Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 4746

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2024 | Month : January | Volume : 18 | Issue : 1 | Page : EC16 - EC20 Full Version

Histopathological Spectrum of Appendicular Lesions: A Cross-sectional Study


Published: January 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/65534.18968
Prachi Gholap, Swati B Ghanghurde, Priyanka Dhakare

1. Associate Professor, Department of Pathology, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane, Maharashtra, India. 2. Assistant Professor, Department of Pathology, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane, Maharashtra, India. 3. Junior Resident, Department of Pathology, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane, Maharashtra, India.

Correspondence Address :
Dr. Prachi Gholap,
Associate Professor, Department of Pathology, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane-400605, Maharashtra, India.
E-mail: zalteprachin@gmail.com

Abstract

Introduction: Multiple pathologies, ranging from non neoplastic to neoplastic tumours that may or may not obstruct the lumen, might result in appendicitis. Uncommon neoplastic appendix lesions show diverse morphologies, resembling adenomas to colorectal carcinoma. Identifying these traits is vital to differentiate them from non neoplastic mucinous lesions, as they require varied management approaches, including follow-up and chemotherapy.

Aim: To assess the histopathological patterns in patients undergoing appendicectomy and to study the detailed morphological features of different non neoplastic and neoplastic lesions.

Materials and Methods: This cross-sectional study was conducted in western part of Maharashtra for 3 years. It involved surgically removed specimens of appendix received for histopathological evaluation of the appendix from January 2019 to December 2022. A detailed gross examination of the appendicectomy specimens was carried out. Data were analysed using Statistical Package for the Social Sciences (SPSS) software, version 22.0. Categorical data such as sex, clinical presentation, gross presentation of the appendix, and histopathological findings were presented as n (%), whereas quantitative data such as age were presented as mean±SD. A p-value <0.05 was considered statistically significant.

Results: A total of 716 patients were included in this study. The median age of the patients was 25.0 years. The majority of the population belonged to the 21-45 years age group, with 406 (56.7%) patients. The number of males were higher 236 (32.9%) than females 170 (23.4%). The number of patients with inflammatory or non neoplastic lesions was higher than those with neoplastic lesions, with 709 (99.02%) and 7 (0.98%) respectively. The highest number of patients had chronic appendicitis (284; 39.66%), followed by acute on chronic appendicitis (216; 30.16%) and acute appendicitis (188; 26.25%).

Conclusion: In cases of appendicitis, histopathological examination of the appendix should be performed as it provides crucial clinical information in addition to operative findings. Hence, it is a benchmark in diagnosing acute appendicitis.

Keywords

Acute appendicitis, Enterobius vermicularis, Neoplastic lesions, Non neoplastic lesions

One of the most typical causes of sudden abdominal pain in adults and children is appendicitis, with a lifetime risk of 8.6% in men and 6.7% in women (1). The worldwide incidence of acute appendicitis is 96.5 to 100 adults per 100,000 per year. The first line of treatment for acute appendicitis remains appendectomy; however, in some patients with uncomplicated appendicitis, antibiotics are a better option than surgery (2). There is a significant upsurge in the incidence of appendicitis in India, mainly in urban cities, due to the increased intake of a Western diet (3). The clinical diagnosis of acute appendicitis is challenging to establish regardless of the availability of advanced diagnostic tools, and hence histological analysis is regarded as the benchmark (4).

Multiple pathologies, ranging from non neoplastic to neoplastic tumours that may or may not obstruct the lumen, might result in appendicitis. Simple fecaliths, lymphoid hyperplasia, and worm infestation are all instances of obstructive lesions (1). Neoplastic lesions of the appendix exhibit various morphological changes, ranging from those that resemble adenoma to those that imitate colorectal carcinoma, and they are among the uncommon lesions (5). Identifying morphologic characteristics is necessary to distinguish between neoplastic and non neoplastic mucinous appendiceal lesions (6). Such disparate findings require management strategies ranging from routine follow-up to extensive chemotherapy.

