THE NATURAL-HISTORY OF APPENDICITIS IN ADULTS - A PROSPECTIVE-STUDY

Objective The authors relate prehospital delay and in-hospital delay t o the incidence of perforation of appendicitis. Summary Background Dat a Quality assurance studies use perforation rate as an index of qualit y of care. This is based on the assumption commonly presented in retro spective reports that in-hospital delay to surgery influences the inci dence of perforation. Only one limited study prospectively found that prehospital delay increased the perforation rate. Methods During a 6-m onth period, 95 consecutive adults undergoing appendectomies at Foothi lls Hospital in Calgary, Alberta, were questioned as to onset and type of first symptom (i.e., epigastric discomfort, anorexia nervosa, vomi ting, and abdominal pain). Time of emergency room (ER) arrival, surger y consultation, and operating room start were taken from the chart. Su rgical and pathology reports were used to identify status of appendix (normal, inflamed, suppurative, gangrenous, perforated) and presence o f abscess cavity. The status of appendix was related to prehospital an d in-hospital delay to establish significance. Results There were 13(1 4%) normal, 67(70%) inflamed, and 15(16%) perforated appendices. Patie nts with perforated appendices waited 2.5 times longer before reportin g to the ER, compared with patients with inflamed appendices (57 hours vs. 22 hours, p < 0.007). Once in the hospital, patients with perfora ted appendices were identified and treated faster than those with infl amed appendices (7 vs. 9 hours, p < 0.039). Analysis by ER physician w as 3 hours whether the appendix was normal, inflamed, or perforated. A nalysis by the surgeon was significantly shorter in patients with perf orated appendices than patients with inflamed appendices (4 vs. 6 hour s, p < 0.039). Conclusions This prospective study identifies that dela y in presentation accounts for the majority of perforated appendices. Clinical evaluation is effective for identifying patients with more ad vanced disease. Indiscriminate appendectomy as an attempt to decrease perforation is not supported by these data. Hospital perforation rates likely reflect patient factors, illness attitude, and access to medic al care.