Transcript - Catalyst

Epidemiology of Appendicitis
Aya Reiss, MS3
Pediatric Surgery Clerkship
February 11, 2010
SM
 6 y/o M presents to ER with 3 day hx of
abdominal pain
 HPI: Afebrile at presentation (37.4). Day of
admission, nausea and vomiting with emesis
x10 (nonbloody, nonbilious). No change in
bowel habits.
 PMH: Congenital innocent heart murmur
 FH: Noncontributory
SM
 Vitals: T 37.4 HR 118 RR 26 BP 119/91 100RA
 PE:




HEENT: Unremarkable
CV: RRR, no M/R/G
Resp: Clear bilaterally
Abd: Hypoactive bowel sounds. No masses or
hepatosplenomegaly. Tender to palpation in RLQ
at McBurney’s point. Positive obturator and
Rovsing’s sign.
SM
 Labs: WBC 35.3
 Imaging: U/S
SM
SM
SM
 Hospital Course:
 Taken to OR for laparoscopic
appendectomy
 Post-op: IV to PO antibiotics, diet
advanced, WBC decreased (11.1), pain
controlled, patient stable
 Discharged with activity and bathing
restrictions. Clinic f/u in 2 weeks.
Outline
 Demographics
 Theories
 Differential treatment
 Conclusions
Outline
 Demographics
 Infectious disease
 Noncommunicable disease
 Surgical disease
 Theories
 Differential treatment
 Conclusions
Demographics - Infectious1
globalizationstudies.sas.upenn.edu/.../term/91
Demographics 2
Noncommunicable
Demographics - Surgical
 Geographical patterns
 Appendicitis in:
 US 37.1/10,0003
 South Africa 1.1/10,0004
 US vs. Gambia5
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
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Appendicitis
Hypertrophic pyloric stenosis
IBD
Perirectal abscess and anal fissure
Neuroblastoma
Gastroschesis
Outline
 Demographics
 Theories





Pathophysiology
Dietary Fiber
Hygiene
Tropical enteropathy
Viral infection
 Differential treatment
 Conclusions
Pathophysiology6
Outline
 Demographics
 Theories

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Pathophysiology
Dietary Fiber
Hygiene
Tropical enteropathy
Viral infection
 Differential treatment
 Conclusions
Dietary Fiber Hypothesis7
 1880s-90s - Decreased consumption of
cellulose link with appendicitis - Bristol
 1890s - White bread vs. brown bread
increase digestive tract disease- US/UK
 1920s - Food refinement is a cause - India
 1950s - High fiber diet East/South Africa
decrease frequency
 1956 - Sugar and refined cereal foods
promote - West
Dietary Fiber Hypothesis
 Observation: lack of
dietary fiber and
increased refined
products increases
digestive tract
disease
 Controlled studies:
inconclusive
findings8,9
 NHANES II: racial
patterns prevail10
Outline
 Demographics
 Theories





Pathophysiology
Dietary Fiber
Hygiene
Tropical enteropathy
Viral infection
 Differential treatment
 Conclusions
Hygiene Hypothesis
 1980s - Better
living standards
and sanitation
increase
appendicitis11
Hygiene Hypothesis
 Less frequent infections
 Predispose to lymphoid hyperplasia
and obstruction
 Alter response to infection - hygienic
environments trigger acute
appendicitis when exposed
 Treg downregulate TH1 and TH2
responses in individuals in
daycare, born on farms, from
larger families12
Outline
 Demographics
 Theories

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Pathophysiology
Dietary Fiber
Hygiene
Tropical enteropathy
Viral infection
 Differential treatment
 Conclusions
Tropical Enteropathy
8,13
Hypothesis
 Villi blunting, crypt
hyperplasia,
inflammation of
lamina propria
 Largely correlative
 Consistent with
hygiene hypothesis
Tropical Enteropathy
Hypothesis
 Chronic or recurrent gut infection
correlates with decreased disease and
vice versa
 Emergence of disease with migration
into environments of improved
sanitation
Outline
 Demographics
 Theories

