Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 35-38

Patterns of inflammatory lesions of the appendix in a Nigerian Tertiary Health Facility


1 Department of Pathology, University College Hospital; Department of Pathology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
2 Department of Pathology, University College Hospital, Ibadan, Oyo State, Nigeria
3 Department of Anatomical Pathology, Edo University, Iyamho, Edo State, Nigeria
4 Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan, Oyo State, Nigeria

Date of Submission24-Jun-2020
Date of Decision29-Aug-2020
Date of Acceptance12-Sep-2020
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Mustapha A Ajani
Department of Pathology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_41_20

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  Abstract 


Background: Appendicitis is most common between the ages of 10 and 20 years, although all ages can be affected. Acute appendicitis is the most common cause of acute surgical abdomen worldwide and its incidence varies with geographical location. The aim of this study was to review all the inflammatory lesions of the surgically removed appendix in University College Hospital, Ibadan, Nigeria and to describe the histopathological patterns of these lesions. Methods: This study was a retrospective review of all appendectomy specimens submitted to the Department of Pathology, University College Hospital, Ibadan, Nigeria from January 2009 to December 2018. Patients’ biodata, clinical parameters, and histological diagnoses were extracted from departmental surgical day books. The data were analyzed using IBM SPSS Statistics (version 23; IBM Corporation, Armonk, New York) and expressed as frequency distribution. Results: A total of 1071 appendectomy specimens were received in our laboratory during the 10-year study period, accounting for 3% of all specimens received. There were 1062 cases of inflammatory lesions, accounting for 99.2% of the cases. There was a male preponderance with male to female ratio of 1.2:1. The age was from 1 to 83 years. The most common histological diagnosis was acute suppurative appendicitis with peritonitis accounting for 47.6% of all the cases. Conclusion: The findings in our study supports the fact that acute suppurative appendicitis is the most common inflammatory disease of the appendix which is consistent with other similar studies that have been done in our environment and in the developed world.

Keywords: acute suppurative appendicitis, Ibadan, inflammatory lesions of appendix, Nigeria, peritonitis


How to cite this article:
Ajani MA, Awosusi BL, Omenai SA, Adegoke OO, Ajani TA. Patterns of inflammatory lesions of the appendix in a Nigerian Tertiary Health Facility. J Med Trop 2021;23:35-8

How to cite this URL:
Ajani MA, Awosusi BL, Omenai SA, Adegoke OO, Ajani TA. Patterns of inflammatory lesions of the appendix in a Nigerian Tertiary Health Facility. J Med Trop [serial online] 2021 [cited 2021 Jun 21];23:35-8. Available from: https://www.jmedtropics.org/text.asp?2021/23/1/35/314854




  Introduction Top


Acute appendicitis is mostly diagnosed through clinical examination and further confirmed by routine histology of the removed appendix. Most patients present with classical symptoms and signs.[1] Abdominal pain is the primary presenting complaint of most patients with acute appendicitis.[1] The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa was first described by Murphy, but this is usually seen in only about 50% of cases.[1] Acute appendicitis is the most common cause of acute surgical abdomen worldwide and its incidence varies with geographical location.[2] It is also the most common nonobstetric surgical emergency seen during pregnancy.[3] Appendicitis is most common between the ages of 10 and 20 years, although all ages can be affected.[2]

Inflammation of the appendix is thought to be caused by luminal obstruction. This usually results from various etiologies that lead to increased mucus production and bacterial overgrowth, resulting in tension of the appendiceal wall and eventually necrosis with potential perforation.[4] Physical examination findings specific for acute appendicitis include the psoas sign, the obturator sign, and the Rovsing sign. Ultrasonography, computed tomography (CT), and magnetic resonance imaging are options for the evaluation of patients with suspected acute appendicitis.[4]

Various studies have shown differences in sex, age, and seasonal variations in incidences of appendicitis. The incidence is higher among the Caucasians and also in people living in the developed world, although this appears to be declining.[5],[6] In Nigeria, the incidence of acute appendicitis is relatively low with varying reports of average annual frequencies ranging from 22.1 to 49.8 new cases, but in other African countries annual frequencies are relatively higher ranging from 22.9 to 129 new cases per 100,000 persons.[7],[8],[9],[10],[11]

The aim of this study was to review all the inflammatory lesions of the surgically removed appendix in University College Hospital, Ibadan, Nigeria and to describe the histopathological patterns of these lesions.


  Materials and methods Top


This was a retrospective review of histopathology reports of all the inflammatory lesions of the appendix seen at the Department of Pathology, University College Hospital, Ibadan, Nigeria from January 2009 to December 2018. Our laboratory is a referral center for other smaller hospitals in Ibadan and its environs. The University College Hospital is an 850-bed hospital. Patient’s biodata was extracted from the laboratory request forms and departmental surgical day books. The data were analyzed in terms of frequency, age, and sex distribution as well as histological characteristics of pathologic lesions (acute appendicitis with or without peritonitis, lymphoid hyperplasia, submucosal fibrosis, xanthogranulomatous appendicitis, eosinophilic appendicitis, and schistosomal appendicitis) using IBM SPSS Statistics (version 23; IBM Corporation, Armonk, New York). The data for these patients were presented in tables and figures.


