Prasad K¹, Varala Veenamercy^2*, Shreesha D Rao³

¹Assistant Professor, Department of General Surgery, Subbaih Institute of Medical Sciences, Shivamogga, INDIA.

²Surgical Resident, ³Professor & HOD, Department of General Surgery, Sahyadri Narayana Multi Speciality Hospital, Shivamogga, INDIA.

Email: shashank.kj@gmail.com

RESULTS

Total 78 patients meeting the inclusion criteria were selected for the study. The clinical details of patients in the study were entered in a specially prepared proforma. The analysis was done to study the various clinical parameters.

Table 1: Social Profile of the study subjects

The above table shows gender wise distribution of patients in the study group. 36 patients (46.15 %) were male and remaining 42 patients (53.85 %) were female. With majority of them belonging to the age group of 25 to 35 years with a mean age of 32.8 years.

Table 2: Distribution of pain among the study subjects

In the study 46.15% had pain in Right iliac fossa, 24.36% had diffuse pain, 12.82% had pain in Right hypochondrium and 8.97% had pain in Umbilicus

Table 3: Distribution of clinical symptoms among the study

Above table shows symptoms wise distribution of cases in the study group. All 78 patients had abdominal pain, vomiting seen in 60 (76.92%) patients, anorexia in 48 (61.54 %) patients, fever in 32 (41.03 %) patients, diarrhoea in 5 (6.41%) patients, constipation in 12 (15.38%) patients, and lump seen in 10 (12.82 %) patients.

Table 4: Distribution of clinical signs

Above table shows clinical signs wise distribution of patients in the study group. 77 out of 78 patients (98.72%) had tenderness, rebound tenderness observed in 26 (33.33 %) patients, Guarding /rigidity in 18 (23.08%) patients, distension in 17 (21.79%) patients, tachycardia in 26 (33.33%) patients

Table 5: Bowel Sound Distribution among subjects

In the study, 67.95% had normal bowel sound, 17.95% had sluggish bowel sound, 7.69% had absent bowel sound and 6.41% had Exaggerated bowel sound.

DISCUSSION

Acute abdomen encompasses a significant number of emergency admissions. An early diagnosis and prompt treatment is paramount for a successful management. Accurate diagnosis of non- traumatic acute abdominal diseases is challenging but can be achieved by detailed history, proper clinical examination and judicious use of appropriate radiological investigations.¹ Majority of patients in our study belong to the age group of 26-35 years (n=17, 21.79%), followed by age group of 56-65 years (n=16, 20.51%) and in the age group of 16-25 years (n=13, 16.67%) and 36-45 years (n=13, 16.67%). This may be a reflection of the population demographics of our country where the majority of the population is young adults. Acute appendicitis is relatively rare in infants and becomes increasingly common in childhood and peaks in early adult life. After middle age, the risk of developing appendicitis is quite small74. In our study acute appendicitis was commonly seen in age group of 15 to 45 years (31 out of 36 patients). Acute cholecystitis was commonly seen in age group of 36 to 65 years (9 out of 12 patients) and perforation peritonitis, intestinal obstruction and acute mesenteric ischemia were predominantly seen in the elderly age group (19 out of 30 patients were > 55 years age). Similar results were observed in the study done by Batra et al.¹⁰ where most common age group of acute abdomen was 26 - 35 years, while another study done by Sabhnani and Tomar¹¹ also reported most common age group for acute abdomen as 21-40 years. In another study of Reddy et al.¹² and Arora et al.¹³ the predominant age group for acute abdomen was 21-30 years. In a study done by Samir et al.¹⁴, acute appendicitis was common in middle age group and perforation peritonitis, intestinal obstruction were common in old age group. In our study out of 78 patients, 42 (53.85 %) were males and 36 (46.15%) were females. Similar findings were reported in other studies on acute abdomen done by Reddy et al.¹² and Batra et al.¹⁰ Another study done by Kumar et al.¹⁵ also reported more number of male patients than female with a ratio of 2.74:1. In another large study of 125 patients of acute abdomen done by Arora et al. ¹³, majority of patients were male.

SYMPTOMS: In our study, abdominal pain was present in all patients. Pain was in right iliac fossa in 46.15%, 24.36% had pain in all quadrants of the abdomen, 8.97 % had pain in umbilical region and 12.82% had pain in right hypochondrium.

