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HISTOPATHOLOGICAL ANALYSIS OF APPENDECTOMY SPECIMENS IN A TERTIARY CARE HOSPITAL; A DESCRIPTIVE STUDY

.. Objectives: To analyse the pattern and morphologies of all the surgically resected appendices in the surgical emergency of holy family hospital in relation to gender, age and the percentage of negative appendectomies. Study Design: Descriptive Cross Sectional study. Setting: Surgical Unit 1 Holy Family Hospital, Rawalpindi. Period: January 2013 to April 2019. Material & Methods: 1993 patients (1011 males, 982 females) which underwent appendectomy were included in this study. Structured proforma was made. All the specimens were sent to pathology lab for histopathology. Detailed histopathological report was received in the OPD follow-up of the patient. All the data was analysed using SPSS version 22. Results: Acute appendicitis (57.3%) was the most common morphology followed by suppurative appendicitis (11.1%). One case was carcinoid tumour (0.05%). The incidence of negative appendectomy was 8.42% while the incidence of perforated appendix was 3.5%. Conclusion: Appendicitis is one of the most common surgical Emergency and histopathology is gold standard in definitive diagnosis.


INTRODUCTION
Appendix is part of the gastrointestinal tract and is known to be as a true diverticulum of cecum and is prone to inflammation; both acute and chronic. The diagnosis of the appendicitis is often difficult pre-operatively due to its location the common differential diagnosis come out to be mesenteric lymphadenitis, acute salpingitis, ectopic pregnancy, mittelschmerz syndrome and Meckel diverticulitis. 1 Surgical acute abdomen is a common presentation in emergency settings of a tertiary care hospital and among the most common causes is acute appendicitis. It is a disease of all age groups with a total life time risk of 8.6%. And 6.7% among males and females respectively the incidence of disease varies from region to region and is usually 110-140 per 100,000 population. Males are slightly more prone to develop the disease. 2,3 Pathologists have come to a conclusion that in about 50 to 80 percent increased intramural pressure leads to venous congestion of the organ and there by resulting in acute appendicitis, however after inflammation has occurred there is sequela of events that result in different morphologies of appendix. Appendicitis may occur due to obstruction by worms, fecolith or gall stones. Stasis of the intra-luminal contents causes bacterial proliferation and thereby favouring ischemia and inflammatory response resulting in the both microscopic and macroscopic changes i;e edema, neutrophilic infiltration and loss of the glistening serosa into dull, granular, erythematous surface. If the inflammatory response continues localized abscesses form in the wall of the appendix leading to the formation of the acute suppurative appendicitis, further inflammation causes ulceration and necrosis of the wall and hence causing gangrenous and perforated appendicitis leading to peritonitis; a life threatening emergency. 1 Carcinoid tumor is the most common tumor of appendix. It is neuro-endocrine in nature. It is almost always benign and nodal metastasis is very infrequent. It may cause obstruction of the lumen of the appendix and hence mimic the presentation of acute appendicitis. 1 Patient typically presents with peri-umbilical pain shifting to right iliac fossa, nausea, vomiting, fever, anorexia, tenderness and rebound tenderness in the right iliac fossa with leucocytes and neutrophils raised. Radiological investigation of choice is spiral CT scan provide substantial evidence for a provisional diagnosis of acute appendicitis however such a challenging diagnosis may lead to negative appendectomy, therefore histopathology remains the gold standard in diagnosing and confirming the disease. 5 This study aims to analyse the pattern and morphologies of all the surgically resected appendices in the surgical emergency of holy family hospital in relation to gender, age and the percentage of negative appendectomies done in this setting.
The rationale of our study is that hospital administrations, surgeons and histopathologists will have a reference of our regional pattern of histopathology of appendix specimens. This will be an addition to the already present literature and will open gateways for future research in the pathogenesis of the specific type of appendicitis.

