46
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1975
The Prevention of Perforated Appendicitis A Challenge for Health Education A.P JOHNSON, JR., M.D., MARY ASHLEY, R.N., M.PH., JOSEPH L. ALEXANDER, M.D., FA.C.S., Division of, Geleral Siurgerv, Martinr Luther Kinig, Jr: -Los A tigeles CountyCGeneral Ho.spital and Clia,lles R. Drew Postgradhnate Medical Schliool Los Angeles, Calilornia
A ppendicitis is the most frequent inflammatory lesion of the abdominal cavity. According to the National Center for Health Statistics, the incidence of appendicitis in the United States is 1.7 per 1000. Little is known about the etiology of the disease, but it is felt that a mucosal lesion is the initiating factor which results in obstruction of the appendiceal lumen. This is followed by distension and ischemia and an unbridled inflammatory process. Lymphoid hyperplasia is most often the initiating factor during the first decade of life, while obstruction secondary to a fecalith is the predominating factor in the remaining decades. Appendicitis occurs most frequently during the second and third decades of life. It is not unknown in infancy and old age where it is accompanied by higher morbidity and mortality, due to difficulty in making the diagnosis in these age groups. This communication reviews the Martin Luther King, Jr. General Hospital's experience with the management of acute appendicitis during the first 21 months of its existence and outlines a health education program conceived in an attempt to reduce the high incidence of perforated appendicitis with its attendant complications. MATERIALS AND METHODS
The period covered is from March 30, 1972 to December 31, 1973. Of the patients admitted with a clinical dignosis of acute appendicitis, 81 had surgical exploration. Excluded from the study are those patients admitted for observation and proved not to have the disease. The age range was three to 63. There were 57 males (70%1/o) and 24 females (30%). The two
cases of appendicitis in pregnancy in our series occurred during the first trimester. Both were ruptured and one ended in spontaneous abortion. Nine (1O1) of the 81 operated patients had normal appendices. The missed diagnoses in these patients were: mesenteric adenitis(6), perinephric abscess or Pott's disease (1), dermoid tumor of the right ovary with torsion (1) and a benign tumor of the terminal ileum (1). Twenty-two of the 72 remaining cases, with positive diagnosis of appendicitis, were perforated, an incidence of 30.5%. The average number of hours with symptoms prior to admission was 106 in the perforated group and 31 in the non-perforated group. The length of hospitalization for the perforated group averaged 13 days and for the non-perforated group, five days. There were no deaths. DISCUSSION
The incidence of perforation in our series was 30.5%. This incidence seemed high and unacceptable, prompting us to review the literature in an effort to compare our experience with others. A selected review of the literature revealed an incidence of perforation that was as high or higher in series involving comparable patient populations. Clements et al.l reviewed 1103 cases of acute appendicitis in a rural community. Their study extended over a 33 year period, 1930-1962, with an incidence of perforation and gangrene of 39%. In their experience, the incidence of frank perforation decreased from 35% to 18% while the rate of diffuse acute peritonitis decreased from 15% to 2.5%. Their mortality decreased from 4.4% (1930-1932) to 0.4% (1956-1962). The overall morality rate
Vol. 67, No. 1
Perforated Appetndicitis
was 1.6%. These results indicate that the improvement in mortality was due to earlier diagnosis as well as post-operative management. Clement's et al.' experience is in contrast to that reported by Barnes2 who reports an 18% constancy of perforation over a 23 year period (1937-1959). The experience of Babcock and McKinley3was similar with a 23 to 27% incidence of perforation over a 20-year period (1936-1955) at Gersinger Memorial Hospital and Foss Clinic. Williams et al.4 in their series of 83 cases of appendicitis in patients over age 60 found a perforation rate of 36%/o. Foster, in reviewing appendicitis in infancy and childhood at Vanderbilt University Hospital, found a perforation rate of 38%. This study included 358 children ranging in age from birth to 12 years and extended over a 19-year peiod. Since our hospital serves an urban inner city population, we believe that our patient population is more comparable to those of Massachusetts General and Geisinger Memorial Hospitals. These institutions report a constancy in the incidence of perforated appendicitis over the past 20 or more years. These unimproved statistics suggest that in order to obtain results superior to those reported by such well established institutions, a health education program is essential. This program should be designed to modify the behavior of the patient population so that they will seek early medical attention for the evaluation of abdominal pain. Upon reflection on our experience and prospects in the management of acute appendicitis, we have embarked upon a health education program which has the following objectives and strategies: 1. To prepare educational material for teachers and public school nurses regarding their role in early referral of patients with abdominal pain. 2. To develop an instructional package that can be incorporated into the school curriculum that emphasizes personal care with specific information regarding abdominal pain. 3. To develop educational programs for the parents to be presented in hospital waiting rooms, the community. church and school groups.
