessary after conservative management. From their studies they found that the rate of recurrence is low, recurrent attacks milder than the original ones,1 that the patient is admitted only once and saves the cost of another admission, and that possible complications of surgery are avoided.22 There are also arguments for immediate appendicectomy routinely.13,14 The proponents argue that it is feasible, reduces hospital stay and saves cost, detects and treats previously undetected pathologies without recurrence. 10

Against this are operative difficulties and dissemination of infection, wound infection, possibility of bowel 8 injury leading to perforation and fecal fistulae.13 Exploration showed adhesions and bowels matted together.

Right hemicolectomy is carried out when an unexpected mass cannot be differentiated from an inflammatory appendix. 15,27 In our work, right hemicolectomy was not a preferred option but we did one for bowel injury during immediate appendicectomy.

The limitations of this study included lack of advanced technological diagnostic armamentarium , especially computed tomography which plays an important role in diagnosis of this condition.There was also the absence of facilities for histological examination nearby. Patients were generally poor and could not pay for many diagnostic investigations.

9 Conclusion

In this study, most inflammatory masses in the right iliac fossa (97%) originated from the appendix. Some appendices, as shown by our study, disintegrate and disappear completely,or remain as mere stumps or short fibrosed remnants. After conservative treatment, we have shown evidence of continuing inflammatory process in two appendices and this is a potential for recurrent appendicitis and appendicular mass and abscess. In poor rural settings, where resources are limited, with difficulty in transportation,and hospitals may not be accessible, interval appendicectomy is to be recommended. This is in spite of the fact that some patients treated conservatively remain free of recurrent disease.

10 Acknowledgement

Miss Josephine Odoemena painstakingly retrieved the case notes of patients , and Doctors M.C.Nwagboso,

Nweze Ekwuribe, C.O.Umunna, and C.Okoronkwo assisted at one time or the other at operations on the patients. To all these I express my gratitude.

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