INTRODUCTION

Health is very important to us [1, 2]. One of the most common causes of acute abdomen is found in children and adults is Appendicitis. It has an estimated lifetime risk of 8.6% among males, and 6.7% among females [3]. Appendicitis occurs most often between all age groups from 5 and 45 with a mean age of 28. The incidence is approximately 233/100,000 people [4]. The cause of appendicitis is usually from occlusion of the appendiceal orifice lumen. When the lumen of the appendiceal orifice gets occluded, bacteria will build up in the appendix and cause acute inflammation with aperture and formalization of an abscess [5].

Acute pain in the abdomen is the first submitting complaint of patients which brings him to the hospital with acute inflammation of the appendix (appendicitis). The succession of diagnoses for central abdominal cramping pain supervened by vomiting with pain transmitted to the iliac fossa of the right side was the first substantive by Murphy but may be existing only in 50% of cases [6]. There is no certain test for diagnoses of appendicitis, but the reasonable use of urine and blood simple tests, especially inflammatory restraint data, in addition to some radiological tests, can give exclusion of other causes of acute abdomen and support the diagnosis of acute appendicitis [7].

Ruptured appendicitis leads to longer hospital stays and may be associated with many post-operative complications, morbidity, and mortality. Earlier diagnosis and management of acute appendicitis may prevent perforation. A delay in treatment is a major determinant of rupture and so, the occurrence of ruptured appendicitis may be a sentinel event that indicates the problems that are presented in access to health care [8-10].

Study Objectives:

The study objective was to review the incidence of occurrence and leading risk factors of acute appendicitis neglected to rupture in Saudi Arabia.

PARTICIPANTS AND METHODS:

Study Design: A review article.  

Study duration:  Data was collected during the period from 1– 31 November 2019.

Data collection: Medline and PubMed database searches were performed for articles about acute appendicitis, especially in Saudi Arabia and to show the signs, symptoms, and complications of ruptured appendicitis, published in English around the world. The keyword search headings included “acute appendicitis, rupture appendicitis, diagnosis of ruptured appendicitis, Saudi Arabia", and a combination of these was used. References list of each included study was searched for further supportive data.

Statistical analysis: No software has been utilized to analyze the data. The data was extracted based on a specific form that contains (Author’s name, study type, objective, summary, results, and outcomes). These data were reviewed by the group members to determine the initial findings. A double revision of each member’s outcomes was applied to ensure the validity and minimize the mistakes.

RESULTS:

The search of the aforementioned databases returned a total of 53 studies that were included for title screening. 32 of them were included for abstract screening, which leads to the exclusion of 15 articles. The remaining 17 publications full-texts were reviewed. The full-text revision leads to the exclusion of 12 studies, and 5 were enrolled for final data extraction (Table 1).

The included studies had different study designs and population types.

Table 1: Author, objectives and outcomes of the included studies

DISCUSSION:

The detection, identification, and diagnosis of appendicitis are not always easy or direct. About 20-33% of cases expected of having acute appendicitis came to the hospital with atypical manifestations [16]. The great importance of diagnosis is the expectation of liability to the rupture of the inflamed appendix, which results in great morbidity and prolonged hospital stay.

The most efficient method to diminish the occurrence of ruptured appendicitis is to decrease catching the patients to the theater even despite enhancing the rate of undesirable appendectomy [17]. 

The clinical evaluation of acute appendicitis has an overall precision rate (sensitivity and specificity) of 45–81% and 36–53% respectively. Improvements in clinical skills and advances in investigative tools (CT) scan and (US) promoted the successful diagnosis of patients with doubted appendicitis because the clinical manifestations of appendicitis are always imprecise [18].

Anyhow, the physicians had to trust patients' speeches, i.e the while when symptoms, as abdominal cramps, nausea, vomiting, or loss of appetite, stated by the patient was considered as the beginning of appendicitis indicators [19].

In a previous study, the frequency of occurrence of burst appendicitis was 32%–72% frequently resulted from late diagnosis due to ambiguous history taking and physical examination [20–23]. Another previous study found ruptured appendicitis was reported in 50% of patients which is supported by the results of the previous research. The threatening factors related to ruptured appendicitis were male sex, temperature =38°C, loss of appetite, in addition to period of pain in the preadmission time [24].

New research by Augustin et al. [25] found that the risk of appendicular rupture elevated 36 hours after the beginning of pain. Also, in another study, Singh et al. [26] it was found a significant relationship between perforated appendicitis in children and a period of pain in the preadmission time of more than 72 hours.

A study by Eko et al. [27] reported that period of pain and other manifestations in the preadmission period should not surpass 18 hours to decrease the postoperative complications and morbidities and length of hospital stay. In contrast, Abou-Nukta et al. [28] concluded that postponing appendectomy by 12–24 hours after starting symptoms did not significantly associate with an increase in the rate of appendicular rupture, length of hospital stay or operation time.

Also, a recent study by Teixeira et al. [29] reported that prolongation in the time from acute appendicitis diagnosis to appendectomy did not increase the rate of perforation [30].

Henceforth, while appendectomy due to acute appendicitis is considered one of the commonest abdominal operations carried out by general surgeons, rates of the postoperative complications and morbidity remain between 9% and 18%, respectively [31]. The death rate of ruptured appendicitis in geriatric patients was from 2.3% to 10% and mostly associated with infection and primary associated original illness [32-34]. A previous study reported, there was a 1.9% rate of deaths from infection of the surgical site and associated disease, which is supported by the results of previous studies [13].

CONCLUSION:

Acute appendicitis should still be considered important one of the causes of acute abdomen in surgical patients. Delay in bringing the patient to the hospital is associated with increased rates of appendicular rupture and postoperative complications. There is a profound effect of acute appendicitis neglected to rupture on both patients and healthcare organizations; hence efforts should be focused on implementing complex multidisciplinary prevention strategies.

We propose that health care workers in the surgical center undergo instruction to stress the importance of integrating these measures into everyday practice as well as through the quality of service provided to acute appendicitis patients and avoiding acute appendicitis neglected to rupture.

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