Risk of Appendicitis in Patients With Incidentally Discovered Appendicoliths
Risk of Appendicitis in Patients With Incidentally Discovered Appendicoliths
Risk of Appendicitis in Patients With Incidentally Discovered Appendicoliths
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* Corresponding author. Department of Surgery, Aga Khan University, Stadium Road, Karachi 74800, Pakistan. Tel.: þ922134864751; fax:
þ922134934294
E-mail address: rehman.alvi@aku.edu (A.R. Alvi).
0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2017.08.021
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khan et al risks from incidental appendicoliths 85
hard, calcified fecal masses of variable sizes in the lumen of questions with regard to the occurrence of appendicitis at the
appendix. In 1939, Wangensteen and Dennis demonstrated time of CT scan or any time thereafter.
obstruction of the appendix to be the most likely cause of
appendicitis.3 Since then, multiple studies have emphasized Statistical analysis
the role of appendicoliths in the pathogenesis of acute
appendicitis.4 Data were collected and stored in Microsoft Excel (version
Although this association is well established, the man- 2010). Simple descriptive analysis was performed and re-
agement of incidentally found appendicoliths on radiolog- ported as frequencies with percentages for categorical vari-
ical imaging is less clear. In 1966, Forbes and Lloyd-Davies ables and means with standard deviations. Cases and controls
recommended appendectomy for incidentally discovered were matched for age, gender, and dates of CT scan performed
appendicoliths, citing the reported incidence of appendico- during the study period.
liths in 0.8%-44% of patients with acute appendicitis.4
However, more recently, Rabinowitz et al. studied 74
patients with incidental appendicoliths and concluded that
although appendicoliths do increase the risk of appendicitis, Results
it is not enough to warrant prophylactic appendectomy.5 In
another study, Rollins et al. reported that of 75 patients of Of the 200 patients identified as having incidental appendi-
pediatric age group having asymptomatic appendicoliths coliths on radiological imaging, we could establish telephonic
found incidentally, 5.8% developed acute appendicitis, contact with 111 patients (55.5%), who were included in the
making them conclude that prophylactic appendectomy is study. A 1:1 matched control group of 111 patients was
not indicated.6 selected and also contacted for occurrence of appendicitis.
Although acute appendicitis remains a clinical diagnosis, The mean age ( standard deviation) for the patients with
increased use of computed tomographic (CT) scans in the appendicoliths was 38 15 y with 36 (32%) being females
emergency departments across the world has increased (Table 1). Mean length of appendix was 66 16 mm, and mean
incidental findings with no immediate clinically significant width was 5.8 0.9 mm. Positions of the appendix were pelvic
consequences.7 Thus, from the prevailing concepts for (21, 19%), postileal (13, 11.7%), preileal (17, 15.3%), promonteric
etiology of acute appendicitis arises the question of the risk of (23, 20.7%), retrocecal (20, 18%), and subileal (17, 15.3%).
appendicitis when appendicoliths are found incidentally. The Noncontrast-enhanced (neither intravenous nor oral) CT scan
objective of this study was to determine the risk of appendi- was performed in 98 patients (88%). The most common
citis in patients with appendicoliths found incidentally on CT pathological finding in these CT scans was urolithiasis in 58
scans performed for reasons other than acute appendicitis. patients (52%), whereas 37 (33%) of the CT scans were within
normal limits with no pathological findings.
Overall, single appendicolith was seen in 44 patients (40%),
Materials and methods whereas 36 patients (32%) had two appendicoliths, nine (8%)
patients had three appendicoliths, and three (3%) had more
This was a retrospective matched cohort study of patients in than 3 appendicoliths, whereas 19 (17%) had sludge (Table 2).
whom appendicoliths were found incidentally on abdominal Mean diameter of the appendicolith was 3.6 1.1 mm (1.4-
CT scans performed from January 2008 to December 2014. All 7.8 mm). Overall, 65 (58%) of appendicoliths were either at the
patients aged 16 y at the time of CT scan were included. proximal end or filled the entire appendiceal lumen, 34 (31%)
Hospital radiology search software was used to identify CT at mid area, and 12 (11%) at the distal end of appendix.
scans that were performed for indications other than appen- At a mean follow-up of 4.0 1.7 y (1.8-8.85), no patient in
dicitis but reported appendicoliths and no radiological either the study group or control group developed acute
evidence of appendicitis. The CT scans were reviewed by appendicitis.
consultant radiologist and radiology resident who ascertained
number, diameter, and position of the appendicoliths.
