213

ORIGINAL ARTICLE
To determine the factors that affect the delay in diagnosis of
acute appendicitis, affecting the morbidity and mortality of
patients, at a tertiary care center in Karachi, Pakistan
Ayaz Ghulam Rasool, Maaz Obaid, Muhammad Azam Akhter, Lal Shehbaz, Shua Nasir, Zain Ali

Received: Abstract
17th April 2016
Object: The aim of our study is to determine the factors that affect the delay in diagnosis of
Accepted: acute appendicitis, in order to decrease the morbidity and mortality of this condition.
14th August 2016 Method: The type of study is a cross sectional study, conducted for a period of one year from
May 2014 to May 2015 at a tertiary care center in Karachi, Pakistan. The total study popula-
tion consisted of 150 patients, the inclusion criteria was all the patients who were above 16
years of age, and presented to the emergency department with delayed presentation (two or
more than two days after initial attack) of acute appendicitis, and gave consent to take part in
the study, the exclusion criteria was all the patients who were under 16 years of age, presented
earlier than two days of signs and symptoms of acute appendicitis and those who refused to
give consent. Characteristics of patients were noted in a pre designed proforma. Various char-
acteristics of the patients were noted including age, gender, address, reason for delay, diagno-
sis made by the physician etc. Data was analyzed using SPSS version 23.
Results: The study population consisted of 150 patients, having a mean age of 35± 12 years, of
which 92 (61.33%) were males and 58 (38.66%) were females. 42 (28%) of the patients were
misdiagnosed by the physicians in the emergency department on initial presentation and were
referred as an outpatient case, while 50 (33.33%) of the patients were managed by non physi-
cians on the initial attack of appendicitis, which included homeopaths, hakeems, spiritual
healers, chiropractors, nurses, and patients who self medicate, and 32 (21.33%) of the patients
stayed at home, and did not seek any medical attention in the initial two days of appendicitis.
The most common reason for the delay was a lack of financial resources from the patient or the
family which accounted for 43.33% of the cases.
Conclusion: For the proper management of acute appendicitis it is imperative that an early
diagnosis and surgical intervention be done, which significantly decreases the complications,
morbidity and mortality of these patients. There is an emergent need to educate the public to
seek adequate care in due time so as to avoid unnecessary complications.

