Institutional and population based analyses on misdiagnosis of appendicitis in Khulna , Bangladesh

The aim of the present study was to identify factors associated with misdiagnosis of appendicitis to propose solutions to decrease the misdiagnosis rate of appendicitis. The study conducted an institutional and a population based analyses on misdiagnosis of appendicitis conducted in Khulna district, Bangladesh. The study dealt with 2 groups of patients. Group 1 consisted of the patients treated in Gazi Medical College Hospital (GMCH), Khulna either in out-patient department (OPD) within the last 3 years (from 2014 to 2016), treating doctors suggested appendicectomy and in indoor-patient department (IPD) within the last 5 years (from 2012 to 2016), the diagnosis was done either during operation or admitted as postoperative complications. Patients for Group 2 were selected purposively from the patients who were from different villages of Rupsha and Fakirhat Upazila or from Khulna city previously underwent appendicectomy within the last 5 years (from 2012 to 2016) in different hospitals other than GMCH, Khulna and previous symptoms were still existed. The study revealed that the majority of the patients were female (OPD 81.5%, IPD 68.8% in Group 1 and 83.2% in Group 2). The misdiagnosis rate of appendicitis for the patients attended GMCH OPD and GMCH IPD was 23.0% and 8.9%, respectfully. The overall misdiagnosis rate of appendicitis for the patients attended GMCH was 14.0%. In case of the patients attended GMCH OPD, most of them had UTI and chronic cystitis (45.5%). In case of the patients attended GMCH IPD, most of them had non-inflamed appendix (84.4%). The misdiagnosis rate of appendicitis for the patients in Group 2 was 23.2%. Some factors were identified and bearing in mind the factors, all the concerned should be more careful and conscious while making the diagnosis of appendicitis to avoid misdiagnosis and patients’ suffering.


Introduction
Appendicitis is the inflammation of the vermiform of appendix, usually which requires its surgical removal (appendicectomy/ appendectomy) for the treatment of the disease due to its life threatening complications.Appendicitis may present many vague symptoms including abdominal pain (beginning ment (OPD) within the last 3 years (from 2014 to 2016), treating doctors suggested appendicectomy and in indoor-patient department (IPD) within the last 5 years (from 2012 to 2016), the diagnosis was done either during operation or admitted as postoperative complications.Patients for Group 2 were selected purposively from the patients who were from different villages of Rupsha and Fakirhat Upazila or from Khulna city previously underwent appendicectomy within the last 5 years (from 2012 to 2016) in different hospitals other than GMCH, Khulna and previous symptoms were still existed.
Data were collected, compiled and entered in spreadsheet (Microsoft Excel) and analyzed using appropriate statistical tools.Results were reported as percentage (%).

Results
The number of patients (Group 1) attended GMCH, Khulna, OPD within the last 3 years (from 2014 to 2016) and IPD within the last 5 years (from 2012 to 2016) was 621 and 1081, respectfully.The number of patients (Group 2) attended elsewhere other than GMCH, Khulna, previously underwent appendicectomy within the last 5 years (from 2012 to 2016) but previous symptoms were still existed was 656 (Rupsha-296, Fakirhat-328 and others-32).
Table 1 shows the ender distribution of the patients in Group 1 and Group 2. Majority of the patients were female (OPD 81.5%, IPD 68.8% in Group 1 and 83.2% in Group 2).
Table 2 shows the distribution of the patients in Group 1 with diagnosis of appendicitis.The misdiagnosis rate of appendicitis for the patients attended GMCH OPD and GMCH IPD was 23.0% and 8.9%, respectfully.The overall misdiagnosis rate of appendicitis for the patients attended GMCH was 14.0%.Fig. 1 presents the updated disease profiles of the patients misdiagnosed for appendicitis in Group 1 who attended GMCH OPD.The most of the patients had UTI and chronic cystitis (45.5%).Fig. 2 shows the updated disease profiles of the patients misdiagnosed Mediscope 2017;4(2):29-34 30 of approximately 7%. 1 Appendicectomy may be performed as an open (laparotomy) operation or laparoscopically (minimally invasive surgery) and it is the most frequently performed surgical procedure.The adverse outcomes of presumed appendicitis are: perforation, often occurring in the prehospital setting, and misdiagnosis, resulting in removal of a normal appendix.][4][5][6][7] Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. 8This relatively high rate of unnecessary appendicectomy is being challenged while there is dramatic expansion of diagnostic testing options for appendicitis during the last decade.Many investigators have demonstrated that in research environments, advanced diagnostic testing using computed tomography (CT), ultrasonography (USG), and laparoscopy decreases the frequency of misdiagnosis. 9-14However, some other investigators contrary to expectation have reported that the frequency of misdiagnosis leading to unnecessary appendicectomy has not changed with the introduction of CT, USG, and laparoscopy, nor has the frequency of perforation decreased. 15,16They also have suggested that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.
In the context of our country, the factors leading to misdiagnosis are less understood.Therefore, the aim of our study was to identify factors associated with misdiagnosis of appendicitis to propose solutions to decrease the misdiagnosis rate of appendicitis.

Materials and Method
An institutional and a population based analyses on misdiagnosis of appendicitis was conducted in Khulna district, Bangladesh.
There were two groups of patients in this study.Group  A male preponderance exists, with a male to female ratio of 1.1 to 3:1; the overall lifetime risk is 9% for males and 6% for females.8][19][20] Difficulties of diagnosis of atypical cases result from variation of the anatomical position of the appendix, appendicitis occurring at extremes of age and in females during child bearing age. 21 case of the patients attended GMCH OPD, most of them had UTI and chronic cystitis (45.5%).In case of the patients attended Mediscope 2017;4(2):29-34 32 for appendicitis in Group 1 who attended IPD.The most of the patients had non-inflamed appendix (84.4%).Table 3 presents the distribution of the patients in Group 2 with diagnosis of appendicitis.The misdiagnosis rate of appendicitis for the patients in Group 2 was 23.2%.

Discussion
The present study of institutional and population based analyses on misdiagnosis   23,24 Among the causes which leads doctors to misdiagnosis may be a) low socioeconomical status of the patients, b) poor investigation facilities, c) expensive investigation facilities, d) misinformation to the patients and their attendants, e) malpractice by doctors, etc.No single evaluation can substitute for the diagnostic accuracy of the experienced physician.The decision to obtain USG or CT scan studies depends on institutional preference and the available user expertise, although patient age, sex, and body habitus are important influencing factors.Physicians have a duty to use the requisite care and skills of a competent physician who practices in the same medical community; in other words, they are held to a certain minimum standard of care in performing the procedure.Their staff is also held to similar standards, and a physician along with nurses and anyone else involved in a medical procedure or in the care of a patient can be held liable in a medical malpractice action.Hospitals can also be held responsible if they hired the surgeon and staff that committed a preventable medical error.Therefore, bearing in mind the factors, all the concerned should be more careful and conscious while making the diagnosis of appendicitis to avoid misdiagnosis and patients' suffering.

Fig. 2 .
Fig. 2. Updated disease profiles of the patients misdiagnosed for appendicitis in Group 1, attended IPD.

Table 1 . Gender distribution of the patients in Group 1 and Group 2
1 consisted of the patients treated in Gazi Medical College Hospital (GMCH), Khulna either in out-patient depart-