Acute appendicitis is a disease that can be seen in all age groups and accounts for more than half of acute abdominal diseases in adults (1). Despite being well understood in terms of characteristics and surgical treatment, appendicitis remains the emergency surgical condition with the highest misdiagnosis rate (1,2).
Although advances in technology and diagnostic methods have reduced negative appendectomy (NA) rates, challenges in diagnosing acute appendicitis persist, and NAs remain a significant problem (3,4). NA is more commonly observed in female patients due to gynecological pathologies mimicking acute appendicitis (4).
In this study, we aimed to present the patients, pathologies, and treatment approaches we encountered with gynecological pathologies during laparotomy performed with a preliminary diagnosis of acute appendicitis.
Materials and Methods
Between January 2008 and January 2010, 420 patients who were operated on with a preliminary diagnosis of acute appendicitis were retrospectively analyzed. The diagnosis of acute appendicitis was based on physical examination, laboratory, and radiological findings. In female patients, gynecological consultation was requested in addition to ultrasonographic imaging. Gynecological pathologies and the macroscopic condition of the appendix were evaluated in the patients. The findings were statistically analyzed using the chi-square test.
Results
Of the patients, 260 (61.9%) were male, and 160 (38.1%) were female. During the operation, normal appendices were encountered in 28 patients (6.6%). Among these 28 patients with negative appendectomy, 19 (67%) were female. Negative appendectomies were statistically significantly more common in females than in males (p<0.01). In 18 (64.2%) of these 28 patients with normal appendices, no other pathology was identified. In 10 cases (35.8%), gynecological pathology was detected.
Among these patients, 4 (40%) had corpus hemorrhagic cyst rupture, 4 (40%) had pelvic inflammatory disease, 1 (10%) had an ovarian cyst, and 1 (10%) had ovarian torsion (Table 1). Patients with corpus hemorrhagic cyst rupture underwent cyst excision and bleeding control, those with ovarian cyst rupture underwent cyst excision, 4 patients with PID underwent drainage and antibiotic therapy, and the patient with ovarian torsion underwent oophorectomy.
Discussion
Diseases that mimic acute appendicitis and cause NA can be examined under two main categories: gynecological and non-gynecological causes. Gynecological causes include ectopic pregnancy, abortion, ovarian torsion, cyst rupture, myoma degeneration, and pelvic inflammatory disease, while non-gynecological causes include cholelithiasis, cholecystitis, acute pancreatitis, and peptic ulcers (5). Non-gynecological causes are also encountered in male patients. It should be noted that surgeons may encounter gynecological diseases in patients undergoing laparotomy with a preliminary diagnosis of acute appendicitis (5,6).
In our clinic, located in a training and research hospital, intraoperative consultation is requested for all cases with gynecological pathologies, and necessary interventions are performed by obstetrics and gynecology specialists. Patients with corpus hemorrhagic cyst rupture underwent cyst excision and bleeding control, those with ovarian cyst rupture underwent cyst excision, 4 patients with PID underwent drainage and antibiotic therapy, and the patient with ovarian torsion underwent oophorectomy.
According to the literature, NA is statistically significantly more common in females (4-8). This is attributed to the proximity of the appendix to reproductive organs in women of reproductive age and to diseases like ovarian cysts and PID presenting symptoms similar to acute appendicitis (8). In a study by Seetahal et al., of 23,655 women aged 18-45 who underwent NA, 3,879 (16.4%) had right lower quadrant pain, 2,176 (9.2%) had ovarian cyst rupture, and 1,608 (6.8%) had endometriosis pathologies (4).
In another study by Nakhgevary et al. (9), of 108 female patients, 52 (48%) underwent NA, and of these, 23 (44%) had normal appendices, 20 (38%) had pelvic inflammatory disease, and 9 (18%) had ovarian pathologies. In our study, similar to the literature, gynecological pathology was detected in 10 of 19 female patients who underwent NA, with PID (40%) and hemorrhagic cyst rupture (40%) being the most frequent findings.
While patient history and physical examination findings remain crucial in diagnosing acute appendicitis, various imaging techniques, blood analyses, acute phase reactants, and diagnostic modalities have been developed to reduce NA rates (10,11).
Abdominal ultrasonography (USG) is commonly used as an auxiliary technique (10-13). According to various publications, sensitivity for abdominal USG in diagnosing acute appendicitis ranges from 65-90%, specificity from 90-100%, efficiency from 89-95%, positive predictive value from 80-89%, and negative predictive value from 76-92% (11-13). However, failure to visualize the appendix on USG does not rule out acute appendicitis (10). In our study, all 10 NA cases underwent USG, which was consistent with acute appendicitis, but gynecological pathology was detected during surgery.
NA rates vary between 11% and 18% (4,8). In the past, high NA rates were considered acceptable as they were thought to prevent perforated appendicitis (2,4,8). However, NA increases morbidity and mortality due to longer hospital stays and higher infection risks (2).
In parallel, Seetahal et al. (4) reviewed 475,651 appendectomies between 1998 and 2007, finding that NA incidence decreased from 14.7% in 1998 to 8.4% in 2007. The same study reported that NA was statistically more frequent in females. In our study, NA was performed on 28 patients (6.6%), and it was statistically more frequent in females. We attribute our low NA rate to requesting abdominal ultrasonography for every suspected acute appendicitis case and gynecological consultation for female patients before surgery.
Despite advancements in diagnostic methods, NA rates remain high among females. To prevent NA, female patients should be carefully evaluated, and the possibility of gynecological pathologies mimicking acute appendicitis should be considered. Addressing this issue and investigating gynecological pathologies in suspicious cases could effectively reduce NA rates in females.
