SYNOPSIS FOR PG DISSERTATION FOR MD/MS,
UNDER RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BENGALURU.
1. Name and DR. TONY MATHEW
Address of the candidate DEPT. OF GENERAL SURGERY,
(in block letters) S. NIJALINGAPPA MEDICAL COLLEGE
BAGALKOT-587102 2. Name of the institution S. NIJALINGAPPA MEDICAL COLLEGE & HSK
HOSPITAL, NAVAVAGAR,
BAGALKOT-587102. 3. Course of study and subject M S (General Surgery) 4. Date of admission to course 29th may 2012 5. Title of the Topic:
“CLINICO PATHOLOGICAL EVALUATION OF ACUTE APPENDICITIS AND
THE ROLE OF ULTRASOUND IN DIAGNOSIS. A PROSPECTIVE STUDY IN
HANAGAL SHRI KUMARESHWAR HOSPITAL BAGALKOT.” 6. Brief resume of the intended work:
6.1 : Need for the study:
Appendicitis is the one of the most common surgical emergency with a lifetime risk
of 8.6% in males and 6.7% in females.(1) The diagnosis of acute appendicitis is
predominantly based on clinical findings. When appendicitis manifests in its classic form,
it is easily diagnosed and treated. Unfortunately, these classic symptoms occur in just over
half of patients, therefore an accurate and timely diagnosis of atypical appendicitis
remains clinically challenging and is one of the most commonly missed problems in the
1 emergency department. Furthermore, the consequence of missing appendicitis, leading to perforation, significantly increases morbidity and prolongs hospital stay. (2) Although the mortality rate has been vastly reduced, the diagnostic inaccuracy rate of 15% to 20% has remained unchanged in the past century. High rates of negative appendicectomy
(operation without histological confirmation of appendicitis) have been reported with some groups such as females of reproductive age (up to 26%).(3) The main factors contributing to this high negative laparotomy rate have been the nonspecific clinical features of acute appendicitis. A complication rate of up to 6.1% following removal of normal appendices was also reported.(4).To decide between lesser of two evils ,that is, a negative appendicectomy or an appendicular perforation can be often be a vexing problem. Ultrasound has been proposed as an ideal noninvasive adjunct to diagnosis in suspected appendicitis. This study tries to correlate between clinically diagnosed acute appendicitis and histopatologically examined specimen and the role of ultrasound in diagnosis of acute appendicitis in patients admitted in HANAGAL SHRI
KUMARESHWAR HOSPITAL AND RESEARCH CENTRE, Bagalkot.
6.2 Review of literature:
Acute appendicitis is one of the most common surgical emergencies. Its diagnosis is usually made depending on the presenting history, clinical evaluation and laboratory tests.Credit for performance of the first appendectomy goes to Claudius Amyand. a surgeon at St. George's Hospital in London and Sergeant Surgeon to Queen Ann, King
George I, and King George II. In 1736, he operated on an 11 -year-old boy with a scrotal hernia and a fecal fistula. Within the hernia sac, Amyand found the appendix perforated by a pin. He successfully removed the appendix and repaired the hernia.(5)
In 1824, Louyer-Villermay presented a paper before the Royal Academy of Medicine in Paris.He reported on two autopsy cases of appendicitis and emphasized the importance of the condition.Fergus, in Canada, performed the first elective appendectomy in 1883.(6)
Reginald Fitz, a professor of pathologic anatomy at Harvard, is credited for coining the term "appendicitis". His landmark paper definitively identified the appendix as the primary cause of right lower quadrant inflammation.(7)
The greatest contributor to the advancement in the treatment of appendicitis is
Charles McBurney. In 1889, he published his land-mark paper in the New York Medical
Journal describing the indications for early laparotomy for the treatment of appendicitis. It is in this paper that he described McBurney's point as the point of maximum tenderness, when one examines with the fingertips is, in adults, one-half to two inches inside the right anterior spinous process of the ilium on a line drawn to the umbilicus.(8)
McBurney subsequently published a paper describing the incision that bears his name in 1894. However, McBurney later credited McArthur with first describing this incision.(9)
Alfred Alvarado , conducted a retrospective study of 305 patients admitted at
