Young Women Risk Unnecessary Surgery for Suspected Appendicitis

Peter Russell

December 05, 2019

Thousands of people in the UK, particularly young women, undergo unnecessary surgery each year for suspected appendicitis, according to a large-scale review of data.

The study also found that women aged 16 to 45 had a disproportionate risk of admission without surgical intervention.

Appendicitis is the most common general surgical emergency worldwide. However, its diagnosis remains challenging. One key concern is overtreatment, in the form of normal appendicectomy, which is associated with avoidable healthcare costs and postoperative complications.

Assessing Risk Prediction

Researchers from the Academic Department of Surgery at the University of Birmingham examined whether existing risk prediction models could reliably identify UK patients with a low risk of appendicitis presenting to hospitals with acute right iliac fossa (RIF) pain.

The study, published in the British Journal of Surgery (BJS), involved 154 UK acute surgical units, and 5345 patients, of which 67.6% were women.

"What's key is that unlike most previous studies, we've included patients who were presenting with abdominal pain," explained Dmitri Nepogodiev, research fellow at the University of Birmingham, and study co-author. "Most studies have focused on the patients who actually had an appendicectomy, whereas we caught a bigger pool of people who actually came with abdominal pain."

In addition, comparative data was collected from hospitals across Italy, Portugal, the Republic of Ireland, and Spain.

The study found that:

  • Women in the UK were more than twice as likely to undergo surgery with removal of a normal appendix (28⋅2%) than men (12⋅1%).

  • Of all patients presenting with RIF pain, women were less likely to be diagnosed with confirmed appendicitis (17.3%) than men (48⋅6%).

Unnecessary Treatment

"One of the big surprising findings is that most people who present with abdominal pain for suspected appendicitis don't have appendicitis," Dmitri Nepogodiev told Medscape News UK. "So, there's a large number of people who are being admitted to hospital, being investigated, having to go through the whole experience, and are then being discharged, usually without having had any sort of treatment.

"Amongst the women, less than 1 in 5 of them actually have appendicitis."

A principle reason why more women present with appendicitis symptoms was that "compared to men, there's a bigger range of things that can cause that pain, mostly relating to menstrual pain, ovarian cysts, and other gynaecological problems".

The authors proposed that all patients presenting with symptoms of appendicitis should be assessed using a sex-appropriate risk prediction model. For instance, of 15 validated models, the Adult Appendicitis Score performed best overall, but the Appendicitis Inflammatory Response Score performed best for men.

"Using a standardised scoring system allows us to make sure that we're looking at patients in an objective manner across the whole NHS," said Dmitri Nepogodiev. "The scoring systems aren't perfect but what we have found is that if you have a low score, then the probability of you having appendicitis is very low.

"Of the low scoring women, only about 1 in 30 will have appendicitis. It really doesn't make logical sense to admit 30 women for the sake of one of them potentially having appendicitis."

The researchers also plan a future assessment of risk prediction methods for children, and adults over the age of 45.

The study also found that normal appendicectomy rates were much lower in European comparator countries than in the UK.

Those were 10⋅2% versus 28⋅2% in women, and 2.6% versus 12.1% in men.

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis, BJS

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