Approval from institutional ethics review committee was
obtained prior to the start of the study. As per the institutional Table 1 e Patient demographics, type of CT scan, and the
policy, informed consent was taken on telephone in the most common findings.
presence of a witness. The consent was then documented and Variables n (%)
signed by both the interviewer and witness on the approved
Mean age 38 15
consent form.
Male 75 (67.5)
Age- and gender-matched control group was identified
from the radiology database and included those patients who Type of CT scan
had undergone an abdominal CT scan during the study period Contrast enhanced 13 (11.7)
for indications other than appendicitis and had neither Noncontrast enhanced 98 (88.2)
radiological evidence of appendicolith nor a clinical suspicion Findings of CT scan
of appendicitis. Both groups were contacted by the authors for Urolithiasis 57 (51.3)
a standardized telephonic interview to determine the occur-
Within normal limits 36 (32.4)
rence of appendicitis after being discharged from the hospital.
Others 17 (15.3)
The interview was conducted in Urdu language and included
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86 j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 8 ( 2 2 1 ) 8 4 e8 7
Discussion
Conclusion
The present study demonstrates that patients with incidental
Patients found to have appendicoliths discovered incidentally
appendicolith did not have an increased risk of developing
did not develop appendicitis in our study at a mid-term follow-
appendicitis compared with the general population. Appen-
up. Therefore, prophylactic appendectomy cannot be recom-
dicoliths or fecaliths have been considered to be the most
mended, and these patients can be reassured that they are not at
common cause of appendicitis ever since the first successful
an increased risk of appendicitis compared with the general
removal of the appendix by Hancock in 1848,8 description of
population. Further studies that can determine the lifetime risk
“appendicitis” by Fitz in 1886,2 and demonstration of the
of appendicitis in patients with appendicoliths should be con-
obstructive phenomenon in pathogenesis of acute appendi-
ducted. Studying the characteristics of appendicolith/s including
citis by Wangensteen and Dennis in 1939.3 The association
the size, number, and position in patients with appendicitis can
between the presence of appendicoliths and acute non-
help in further elucidating the risk in asymptomatic patients.
perforated or perforated appendicitis has been reported in
multiple recent studies,9-11 and all current textbooks describe
the role of appendicoliths as an etiological factor in patho-
genesis of acute appendicitis.12,13 In contrast, incidental Acknowledgment
appendicoliths that have been reported to occur in up to 32%
of asymptomatic population have not been well studied.14 The The authors acknowledge Dr M.S.K, MD, at the Department of
earliest description of incidentally discovered appendicoliths Family and Community Medicine, School of Community
was by Forbes and Lloyd-Davies in their study describing Medicine, University of Oklahoma, Tulsa, Oklahoma, for his
appendicoliths associated with appendicitis. They recom- advice and expertise in the analysis of data and preparation of
mended to perform prophylactic appendectomy when the manuscript.
appendicoliths are found incidentally.4 Although it is clear Authors’ contributions: M.S.K. conceived, designed,
that appendicoliths do have a role in pathogenesis of acute executed, and analyzed the project. He also prepared and wrote
appendicitis, the threat posed by them in asymptomatic pa- the manuscript. M.B.H.C. conceived, designed, and executed the
tients is less clear. Thus, scientific evidence to recommend project. N.S. designed the project and analyzed the data. M.T.
any measures be it prophylactic appendectomy or reassur- executed the project and participated in manuscript prepara-
ance is weak as the studies involving a larger sample size with tion. W.A.M. supervised the execution of project and
a longer and more reliable follow-up have been lacking. The manuscript writing. A.R.A. supervised the designing, execution,
present study has reported no increased risk of acute appen- and analysis of project and manuscript writing.
dicitis in these patients at a mid-term follow-up.
Understanding the risk of appendicitis in patients with Disclosure
incidentally discovered appendicoliths can help clinicians and
patients take a more evidence-based approach while deciding The authors reported no proprietary or commercial interest in
on the management plan. With the most common successful any product mentioned or concept discussed in the article.
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khan et al risks from incidental appendicoliths 87
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