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THE EPIDEMIOLOGY OF APPENDICITIS AND APPENDECTOMY IN THE
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APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 911. Incidental appendectomies are com 200 000 discharge records are randomly se. monly performed at the time of other ab lected for review from a sample of 289 432. dominal or pelvic surgery to prevent future hospitals stratified by size number of beds. appendicitis 16 Because the epidemiol and geographic region 19 Stratum. ogy of incidental appendectomy for the specific weights are applied to derive na. United States as a whole has not been well tional estimates Information obtained. characterized the impact of this surgical from the hospital records includes patient. practice is difficult to assess Morbidity demographic characteristics diagnoses. from the procedure is generally considered surgical procedures performed discharge. to be negligible 17 however the preven status dates of admission and discharge. tive value of incidental appendectomy par hospital characteristics and region of the. ticularly in the elderly has been the subject country Up to seven diagnoses and four. of recent debate 16 18 surgical procedures are coded for each pa. We analyzed 15 years of data from the tient using the Eighth Revision Interna. National Hospital Discharge Survey to de tional Classification of Diseases Adapted for. scribe the epidemiology of appendicitis and Use in the United States ICDA 8 20 for. incidental appendectomy in the United the years 1970 1978 and the International. States Using a life table model we estimate Classification of Diseases Ninth Revision. the current lifetime risk of appendicitis in Clinical Modification ICD 9 CM 21. the United States and describe the preven after 1978 The degree to which discharge. tive value of incidental appendectomies diagnoses are confirmed by pathologic or. performed in persons of different ages laboratory findings is unknown. Data tapes were obtained for the years, MATERIALS AND METHODS 1970 1984 Primary appendectomy was de. Since 1963 the National Center for fined as a nonincidental appendectomy. Health Statistics has conducted the Na procedure code either 41 1 ICDA 8 or. tional Hospital Discharge Survey which 47 0 ICD 9 CM table 1 A primary ap. provides data on a representative 0 5 per pendectomy was defined as positive if the. cent sample of patients hospitalized in non patient also had a discharge diagnosis of. federal acute care facilities in the United acute appendicitis with peritonitis ICDA. States 1 Each year approximately 8 diagnostic code 540 0 and ICD 9 CM di. Diagnostic and surgical procedure codes for appendicitis and appendectomy from the Eighth Revision. International Classification of Diseases Adapted for Use in the United States ICDAS and the International. Classification of Diseases Ninth Revision Clinical Modification ICD 9 CM. ICDA 8 1970 1978 ICD 9 CM 1979 1984,Diagnostic codes. 540 Acute appendicitis 540 Acute appendicitis, 640 0 With peritonitis abscess perforation 640 0 With generalized peritonitis per. peritonitis or rupture foration peritonitis or rupture. 640 1 With peritoneal abscess, 540 9 Without mention of peritonitis 540 9 Without mention of peritonitis. 541 Appendicitis unqualified 541 Appendicitis unqualified. Procedure codes, 41 Operations on appendix 47 Operations on appendix.
41 1 Appendectomy 47 0 Appendectomy excludes incidental. 47 1 Incidental appendectomy,912 ADDISS ET AL, agnostic codes 540 0 and 540 1 acute ap with an intact appendix we constructed a. pendicitis without mention of peritonitis life table in 5 year age intervals using com. code 540 9 or appendicitis unqualified bined incidence data from 1979 to 1984. code 541 A patient with a positive pri 25 In the life table analysis persons who. mary appendectomy was therefore consid had had an appendectomy were considered. ered to have acute appendicitis the terms no longer at risk of appendicitis and were. are used interchangeably in this paper A excluded from the denominator of succes. primary appendectomy was defined as neg sive age groups Lifetime risk was calcu. ative if none of these diagnostic codes for lated assuming a life span of 75 years and. acute appendicitis was recorded Negative an incidence of appendicitis and appendec. appendectomies which included the diag tomy that remained constant at 1979 1984. noses of chronic or recurrent appendi levels, citis and appendiceal lymphoid hyper SAS statistical software was used to ana. plasia were considered to represent proce lyze the data 26 The Pearson correlation. dures performed on patients who had been coefficient r was used to determine the. suspected of having appendicitis since in degree of linear correlation between vari. cidental appendectomy was not specified ables No generally acceptable methods ex. but were found at the time of surgery not ist for calculating confidence intervals for. to have acute appendicitis rates and proportions over multiple years. An incidental appendectomy was defined for these data values are therefore pre. as procedure code 47 1 in the ICD 9 CM sented as point estimates However for. each year from 1970 to 1984 the relative,table 1 incidental appendectomies were. standard error for the number of appendec,not recorded before 1979 Diagnostic accu. tomies and appendicitis cases varied from,racy was defined as the proportion of all.