In light of this context, the present study aims to assess the histopathological patterns in all the patients who underwent appendectomy. Additionally, the study focuses on analysing the detailed histopathological features of non neoplastic and neoplastic lesions.

Material and Methods

This cross-sectional study was conducted in western part of Maharashtra for three years (January 2019 to December 2022). The Institutional Ethical Committee (IEC) approval number for this study was ICEC/01/02/2022.The written informed consent for data and images were obtained from the participants. The study included surgically removed specimens of appendix received for histopathological evaluation of the appendix.

Inclusion criteria: The study included the appendix resected along with other organs like colectomy.

Exclusion criteria: Patients with missing data (incomplete demographic information, preoperative imaging findings, surgical approach details, or histopathological reports), negative appendectomy (follicular cyst, twisted ovarian cyst, haemorrhagic endometriotic cyst), and patients in whom the appendix was removed as part of other surgical procedures, such as intestinal resection for ischaemic bowel disease and specimens from right hemicolectomies for colonic malignancies, were excluded from this study.

Data collection: Demographic details of the patients were reviewed from histopathology requisition forms, including age, gender, signs and symptoms, and significant clinical history. A detailed gross examination of the appendicectomy specimens was conducted. All tissues were stained with Haematoxylin and Eosin (H&E stain). Histopathological diagnosis were proposed based on the data, and the lesions were categorised according to the criteria stated in standard books (7).

Endpoints: The primary endpoint was to study the histopathological patterns in all patients who underwent appendicectomy. Additionally, the secondary endpoint was to study the detailed morphological features of different non neoplastic and neoplastic lesions (benign and malignant).

Statistical Analysis

The statistical analysis was performed using SPSS version 22.0. Descriptive data were expressed as mean±SD (SD), as well as numbers (n) and percentages (%).

Results

A total of 716 patients were included in this study. The median age was 25.0 years. The proportion of the male population (427, 59.6%) was higher than the female population (289, 40.4%). The majority of patients presented with acute appendicitis (573, 80.0%), followed by pain in the abdomen (45, 6.2%) and pain in the right iliac fossa (39, 5.4%). Approximately 469 (65.5%) of the patients had a congested gross presentation of the appendix. The demographic characteristics of the patients are summarised in (Table/Fig 1).

Age and gender-specific distribution: When the age and gender-specific distribution were considered, it was evident that the majority of the population belonged to the age group of 21-45 years (406, 56.7%). This age distribution pattern was similar in patients with inflammatory/non neoplastic lesions (400, 57.5%) and in patients with neoplastic lesions (3, 75.0%). The proportion of the male population was higher than the female population in this (21-45 years) age group of patients (236, 33% vs. 170, 23.7%). This pattern of sex distribution was consistent in patients with inflammatory/non neoplastic lesions (234, 33.6% vs. 166, 23.8%) and in patients with neoplastic lesions (3, 75.0% vs. 0). (Table/Fig 2) provides a summary of these findings.

Distribution of various lesions of the appendix based on incidence: The number of patients with inflammatory or non neoplastic lesions was higher than those with neoplastic lesions (709, 99.02% vs 7, 0.98%). The inflammatory or non neoplastic lesions observed in this study included chronic appendicitis (chronic appendicitis , chronic appendicitis with RLH, chronic appendicitis with peri-appendicitis, chronic sclerosing appendicitis, chronic obliterating appendicitis, Chronic granulomatous appendicitis) in 284 patients (39.66%), acute on chronic appendicitis (acute on chronic appendicitis, acute on chronic appendicitis with peri-appendicitis, acute on chronic appendicitis with perforation) in 216 patients (30.16%), acute appendicitis (acute appendicitis, acute appendicitis with peri-appendicitis, acute phlegmonous appendicitis, acute appendicitis with perforation, acute necrotizing appendicitis, acute suppurative appendicitis, acute ulcerative appendicitis) in 188 patients (26.25%), appendicitis with parasitic infestation characterised by the presence of adult E. vermicularis worm in the patient’s lumen (Table/Fig 3) (6, 0.83%), and tuberculous appendicitis in six patients (0.83%).