MATERIAL & METHODS
1993 patients were included in this descriptive cross-sectional study conducted in surgical unit 1 from January 2013 to April 2019. All the operated cases of appendicitis whether emergency, elective or incidental were included in this study. Structured Performa consisting of patient's demographic profile, clinical examination and per-operative findings were provided to the pathology department. All the specimens sent for histopathology were fixed in 10% formalin solution and sent to pathology department within 12 hours of surgery. Detailed report of histopathology was received from pathology department when the patient came for follow up in outdoor department of surgical unit 1. Histopathology report included gross as well as microscopic examination of the specimens. Data was analysed using spss version 22.0.

RESULTS
Out of the total 1993 specimens, 1011 (50.7%) were male and 982 (49.3%) were female with the mean age of 22.76 Years ± 12.53 years, mode 17 years and median was 21.50 years. The youngest being 5 years of age and oldest being 78 yrs old.

DISCUSSION
The incidence of acute appendicitis has risen in the past few decades particularly in Europe, America and Australasia with upto 16% of population undergoing appendectomy in some part of their lives. Acute appendicitis is rare among neonates and infants however the incidence increases with age with peak incidence among teens and young adults. The incidence decreases after the middle age. 6 The mean age of the patients presenting in our study is 22.76 Years ± 12.53 years where more than 80 % patient were less than 40 years of age. The male to female ratio in our study was comparative to other studies i;e male predominance 3:2 at age 25. 5,6,7,8,9 Acute appendicitis was the most common histopathological diagnosis accounting for 57.3% followed by acute suppurative appendicitis 11.1%, this is comparative to the study done by Zulfikar et al. 10

3
Fibrosing/resolving appendicitis and granulomatous appendicitis were 0.85 % which is very much comparative to the study done by Park et al where they found it to be 1%. 11 The diagnosis of chronic resolving/ fibrosing appendicitis and granulomatous appendicitis is questionable and its existence is debatable.
The rate of perforation of appendix was slightly higher 3.5% as comparison to the studies conducted elsewhere and less as compare to some of the other studies, however the rate of perforation in extreme of ages was similar to other studies conducted. Worldwide the rate of perforation is affected by the duration of symptoms, age, gender and race of the patients so its highly variable in geographical distribution. 12,13 Parasitic infestation is one of the causes that lead to the luminal obstruction of the appendix and hence appendicitis. Its not a very uncommon cause, the rate of parasitic infection also known as oxyuriasis was 1.5% in our study. It is comparative to the other studies conducted in different geographical regions of the world where the rate is about 0.3 to 3.15%. 13,14,15 The Organism isolated from all our specimens was Enterobius Vermicularis. All of the specimens in this category had eosinophilic infiltration and granulomatous changes.
Carcinoid tumor was only found to be in 1 case only (0.05%) this is comparative to the other studies conducted. 15,16,17 In our study the patient did not present with the typical symptoms of acute appendicitis but presented with classic symptoms of carcinoid tumor and on investigation the tumor was found to be at the tip of appendix and was localized and hence only appendectomy was done.
In our study the rate negative appendectomies came out to be 8.42% which is a globally acceptable. The acceptable incidence of negative appendectomies is said to be between 10 to 20 % depending upon the geographical location, age and gender. Various studies show a rate of 6.1% to 34.2% with rate being higher among female patients. These negative appendectomies may be avoided if a short term course of antibiotics is given to the patients and the level of inflammation may be monitored with clinical symptoms and laboratory investigations. 17,18,19,20  Our study was very extensive in differentiating the different types of appendicitis and therefore many of our subtypes couldn't be compared with local, regional or international publications. Our limitations were that we did not correlate our study with the duration of symptoms of the patient which has a key role in the ultimate histopatholgy and the surgeon and histopathologist were not same in all cases.

CONCLUSION
Acute appendicitis is the most common morphology followed by the acute suppurative appendicitis. Incidence of negative appendectomy was in correlation to the internationally acceptable range, this incidence should be lowered using advanced radiological investigations and diagnostic laproscopy. Our study may be used as a regional reference for prevalence of different types of appendicitis. Mentor, Guidance.
Article writing.
Data analysis.
Results discussion.
Data collection.