47
4. To develop educationail programs, procedures, and policies, for pediatric and medical house staff and nurses regarding the mainagement of' abdominal pain.
Meetings are planned with the L.A. County and L.A. Unified School Nurses for October 1974 to present information and describe our educational program. Similar meetings are also planned with junior and senior high school faculty members. It is our belief that by initiating the forementioned programs, we can further lessen the incidence of perforated appendicitis among members of our hospital community, and thereby avoid many of the complications that result in increased morbidity and mortality. SUMMARY
We have presented a series of 81 patients who underwent surgery for acute appendicitis at Martin Luther King Jr. General Hospital over its first 21 months of existence. Our incidence of perforation was 30.5%, which is comparable to other institutions with similar patient populations. In an effort to decrease the rate of perforations, we have embarked on a community wide educational program designed to encourage patients with abdominal pain to seek earlier medical attention. It is our hope that subsequent studies will show a decline of perforated appendicitis in our hospital community. LITERATURE CITED
1. CLEMENTS. N. and J.E. OLSON, and J.H. POWERS: Acute Appendicitis in a Rural Community-Series IV. Ann. Surg., 161: 231, 1965. 2. BARNES, B.A. and G.E. BEHRINGES, F E. WHEELOCK and E.W7- WILKINS. Treatment of Appendicitis at the Massachusetts General Hospital (1937-1959). J.A.M.A., 180:122, 1962. 3. BABCOCK, J. R. and W M. McKINLEY Acute Appendicitis: An Analysis of 1,662 Consecutive Cases. Ann. Surg., 150:131, 1959. 4. WILLIAMS, J. S. and H.W, HALL, JR.: Acute Appendicitis in the Elderly: A Review of 83 Cases. Ann. Surg., 162:208, 1965. 5. FOSTER, J.H. and WH. EDWARDS. Acute Appendicitis in Infancy and Childhood: A Twenty Year Study in a General Hospital. Ann. Surg., 146:70, 1957.
ATTEND THE NMA CONVENTION IN MIAMI THIS SUMMER AUGUST 10-15, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1975
The Prevention of Perforated Appendicitis A Challenge for Health Education A.P JOHNSON, JR., M.D., MARY ASHLEY, R.N., M.PH., JOSEPH L. ALEXANDER, M.D., FA.C.S., Division of, Geleral Siurgerv, Martinr Luther Kinig, Jr: -Los A tigeles CountyCGeneral Ho.spital and Clia,lles R. Drew Postgradhnate Medical Schliool Los Angeles, Calilornia
A ppendicitis is the most frequent inflammatory lesion of the abdominal cavity. According to the National Center for Health Statistics, the incidence of appendicitis in the United States is 1.7 per 1000. Little is known about the etiology of the disease, but it is felt that a mucosal lesion is the initiating factor which results in obstruction of the appendiceal lumen. This is followed by distension and ischemia and an unbridled inflammatory process. Lymphoid hyperplasia is most often the initiating factor during the first decade of life, while obstruction secondary to a fecalith is the predominating factor in the remaining decades. Appendicitis occurs most frequently during the second and third decades of life. It is not unknown in infancy and old age where it is accompanied by higher morbidity and mortality, due to difficulty in making the diagnosis in these age groups. This communication reviews the Martin Luther King, Jr. General Hospital's experience with the management of acute appendicitis during the first 21 months of its existence and outlines a health education program conceived in an attempt to reduce the high incidence of perforated appendicitis with its attendant complications. MATERIALS AND METHODS
The period covered is from March 30, 1972 to December 31, 1973. Of the patients admitted with a clinical dignosis of acute appendicitis, 81 had surgical exploration. Excluded from the study are those patients admitted for observation and proved not to have the disease. The age range was three to 63. There were 57 males (70%1/o) and 24 females (30%). The two
cases of appendicitis in pregnancy in our series occurred during the first trimester. Both were ruptured and one ended in spontaneous abortion. Nine (1O1) of the 81 operated patients had normal appendices. The missed diagnoses in these patients were: mesenteric adenitis(6), perinephric abscess or Pott's disease (1), dermoid tumor of the right ovary with torsion (1) and a benign tumor of the terminal ileum (1). Twenty-two of the 72 remaining cases, with positive diagnosis of appendicitis, were perforated, an incidence of 30.5%. The average number of hours with symptoms prior to admission was 106 in the perforated group and 31 in the non-perforated group. The length of hospitalization for the perforated group averaged 13 days and for the non-perforated group, five days. There were no deaths. DISCUSSION