Ziauddin University Keywords: acute abdomen, appendicitis, delay in management, delayed appendicitis, appen-
Hospital Karachi dicectomy.
AG Rasool
M Obaid Abbreviations: UTI= urinary tract infection, PID= Pelvic inflammatory disease
MA Akhtar
L Shehbaz Introduction: diagnosis and surgery, which leads to complica-
S Nasir One of the most common surgeries performed tions such as perforation of the vermiform ap-
ZAli as an emergency procedure is appendectomy, pendix, but the rate of development of compli-
Correspondence: which is done to eradicate the acute surgical cations depend on various other factors such as
Dr. Zain Ali, House officer, emergency that is appendicitis, which is a com- the immune state of the patient and cause of ap-
Civil Hospital Karachi mon cause of acute abdomen across all age pendicitis, the mortality rate for this condition
Cell:0331-2913458
mail: drzainali88@gmail. groups.1,2 One of the major causes for increased is between 0 and 2.4%, while the mortality rate
com morbidity and mortality for appendicitis is late for appendicectomy for un-complicated appen-
Pak J Surg 2016; 32(4):213-217
To determine the factors that affect the delay in diagnosis of acute appendicitis, affecting the morbidity and mortality of patients, at a tertiary care center in Karachi, Pakistan 214
dicitis is 0.8 per 1000, and for complicated cases Pakistan. The total study population consisted
(perforated) is 5.1 per 1,000. There is controver- of n=150 patients, the inclusion criteria was all
sy over the facts of what causes delay in surgery, the patients who were above 16 years of age, and
either it is pre-admission or post-admission de- presented to the emergency department with de-
lay, but it is universally accepted that delay in the layed presentation (two or more than two days
diagnosis and intervention leads to increased after initial attack of acute appendicitis) of acute
morbidity and mortality.3 Among the patients appendicitis, and gave consent to be partake in
who belong to the old age group, mortality and the study, the exclusion criteria was all the pa-
morbidity is high, due to co morbidities, and tients who were under 16 years of age, presented
delay in intervention due to an increased num- earlier than two days of signs and symptoms of
ber of possible diagnoses.4 Appendicular mass, acute appendicitis and those who refused to give
gangrene, perforation, abscess and generalized consent. Characteristics of patients were noted
peritonitis are the complications which can oc- in a pre designed proforma, which included
cur if appendicitis is not treated in a timely man- various variables such as patients age, gender,
ner. The life time risk for development of acute address, time of onset of signs and symptoms
appendicitis in males and females is 8.6% and of appendicitis, mode of transportation to the
6.7% respectively.5,6 The late presentation can hospital, complete history and physical exami-
lead to gangrene and perforation, among the nation of the patients, complications of acute
pediatric age group these complications can de- appendicitis, such as perforation, appendicular
velop in 8 to 24 hours, while in adults the com- mass, auto amputation, gangrene or abscess, lab-
plications develop in 36 hours.7 In our region oratory investigations such as complete blood
of the globe, there are various different causes picture, Urine analysis, serum urea, creatinine
of delay to diagnosis and treatment such as, il- and electrolytes, ultrasound abdomen, chest X-
literacy about the disease, home remedies, al- ray and CT scan of the abdomen was also done
ternative medicine like homeopathy, ayurvedic for the patients. Data was analyzed using SPSS
medicine, hakeem, Chinese medicine, spiritual version 23, Quantitative variables were noted
healing practices, quacks and other factors like, as frequency and percentages, while qualitative
financial issues, lack of proper ambulance and variables were noted as mean and standard de-
emergency services in district hospitals.8 Vari- viation.
ous other diseases like acute gastro enteritis,
UTI, and PID mimic the signs and symptoms Results:
of acute appendicitis and it is difficult to distin- The study population consisted of 150 pa-
guish among these illnesses, which results in de- tients, having a mean age of 35 ±12 years, hav-
lay in diagnosis and intervention. A test’s sensi- ing an age range of 16 to 70 years, of which 92
tivity and specificity determines its significance (61.33%) were males and 58 (38.66%) were
along with the positive and negative predictive females. The various demographic characteris-
values. Appendicitis is frequently misdiagnosed tics of the patients are given in Table 1. In our
and is among the major reasons for malpractice study the majority of the patients were between
by the emergency room physicians. The aim of 20 and 40 years of age that is 54% of the study
our study is to determine the factors that affect population, the length of hospital stay varied
the delay in diagnosis of acute appendicitis, in according to the pre existing co morbidities in
order to decrease the morbidity and mortality of the patient population, the majority of the pa-
this condition. tients had a hospital stay of less than 10 days.
42 (28%) of the patients were misdiagnosed by
Materials and Methods: the physicians in the emergency department on
The type of study is a cross sectional study, con- initial presentation and were referred as an out-
ducted for a period of one year from May 2014 patient case, while 50 (33.33%) of the patients
to May 2015 at a tertiary care center in Karachi, were managed by non physicians on the initial
Pak J Surg 2016; 32(4):213-217
215 Ayaz Ghulam Rasool, Maaz Obaid, Muhammad Azam Akhter, Lal Shehbaz, Shua Nasir, Zain Ali