Nazereth Hospital, Philadelphia from Jan,1975 to Dec,1976 with presentation suggestive of Acute appendicitis with an aim to formulate a practical scoring system for early diagnosis of acute appendicitis. Signs, symptoms and laboratory findings were analyzed for sensitivity, specificity, predictive value and joint probability. It was found that none of the signs or symptoms or laboratory investigations were sensitive or specific enough to make the accurate diagnosis of appendicitis alone. Thus a scoring system consisting of 3 symptoms, 3 signs and 2 laboratory investigations was formulated.(10)
Kalan et al in a study found that use of Alvarado scoring worked very well in diagnosing Acute appendicitis in men and children with sensitivity of 93% and 100%
3 respectively, but the results were disappointing in women where the sensitivity was only
67%. (11)
Bengezi, OA, AL-Fallouji M, in their prospective study of 345 consecutive patients admitted with the diagnosis of acute appendicitis, among them 196 patients with score 8-
10, 190 patients had acute appendicitis (97%). And they concluded that Modified
Alvarado score is simpler, easier to read and interpret and more practical and reliable than
Alvarado score.(12)
Malik AA and Wani NA in their study on 106 patients concluded that the high score in men and children were found to be an easy and satisfactory aid in the early diagnosis of acute appendicitis, but a high false positive rate for acute appendicitis was found in women.(13)
Lamparelli MJ, Hoque HM, Pogson CJ and Bell AB assessed a total of 84 consecutive patients prospectively using the Modified Alvarado score. The rate of negative appendicectomy in the study group was 0% compared to 18% in the control group.(14)
C D Douglas et al in a randomized control trial comparing clinical diagnosis
(control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score
(intervention group) measured Sensitivity and specificity of ultrasonography in diagnosing acute appendicitis at 94.7% and 88.9%, respectively.(15)
Siddique K, Jamil A, Ali Q, Ehsan A, Anwar I, Zafar in their study 209 out of
267,220 patients (82.4%) had appendicectomy while 47 patients (17.6%) had no surgery.
Overall the MAS system showed a sensitivity of 57.8% and a specificity of 78%.Negative appendicectomies were seen more in females than males. For males, the sensitivity was
62.3% and the specificity was 92%. For females the sensitivity and specificity were
52.7% and 65% respectively. Ultrasound was able to diagnose appendicitis in 157 patients (71.3%). The combined results of MAS and Ultrasound showed a combined sensitivity of
74% and specificity of 82%. (16)
6.3 Objectives of the study:
o To study various presentations of acute appendicitis.
o To evaluate the sensitivity and specificity of ultrasound in the diagnosis of
acute appendicitis.
o To determine the incidence of negative appendectomy in HSK hospital
Bagalkot by clinico pathological study.
7. Materials and Methods:
7.1 Source of data:
All patients with right lower abdominal pain, admitted in HSK hospital Bagalkot , in
whom acute appendicitis is suspected will be will be taken for this prospective study
from January 2013 to June 2014
Inclusion criteria:
o All patients above the age of 12yrs
o Acute right lower abdominal pain clinically presumed to be of appendicular
origin.
Exclusion criteria:
o Patients less than 12 years of age
o Patient with other pre-existing illeoceacal pathology like Tuberculosis or
malignancy which are the underlying causes for Appendicitis.
o Patient who are not willing for appendicectomy
Study Design: Prospective study
5 Sample size:
The sample size calculation was done using open epi software 2.3.1 version
Formula used DEFF × NP (1- P)
2 2 [d /z 1-α/2 ]×(1-N)+p(1-p)
N- Infinite population
P(1) -8.6%
Absolute error (d) -7%
Sample size calculated for this study is 62 approx 65
7.2 Method of collection of data :
Method:
Patients presenting with pain in the right lower quadrant of abdomen after clinical examination are provisionally diagnosed to have acute appendicitis and will be admitted to the hospital. A minimum of 65 cases with the following inclusion and exclusion criteria will be selected for study and will be allocated alternatively to each of the clinical study.
A pretested Performa will be used to collect relevant information (patient data, clinical findings, lab investigations, sonological findings, HPR etc.) from all the selected patients.
Modified Alvarado score will be applied on these patients which consists of three symptoms, three signs and a laboratory finding as described by Alvarado and later modified by Kalan et al.
