docHistopathological study of Enterobius vermicularis among
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Histopathological study of Enterobius vermicularis among
الجامعة اإلسالمية ـ غزة The Islamic University– Gaza عمادة الدراسات العليا Deanery of Postgraduate Studies كلية العلوم Faculty of Science ماجستير العلوم الحياتية Master of Biological Sciences علم الحيوان Zoology ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Histopathological study of Enterobius vermicularis among appendicitis patients in Gaza strip دراسـة نـسيـجـية للـدودة الـدبـوسـية بـيـن مـرضـي الـتهـاب الـزائـدة الـدوديـة فـي .قـطاع غـزة Prepared by Shereen Mohamed Hamdona Supervisors Dr. Adnan Al- Hindi Faculty of Science Dr. Abdel Monem Lubbad Faculty of Medicine The Islamic University- Gaza Submitted in Partial Fulfillment of Requirements for the Degree of Master of Biological Sciences/Zoology Faculty of Science ھ1434/ م2013 َ َ ُ َ قـال رسـول اللـ ِه صـلـى اللـه عـليـ ِه وسلـم ُ َ ُ ٌ َ َ َ َ َ َّ ن رجـل آتـاه اللـه "ال حسـد إال فـي اثنتيـ ِ َ َّ ََ َ ً َ َّ َ ُ َ مـاال فسلطـه علـى هلكتـِ ِه فـي احلـق ََ ُ َ ُ ٌ َ ُ حكمـة ورجـل آتـاه اللـه الـ ِ َ ُ َ َ فهـو يقض ِـي ِبهـا َ ُ َ ُّ و يـع ِلمهـا" صـدق رسـول اللـه Dedication I dedicate this research to my family for their steadfast support and emotional guidance, especially my mother. And dedicate to my friends, hospitals, patients and everyone gave me help in this research. i Declaration I certify that this thesis submitted for the degree of master is the result of my own research, except where otherwise acknowledged, and that this thesis or any of its parts has not been submitted for higher degree to any other university or institution. Shereen M. Hamdona © Copyright by Shereen M. Hamdona 2013 ii Abstract Enterobius vermicularis is one of the most common intestinal parasite in human. The adult worms inhabit the lumen of the intestine in the region of the ileum, cecum. It estimated that 400 million persons are infected by pinworm worldwide. The adult worms lay them eggs in appendix, but still remains controversial if it causes appendicitis. The aim of this study was to examine the relationship between Enterobius vermicularis infection and appendicitis among patients in Gaza strip. A cross sectional study included 200 patients who had appendectomy from three hospitals in Gaza strip. The inflamed appendix was the cause of attending the hospital. Histopathological examination for each appendix was carried out. Using questionnaire (interview with patients who underwent appendectomy), and data and information were obtained from patient analyzed by using SPSS. The study showed that 30 (15.0%) of 200 appendices had E. vermicularis in histopathological examination. It was found that ages of patients with histologically proven E. vermicularis in appendices less than 18 years old 18 (18.2%). Also, 13 (16.5%) of females, 17 (14.0%) of males patients E. vermicularis in appendices. Patients who had the highest infection with E. vermicularis were students (17.3%). In conclusion E. vermicularis occurs more frequently inflamed appendices than in normal. From these results we can conclude that E. vermicularis could be associated to cause of appendicitis in Gaza strip. Keywords Enterobius