The incidence of perforation in our series was 30.5%. This incidence seemed high and unacceptable, prompting us to review the literature in an effort to compare our experience with others. A selected review of the literature revealed an incidence of perforation that was as high or higher in series involving comparable patient populations. Clements et al.l reviewed 1103 cases of acute appendicitis in a rural community. Their study extended over a 33 year period, 1930-1962, with an incidence of perforation and gangrene of 39%. In their experience, the incidence of frank perforation decreased from 35% to 18% while the rate of diffuse acute peritonitis decreased from 15% to 2.5%. Their mortality decreased from 4.4% (1930-1932) to 0.4% (1956-1962). The overall morality rate
Vol. 67, No. 1
Perforated Appetndicitis
was 1.6%. These results indicate that the improvement in mortality was due to earlier diagnosis as well as post-operative management. Clement's et al.' experience is in contrast to that reported by Barnes2 who reports an 18% constancy of perforation over a 23 year period (1937-1959). The experience of Babcock and McKinley3was similar with a 23 to 27% incidence of perforation over a 20-year period (1936-1955) at Gersinger Memorial Hospital and Foss Clinic. Williams et al.4 in their series of 83 cases of appendicitis in patients over age 60 found a perforation rate of 36%/o. Foster, in reviewing appendicitis in infancy and childhood at Vanderbilt University Hospital, found a perforation rate of 38%. This study included 358 children ranging in age from birth to 12 years and extended over a 19-year peiod. Since our hospital serves an urban inner city population, we believe that our patient population is more comparable to those of Massachusetts General and Geisinger Memorial Hospitals. These institutions report a constancy in the incidence of perforated appendicitis over the past 20 or more years. These unimproved statistics suggest that in order to obtain results superior to those reported by such well established institutions, a health education program is essential. This program should be designed to modify the behavior of the patient population so that they will seek early medical attention for the evaluation of abdominal pain. Upon reflection on our experience and prospects in the management of acute appendicitis, we have embarked upon a health education program which has the following objectives and strategies: 1. To prepare educational material for teachers and public school nurses regarding their role in early referral of patients with abdominal pain. 2. To develop an instructional package that can be incorporated into the school curriculum that emphasizes personal care with specific information regarding abdominal pain. 3. To develop educational programs for the parents to be presented in hospital waiting rooms, the community. church and school groups.
47
4. To develop educationail programs, procedures, and policies, for pediatric and medical house staff and nurses regarding the mainagement of' abdominal pain.
Meetings are planned with the L.A. County and L.A. Unified School Nurses for October 1974 to present information and describe our educational program. Similar meetings are also planned with junior and senior high school faculty members. It is our belief that by initiating the forementioned programs, we can further lessen the incidence of perforated appendicitis among members of our hospital community, and thereby avoid many of the complications that result in increased morbidity and mortality. SUMMARY
We have presented a series of 81 patients who underwent surgery for acute appendicitis at Martin Luther King Jr. General Hospital over its first 21 months of existence. Our incidence of perforation was 30.5%, which is comparable to other institutions with similar patient populations. In an effort to decrease the rate of perforations, we have embarked on a community wide educational program designed to encourage patients with abdominal pain to seek earlier medical attention. It is our hope that subsequent studies will show a decline of perforated appendicitis in our hospital community. LITERATURE CITED
1. CLEMENTS. N. and J.E. OLSON, and J.H. POWERS: Acute Appendicitis in a Rural Community-Series IV. Ann. Surg., 161: 231, 1965. 2. BARNES, B.A. and G.E. BEHRINGES, F E. WHEELOCK and E.W7- WILKINS. Treatment of Appendicitis at the Massachusetts General Hospital (1937-1959). J.A.M.A., 180:122, 1962. 3. BABCOCK, J. R. and W M. McKINLEY Acute Appendicitis: An Analysis of 1,662 Consecutive Cases. Ann. Surg., 150:131, 1959. 4. WILLIAMS, J. S. and H.W, HALL, JR.: Acute Appendicitis in the Elderly: A Review of 83 Cases. Ann. Surg., 162:208, 1965. 5. FOSTER, J.H. and WH. EDWARDS. Acute Appendicitis in Infancy and Childhood: A Twenty Year Study in a General Hospital. Ann. Surg., 146:70, 1957.
ATTEND THE NMA CONVENTION IN MIAMI THIS SUMMER AUGUST 10-15, 1975