5 percent to 9 percent 19,primary appendectomies that were positive. and was considered equivalent to the posi, tive predictive value of the surgeon s pre RESULTS. operative diagnosis The perforation ratio, was the percentage of primary positive ap In the period 1979 1984 an estimated. pendectomies with evidence of perforation 3 4 million appendectomies were performed. peritonitis rupture or abscess ICDA 8 di in the United States 561 000 per year a. agnostic code 540 0 and ICD 9 CM diag crude annual incidence of 26 per 10 000. nostic codes 540 0 and 540 1 The case population Of these 53 percent were pri. fatality ratio was defined as the percentage mary appendectomies 85 3 percent of. patients with primary appendectomy,of patients with appendectomy who died. 251 000 per year had a discharge diagnosis,during hospitalization.
of acute appendicitis primary positive ap, In evaluating temporal trends we used pendectomy The crude incidence of acute. US resident population estimates for the appendicitis was 11 per 10 000 population. years 1970 1984 to calculate annual rates per year Forty seven percent of appendec. of appendicitis and appendectomy 22 23 tomies were incidental the annual rate of. For all other analyses the mean annual incidental appendectomy was 12 per 10 000. incidence for the years 1979 1984 was de population These national figures were. termined by combining discharges for these based on a total of 16 457 hospital records. years and using the 1980 US Census data with a procedure code of appendectomy. for the denominator 24 Regional com The case fatality ratio for both primary. parisons were based on the nine geographic positive and primary negative appendec. divisions of the US Census 22 24 tomy was 0 3 percent The case fatality ra. To determine lifetime and 1 year risk of tio for primary positive appendectomy was. appendicitis and appendectomy in persons 4 6 percent in persons aged 65 years or more. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 913. and 0 2 percent in persons aged less than eases of the appendix and gynecologic con. 65 years ditions table 2,Between 1979 and 1984 appendicitis ac. counted for an estimated 1 million hospital Incidental appendectomy. days annually The median length of hos The incidence of incidental appendec. pital stay was 4 days for patients with pri tomy was 6 6 times higher in females than. mary appendectomy 9 days if the appendix in males figure 1 In females 62 7 percent. was perforated and 7 days for incidental of all appendectomies were incidental com. appendectomy performed at the time of pared with 17 7 percent in males Women. another surgical procedure aged 35 44 years had the highest rate of. incidental appendectomy 43 8 per 10 000, Primary positive appendectomy population per year and were 12 1 times. appendicitis more likely to have an incidental appendec. tomy than were men of the same age In, The age specific incidence of acute ap males the annual incidence of incidental. pendicitis followed a similar pattern for appendectomy gradually increased with. males and females but males had higher age to a rate of 7 3 per 10 000 population. rates at virtually all ages with an overall among men aged 65 years or more Median. male female rate ratio of 1 4 1 figure 1 age at incidental appendectomy was 34. The incidence was highest in males aged years for females and 47 years for males In. 10 14 years 27 6 per 10 000 population per females primary surgical procedures most. year and in females aged 15 19 years 20 5 commonly performed at the time of inci. per 10 000 population per year In persons dental appendectomy were abdominal hys. aged 45 years or more appendicitis rates terectomy 45 0 percent oophorectomy or. remained relatively constant at approxi salpingectomy 37 5 percent cholecystec. mately six per 10 000 for males and four tomy 18 4 percent excision of ovarian. per 10 000 for females The median age for tissue 7 2 percent and cesarean section. both males and females with primary pos 4 9 percent In males the most common. itive appendectomy was 21 years 69 per primary surgical procedures were cholecys. cent of persons with appendicitis were less tectomy 36 6 percent total or partial ex. than 30 years old cision of the intestine 11 8 percent and. inguinal hernia repair 4 9 percent,Primary negative appendectomy and.
diagnostic accuracy Appendiceal perforation, The incidence of primary negative ap A total of 19 2 percent of appendicitis. pendectomy was higher in females than in cases primary positive appendectomies in. males and was highest among women in males and 17 8 percent in females involved. the childbearing years figure 1 The rate appendiceal perforation rupture abscess. of negative appendectomy among females or generalized peritonitis The perforation. aged 15 24 years 4 9 per 10 000 population ratio was lowest among persons aged 20 24. per year was 2 5 times higher than that for years 9 1 percent and increased directly. males of the same age Overall diagnostic with age to 51 percent in persons aged 65. accuracy was lower for females 78 6 per years or more figure 3 children aged less. cent than for males 91 2 percent In fe than 5 years were also at increased risk In. males diagnostic accuracy dropped sharply contrast the age specific incidence of ap. during the childbearing years in males it pendiceal perforation was highest among. did not vary appreciably with age figure 2 persons aged 10 14 years 3 5 per 10 000. Diagnoses most commonly associated population per year a gradual increase in. with primary negative appendectomy in incidence with age was observed for persons. cluded mesenteric lymphadenitis other dis over age 35 figure 3. 914 ADDISS ET AL,Positive Primary Appendectomies, 0 4 51 10 14 15 18 10 14 15 14 13 44 4S S4 S5 M 15 74 2 75. Negative Primary Appendectomies, 0 4 5 0 10 14 1MB 10 14 15 14 15 44 45 54 55 14 65 74 2 75. Incidental Appendectomies, 0 4 5 1 10 14 15 11 10 24 15 14 15 44 45 54 55 14 15 74 2 75. FIGURE 1 Annual incidence of appendectomy per 10 000 population in the United States 1979 1984 by. age group sex and type of appendectomy, Race region and season appendectomy The incidences of primary.