Upon comparing the sex distribution between non neoplastic and neoplastic lesions, it was observed that the proportion of the male population was higher than the female population in all inflammatory/non neoplastic lesions and neoplastic lesions except for chronic appendicitis (162, 57.85% vs. 118, 42.14%). In this study, granulomatous appendicitis was seen with multiple discrete epithelioid granulomas with Langhan’s giant cells in the wall (Table/Fig 4), and typical presentation of granulomatous appendicitis (TB) was seen with epithelioid cell granulomas with caseation seen in the wall (Table/Fig 5). Unexpected pathological findings such as neuroendocrine tumour, characterised by mucosal ulceration, cords, and nests of tumour cells with stippled chromatin; salt and pepper appearance in the wall (0.1%) (Table/Fig 6), Low-Grade Appendiceal Mucinous Neoplasm (LAMN) (0.1%), and mucinous adenocarcinoma (3, 0.4%), were observed in some of the neoplastic lesions of the appendix (Table/Fig 7). Other histopathological findings of appendectomy specimens included amoebic ulcer with perforation, mucinous cystadenoma (extensively denuded mucosa, presence of mucin in the lumen, and fibrotic wall with lymphoid aggregates as seen in (Table/Fig 8)), well-differentiated adenocarcinoma with involvement of appendicular cut margin (tumour arising from mucosal epithelium involving the muscularis layer as seen in (Table/Fig 9)), acute pyogenic appendicitis with peri-appendicitis, etc.

Histopathological findings of appendectomy specimens: Among the cases of inflammatory appendicitis, the histopathological examination revealed that chronic appendicitis (195, 27.23%) was the most common diagnosis. In contrast, Chronic sclerosing (4, 0.55%), Chronic obliterative appendicitis (4, 0.55%), and Chronic granulomatous appendicitis were the least frequent [Table/ Fig-10]. Other histopathological findings included Acute appendicitis with Meckel’s diverticulum (0.13%), Acute on Chronic appendicitis with Parasitic infestations (0.13%), etc.

Discussion

The diagnosis of acute appendicitis mainly relies on the evaluation of the patient’s history, laboratory, and radiologic findings, in addition to the surgeon’s judgment and experience (8). There are two primary reasons for conducting a histopathological examination of the appendix: it enhances the diagnosis of pathological lesions of the appendix, and it can help identify potential additional pathologies that may not be recognisable during intraoperative procedures, which may require more aggressive management strategies (9).

However, it has been observed that excised appendix specimens are not routinely sent for histopathological examination. Some argue that this may be due to the infrequent occurrence of aberrant findings with low clinical significance or the costs associated with specimen processing (10),(11),(12). On the contrary, a few published papers have reported that aberrant findings are more common. This highlights that the omission of histopathological examination of the appendix may result in the improper diagnosis of underlying diseases, potentially affecting the patient’s treatment strategies (13).

A study by Qadir A et al., showed that appendicitis peaks in the second and third decades of life, observed in both males and females (14). This finding was consistent with the results observed in present study, where the incidence of appendicitis was higher in the age group of 21-45 years (406, 56.7%). This was supported by other studies that have reported that almost 80% of appendicitis cases occur in individuals below 40 years of age (3),(15),(16),(17).

It has been observed that males in the adolescent age group have a higher incidence of appendicitis compared to females (3),(16),(17),(18). This supports present study, which observed a higher proportion of males compared to females (427, 59.6% vs 289, 40.3%). However, a study by Vijayasree V et al., had contrasting results, showing a slightly higher female preponderance (19).

