Surgical Science, 2011, 2, 318-321
doi:10.4236/ss.2011.26067 Published Online August 2011 (http://www.SciRP.org/journal/ss)
Patient Safety in Delayed Diagnosis of Acute Appendicitis
Aly Saber1, Mohammad A. Gad2, Goda M. Ellabban2
1 Department of General Surgery, Port-Fouad General Hospital, Port-Fouad, Egypt
2Department o f S urg e ry, Faculty of medicine, Suez Canal University, Ismailia, Egypt
Received January 11, 2011; revised March 24, 2011; accepted July 21, 2011
Abstract
Introduction: acute appendicitis is the major surgical abdominal disease in emergency departments and is
also among the five leading causes of litigation against emergency physicians. Delayed diagnosis of appen-
dicitis is more likely to occur in patients, who present atypically, and those lack a thorough physical exami-
nation, or those received intramuscular narcotic analgesia. The aim of this study was to study the effect of
delay in diagnosis of acute appendicitis as regard postoperative findings, length of hospital stay and post-
operative complications. Patients & Methods: patients with complicated appendicitis were subjected to the
present study and treated by a single surgical team. The parameters of our study were incidence of perfora-
tion or gangrene at surgery, length of stay and post-operative complications. Results: the present study
showed that delay in diagnosis of acute appendicitis is associated with a more advanced stage of disease and
a higher morbidity. Conclusion: careful attention to the patient’s history; a thorough physical examination
and early clinical review help to minimize the possibility of delayed diagnosis of appendicitis. Appendicitis
with a delay in treatment usually leads to high perforation rates, and unfavorable outcome.
Keywords: Acute Appendicitis, Delayed Diagnosis, Patient Safety
1. Introduction
Acute appendicitis is the major surgical abdominal dis-
ease in emergency departments [1] and it is also among
the five leading causes of litigation against emergency
physicians. The vast majority of causes of the claims
against physicians were clustered around “diagnosis er-
ror”, accounting for about one-third of the claims [2].
Appendicitis is more common for negligent adverse
events in claim data as it was 25 times more likely to
generate a claim for negligence than breast cancer [2,3].
The error rate in diagnosing patients with pain in the
right iliac fossa approaches 40%, and the appendix is
normal in approximately 20% of patients who undergo
exploratory laparotomy because of suspected appendici-
tis [2].
It is still difficult to make a correct preoperative diag-
nosis early enough that patients can avoid unnecessary
appendectomies and reduce the risk of perforation. This
is because the initial symptoms of early appendicitis are
nonspecific and may often confuse treating physicians.
In addition, attempts at seeking a correct diagnosis and
avoiding unnecessary appendectomies may actually cause
the delay of surgery and increase the possibility of per-
foration and morbidity [4].
A delay in diagnosis of appendicitis is more likely to
occur in patients, who present atypically, with fewer
complaints of right lower quadrant pain and those lack a
thorough physical examination, or those received intra-
muscular narcotic analgesia [5]. Diagnostic aids can dra-
matically reduce negative appedecectomies, perforations
and hospital stay. These aids are laparoscopy, scoring
systems, ultrasonography and computed tomography [6].
2. Aim of the Work
The aim of this study was to study the effect of delay in
diagnosis of acute appendicitis as regard postoperative
findings, length of hospital stay and post-operative com-
plications.
3. Patients & Methods
3.1. Study Site & Population
Information collected from database in Port Fouad gen-

A. SABER ET AL.319
Table 1. Distribution of complications among complicated
cases.
eral hospital between January 1, 2006 and March 1, 2008.
All patients, male and females at any age, admitted dur-
ing that period for surgery for complicated appedecec-
tomy were subjected to the present study and treated by a
single surgical team consisted of a consultant surgeon,
general surgeon and two residents.
3.2. Collected Data
Data were collected from the registration and statistics
unit in Port Fouad general hospital within the above-
mentioned period. Data included all cases of complicated
appedecectomies subjected to surgery by the same single
surgical team.