positive primary negative and incidental, Race white or nonwhite was recorded appendectomy were each 1 4 1 6 times. for 91 percent of all hospital discharges for higher for whites than for nonwhites a. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 915. 0 4 10 14 15 19 20 24 25 14 15 44 45 54 55 64 65 74 S75. FIGURE 2 Diagnostic accuracy of primary appendectomies performed in the United States by age group. and sex 1979 1984 Diagnostic accuracy was defined as the proportion of all primary appendectomies with a. discharge diagnosis of appendicitis, Discharge diagnoses and surgical procedures most commonly recorded for persons with primary negative. appendectomy National Hospital Discharge Survey 1979 1984. Females Males, ICD 9 CM code Diagnosis or procedure National National. discharges estimate discharge estimate,unweighted no unweighted no. Diagnostic code,543 9 Other diseases of the appen,dixt 23 1 41 169 194 16 6 13 645 61.
543 0 Lymphoid hyperplasia of the,appendix 2 5 4 485 25 3 3 2 693 16. 542 Other appendicitis 18 2 32 514 150 15 8 12 988 67. 289 2 Mesenteric lymphadenitis 19 4 34 629 172 29 0 23 825 117. 789 0 Abdominal pain 10 6 18 955 99 15 4 12 661 61. 558 9 Gastroenteritis noninfec,tious 4 8 8 503 44 10 8 8 840 40. 574 Cholelithiasis 5 1 9 161 42 3 9 3 182 12,620 2 Ovarian cyst 8 8 15 684 73 0 0 0. 218 Uterine leiomyoma 7 5 13 311 56 0 0 0,617 Endometriosis 6 6 11 811 52 0 0 0. 616 0 Cervicitis endocervicitis 5 0 8 839 35 0 0 0. Procedure code,65 3 65 6 Oophorectomy 14 6 26 040 119 0 0 0.
65 2 Excision or destruction of,ovary 5 3 9 420 43 0 0 0. 68 3 68 4 Abdominal hysterectomy 14 4 25 664 114 0 0 0. 51 2 Cholecystectomy 6 9 12 359 54 4 5 3 728 15,54 5 Lysis of adhesions 5 0 8 879 43 2 3 1 918 9. 54 1 Laparotomy 1 7 2 990 16 2 9 2 395 10,54 2 Diagnostic laparotomy 2 8 4 995 23 0 4 309 2. International Classification of Diseases Ninth Revision Clinical Modification ICD 9 CM. t Colic concretion diverticulum fecalith fistula intussusception mucocele or stercolith. Chronic recurrent relapsing or subacute,916 ADDISS E T AL. difference that persisted when data were the middle Atlantic states table 3 Diag. stratified by sex age group and region The nostic accuracy which was lowest 81 1 per. perforation ratio for nonwhites was 21 8 cent in the west north central states and. percent compared with 18 2 percent for highest 89 4 percent in the middle Atlan. whites Diagnostic accuracy was 86 1 per tic states tended to be inversely related to. cent in nonwhites and 85 3 percent in the incidence of primary appendectomy. whites r 0 52 and positively correlated with, Regional differences which persisted the perforation ratio r 0 37 but these.
when data were stratified by racial group trends were not statistically significant Re. were also observed The annual incidence gions with the highest rates of primary. of appendicitis was highest 15 4 per 10 000 appendectomy were also highest for inci. population in the west north central states dental appendectomy. and lowest 9 4 per 10 000 population in The incidence of primary appendectomy. 0 4 10 14 15 18 20 24 25 14 15 44 45 54 55 M 15 74 273. FIGURE 3 Appendicitis perforation rate and perforation ratio in the United States by age group 1979 1984. Perforation rate was defined as the mean annual incidence of perforated appendicitis per 10 000 population. Perforation ratio was defined as the percentage of primary positive appendectomies with appendiceal perfora. Diagnostic accuracy perforation ratio and incidence of primary appendectomy acute appendicitis and. incidental appendectomy per 10 000 population per year by US Census region National Hospital Discharge. Survey 1979 1984,Pnmaiy Incidental,Appendicitis Diagnostic Perforation. US Census region appendectomy appendectomy,rate accuracy ratio. New England 14 2 12 5 87 8 18 2 11 2,Middle Atlantic 10 6 9 4 89 4 19 3 5 9. East North Central 11 4 9 7 85 7 18 4 12 3,West North Central 19 1 15 4 81 1 17 7 19 1. South Atlantic 11 6 9 5 82 2 18 8 11 7,East South Atlantic 14 1 11 8 83 6 16 3 16 9.