Distribution of various lesions of the appendix based on incidence: The number of patients with inflammatory or non neoplastic lesions was higher than those with neoplastic lesions (709, 99.02% vs 7, 0.98%). The inflammatory or non neoplastic lesions observed in this study included chronic appendicitis (chronic appendicitis , chronic appendicitis with RLH, chronic appendicitis with peri-appendicitis, chronic sclerosing appendicitis, chronic obliterating appendicitis, Chronic granulomatous appendicitis) in 284 patients (39.66%), acute on chronic appendicitis (acute on chronic appendicitis, acute on chronic appendicitis with peri-appendicitis, acute on chronic appendicitis with perforation) in 216 patients (30.16%), acute appendicitis (acute appendicitis, acute appendicitis with peri-appendicitis, acute phlegmonous appendicitis, acute appendicitis with perforation, acute necrotizing appendicitis, acute suppurative appendicitis, acute ulcerative appendicitis) in 188 patients (26.25%), appendicitis with parasitic infestation characterised by the presence of adult E. vermicularis worm in the patient’s lumen (Table/Fig 3) (6, 0.83%), and tuberculous appendicitis in six patients (0.83%).

Upon comparing the sex distribution between non neoplastic and neoplastic lesions, it was observed that the proportion of the male population was higher than the female population in all inflammatory/non neoplastic lesions and neoplastic lesions except for chronic appendicitis (162, 57.85% vs. 118, 42.14%). In this study, granulomatous appendicitis was seen with multiple discrete epithelioid granulomas with Langhan’s giant cells in the wall (Table/Fig 4), and typical presentation of granulomatous appendicitis (TB) was seen with epithelioid cell granulomas with caseation seen in the wall (Table/Fig 5). Unexpected pathological findings such as neuroendocrine tumour, characterised by mucosal ulceration, cords, and nests of tumour cells with stippled chromatin; salt and pepper appearance in the wall (0.1%) (Table/Fig 6), Low-Grade Appendiceal Mucinous Neoplasm (LAMN) (0.1%), and mucinous adenocarcinoma (3, 0.4%), were observed in some of the neoplastic lesions of the appendix (Table/Fig 7). Other histopathological findings of appendectomy specimens included amoebic ulcer with perforation, mucinous cystadenoma (extensively denuded mucosa, presence of mucin in the lumen, and fibrotic wall with lymphoid aggregates as seen in (Table/Fig 8)), well-differentiated adenocarcinoma with involvement of appendicular cut margin (tumour arising from mucosal epithelium involving the muscularis layer as seen in (Table/Fig 9)), acute pyogenic appendicitis with peri-appendicitis, etc.

Histopathological findings of appendectomy specimens: Among the cases of inflammatory appendicitis, the histopathological examination revealed that chronic appendicitis (195, 27.23%) was the most common diagnosis. In contrast, Chronic sclerosing (4, 0.55%), Chronic obliterative appendicitis (4, 0.55%), and Chronic granulomatous appendicitis were the least frequent [Table/ Fig-10]. Other histopathological findings included Acute appendicitis with Meckel’s diverticulum (0.13%), Acute on Chronic appendicitis with Parasitic infestations (0.13%), etc.

In present study, the majority of patients presented with abdominal pain (45, 6.2%), followed by pain in the right iliac fossa (39, 5.4%). This was similar to a study by Sujatha R et al., which reported the same observations (20).

In the present study, among cases of inflammatory appendicitis, the histopathological examination revealed that chronic appendicitis (195, 27.23%) was the most common diagnosis. In contrast, chronic obliterative appendicitis (4, 0.55%) and chronic sclerosing appendicitis (4, 0.55%) were the least frequent. The number of patients with inflammatory or non neoplastic lesions were higher than those with neoplastic lesions (709, 99.02% vs 7, 0.98%). This finding was consistent with the observations reported by Blair NP et al., which showed that 80.0% of appendectomy cases were non neoplastic, while only 4.0% were neoplastic (21).

This study also reported the presence of E. vermicularis in the appendix in 6 cases (0.83%). This finding aligns with another study by Sujatha R et al., which reported three cases (1.3%) presenting with symptoms similar to acute appendicitis (20). Worldwide, the incidence rate of E. vermicularis ranges from 0.2-41.8% (22).