  Results Top


A total of 1071 appendectomy specimens were received in our laboratory during the 10-year study period, accounting for 3% of all specimens received. There were 1062 cases of inflammatory lesions seen accounting for 99.2% of the cases received with an average rate of 107.1 cases per year and an incidence rate of 24 cases per 10,000 persons. There were 573 males and 489 females constituting a male to female ratio of 1.2:1. The age range of patients in this study was 1–83 years. The peak age of occurrence in this study was 20–29 years and closely followed by the 10–19-year age group, both constituting over 60% of the cases. The least number of cases (two patients) was seen in the age group 80–89 years constituting 4.4% of the cases [Table 1].
Table 1: Distribution of cases according to age group and histological diagnosis

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The most common histological diagnosis was acute suppurative appendicitis with peritonitis [Figure 1] accounting for 47.6% of the cases seen. Forty-seven cases were found to be normal (4.4%), whereas xanthogranulomatous appendicitis was seen only in one patient (0.1%).
Figure 1: Photomicrograph showing infiltrates of aggregates of neutrophil polymorphs within the muscularis propria and serosa consistent with acute suppurative appendicitis with peritonitis (hematoxylin and eosin stain, ×40)

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Acute appendicitis with peritonitis occurred more in males than females with a ratio of approximately 2:1. The peak age of occurrence was 20–29 years, constituting 31.3%, and closely followed by age groups 10–19 years and 30–39 years constituting 23.9% each. Acute appendicitis occurred more in females (63.8%) than males (36.2%), whereas acute appendicitis with peritonitis occurred more in males (65.7%) than females (34.3%). Only 10 cases of schistosomal appendicitis [Figure 2] were seen constituting 0.9% of all the inflammatory appendiceal lesions. The peak age of occurrence of reactive lymphoid hyperplasia [Figure 3] was in the second decade of life constituting 1.7% (18 cases) of the inflammatory lesions.
Figure 2: Photomicrograph showing multiple granulomas composed of aggregates of epithelioid cells admixed with lymphocytes, plasma cells and eosinophils, foreign body-type multinucleated giant cells, and calcified eggs of Schistosoma spp. These features are consistent with schistosomal appendicitis (hematoxylin and eosin stain, ×100)

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Figure 3: Photomicrograph showing reactive lymphoid follicles of varying sizes with prominent germinal centers consistent with reactive lymphoid hyperplasia (hematoxylin and eosin stain, ×100)

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  Discussion Top


The surgically removed appendix is one of the commonly received specimens in the histopathology laboratory during the study period. It constituted about 3% of the total histological specimens received in our hospital laboratory, which is relatively higher than 1.6% in a study in Zaria, Northern Nigeria, by Ahmed et al.[11]

Acute appendicitis is a relatively common disease entity, and it was thought to be rather rare in Africans as a result of their dietary habits.[2] The incidence of acute appendicitis is actually common in Africans and is on a steady rise and this could be attributable to urbanization and a change to westernized diet, which consists of low fiber.[2],[12] It is believed that a diet high in fiber results in increased peristalsis and a reduction in the incidence of acute appendicitis.[2] Therefore, in some regions such as sub-Saharan Africa and Southeast Asia where high fiber diet is the staple food, the incidence of acute appendicitis is less.[13]

Acute appendicitis was found to occur more in males in this study with a male to female ratio of 1.2:1. This finding of a higher incidence of acute appendicitis in males is similar to other reports both within and outside Nigeria.[7],[9],[14],[15] However, some studies, including that of Duduyemi[2] from Abuja and Addiss et al.[5] from United States of America, reported a slightly higher incidence in females.

In this study, the peak age of occurrence is in the third decade of life. Most studies from different parts of the world reported a peak incidence in the second and third decades of life.[1],[5],[15] Our finding compares with that of Duduyemi,[2] Alatise and Ogunweide[16] in Ile-Ife, and Fashina et al.[17] in Lagos. However, Ali et al. in Maiduguri,[18] reported a peak age in the 4th decade of life. This finding is also consistent with what similar studies in Africa reported. A study from Ghana by Ohehe-yeboah reported the peak incidence was in the third decade in both sexes,[10] while Chimasa in South Africa reported most of the cases were in the second decade of life.[19]

This study showed a wide range of histological diagnoses. The negative appendicectomy rate of 4.1% is similar to the findings of negative appendectomy of 4.1% in a tertiary hospital in Ghana.[10] These are relatively low compared with most studies reviewed which reported a range of 8.6–35.8% negative appendectomies.[8],[9],[17],[19] This low rate may be due to the adequate clinical examination with improved radiological investigations used in arriving at diagnosis before surgical intervention. The most common histological diagnosis is acute suppurative appendicitis and this is similar to most other studies.[2],[7],[8],[9] Other chronic presentations are usually of the granulomatous inflammatory pattern which could be due to schistosomal infestation or tuberculosis and reactive lymphoid hyperplasia.[8],[9],[14] Our study had significantly higher percentages of cases of acute appendicitis with peritonitis when compared to the study of Duduyemi[2] (47.6% vs. 22.8%). The cases of perforated appendix in this study compared with the study done by Deneke and Tadesse[12] (9.5%) but was relatively low when compared to the findings of Abdulkareem and Awelimobor[8] (30.5%). This could be a factor of how early surgical intervention is offered in patients with acute abdomen.