Parameters of evaluation:
1) Incidence of perforation or gangrene at surgery,
2) Length of stay (LOS), and
3) post-operative complications.
The operative finding was graded as four-grade system
Grade 1 (G I) for acute appendicitis, Grade 2 (G II) for
gangrenous acute appendicitis, Grade 3 (G III) for perfo-
ration, and Grade 4 (G IV) for a periappendicular abscess
[7].
Definition of delayed diagnosis:
Delayed diagnosis was considered as:
a) discharge from the emergency room department
(ED) at the first visit or,
b) a time from initial examination to surgery of 20
hours or more [8].
3.3. Statistical Analysis
Gathered data was analyzed using the Statistical Package
for Social Sciences 15 (SPSS Inc., Chicago, IL, USA)
and MedCalc version 9.2. Qualitative data was expressed
as numbers and percentages while quantitative data was
expressed as mean ± standard deviations (SD). Chi
square was used to test significance of the difference
between qualitative data and Student t test was used to
test significance of the difference between quantitative
data. Probability value (p-value) < 0.05 was considered
statistically significant.
4. Results
Complication Grade Number %
Gangrenous II 14 63.6%
Perforated III 6 27.3%
Periappendicular abscess.IV 2 9.1%
the emergency room department in 21 patients and in
only one patient, the delay was due to reluctant adminis-
trative attitude.
The length of hospital stay was studied in patients
treated for simple non-complicated appendicitis and those
with complicated appendicitis (Table 2). Post-operative
complications were monitored and addressed as: pro-
longed ileus, wound sepsis and intra-abdominal sepsis.
Postoperative bowel function was studied in both
groups. In non-complicated appendicitis patients, the
bowel motions were regained as early as 8 - 12 hours
while in those with complicated appendicitis ileus was
apparent as mild abdominal distension and delayed res-
toration of gut movement up to 36 - 72 hours (Table 3).
Septic complications were detected in both groups.
The incidence was greater in complicated than non-
complicated appendicitis patients as well as the pattern
of sepsis was different in both groups. In non-compli-
cated appendicitis patients, no intra-abdominal sepsis
was detected while in complicated appendicitis patients,
intra-abdominal sepsis was detected as pelvic abscess in
2/22 patients and deep wound sepsis was seen in 6/22
patients (Table 4).
Role of Surgical and Non-surgical Residents
The role of surgical and non-surgical residents in delayed
diagnosis of patients with acute appendicitis was traced.
We reviewed the patients files, subjected to the present
study, regarding the full history, clinical examination,
vital signs recording by both surgical and non-surgical
residents.
5. Discussion
Acute appendicitis is the second most common cause of
surgical abdominal disease in late adulthood and major
errors in management are made frequently and the condi-
tion is associated with significant morbidity and mortal-
ity [9].
The overall number of appedecectomies done within the
period of study was 112 by the same single surgical team.
The total number of complicated appedecectomy was 22
patients, 16 males and 6 females. Perforated appendicitis
was seen in 6 and gangrenous appendicitis in 14 patients
and 2 cases showed evidences of periappendicular ab-
scess (Table 1).
A perceived high rate of complicated, gangrenous or
perforated, appendicitis, despite advances in laboratory
and radiographic diagnostic modalities, prompted a re-
view of cases of appendicitis as regard the time course
from presentation to definitive treatment. The high rate
The pattern of delayed diagnosis was discharge from

A. SABER ET AL. 320
Table 2. Length of hospital stay in simple and complicated
cases.
Types Minimum Maximum Mean ± SD
Simple (n = 90) 24 hr 48 hr 36.29 ± 8.5 hr
Complicated (n = 22) 96 hr 168 hr 126.31 ± 34.1 hr
t-test 22.6
p-value 0.00*
*Statistically significant difference.
Table 3. Time in hours elapse d till regain of bowel motions.
Group Minimum Maximum Mean ± SD
non-complicated 8 hr 12 hr 10.12 ± 1.45 hr
Complicated 36 hr 72 hr 54.61 ± 15.31 hr
t- test 27.45
p-value 0.00*
*Statistically significant difference.
