Predictors of in-hospital appendiceal perforation in patients with non-perforated acute appendicitis with appendicolithiasis

1. This retrospective study found that in patients initially presenting with acute appendicitis with appendicolithiasis, the length of hospital stay, age above 65 or between 18-25, hypertension, elevated BMI, and hyponatremia at initial presentation were all predictors of in-hospital appendiceal perforation.

Evidence Rating Level: 2 (Good)

Among the most common surgical pathologies, appendicitis is a condition which, if left untreated, could potentially result in perforation. A subset of patients presenting with appendicitis also present with appendicolithiasis (calcified deposits in the appendix), which increases the risk of a complicated appendicitis and/or perforation. The current retrospective study analyzed the data of patients diagnosed with non-perforated acute appendicitis who also presented with appendicoliths. Researchers analyzed medical records, clinical data, and imaging findings to uncover factors that could predict the risk of appendiceal perforation during the course of the illness. Over 16 percent of patients had in-hospital progression to appendiceal perforation, and results also indicated that length of stay was more than twice as long in patients whose appendicitis perforated (3.0 days versus 1.2 days, p < .001). Patient factors such as age above 65 years or between 18 to 25 years (OR 4.12; 95% CI: 1.36—12.48), hypertension (OR: 3.08; 95% CI: 1.01—8.56), elevated BMI above 30 kg/m2 (OR: 2.78; 95% CI: 1.22—6.04), and hyponatremia (OR: 2.95; 95% CI: 1.19—6.90) were significant predictors of in-hospital appendiceal perforation. Histopathological analyses found that signs of severe acute inflammation and/or micro-abscesses and epithelial damage were significantly more common in patients with appendicoliths compared to those without (p < .05). Time to appendectomy in this study was not a significant contributor to risk of perforation, contrary to previous studies, and no other lab markers, including degree of leukocytosis at presentation, were associated with increased risk for in-hospital perforation. A limitation of this study’s retrospective nature is the inability to quantify the importance of other lab markers such as C-reactive protein levels and hyperbilirubinemia as predictors of appendiceal perforation. However, the employment of histopathological analysis was useful in identifying perforation that was not detected on CT due to limited sensitivity, and this is the first study to investigate factors associated with in-hospital progression to perforation in patients with appendicolithiasis. The results of this study provide insight into the relative risk of appendiceal perforation in hospital for patient with or without appendicolithiasis. 

Click to read the study in BMC Surgery

Image: PD

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