West South Central 14 9 12 4 83 5 18 8 18 2,Mountain 15 5 13 4 86 6 16 3 10 6. Pacific 13 2 11 6 88 1 20 6 7 3,Entire United States 13 0 11 1 85 3 18 6 11 8. The numbers of hospital records sampled during this period with a diagnostic or procedure code for primary. appendectomy acute appendicitis or incidental appendectomy were 8 717 7 463 and 7 740 respectively. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 917. and appendicitis but not incidental appen perforation ratio and diagnostic accuracy. dectomy appeared to increase during the was noted for males r 0 50 p 0 07. summer months figure 4 During the than for females r 0 31 p 0 29 both. months of May through August the num diagnostic accuracy and perforation ratio. ber of cases of appendicitis adjusted to tended to be higher among males figure 6. 31 day months was 11 3 percent higher Between 1979 when incidental appen. than during the winter months of Novem dectomies were first coded and 1984 inci. ber through February dental appendectomy rates decreased by. 27 7 percent in females and 13 6 percent in, Secular trends 1970 1984 males figure 5 In women this decline was. Between 1970 and 1984 the overall in greatest 33 6 percent between the ages of. cidence of primary appendectomy de 25 and 54 years. creased by 22 1 percent declines were ob, served in positive 14 6 percent and Life table analysis risk of appendicitis. negative 52 5 percent appendectomy rates Assuming a constant incidence of appen. for both sexes figure 5 The greatest dicitis and appendectomy at 1979 1984 lev. changes occurred in the younger higher els the lifetime risk for a child aged less. risk groups among persons aged 10 24 than 5 years of having his or her appendix. years the primary appendectomy rate de surgically removed primary or incidental. creased 25 5 percent from 32 6 cases per appendectomy was 12 0 percent for males. 10 000 population per year to 24 3 cases per and 23 1 percent for females table 4 The. 10 000 population per year Among non lifetime risk of appendicitis was 8 6 percent. white racial groups the incidence of pri for males and 6 7 percent for females 2 9. mary appendectomy declined slightly from percent of males and 16 0 percent of fe. 9 7 per 10 000 in 1970 to 9 2 per 10 000 in males could expect to undergo incidental. 1984 appendectomy, Diagnostic accuracy appeared to increase The risk of appendectomy during the.
steadily during these 15 years from 74 per next year of life for those who had not yet. cent to 83 percent in females and from 86 had their appendix removed was higher for. percent to 92 percent in males The perfo females than for males table 5 The high. ration ratio also increased from 15 6 per est risk of appendectomy from any cause. cent in 1970 1972 to 19 5 percent in 1982 was found in females aged 35 39 years six. 1984 A stronger association between the of every 1 000 women in this age group. a 150 All Primary,Jan Fob Mar Apr Uay Jun Jul Aug 8 p Ool Nov D o. FIGURE 4 Numbers of pnmary appendectomies in thousands in the United States by month 1979 1984. Adjusted to 31 day monthly totals annual data combined. 918 ADDISS ET AL,24 Female Incidental,1S Male positrve. a Female positive,M Mala Incidental,70 71 72 73 74 75 70 77 78 79 80 81 82 83 84. FIGURE 6 Appendicitis and appendectomy trends per 10 000 population in the United States 1970 1984. by year sex and type of appendectomy primary positive primary negative and incidental. Diagnostic Accuracy, FIGURE 6 Appendicitis perforation ratio and diagnostic accuracy in the United States by year and sex. 1970 1984 Standard deviations error bare and regression lines are shown for males A and females O. Each point represents data by sex for a single year. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 919. would be expected to undergo appendec age group three of 1 000 males in this age. tomy during the next year and five of these group would be expected to have an appen. procedures would be incidental appendec dectomy during the following year and few. tomies In contrast the highest risk of ap of these 4 percent would be incidental. pendectomy in males was in the 10 14 year appendectomies. Cumulative lifetime risk to age 75 years for appendectomy per 10 000 population National Hospital Discharge. Survey 1979 1984,Age Primary Primary positive Incidental.
All appendectomies, group appendectomies appendectomies appendectomies. yean Males Females Males Females Males Females Males Females. 0 4 1 198 2 310 938 843 861 666 287 1 602,5 9 1 176 2 295 927 832 851 657 274 1 595. 10 14 1 111 2 245 863 776 792 606 271 1 595,15 19 968 2 144 722 673 662 518 266 1 577. 20 24 830 1 989 585 547 536 418 260 1 526,25 29 728 1 803 489 454 447 345 251 1 413. 30 34 637 1 567 408 379 375 290 238 1 235,36 39 563 1 311 344 310 318 238 227 1 033.
40 44 482 1 028 281 245 259 195 206 802,45 19 416 759 231 198 213 158 189 572. 50 54 355 517 187 156 174 127 172 367,55 59 300 369 155 120 144 100 147 251. 60 64 232 269 115 89 106 75 118 181,65 69 161 175 77 57 72 48 85 119. 70 74 94 86 44 28 43 22 50 58, Risk of appendectomy in the next year of life per 100 000 population for persons who had not yet had their. appendix removed fry5 year age group National Hospital Discharge Survey 1979 1984. All Primary Primary positive Incidental, group appendectomies appendectomies appendectomies appendectomies.
years Males Females Males Females Males Females Males Females. 0 4 51 39 24 24 22 20 27 15,5 9 146 130 139 123 129 108 7 7. 10 14 319 258 307 222 279 187 11 36,16 19 304 389 292 267 269 209 12 122. 20 24 221 458 204 195 186 152 17 264,25 29 196 567 169 168 160 115 27 409. 30 34 156 596 133 142 120 106 23 455,35 39 173 640 131 133 120 89 42 608. 40 44 136 689 102 96 95 74 35 493,45 49 127 516 91 87 80 64 36 429.