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

Pathophysiology
Dietary Fiber
Hygiene
Tropical enteropathy
Viral infection
 Differential treatment
 Conclusions
Viral Infection14
 Stimulates lymphoid hyperplasia and
lumen obstruction
 Could lead to mucosal ulceration
predisposing to subsequent bacterial
infection
Viral infection
Viral Infection
Outline
 Demographics
 Theories
 Differential Treatment
 Antibiotics vs. surgery
 Conclusions
Antibiotics vs. Surgery
 Standard of practice in North America is
surgery for children15
 Efficacy antibiotic tx for uncomplicated from
85-100% with 10-35% chance recurrence in
all age groups16
 Recent meta-analysis (in adults)17:
 Antibiotics have 68% success rate
 Appendectomy remains gold standard
 Antibiotics appropriate primary treatment to
reduce risk of complications
Outline
 Demographics
 Theories
 Differential Treatment
 Conclusions
Conclusions
 Geography of appendicitis is varied
 Different hypotheses exist to explain these
differences but nothing conclusive to date
 Strong evidence for surgical treatment of
appendicitis
 Developing greater understanding of possible
causes might lead to preventative action
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Freifeld C and J Brownstein. 2007. HealthMap - Global Disease Alert Map.
http://globalizationstudies.sas.upenn.edu/taxonomy/term/91. Accessed January 2010.
WHO, 2008. The world health report 2008: primary health care now more than ever. World Health
Organization. Geneva. Annual report.
Addiss DG, Shaffer N, Fowler BS and RV Tauxe. 1990. The epidemiology of appendicitis and
appendectomy in the United States. Am J Epidemiol 132:910-025.
Walker AR, Shipton E, Walker BF, Manetsi B, Van Resnburg PS and HH Vorster. 1989. Appendicectomy
incidence in Black and White children ages 0 to 14 years with a discussion on the disease’s causation.
Trop Gastroenterol 10:96-101.
Bickler SW and B Sanno-Duanda. 2000. Epidemiology of paediatric surgical admissions to a
government referral hospital in the Gambia. Bull World Health Organ 78(11):1330-1336.
UpToDate. 2010. Evaluation and diagnosis of appendicitis in children. Accessed February 2010.
Walker ARP and I Segal. 1994. Appendicitis: an African perspective. J R Soc Med 88:616-619.
Bickler SW and A DeMaio. 2008. Western diseases: current concepts and implications for pediatric
surgery research and practice. Pediatr Surg Int 24:251-255.
Nelson M, Morris J, Barer DJ and S Simmonds. 1986. A case-control study of acute appendicitis and
diet in children. J Epidemiol Community Health 40:316-318. - No difference in fiber intake between kids
with and without appendicitis.
Block G and E Lanza. 1987. Dietary fiber sources in the United States by demographic group. J Nat
Cancer Inst 79:83-91.
References cont.
11.
12.
13.
14.
15.
16.
17.
Barker DJP, Osmond C, Golding J and MEG Wadsworth. 1988. Acute appendicitis and
bathrooms in three samples of British children. British Medical Journal 296:956-958.
UpToDate. 2010. T helper subsets: Differentiation and role in disease. Accessed
February 2010.
Bickler S. 2006. Tropical enteropathy protects against Western diseases in environments
of poor sanitation. Medical Hypotheses 67:146-150.
Alder AC, Thomas BF, Woodward WA, Haley RW, Sarosi G and EH Livingston. 2010.
Association of Viral Infection and Appendicitis. Arch Surg 145:63-71.
Muehlstedt SG, Pham TQ and DJ Schmeling. 2004. The management of pediatric
appendicitis: a survey of North American Pediatric Surgeons. J Pediatr Surg 39:875.
Vons C. 2009. Can acute appendicitis be treated by antibiotics and in what conditions?
Journal de Chirurgie 1465:517-521.
Varadhan KK, Humes DJ, Neal KR and DN Lobo. 2010. Antibiotic Therapy Versus
Appendectomy for Acute Appendiciis: A Meta-Analysis. 34:199-209.