The term "acute appendicitis" was first introduced by Reginald H. Fitz in 1886, who established a connection between the condition then referred to as typhlitis and acute inflammation of the vermiform appendix ^[1]. Histologically, appendicitis is characterized by inflammation of the mucosal lining of the appendix, which can progress to involve deeper layers due to factors such as venous congestion, ischemia, and bacterial invasion. These pathological processes manifest as the classical signs and symptoms associated with acute appendicitis ^[2].

Acute appendicitis remains one of the most common causes of surgical emergencies worldwide and is a leading indication for emergency abdominal surgery, making appendicectomy one of the most frequently performed operations globally ^[3]. In some regions, such as the West African sub-region, it is considered the leading cause of acute surgical abdomen ^[4]. Despite advances in diagnostic techniques, appendicitis continues to pose diagnostic challenges for clinicians. The clinical presentation can be highly variable, and not all patients exhibit the typical signs and symptoms traditionally associated with the condition. Consequently, misdiagnosis or delayed diagnosis remains a concern.

The lifetime risk of developing acute appendicitis in developed countries is estimated at approximately 6.7% for females and 8.6% for males ^[5]. However, the lifetime probability of undergoing an appendectomy is even higher—9.89% for males and 9.61% for females ^[6]. This discrepancy underscores the occurrence of negative appendectomies, where surgery is performed but histopathological examination reveals no inflammation. A negative appendicectomy is defined by the absence of inflammation or intramural neutrophilic infiltration in the removed appendix ^[7]. Such cases often result from overreliance on subjective clinical findings, which can be nonspecific or misleading.

Improving diagnostic accuracy is essential to reduce the incidence of unnecessary surgeries and associated healthcare burdens. Therefore, this study aims to evaluate the clinical presentation and management of acute appendicitis at a tertiary care hospital in northern India.

This prospective observational study was conducted in 2022- 2024 at Integral Institute of medical sciences and research Lucknow Uttar Pradesh in northern India. A total of 200 adult patients (aged 18 years and above) who underwent surgery for suspected acute appendicitis were consecutively enrolled. Pediatric patients were excluded from the study.

Patient Evaluation

Upon presentation at the adult emergency department, patients were initially evaluated by trained surgical residents using predefined clinical parameters. The evaluation included a detailed history, thorough physical examination, and the measurement of vital signs. The normal vital sign ranges were defined as follows:

• Temperature: Morning temperature <37.2°C or afternoon temperature <37.7°C (measured axillary)
• Blood Pressure: Systolic 90–130 mmHg and diastolic 60–85 mmHg
• Pulse Rate: 60–100 beats per minute
• Respiratory Rate: 14–22 breaths per minute

During the abdominal examination, specific attention was paid to signs such as direct tenderness, rebound tenderness, guarding, and the presence of a palpable mass in the right lower quadrant.

Abdominal Ultrasound

Abdominal ultrasound was performed as part of the diagnostic workup. The following sonographic parameters were used to assess for acute appendicitis:

• Appendiceal wall thickness (>6 mm indicating edema)
• Aperistaltic and non-compressible appendix
• Evidence of fat stranding in the adjacent mesentery
• Presence of free fluid in the right lower quadrant
• Sonographic tenderness at McBurney’s point
• Visualization of an appendicolith (which was considered definitive for appendicitis)

In cases where only one of the above parameters (excluding an appendicolith) was identified, the ultrasound diagnosis was considered suggestive of probable acute appendicitis. The presence of two or more of these parameters was required to confirm a diagnosis of definite acute appendicitis. If none of the specified parameters were present and no alternative diagnosis was identified, the ultrasound was reported as normal or unremarkable.

Intraoperative Assessment

During surgery, the operating surgeon performed a gross evaluation of the appendix. The assessment focused on several intraoperative parameters including:

• The presence and extent of erythema
• The size and overall appearance of the appendix
• Characteristics of the appendiceal wall (e.g., whether it was edematous, compressible, or exhibited dark discoloration and fragility)
• The presence of perforation, fecalith, or other complications

Based on the intraoperative findings, the appendix was categorized as follows:

• Grossly Normal
• Inflamed or with a phlegmon (classified as simple or uncomplicated appendicitis)
• Gangrenous, Perforated, or Associated with Abscess/Peritonitis (classified as complicated appendicitis)

A gangrenous appendix was defined as one with a darkened, non-functional, and fragile wall in the absence of perforation.

Post-Appendectomy Outcome Assessment

Patient outcomes were monitored from the time of presentation in the emergency department until discharge. Outcome assessment included both intraoperative and postoperative complications. Intraoperative complications recorded included any excessive bleeding or accidental injury to adjacent bowel or bladder structures. Postoperative complications were assessed by monitoring for the development of:

• Surgical site infections
• Postoperative intra-abdominal collections
• Wound dehiscence
• Respiratory complications (such as aspiration pneumonia or hospital-acquired pneumonia)

Data Analysis and Presentation

Data coding and analysis were performed using Microsoft Excel along with freely available online statistical software. Discrete variables are presented as frequencies and percentages, while continuous variables are summarized as means with their standard deviations. The association between independent patient variables and the development of complications was evaluated using chi-square analysis. A 95% confidence interval was applied, and a p-value of <0.05 was considered statistically significant in all computations.

A total of 200 patients diagnosed with acute appendicitis were evaluated in the adult emergency department of the hospital during the study period. All patients underwent surgical intervention. Acute appendicitis emerged as the most frequent emergency surgical condition, accounting for 46.4% of emergency operations during this time.