50 54 116 309 65 71 61 54 50 238,55 59 139 206 81 63 76 51 59 143. 60 64 144 192 78 65 69 54 66 127,65 69 136 181 65 58 59 53 70 123. 70 74 190 172 89 56 86 44 101 116,76 79 192 178 89 72 83 65 104 106. 80 84 125 140 67 68 52 65 59 72,85 101 99 43 41 40 41 68 57. 920 ADDISS ET AL, The preventive value of each incidental mary negative nonincidental appendec.
appendectomy performed in different age tomies were performed at the time of. groups can be estimated using the life table another major procedure primarily oopho. For example 1 000 incidental appendecto rectomy abdominal hysterectomy or cho. mies could be expected to prevent 52 cases lecystectomy In these cases which was the. of appendicitis when performed in women incidental procedure We accepted non. aged 15 19 years 24 cases when performed incidental appendectomy codes at face. in women aged 35 39 years and eight cases value assuming that acute appendicitis. when performed in women aged 60 64 may have been suspected preoperatively. years Between 1979 and 1984 approxi rule out appendicitis and that other pa. mately 260 000 incidental appendectomies thology had been discovered at the time of. were performed annually in persons under surgery In doing so we may have overes. 75 years of age Using the life table model timated the number of primary negative. which is age adjusted we can see that these appendectomies 30 and underestimated. 260 000 procedures prevented an estimated diagnostic accuracy Preoperative diag. 7 300 future lifetime cases of acute appen noses which could have helped resolve this. dicitis 36 incidental appendectomies were issue were not available The diagnostic. therefore performed for each case of appen accuracy of 85 percent found in this study. dicitis averted however is well within the range reported. in hospital based studies where pathologic,findings and preoperative diagnoses were. DISCUSSION available 27, To describe the epidemiology of appen Our findings using national data gener. dicitis and appendectomy in the United ally confirm the observations of others in. States we analyzed longitudinal nationally regional studies and hospital case series. representative population based data from The overall incidence of appendicitis in the. the National Hospital Discharge Survey United States 1 1 per 1 000 population per. Previous studies of appendicitis in this year is comparable to the rates of 0 96 1 2. country have been based on hospital case per 1 000 reported from Connecticut South. series for which accurate denominator data Carolina and California 16 30 31 Al. were unavailable 27 28 or on regional or though the incidence appears to be declin. statewide data 16 29 32 ing appendicitis related morbidity remains. Our data have several important limita high and deaths from appendicitis still oc. tions The actual number of hospital dis cur particularly in the elderly 35 36. charges sampled in any given year was rel One of the most striking epidemiologic. atively small and it was often not possible features of appendicitis is the marked var. to stratify data by variables of interest In iation in incidence by age and sex In both. addition the discharge records did not males and females the highest rates were. specify whether acute appendicitis was a observed in persons aged 10 19 years a. surgical or a pathologic diagnosis To the finding consistent with those of several. extent that the diagnosis was not con other studies 16 30 31 37 39 In males. firmed the incidence of acute appendicitis however the peak incidence appeared at. may have been overestimated and the neg ages 10 14 years compared with ages 15. ative appendectomy rate underestimated 19 years in females The incidence of ap. since surgical diagnoses are more likely to pendicitis was consistently higher in males. be positive than those which are patholog than in females even when persons with. ically confirmed 33 34 previous appendectomy were excluded from. It is also possible that some incidental the denominator Appendicitis rates 1 2 to. appendectomies were miscoded as nonin 2 3 fold higher for males have also been. cidental For example 24 percent of pri reported by other investigators 30 31 38. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 921. 40 but this difference remains unex of primary positive appendectomy between. plained The elevated rates in males across 1970 and 1984 reflects changing medical or. all age groups suggest that hormonal surgical practices rather than an actual de. changes in females may not play as signif cline in the rate of appendicitis In contrast. icant an etiologic role as previously hypoth to this pattern in the United States and. esized 41 Europe the incidence of acute appendicitis. In contrast primary negative appendec appears to be increasing in developing. tomy was more common in females with countries where it has historically been low. the highest rates occurring in women of 5 38 53 55 The increase has been at. childbearing age Accurate diagnosis is par tributed to dietary changes 5 55 im. ticularly difficult in this group since gy provements in socioeconomic status and. necologic disease often mimics the symp hygienic standards 11 54 and better ac. toms of acute appendicitis 42 In addition cess to health services 56 Some of these. early surgical intervention which has re same factors may help explain the relative. cently been encouraged because of an in stability in appendicitis rates among non. creased risk of tubal infertility following