M. Khan1, M. B. Chaudhry2, N. Shahzad1, M. Wajid1, W. A. Memon2, A. Alvi1 1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Medical College,Radiology,Karachi, Sindh, Pakistan
Introduction:
Appendicoliths are frequently considered as the cause of appendicitis. However, not all appendicoliths lead to appendicitis and are commonly detected incidentally on computed tomographic scans in uninflamed appendixes. The differences between appendicoliths associated with appendicitis and ones that are found incidentally have not yet been studied. The objective was to determine if greater number, greater diameter and a more proximal location of appendicoliths in appendix is associated with appendicitis
Methods:
A retrospective case-control study of patient with appendicoliths identified on Computed-Tomographic (CT) scan from 01/2008-12/2014 was completed. Patients were divided into two groups; those with appendicitis and appendicoliths (AA) (cases) and those with incidentally discovered appendicoliths (IA) without evidence of appendicitis (controls). The number, diameter and position of the appendicolith/s were ascertained and studied in relation to appendicitis at presentation.
Results:
In total, 321 patients were found to have appendicoliths on abdominal CT scans. Of these, 103 (32%) patients were in the AA group while 218 (68%) patients were in the IA group. The proportion of patients with appendicitis significantly increased with multiple appendicoliths: 28 (23.5%) with 1 appendicolith, 31 (35.2%) with 2 appendicoliths, 13 (43.3%) with 3 appendicoliths and 19 (70.4%) with >3 appendicoliths (p<0.001). Mean diameter of appendicoliths in the AA group was significantly greater than the appendicoliths of the IA group (6.7+-2.8 vs 3.9+-1.2mm respectively, p<0.001). When analyzing the location of appendicoliths, the proportion of patients with appendicitis was greater for more proximal location of the largest appendicolith; 34 (50.7%) at the base, 28 (32.2%) at the proximal third, 28 (31.5%) at the middle third, and 5 (17.2%) at the distal third (p<0.001). However, 29 (75%) patients with sludge that filled the entire appendix were in the IA group. After multivariable logistic regression analysis it was found that 3 or more appendicoliths, diameter of largest appendicolith of greater than 4 mm and location of largest appendicolith at the base were significantly associated with appendicitis.
Conclusion:
Multiple appendicoliths, greater diameter and more proximal position of appendicoliths are more likely to cause appendicitis. These results support the proposed concept of the obstructive phenomenon underlying the occurrence of appendicitis. This knowledge will aid in the diagnosis of equivocal cases of appendicitis.