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Hale and colleagues performed a retrospective chart review of 12 months of data examining patients who underwent appendectomy. These data were obtained from 147 Department of Defense hospitals worldwide, covering January 1992 through January 1993. They evaluated the demographics, lab data, diagnosis, and complications of 4950 patients.
The median age of patients undergoing appendectomy was 23 years, with a 2:1 male-to-female predominance. A normal appendix was found in 13% of cases, acute appendicitis in 66%, and a perforated appendix in 21%. The rate of perforation was significantly increased in patients younger than 8 years and older than 45 years. In fact, the perforation rate in these two subgroups was 48% vs. the 20% noted in all groups combined. Hale et al did not comment on presenting signs, symptoms, or ancillary radiologic studies, but they did evaluate two parameters of import to the emergency physician. Temperature at time of presentation and the white blood cell count (WBC) were correlated with final diagnosis. A preoperative temperature higher than 100.5°F was present in 15-40% of patients. Only 15% of patients with acute appendicitis had a temperature higher than 100.5°Fthe same percentage as those with a postoperative diagnosis of normal appendix. Although more patients with a perforated appendix were febrile, only 40% of this group had a fever. Similarly, the discriminating power of the WBC was equally poor. While 90% of patients with acute and perforated appendices had a WBC more than 10,000, 60% of patients with a normal appendix had a WBC more than 10,000. Even though this value was statistically significant on multivariate analysis, there seems to be little to hold onto from a clinical standpoint. The series also included 39 pregnant women, two-thirds of whom had an acute or perforated appendix.
The complication rate for the procedure or disease process was 5%; most complications were due to wound or urinary tract infections. Four patients diedthree from sepsis and one from a postoperative pulmonary embolus.
As Hale et al wrote, "the more things change, the more they stay the same." It seems that time and again, we revisit the issue of appendicitis and come up with the same results. Perforation rates remain at 20-30%, despite all our fancy diagnostic tests, and the groups at the extremes of age suffer disproportionately from this complication. The high rate of perforation probably also explains why the negative appendectomy rate is 22% for children younger than 5 years. The good news is that the mortality from appendectomy (or laparotomy for perceived appendicitis) is less than 1%.
This study also helps fuel the discussion with our surgical colleagues regarding the use (or lack thereof) of temperature and WBC elevation. Neither of these parameters has adequate discriminating power. There is no laboratory or radiologic test pure enough to make the diagnosis. The diagnosis can haunt us, the presentations are usually atypical, and they never sound like what we were taught in medical school. We must remain undeterred in our attempts to do the right thing for patients. Do not let atypical histories, normal white counts, or absence of fever deter you. Consider it always, and consider it early. Stick to your guns and call the surgeon. (Hopefully they read the article as well.) (Dr. Heilpern is Assistant Professor of Medicine, Emory University School of Medicine, Director of Undergraduate Medical Education, Division of Emergency Medicine, Atlanta, GA.)