whites in the United States between 1970. appendiceal perforation 43 may explain and 1984 a decrease of 4 percent com. the higher rates of primary negative appen pared with a 16 percent decline among. dectomy in females whites, A slight but consistent increase in appen Regional variation in the incidence of. dicitis was noted during the summer appendicitis independent of race or age. months a pattern found in some previous distribution was also noted Geographic. studies 44 46 but not others 27 37 38 variation in appendicitis and appendec. The reasons for this seasonal pattern are tomy has been well documented and has. unknown speculation has focused on been associated with differences in latitude. changes in atmospheric pressure 47 and 57 medical and surgical practices 56 58. on both increases 38 and decreases 45 59 appendicitis case definitions 56 and. in relative humidity The increase in inci actual risk of disease 60 Whether ethnic. dence during the summer months may also or cultural differences contribute to the. reflect an infectious etiology for acute ap geographic variation in the United States. pendicitis a hypothesis supported by simi is unknown although this possibility is sug. lar summer peaks of other enteric infec gested by anecdotal observations For ex. tions 46 and by the association of an acute ample immigrants from Germany where. appendiceal syndrome with Yersinia and appendectomy and appendicitis mortality. other enteric pathogens 12 14 rates are exceptionally high 59 settled. The overall incidence of appendicitis ap primarily in the upper Midwest 61 the. pears to have decreased by 15 percent since region with the highest incidence of acute. 1970 the greatest declines were observed appendicitis in the United States Differ. in the populations at highest risk Declining ences in surgical practices may also have. rates of appendicitis have been reported in played a role since the regions with the. the United States and Europe since World highest rates of appendicitis were generally. War II 48 52 but the reasons for this are also highest for negative and incidental ap. unclear Changes in nutrition and diet 51 pendectomy The precise relation between. increased use of antibiotics 49 improve surgical practice and the incidence of ap. ments in socioeconomic status 50 and pendicitis is difficult to determine how. changes in patterns of infectious disease ever since both the diagnosis and the cure. and immunity 52 have all been proposed of acute appendicitis depend on surgery If. as possible explanations but no causal as some cases of appendicitis do in fact resolve. sociations have been demonstrated It is without surgical intervention as some have. also possible that the decrease in the rate suggested 32 62 then surgical practice. 922 ADDISS ET AL, could indeed contribute to the observed racy and the total primary appendectomy. regional variation rate appeared to be inversely related when. The classic signs and symptoms of ap data were analyzed by region suggesting. pendicitis do not reliably distinguish be that in areas where the clinical threshold. tween patients who will have positive ap for operating is lower diagnostic accuracy. pendectomies and those who will have is reduced, negative appendectomies 27 Although Although the incidence of appendiceal.
improved diagnostic accuracy has been re perforation did not vary as markedly with. ported with use of computer algorithms 63 age as did the incidence of appendicitis the. 64 and high resolution ultrasound 65 66 two curves tended to be parallel the peak. clinical skill and experience remain the ba incidence for both perforation and appen. sis for managing patients with suspected dicitis occurred in persons aged 10 14. appendicitis 67 The challenge to the sur years In contrast the perforation ratio was. geon is to prevent appendiceal perforation strongly age related being highest in the. by early operation in cases of true appen elderly and the very young This J shaped. dicitis but at the same time make the di pattern has been noted by other investiga. agnosis with sufficient specificity to avoid tors 70 75 and is thought to reflect both. unnecessary negative appendectomies Be the increased diagnostic difficulty and the. cause the initial signs and symptoms of less timely surgical intervention for persons. appendicitis are not pathognomonic the in these extreme age groups 75 77. prevailing view has been that an acceptably In the life table analysis we assumed a. low perforation ratio can be achieved only constant incidence of appendectomy and. by surgeons who operate early and there appendicitis at 1979 1984 levels Because. fore perform a certain number of negative incidence appears to be declining the cur. appendectomies 68 69 the optimal neg rent risk of appendectomy and appendicitis. ative appendectomy rate has been claimed in the United States may have been over. to be as high as 23 percent 27 Others estimated Nonetheless at rates observed. have argued that a low perforation ratio for 1979 1984 one in eight males and one. alone is a poor indicator of the quality of in four females can expect to have their. surgical practice 70 especially if it is appendix surgically removed during their. achieved at the expense of excessively high lifetime approximately one half of these. numbers of negative appendectomies procedures will be incidental appendecto. which can be associated with significant mies The appropriateness and preventive. morbidity 71 Indeed