72 h Is the Time Critical Point to Operate in Acute Appendicitis

Delay of operative management of acute appendicitis may adversely affect post-operative outcomes and increase the likelihood of post-operative complications occurring. We aim to correlate the duration of symptoms with intra-operative findings to create a timeline of the pathological change in appendicitis.

Appendicectomies performed at a large teaching hospital between June 2015 and July 2016 were prospectively analysed. Time of onset of pain, operative findings, pre-operative C-reactive protein (CRP) and white cell count (WCC) were recorded. Intra-operative findings were categorised by the macroscopic appearance of the appendix, which was subdivided into erythematous, purulent, necrotic and perforated. These results were correlated with the symptom duration. Statistical analysis was completed using Mann-Whitney U and Chi-squared tests.

One hundred and ninety patients had histologically confirmed appendicitis during the study period. Median time to operation from symptom onset was 49 h. Median time for the appearances of erythematous, purulent, necrotic and perforated appendicitis to develop was 36.5, 41, 55.5 and 86 h, respectively (p value < 0.0001). Median CRP of the non-perforated and perforated appendicitis groups was 22 and 161 mg/L, respectively (p value < 0.0001). Our data demonstrated that after 72 h of symptoms, the likelihood of a perforated appendicitis increased significantly (p value < 0.0001) when compared to 60-72 h.

A significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptoms, when compared to 60-72 h. We can therefore argue that it may be reasonable to prioritise patients approaching 72 h of symptoms for operative management.