Male patients constituted the majority, representing 63.9% of the study population, resulting in a male-to-female ratio of 1.8:1. The mean age of the patients was 27.62 ± 8.6 years, with ages ranging from 18 to 70 years. Half of the patients fell within the 18–25 year age group. Regarding place of residence, 88.5% of the participants were from the capital city.

The average duration of symptoms prior to hospital presentation was 51.34 ± 100.5 hours, ranging from 4 hours to 10 days, with a median of 29 hours and a mode of 24 hours. The most commonly reported symptom was abdominal pain (98.2%), followed by migration of pain (81.9%) and anorexia (70%). On physical examination, right lower quadrant tenderness was the most prevalent finding (93.4%). On initial assessment, 31.7% of the patients were tachycardic, 17% were febrile, and 1.0% were hypotensive.

Table 1. Abdominal Ultrasound Findings vs Intra-operative Stage (n = 200)

Among the 200 patients, definite appendicitis was identified in 145 cases, with 109 classified as simple and 33 as complicated. A small number (3 cases) showed normal findings despite surgical confirmation. Probable appendicitis accounted for 13 cases. There were 15 normal ultrasounds, of which 13 later proved to be simple and 2 complicated. Ultrasound was not performed in 22 patients, and 3 cases revealed alternative pathologies.

Table 2. Stage of Appendicitis vs Duration of Symptoms (n = 200)

Among those who presented within 48 hours, 106 had simple appendicitis, while 12 were complicated. In contrast, patients with symptom duration ≥48 hours had a higher rate of complications (35 cases). This indicates a clear association between delayed presentation and complicated appendicitis.

Table 3. Post-Appendectomy Complications (n = 200)

A total of 9 post-operative complications were recorded, resulting in an overall complication rate of 4.5%. The most frequent was superficial surgical site infection (2.0%). Other complications each accounted for 0.5%, including organ injury, pulmonary complications, and wound issues.

Acute appendicitis is known to predominantly affect younger individuals, especially those in their second and third decades of life. This trend was mirrored in our study, where 50% of the patients were within the 18–25-year age group. Similar age-related distributions have been documented in various studies conducted across Africa ^[8,9–16]. A notable male predominance was also observed, consistent with findings from several other reports ^[17-23].

In this study, the average duration of symptoms prior to presentation was over two days, aligning with observations from both local research and studies conducted in South Africa ^[8,9,12,23]. Abdominal pain was the most frequently reported symptom, consistent with studies from Ethiopia, Nigeria, and South Africa ^[8,9,13,15]. Specifically, 81.9% of patients in our study reported migratory abdominal pain, a figure significantly higher than the 33% reported in South Africa and 52% in an Indian study ^[21,22].

Right lower quadrant tenderness was the most common physical sign, present in 93.4% of cases, which is comparable to findings in previous studies ^[9,15,19,22]. Interestingly, leucocytosis was noted in only 33% of patients in our study, which is relatively low compared to rates of 50.7% and 70% reported in studies from Ethiopia and India, respectively ^[19,22].

Abdominal ultrasound was utilized in 81% of the cases, a proportion higher than what is typically reported in local studies. This may be attributed to our hospital’s role as a tertiary referral center, where patients are often initially evaluated at primary facilities before being referred. Consequently, many undergo imaging on arrival at our emergency department. Furthermore, there is an increasing trend among clinicians to rely on imaging modalities for diagnosis, a shift supported by other research findings ^[23,24]. Several studies suggest that the growing use of preoperative imaging has contributed to a decline in unnecessary appendectomies, highlighting its value in improving diagnostic accuracy ^[24,25].

In terms of surgical approach, the right lower quadrant transverse incision was most commonly used, especially in cases of simple appendicitis. Complicated appendicitis was diagnosed in 23% of patients, a finding that is consistent with some literature ^[11,1519,26], although lower than that reported in other studies ^[9,21]. Intra-operatively, 1.8% of cases revealed a grossly normal appendix. The correlation between intraoperative and histopathological findings remains controversial, with reported concordance rates ranging from 46.6% to 93.5% in different studies ^[27–31].

The overall postoperative complication rate in our study was 3.8%, which is notably lower than those reported in similar studies ^[11,21,23]. Superficial surgical site infections were the most common complication, aligning with previous reports but occurring at a much lower rate ^[9,15,21]. Intra-abdominal collections were the second most frequent complication and required surgical re-exploration. The relaparotomy rate was 1.85%, comparable to a Swedish study but lower than the rate found in a rural South African study.

The relatively low rate of postoperative intra-abdominal complications may be due to the predominance of uncomplicated appendicitis in our cohort. Mortality was also low in our study, potentially reflecting improved surgical care or increased awareness and health-seeking behavior among patients ^[9,19,31]. Lastly, the mean length of hospital stay was shorter than that observed in several previous studies ^{[9,11,16,21,32,33]}, indicating a possible improvement in perioperative management and patient recovery.

This study highlights that acute appendicitis predominantly affects young adults, with a higher incidence in males. Abdominal ultrasound proved to be a valuable diagnostic tool, with most definitive findings correlating well with intraoperative stages. Complicated appendicitis was more frequent in patients with symptoms lasting 48 hours or more. The overall complication rate post-appendectomy was low, with superficial surgical site infections being the most common. These findings underscore the importance of early diagnosis and intervention to prevent complications. Enhanced clinical evaluation combined with timely imaging can significantly improve diagnostic accuracy and reduce negative appendectomy rates.

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