several studies have value of incidental appendectomy particu. shown that clinical training 72 intensive larly in the elderly has recently been ques. in hospital observation 73 and use of en tioned 16 18 78 Although it is generally. hanced algorithms for the differential di considered a benign procedure 17 most. agnosis of abdominal pain 64 can improve incidental appendectomies are performed. diagnostic accuracy without a concomitant in persons over age 35 which is well past. increase in the perforation ratio the age of greatest risk for appendicitis and. The national data also suggested a cor in females who are at lower risk than. relation between diagnostic accuracy and males Furthermore it is possible that the. the perforation ratio when analyzed by re additional surgical and hospital costs of. gion or year small numbers limited statis incidental appendectomy may be more sub. tical power however particularly in the stantial than is generally assumed 16 79. analysis by region Diagnostic accuracy and The question of appropriate surgical pol. the perforation ratio were both higher icy is not whether incidental appendectomy. among men than among women a finding prevents future appendicitis but whether. reported previously 74 Diagnostic accu the procedure should be performed in per. APPENDICITIS AND APPENDECTOMY IN THE UNITED STATES 923. sons at low risk of appendicitis At least is it possible using new technologies to. two different ages 35 years and approxi improve diagnostic accuracy particularly. mately 60 years have been proposed as ages in women of childbearing age who have the. at which to restrict incidental appendec highest rates of primary negative appen. tomy 18 78 The life table model suggests dectomy How can the perforation ratio. that limiting incidental appendectomies to and appendicitis related mortality best be. persons under 35 years of age would reduce reduced in the elderly Under what circum. the total number of incidental procedures stances should incidental appendectomy be. in the United States each year by 50 per considered inappropriate. cent 130 000 operations but it might re Progress in answering these and other. sult in as many as 2 200 additional lifetime questions has been hampered by a lack of. cases of appendicitis including 880 appen clarity and consensus in defining appendi. diceal perforations In comparison limiting citis diagnostic accuracy negative appen. incidental appendectomies to persons un dectomy and incidental appendectomy We. der 60 years of age would reduce the num have proposed simple definitions based on. ber of procedures by only 8 percent and ICD codes that could be used in other stud. result each year in an additional 130 life ies Further understanding of the etiology. time cases of appendicitis 64 with perfo and epidemiology of appendicitis in the. ration To prevent a single lifetime case of United States will require carefully de. acute appendicitis in persons aged 35 and signed prospective studies using pathologi. 60 years 59 and 166 incidental procedures cally confirmed diagnoses and standardized. are required respectively Although the case definitions. overall rate of incidental appendectomy de,clined sharply between 1979 and 1984 little. change was noted among the elderly for REFERENCES, whom the procedure has the lowest preven 1 National Center for Health Statistics Utilization. tive value Additional data on the economic of short stay hospitals United States 1981 an. and health consequences of incidental ap nual summary Washington DC US GPO 1983. Vital and health statistics Series 13 no 72, pendectomy policy are needed to further DHHS publication no PHS 83 1733. refine and guide surgical practice mean 2 Fitz RH Perforating inflammation of the vermi. while the indications for this operation in form appendix with special reference to its early. diagnosis and treatment Trans Assoc Am Physi, older individuals remain controversial cians 1886 1 107 44. 3 Jones BA Demetriades D Segal I et al The, Although acute appendicitis is a common presence of appendiceal fecaliths in patients with.
condition that has been recognized for more and without appendicitis Ann Surg 1985 202. than a century its etiology is poorly under 80 2,4 Pieper R Kager L Tidefeldt U Obstruction of. stood In this study several previously rec appendix vermiformis causing acute appendicitis. ognized epidemiologic patterns were con Acta Chir Scand 1981 148 63 71. firmed Persons aged 10 19 years have the 5 Burkitt DP The aetiology of appendicitis Br J. Surg 1971 68 695 9, highest rates of acute appendicitis appen 6 Barker DJP Morris J Nelson M Vegetable con. dicitis is more common during the summer sumption and acute appendicitis in 59 areas in. and the incidence of the disease appears to England and Wales Br Med J 1986 292 927 30. be higher in males than in females higher 7 Arnbjornsson E Acute appendicitis and dietary. fiber Arch Surg 1983 118 868 70, in whites than in nonwhites and higher in 8 Brender JD Weiss NS Koepsell TD et al Fiber. persons living in certain regions of the intake and childhood appendicitis Am J Public. United States particularly the upper Mid Health 1985 75 399 400. 9 Andersson N Griffiths H Murphy J Is appendi, west In addition the rates of appendicitis citis familial Br Med J 1979 2 697 8. and appendectomy appear to be decreasing 10 Andersson N Cockcroft A Murphy JF et al. Acute appendicitis and social class Br J Clin, Important diagnostic and policy ques Pract 1981 35 272 3.