Location of pain helps to identify underlying site of pathology. Pain from foregut structures, which includes the stomach, pancreas, liver, biliary system, and proximal duodenum, is typically localized to the epigastric region. Pain from midgut structures, which includes, the rest of the small bowel and the proximal third of colon, including the appendix, perceived in the periumbilical region. Hindgut structures, such as distal two- thirds of the colon and pelvic genitourinary organs, usually cause pain in the suprapubic region. Pain is often reported in the back for retroperitoneal structures, such as aorta and kidneys. In appendicitis, typical presentation begins with periumbilical pain (due to activation of visceral afferent neurons). The pain then localizes to the right lower quadrant as the inflammatory process progresses to involve the parietal peritoneum overlying the appendix.^16,17 In patients of intestinal obstruction; pain is colicky and diffuse, which waxes and wanes over 5-minute intervals. Nausea, vomiting, distention, and obstipation are associated with pain.80 Perforation peritonitis patients present with sudden onset severe pain which quickly becomes diffuse as generalized peritonitis ensues.8 Pain caused by biliary diseases is typically in the right upper quadrant and/or epigastrium and may radiate to the back or right shoulder. Pain may be precipitated by fatty food intake. Patients with acute mesenteric ischemia present with an acute onset of severe periumbilical pain which may become diffuse and pain is often out of proportion and requires opioids. In our study, other common symptom was vomiting which was seen in 60 (76.92%) patients, anorexia in 48 patients (61.54 %), fever in 32 patients (41.03 %), constipation in 12 patients (15.38%), and diarrhoea in 5 (6.41%) patients Pain generally precedes vomiting in surgical conditions, with exception of esophageal rupture from forceful emesis. Vomiting is usually present in small bowel obstruction. Nature of the vomiting is diagnostically helpful. With small bowel obstruction, a progression from gastric contents to bilious to feculent emesis is anticipated as the duration of the illness increases. Results reported in literature about symptomatology in acute abdomen are similar to our study. In a study done by Reddy et al. ¹² and Arora et al.¹³ vomiting was second most common symptom and anorexia was third most common symptom after abdominal pain. In study done by Momin et al.¹⁸ and Al-Aquli HA et al.,¹⁹ most common symptoms with abdominal pain were nausea and vomiting. In another study done by Kumar et al.,¹⁵ pain abdomen was the most common symptom of acute abdomen followed by vomiting and distension of abdomen.

CLINICAL SIGNS

In our study, tenderness was the most common clinical sign observed in almost all patients of acute abdomen (n=77, 98.72%). Rebound tenderness was observed in 26 patients (33.33 %) and Tachycardia was present in 26 patients (33.33%), Guarding/rigidity was observed in 18 patients (23.08%). Distension was present in 17 patients (21.79%) and Abnormal bowel sounds were observed in 25 patients (31.05 %), Bowel sounds were exaggerated in 5 patients, all belonging to obstructive pathology while bowel sounds were sluggish in 14 patients and bowel sounds absent in 6 patients. After a thorough history, a focused physical examination was performed. Tachycardia should alert the clinician to a serious cause of the abdominal pain. However, the presence of normal pulse rate does not exclude a serious diagnosis. Abdominal tenderness is the objective expression of pain from palpation. Location of abdominal tenderness helps to identify underlying site of pathology.78 In patients of appendicitis, maximum tenderness is observed over McBurney's point; this point is situated at the junction of the lateral 1/3 and medial 2/3 of the right spino- umbilical line joining the right anterior superior iliac spine and umbilicus. Findings observed in study done by Arora et al. 5 the commonest clinical sign was tenderness present in 117 out of 125 patients followed by guarding in 78 out of 125 patients, tachycardia in 58 out of 125 patients, distension in 43 out of 125 patients, rigidity in 29 out of 125 patients and rebound tenderness in 22 out of 125 patients. In a study done by Momin et al.¹⁸ and Al-Aquli HA et al. ¹⁹ the most common clinical signs were abdominal tenderness followed by voluntary guarding and rebound tenderness.

CONCLUSION

The study strongly suggested that with thorough history taking and proper clinical examination, clinical diagnosis was required for proper identification of cases with Acute Appendicitis. Radiological investigations help in confirming clinical suspicion and giving added information of underlying pathology with accuracy.

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