Upon comparing the age and sex distribution patterns between neoplastic and non neoplastic lesions, it was observed that the highest prevalence of both neoplastic and non neoplastic lesions was found in the age group of 21-45 years (non neoplastic: 404, 56.98%; neoplastic: 4, 57.14%). Additionally, the incidence of non neoplastic lesions was highest in the male population (435,61.35%) compared to the female population (274, 38.60%). Furthermore, this study found that neoplastic lesions were only observed in the male population.

Similar observations were reported by a histopathological study by Kulkarni MP et al., which concluded that the majority of patients with neoplastic and non neoplastic lesions belonged to the age group of 11-40 years and reported an overall male preponderance (241, 55.2% vs. 195, 44.7%) (23). However, a retrospective study by Shrestha O and Baral R demonstrated contrasting results, suggesting that non neoplastic lesions were more common in younger patients with a mean age of 51.2 years (24).

The majority of carcinoids and mucinous neoplasms are accidentally diagnosed during surgery for acute appendicitis. Considering the patient’s mortality and morbidity, the prompt diagnosis of cancer and initiation of appropriate treatment are highly significant. While the macroscopic features may be evident, histopathological assessment can provide valuable insights into the patient’s disease and improve clinical outcomes by identifying previously unrecognised conditions (5).

The novelty of this study lies in its emphasis on the importance of histopathological examination of excised appendix specimens. It highlights the ability of histopathology to uncover additional conditions that may not be apparent during clinical assessment and surgery, which can have implications for subsequent patient care. The study also validates the diagnosis of appendicitis. While the diagnosis of acute appendicitis traditionally relies on patient history, laboratory tests, radiology, and surgeon’s experience, this study underscores the importance of histopathology in improving diagnostic accuracy. It addresses the lack of routine histopathological examination of appendices, arguing that this practice can result in improper diagnosis and treatment. The findings of the study align with existing research on the age and gender distribution of appendicitis, as well as the prevalence of different pathological diagnosis. Furthermore, the study highlights the role of histopathology in early cancer diagnosis and its impact on patient outcomes, emphasising that histopathological assessment is a critical factor in the diagnosis and management of appendicitis.

Limitation(s)

The study was restricted to a single medical centre. The study employed a retrospective design, which implies its reliance on past clinical data. Retrospective studies can be susceptible to data limitations, information gaps, and the potential for recall bias.

Conclusion

The present study concluded that males were slightly more likely than females to develop appendicitis in their second and third decades of life. In all cases of acute appendicitis, a histopathological examination of the appendix should be done as it provides crucial clinical information and operative findings. Unusual findings such as mucinous adenocarcinoma, LAMN, and neuroendocrine tumour of the appendix were reported in this study, highlighting the necessity of histological investigation for every excised appendix. Such findings can significantly impact the course of treatment. It can be concluded that histological examination is the benchmark for diagnosing acute appendicitis.