tions remain unanswered To what extent 11 Barker DJP Osmond C Golding J et al Acute. 924 ADDISS ET AL, apf endicitis and bathrooms in three samples of acute appendicitis in California a population. British children Br Med J 1988 296 956 8 based study of the effects of age Am J Epidemiol. 12 Attwood SEA Mealy K Cafferkey MT et al 1989 129 905 18. Yereinia infection and acute abdominal pain Lan 31 Pearson RJC Acute appendicitis in the New. cet 1987 l 529 33 Haven Standard Metropolitan Area in 1958 and. 13 Madden NP Hart CA Streptococcus miUen in 1959 Conn Med 1964 28 807 10. appendicitis in children J Pediatr Surg 1985 20 32 Lembcke PA Measuring the quality of medical. 6 7 care through vital statistics based on hospital. 14 Tobe T Inapparent virus infection as a trigger of service areas I Comparative study of appendec. appendicitis Lancet 1965 1 1343 6 tomy rates Am J Public Health 1962 42 276 86. 15 Bredesen J Lauritzen AF Knstiansen VB et al 33 Bourke JB Holliday A Balfour TW et al Rela. Appendicitis and enterobiasis in children Acta tionship between surgeons macroscopic diagnosis. Chir Scand 1988 154 585 7 at emergency appendicectomy and subsequent. 16 Sugimoto T Edwards D Incidence and costs of histopathology Abstract Gut 1985 26 A565 6. incidental appendectomy as a preventive measure 34 Jones MW Paterson AG The correlation between. Am J Public Health 1987 77 471 5 gross appearance of the appendix at appendicec. 17 Voitk AJ Lowry JB Is incidental appendectomy tomy and histological examination Ann R Coll. a safe practice Can J Surg 1988 31 448 51 Surg Engl 1988 70 93 4. 18 NockertsSR DetmerDE FrybackDG Incidental 35 Owens BJ Hamit HF Appendicitis in the elderly. appendectomy in the elderly9 No Surgery 1980 Ann Surg 1978 187 392 6. 88 301 6 36 Peltokallio P Tykka H Evolution of the age. 19 National Center for Health Statistics Trends in distribution and mortality of acute appendicitis. hospital utilization United States 1966 86 Arch Surg 1981 116 153 6. Hyattsville MD National Center for Health 37 Ashley DJB Observations on the epidemiology of. Statistics 1989 Vital and health statistics Series appendicitis Gut 1967 8 533 8. 13 no 101 DHHS publication no PHS 89 38 Freud E Pilpel D Mares AJ Acute appendicitis. 1762 in childhood in the Negev region some epidemi. 20 National Center for Health Statistics Eighth re ological observations over an 11 year period. vision international classification of diseases 1973 1983 J Pediatr Gastroenterol Nutr 1988. adapted for use in the United States Vols 1 and 7 680 4. 2 Washington DC US GPO 1968 PHS publi 39 Pieper R Kager L The incidence of acute appen. cation no 1693 dicitis and appendectomy Acta Chir Scand 1982. 21 Health Care Financing Administration Interna 148 45 9. tional classification of diseases ninth revision 40 Soreide O Appendicitis a study of incidence. clinical modification Vols 1 3 Washington DC death rates and consumption of hospital re. US GPO 1980 DHHS publication no PHS 80 sources Postgrad Med J 1984 60 341 5. 1260 41 Arnbjornsson E Varying frequency of acute ap. 22 US Bureau of the Census Current population pendicitis in different phases of the menstrual. reports population estimates and projections Es cycle Surg Gynecol Obstet 1982 155 709 ll. timates of the population of the United States by, age sex and race Washington DC US GPO 42 Nakhgevany KB Clarke LE Acute appendicitis. 1982 Series P 26 no 917 in women of childbearing age Arch Surg 1986. 121 1053 5,23 US Bureau of the Census Current population. reports population estimates and projections Es 43 Mueller BA Daling JR Moore DE et al Appen. timates of the population of the United States by dectomy and the risk of tubal infertility N Engl. age sex and race Washington DC US GPO J Med 1986 315 1506 8. 1986 Series P 25 no 985 44 Wolkomir A Kornak P Elsakr M et al Seasonal. 24 US Bureau of the Census 1980 census of popula variation of acute appendicitis a 56 year study. tion vol 1 Characteristics of the population gen South Med J 1987 80 958 60. eral population characteristics United States 45 Brumer M Appendicitis seasonal incidence and. summary Washington DC US GPO 1983 postoperative wound infection Br J Surg 1970. 25 Kleinbaum DG Kupper LL Morgenstem H 5753 9, Epidemiologic research principles and quantita 46 Brink CF Prinsloo H Van der Poel JS Eie sei. tive methods New York NY Van Nostrand Rein soenvoorkoms van akute appendicitis In Afri. hold Company 1982 kaans S Afr Med J 1985 68 156 8, 26 SAS Institute Inc SAS user s guide basics ver 47 Cihaf M Kabelka M Vhv atmosferickeho tlaku.
sion 5 ed Cary NC SAS Institute Inc 1985 na vyskyt akutni apendicitidy u deti In Czech. 27 Berry J Malt RA Appendicitis near its centenary Rozhl Chir 1980 59 622 6. Ann Surg 1984 200 567 75 48 Raguveer Saran MK Keddie NC The falling in. 28 Kazarian KK Roeder WJ Mereheimer WL De cidence of appendicitis Br J Surg 1980 67 681. creasing mortality and increasing morbidity from 49 Noer T Decreasing incidence of acute appendici. acute appendicitis Am J Surg 1970 119 681 5 tis Acta Chir Scand 1975 141 431 2. 29 Detmer DE Nevers LE Sikes ED Regional re 50 Palumbo LT Appendicitis Is it on the wane Am. sults of acute appendicitis care JAMA 1981 246 J Surg 1969 98 702 3. 1318 20 51 Arnbjornsson E Asp N G Westin SI Decreasing. 30 Luckmann R Incidence and case fatality rates for incidence of acute appendicitis with special ref.


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