  Conclusion Top


The findings in our study compared favorably with other similar studies that have been done in our environment. The incidence of acute appendicitis is gradually rising toward figures in the Western world. Acute appendicitis is still one of the most common surgical emergencies in our environment; therefore, prompt and adequate intervention will go a long way in reducing its morbidity and mortality.

Financial support and sponsorship

NilConflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Humes DJ, Simpson J. Acute appendicitis. BMJ 2006;333:530.  Back to cited text no. 1
    
2.
Duduyemi B. Clinicopathological review of surgically removed appendix in Central Nigeria. Alex J Med 2015;51:207–11.  Back to cited text no. 2
    
3.
Snyder M, Guthrie M, Cagle S. Acute appendicitis: efficient diagnosis and management. Am Fam Physician 2018;98:25–33.  Back to cited text no. 3
    
4.
Mandeville K, Monuteaux M, Pottker T, Bulloch B. Effects of timing to diagnosis and appendectomy in pediatric appendicitis. Pediatr Emerg Care 2015;31:753-8.  Back to cited text no. 4
    
5.
Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of acute appendicitis and appendicectomy in the United States. Am J Epidemiol 1990;132:910-25.  Back to cited text no. 5
    
6.
Blomqvist P, Ljung H, Nyren O, Ekbom A. Appendicectomy in Sweden 1989–1993 assessed by the inpatient registry. J Clin Epidemiol 1998;51:859-65.  Back to cited text no. 6
    
7.
Oguntola AS, Adeoti ML, Oyemolade TA. Appendicitis: trend in incidence, age, sex and seasonal variations in South Western Nigeria. Ann Afr Med 2010;9:213–7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Abdulkareem FB, Awelimobor DI. Surgical pathology of the appendix in a tropical teaching hospital. Niger Med Pract 2009;55:32-6.  Back to cited text no. 8
    
9.
Ojo OS, Udeh SC, Odesanmi WO. Review of the histopathological findings in removed appendices for acute appendicitis in Nigerians. J R Coll Surg Edinb 1991;36:245-8.  Back to cited text no. 9
    
10.
Ohene-Yeboah M, Togbe B. An audit of appendicitis and appendectomy in Kumasi, Ghana. West Afr J Med 2006;25:138-43.  Back to cited text no. 10
    
11.
Ahmed SA, Makama JG, Mohammed U, Sanda RB, Shehu SM, Ameh EA. Epidemiology of appendicitis in Northern Nigeria: a 10-year review. Sub-Saharan Afr J Med 2014;1:185-90.  Back to cited text no. 11
  [Full text]  
12.
Deneke A, Tadesse B. Pattern and clinical presentation of acute appendicitis in adults in Zewditu Memorial Hospital. Ethiop J Health Sci 2003;13:117-23.  Back to cited text no. 12
    
13.
Black J. Acute appendicitis in Japanese soldiers in Burma: support for the “fibre” theory. Gut 2002;51:296-300.  Back to cited text no. 13
    
14.
Abudu EK, Oyebadeyo TY, Tade AO, Awolola NA. Surgical pathologic review of appendectomy at a sub urban tropical tertiary hospital in Africa. J Med Med Sci 2011;2:932-8.  Back to cited text no. 14
    
15.
Al-Omran M, Mamdani M, McLeod RS. Epidemiologic features of acute appendicitis in Ontario, Canada. Can J Surg 2003;46:263-8.  Back to cited text no. 15
    
16.
Alatise OI, Ogunweide T. Acute appendicitis: incidence and management in Nigeria. IFEMED J 2008;14:66–70.  Back to cited text no. 16
    
17.
Fashina IB, Adesanya AA, Atoyebi OA, Osinowo OO, Atimomo CJ. Acute appendicitis in Lagos: a review of 250 cases. Niger Postgrad Med J 2009;16:268-73.  Back to cited text no. 17
    
18.
Ali N, Aliyu S. Appendicitis and its surgical management experience at the University of Maiduguri Teaching Hospital Nigeria. Niger J Med 2012;21:223-6.  Back to cited text no. 18
  [Full text]  
19.
Chimasa I. A clinicopathological review of 324 appendices removed for acute appendicitis in Durban, South Africa: a retrospective analysis. Ann R Coll Surg Engl 2009;91:688-92.  Back to cited text no. 19
    


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