Modified Alvarado score Symptoms/Sign/Investigation Score Symptoms
Migration of pain to right iliac fossa 1
Anorexia 1
Nausea/Vomiting 1
Signs
Tenderness over right iliac fossa 2
Rebound tenderness over right iliac fossa 1 Temperature > 37.5oC (99.5 F) 1 Investigation
Leucocytosis > 10x109/L 2 Total 9
7 Scoring system
1-4 -Appendicitis unlikely
5-6 -Appendicitis possible
7-8 -Appendicitis probable
9 -Appendicitis definitive
Cases with score of 1-4 will be observed and not operated and will be discharged.Cases with score 5 or more abdominal ultrasonography will be done routinely within 4 hours of admission. The sonographic findings were recorded as positive and negative for acute appendicitis. The patients with Alvarado score 5 and above with positive ultrasonography were operated immediately. Patients with negative ultrasound but Alvarado score 8 or above were also operated upon. Patients with Alvarado score 5-6 will be retained for 48 hours under observation and decision to operate will be made depending on progress in their clinical course and sonographic finding. All the specimens of appendix will be sent for histopathological confirmation of acute appendicits.
Statistical analysis:
Data will be analyzed statistically by appropriate statistical method whereever necessary.
7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, only in the patients selected for study
Hb, BT, CT, TC, DC, ESR, Urine – sugar/ albumin/ microscopy.
Blood urea, Serum creatinine, RBS. ECG.
Chest X Ray.
Ultrasonography
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Ethical clearance has been obtained from “Institutional Ethical Committee” of S. N.
Medical College, Bagalkot.
8. List of references:
1) Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed
appendicitis: nationwide analysis. Arch Surg. 2002 Jul;137(7):799-804.
2) Lewis FR, Holcroft JW, Boey J, Dunphy E. Appendicitis. A critical review of
diagnosis and treatment in 1,000 cases. Arch Surg. 1975 May;110(5):677-84.
3) Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of
appendicitis decreased over time?A population-based analysis. JAMA. 2001
Oct 10;286(14):1748-53.
4) Gough IR, Morris MI, Pertnikovs EI, Murray MR, Smith MB, Bestmann MS.
Consequences of removal of a "normal" appendix. Med J. 1983 Apr
16;1(8):370-2.
5) Bernard MJ, David HB. Schwartz’s principles of surgery. 8th ed. New York:
The McGraw-Hill Companies; 2005. p. 1119-37.
6) Zinner MJ, Ashley SW. Maingot’s abdominal operations. 8th ed. Norwalk:
Appleton-Century-Crofts; 1985. p. 1255.
9 7) Seal A. Appendicitis: a historical review. Can J Surg. 1981 Jul;24(4):427-33.
8) McBurney C. Experience with early operative interference in cases of disease
of the vermiform appendix. NY State Med J. 1889;50:676.
9) McBurney C. The incision made in the abdominal wall in cases of
appendicitis. Ann Surg 1894;20:38.
10) Alvarado A. A practical score for the early diagnosis of acute appendicitis.
Ann Emerg Med. 1986 May;15(5):557-64.
11) Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified
Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann
R Coll Surg Engl. 1994 Nov;76(6):418-9.
12) Bengezi OA, Al-Fallouji M. Modified Alvarado score in diagnosis of acute
appendicitis. Br J Surg.1997 May;84:30-3.
13) Malik AA, Wani NA. Continuing diagnostic challenge of acute appendicitis:
evaluation through modified Alvarado score. NZ J Surg. 1998 Jul;68(7):504-5.
14) Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB. A prospective evaluation of
the combined use of the modified Alvarado score with selective laparoscopy in
adult females in the management of suspected appendicitis. Ann R Coll Surg
Engl. 2000 May;82(3):192-5.
15) Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled
trial of ultrasonography in diagnosis of acute appendicitis,incorporating the
Alvarado score. BMJ. 2000 Oct 14;321(7266):919-22.
16) Jamil A, Ali Q, Ehsan A, Anwar I, Zafar A. Evaluation of modified Alvarado
score and ultrasonography in acute appendicitis. IJS. 2007Jun:209-14. 11 9. Signature of the candidate
10. Remark of the guide Recommended;
11. 11.1 Name and designation of DR S.N SHIRBUR M.S , FMAS ,FAIGES
Guide PROFESSOR,
DEPARTMENT OF GENERAL SURGERY,
S. NIJALINGAPPA MEDICAL COLLEGE,
BAGALKOT.
11.2 Signature
11.3 Head of the Department DR . E . B KALBURGI M.S , FAIS , FICS
PROFESSOR AND HEAD
DEPARTMENT OF GENERAL SURGERY,
S. NIJALINGAPPA MEDICAL COLLEGE,
BAGALKOT.
11.4 Signature
12 12.1 Remarks of the Principal
12.2 Signature