Table 1: Characteristics of patients with delayed appendicitis of conservative techniques even for a compli-
No of Percent- cated appendicitis with perforation,12-16 there
Characteristic patients age are two methods to perform appendectomy,
Gender either by the open method or the laparoscopic
Male 92 61.33% method which yields and early mobilization and
Female 58 38.66% less number of days spent in the hospital.17-19
Age group The health care system of Pakistan is designed
<20 years 45 30% in such a way that majority of cases of acute ap-
20 to 40 years 81 54% pendicitis are first seen by general physicians
>40 years 24 16% and practitioners of alternative medicine. The
Length of hospital stay decision made by the afore mentioned entities
<10 days 69 46% then relies on making the diagnosis of as such
11 to 20 days 24 16% that it leads to a regimen of observation, or treat-
>20 days 57 38% ment with medicine (such as antibiotics etc), or
Diagnosis & Management referral for appropriate surgical care and inter-
Managed by Non Doctors 50 33.33% vention. But this unnecessary delay in referral
Managed by District Surgeon 26 17.33% for appropriate surgical care leads to develop-
Misdiagnosed by Physicians 42 28% ment of complications such as perforation etc
Delays at home 32 21.33% and increase in morbidity and mortality.8-11,20-22
Mode of transport to the hospital Various studies7,8,23,24 have sought to seek the
Via Ambulance 76 50.66% causes of this delay in seeking surgical care, in
Via Private transport 44 29.33% our study the male participants accounted for
Via Public transport 30 20% 61.33% of the population which is also similar
Reasons for delay to the results of other studies,6,8 and according
Lack of financial resources 65 43.33% to Salati et al in their study males constituted
Misperception of the gravity of illness, thinking it will go away 33 22% twice the affected population.9 According to a
with rest
study by Aly Saber et al the maximum length of
Lack of transportation availability 19 12.66%
hospital stay was found to be 7 days while in our
No support from family or friends 33 22%
study it was more than 20 days.26 And according
to Ch Chung et al the number of patients misdi-
attack of appendicitis, which included homeo- agnosed by the physicians constituted of 22.1%
paths, hakeems, spiritual healers, chiropractors, of the patient population, while in our study the
nurses, and patients who self medicate, and 32 number of patients misdiagnosed were 28%, and
(21.33%) of the patients stayed at home, and did a similar study in Kashmir yielded 23% of the
not seek any medical attention in the initial two patients misdiagnosed.12,21 According to Salati et
days of appendicitis. The most common reason al, the number of patients who presented with
for the delay was a lack of financial resources delayed appendicitis due to mismanagement by
from the patient or the family which accounted non doctors and due to unnecessary delays at
for 43.33% of the cases, refer to table 1. home were 12.5% and 53% respectively, while
our study shows similar results of 21.33% and
Discussion: 33.33% respectively. Also considering the fact
Appendicitis is one of the most discussed dis- that Pakistan is a developing country, and the
ease in the medical literature,9 it is a well es- transportation system in Pakistan is not fully
tablished fact that for successful outcome with developed, therefore it takes a longer amount of
as little complications as possible, is made pos- time for patients to reach proper facilities which
sible only through early diagnosis and treat- provide surgical care, especially for patients who
ment of the condition,10,11 surgery remains the live in the sub-urban or rural areas. Most of the
gold standard but few authors are proponents patients belonging to the rural areas, are man-
Pak J Surg 2016; 32(4):213-217
To determine the factors that affect the delay in diagnosis of acute appendicitis, affecting the morbidity and mortality of patients, at a tertiary care center in Karachi, Pakistan 216
ual workers by occupation and their sources of Funding Sources: None
living is based on them working on a daily ba-
sis, hence for these patients missing time from Role and contribution of authors:
work is a nuisance which causes unnecessary
financial burden, therefore majority of patients Dr Ayaz Ghulam Rasool, Resident emergency
who belong to his category ignore the signs and medicine, have collected the data and references
symptoms and the gravity of their illness, and Dr Maaz Obaid, Resident emergency medicine,
seek help only when the pain becomes unbear- also helped in collecting data and discussion
able. Also the quack industry in Pakistan is very writing.
well established, and with no regulatory body
governing these quacks and homeopaths, open Dr Muhammad Azam Akhter, Resident emer-
up their clinics in rural areas and take advan- gency medicine, collected the references and
tage of the illiteracy of the population in those helped in introduction and methodology writ-
areas,20,21 patients take medications offered by ing.
these quacks in hopes of getting better which
further delays surgical treatment and leads to Dr Lal Shehbaz, Registrar Emergency Medicine,
more complications.10 Mis-management by phy- has been collecting data and helped in introduc-
sicians specially in the earlier timeline of disease tion, methodology and results writing
is also a hurdle, especially in the pediatric popu-
Dr Shua Nasir, Registrar Emergency Medicine,
lation in which acute appendicitis is difficult to
collected the data and helped in writing intro-
diagnose and manage,8 this combined with the
duciton, result and discussion and gave the final
fact that their first encounter is likely to be with a
touchup to the article.
general physicians, quack, hakeem, homeopath
etc, further aggravates the issue.4,24 Patients who Dr Zain Ali, House officer, did collected the data
are prescribed antibiotics and pain medications and wrote the initial writeup.
by these primary contact care providers often
mask the symptoms and cause a hindrance in References:
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Conflict of Interest: None sicians, and surgeons in the management of acute appendici-

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Pak J Surg 2016; 32(4):213-217