Table 4. Incidence of septic complications among compli-
cated and non-complicated cases.
Group Non-complicated
(n = 90)
Complicated
(n = 22) p-value
Wound sepsis N (%) 2 (2.2%) 6 (27.3%) 0.003*
intra-abdominal
sepsis N (%) 0 (0%) 2 (9.1%) 0.04*
*Statistically significant difference.
of complicated appendicitis with its subsequent sequelae
of increased morbidity is primarily the direct result of
patient delay [10].
In the present study, we showed that delay in diagno-
sis of acute appendicitis was associated with a more ad-
vanced stage of disease and a higher morbidity. Other
study stressed on the pre-admission delay on the part of
the patient and the post-admission delay on the part of
the surgeon as how both shared in causing a more ad-
vanced stage of disease and consequent complications is
still debated [6,9,10].
Although acute appendicitis is among the five leading
causes of litigation against emergency physicians [10,11],
we could not find such files in our local legal medicine
department despite the significant level of delayed diag-
nosis of patients with appendicitis. Because of the initial
symptoms of early appendicitis are nonspecific, a correct
preoperative diagnosis early enough is mandatory to
avoid unnecessary appendectomies and reduce the risk of
perforation [11,12]. We think that it is the role of treating
physicians to seek a correct diagnosis and avoid unnec-
essary appendectomies, the delay of surgery and increase
the possibility of perforation and morbidity.
Our data came in agreement with those studies of
same interest as all suggested that delay may, however,
result in an increase in cost, especially for those patients
in whom the emergency room-operative room period
extends beyond 12 hours, or in an increase in long hos-
pital stay in those in whom admit-operative room dura-
tion is greater than six hours [11-13].
Regarding the role of surgical and non-surgical resi-
dents in delayed diagnosis of patients with acute appen-
dicitis, we found that training background of residents
affected their diagnosis of acute appendicitis in the
emergency department as stated in other study of same
interest 4. The surgical residents were well-oriented to
the clinical data and their diagnosis was based primarily
on the patient’s history and the physical examination.
While the non-surgical residents depended on the labo-
ratory test and ultrasonography as complimentary aids to
the clinical data.
Some studies showed that the diagnosis of acute ap-
pendicitis relies largely on clinical experience and the
performance of complementary tests is oftentimes un-
necessary [14,15]. Others reported that radiological ex-
aminations are very helpful to determine the diagnosis
even when the patient presents atypically [16]. The Al-
varado score is a validated test in clinical adult surgery
practice which can be helpful in the diagnosis of acute
appendicitis [4,6,17] but not in female patients [18].
Due to the fact that no single score may be used alone
to dictate or decline surgery and different cut-off points
may also be considered for different subpopulations [19].
It is well known that precaution appendectomy or mis-
diagnosis of presumed appendicitis is an adverse out-
come that leads to unnecessary surgery, serious interrup-
tion of patient’s daily activities and considerable waste
of hospital resources [20]. Here, the authors stressed on
the higher index of suspicion, better surgical training,
and better senior supervision at the emergency depart-
ments, to avoid preventable morbidity and mortality in
acute appendicitis [21].
6. Conclusions
Diagnosis of acute appendicitis may be a difficult task
and remains a clinical challenge in the emergency de-
partments. Despite technologic advances, the diagnosis
of appendicitis is still based primarily on the patient's
history and the physical examination.
Careful attention to the patient’s history, a thorough
physical examination and early clinical review will
minimize the possibility of a delay in diagnosis of ap-
pendicitis. Appendicitis with a delay in treatment usually
leads to high perforation rates, and unfavorable outcome

A. SABER ET AL. 321
parameters. The problem of late presentation and/or re-
ferral should be addressed, perhaps by education of pri-
mary care physicians and the public. Public education,
specifically targeting those groups at risk, may provide a
substantial and significant solution to the complicated
appendix.
7. Acknowledgements
The authors would appreciate the efforts of Mrs. Mervat
Kamel for her help in writing, preparing tables and edit-
ing the manuscript.
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