References

1.
Snyder MJ, Guthrie M, Cagle S. Acute appendicitis: Efficient diagnosis and management. Am Fam Physician. 2018;98(1):25-33. PMID: 30215950.
2.
Moris D, Paulson EK, Pappas TN. Diagnosis and management of acute appendicitis in adults: A review. JAMA. 2021;326(22):2299-311. [crossref][PubMed]
3.
Oguntola AS, Adeoti ML, Oyemolade TA. Appendicitis: Trends in incidence, age, sex and seasonal variations in South-western Nigeria. Ann Afr Med. 2010;9(4):213-17. [crossref][PubMed]
4.
Vijayasree V, Sunil CSPV, Noel S, Rao TS. Histopathological spectrum of appendicular lesions and correlation with age and sex incidence: A retrospective study. Medpulse Int J Pathol. 2017;4(1):16-20.
5.
Abd Al-Fatah M. Importance of histopathological evaluation of appendectomy specimens. AlAzhar Assiut Med J. 2017;15(2):97-103. [crossref]
6.
Hissong E, Goncharuk T, Song W, Yantiss RK. Post-inflammatory mucosal hyperplasia and appendiceal diverticula simulate features of low-grade appendiceal mucinous neoplasms. Mod Pathol. 2020;33(5):953-61. [crossref][PubMed]
7.
Goldblum J, Lamps L, McKenny J. (2018) Rosai and Ackerman’s Surgical Pathology E-Book. (11th Edition).
8.
Khairy G. Acute appendicitis: Is removal of a normal appendix still existing and can we reduce its rate? Saudi J Gastroenterol. 2009;15(3):167-70. [crossref][PubMed]
9.
Patel VM, Daveshwar MR, Shah HS. Histopathological spectrum of appendicectomy specimen. Int J Health Clin Res. 2020;3(7):162-67.
10.
Cross SS, Stone JL. Proactive management of histopathology workloads: Analysis of the UK Royal College of Pathologists’ recommendations on specimens of limited or no clinical value on the workload of a teaching hospital gastrointestinal pathology service. J Clin Pathol. 2002;55(11):850-52. [crossref][PubMed]
11.
Colleran GH. A comparison of surgical impression, histological findings and microbiological results at open appendicectomy. Ir Med J. 2007;100(9):593-96.
12.
Zdichavsky M, Gögele H, Blank G, Kraulich M, Meile T, von Feilitzsch M. Histological characterisation of appendectomy specimens with intraoperative appearance of vascular injection. Surg Endosc. 2013;27(3):849-53. [crossref][PubMed]
13.
Duzgun AP, Moran M, Uzun S, Ozmen M, Ozer V, Seçkin S, et al. Unusual findings in appendectomy specimens: Evaluation of 2458 cases and review of the literature. Indian J Surg. 2004;66:221-26.
14.
Qadir A, Arif A, Niazi NK. Histological spectrum of appendicular lesions: Ten years experience at a tertiary care hospital. Pak J Pathol. 2021;32(4):157-60.
15.
Noudeh YJ, Sadigh N, Ahmadnia AY. Epidemiologic features, seasonal variations and false positive rate of acute appendicitis in Shahr-e-Rey, Tehran. Int J Surg. 2007;5(2):95-98. [crossref][PubMed]
16.
Nabipour F. Histopathological feature of acute appendicitis in Kerman-Iran from. 2005. Am J Env Sci. 2005;1:130-32. [crossref]
17.
Sushel C, Samad A. Review of the pathologic diagnoses of appendectomy specimens. Ann King Edward Med Univ. 2009;15(4):168-70.
18.
Edino ST, Mohammed AZ, Ochicha O, Anumah M. Intussusception in Kano: A 5-year analysis of pattern, morbidity and mortality. Niger J Med. 2003;12(4):221-24.
19.
Vijayasree V, Sunil CSPV, Noel S, Sesagiri Rao T. Histopathological spectrum of appendicular lesions and correlation with age and sex incidence: A retrospective study. Med Pulse Int J Pathol. 2017;4(1):16-20.
20.
Sujatha R, Anushree CN, Singh N. Histopathological spectrum of appendicectomy specimens A prospective study. Indian J Pathol Oncol. 2017;4(4):638-42.
21.
Blair NP, Bugis SP, Turner LJ, Macleod MM. Review of pathological diagnosis of 2216 appendectomy specimens. Am J Surg. 1993;165(5):618-20. [crossref][PubMed]
22.
Aydin O. Incidental parasitic infestations in surgically removed appendices: A retrospective analysis. Diagn Pathol. 2007;2:16. [crossref][PubMed]
23.
Kulkarni MP, Sulhyan KR, Barodawala SM, Yadav DH. Histopathological study of lesions of the appendix. Int J Health Sci Res. 2017;7(4):90-95.
24.
Shrestha O, Baral R. Mucinous lesions of the appendix: A histopathological study. J Pathol Nep. 2022;12(1):1893-99. Doi: 10.3126/jpn.v12i1.39338.[crossref]

DOI and Others

DOI: 10.7860/JCDR/2024/65534.18968

Date of Submission: May 20, 2023
Date of Peer Review: Jul 27, 2023
Date of Acceptance: Oct 29, 2023
Date of Publishing: Jan 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 21, 2023
• Manual Googling: Aug 16, 2023
• iThenticate Software: Oct 21, 2023 (8%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com