vermicularis, appendicitis, Gaza strip, histopathological. iii دراس ـة نـسيـج ـية لل ـدودة الـدبـوس ـية بـي ـن مـرض ـي الـته ـاب الـزائ ـدة الـدودي ـة ف ـي ق ـطاع غـزة. الـمـلـخــص الدودة الدبوسية هي واحدة من أكثر الطفيليات المعوية انتشارا في اإلنسان ,والديدان البالغة تعيش في تجويف األمعاء فيي مططةية اللفيائفي واألعيور أربعمائية ملييون حالية عيدو فيي ممييأ أنءياء العالم مصابة بالدودة الدبوسية وقد ثبت أن الديدان البالغة تضأ البيض في الزائدة الدوديية ,ولنين ما زال هطاك مدل حول إذا ما كانت الدودة الدبوسيية تسيب التاياا الزائيدة الدوديية وهيدفت هيه الدراسة إلى معرفة عالقة الدودة الدبوسية في التااا الزائدة الدودية بين المرضي في قطاع غزة وقد تم ممأ ميائتي عيطية مين الزائيدة الدوديية مين ثيالي مستشيفيات ,كميال عيدوان ,الشيفاء الطبيي واألوروبي في قطاع غزة وأظارت الطتائج وميود عالقية بيين اليدودة الدبوسيية و التاياا الزائيدة الدودية بطسبة (15.0%) 30وقد بلغ عدد المرضيي اليهين تةي أعميارهم عين 81سيطة 81حالية مرضية؛ أي بطسبة ) (18.2%ممن يعانون من التااا الزائدة الدودية في ومود اليدودة الدبوسيية كما أظارت الطتائج أن نسبة اإلنياي الالتيي يعيانين مين التاياا الزائيدة الدوديية فيي وميود اليدودة الدبوسييية ,(16.5%) 13ونسييبة الرمييال (14.0%) 17كمييا ومييد أن التالميييه االعلييي إصييابة بالتااا الزائدة الدوديية فيي وميود اليدودة الدبوسيية وبلغيت نسيبة اإلصيابة ) .(17.3%و تبيين أن إصابة الدودة الدبوسية تنون بشن اكبر في الزائدة الدودية الملتابة من الزائدة الدودية السليمة. وهها يشير أن ومود الدودة الدبوسية في الزائدة الدودية قد يشن سببا في التااا الزائدة الدودية ومن هه الطتائج نستطتج أن الدودة الدبوسية يمنن أن ينون لاا عالقة في التاياا الزائيدة الدوديية في قطاع غزة كلمات مفتاحية الـدودة الـدبـوسـية ،الـزائـدة الـدوديـة ،قـطاع غـزة ,تـشريـح نـسيـجـي iv Acknowledgments I would like to thank my supervisors Dr. Adnan Al- Hindi Associate professor in medical parasitology Faculty of Science, Islamic University of Gaza and Dr. Abdel Monem Lubbad Associate professor in medical histopathology Faculty of Medicine, Islamic University of Gaza. Thanks for all staff in Kamal Edwan, Al Shifa and European hospitals in Gaza Strip for their kindly cooperation during the study and thanks extended to all people who participated in the study. Thanks to Mr. Moein Redwan and Mr. Jamal Al-Shaiekh Deeb for samples processing in the lab. I would like to thank my family, who supported me and gave all effort and help for achieving my goal, specially my mother. v Table of contents Dedication ……………………………………………………………….i Declaration ………………………………………………………………ii Abstract …………………………………………………………………iii Arabic abstract ………………………………………………………..…iv Acknowledgments ……………………………………………………….v Table of contents ……………………………………….…………….…vi List of tables ………………………………………………………….....x List of figures …………………………………………………...............xi List of abbreviations ……………………………………………………xii CHAPTER ONE: INTRODUCTION 1.1 Background ……………………………………………………..……1 1.2 Objectives ……………………………………………………………2 1.3 Significance ………………………………………………………….3 1.4 Enterobius vermicularis ……………………………………………..3 1.4.1 Taxonomy ………………………………………………….……...3 1.4.2 Life cycle ………………………….…………………………….…4 1.4.3 Morphology ………………………………………………..…..…..5 1.4.4 Geographic distribution and epidemiology ………………………..7 1.4.5 Behavior …………………………………………………..…........9 1.4.6 Habitat ……………………………………………………….…….9 1.4.7 Pathology …………………………….…………………….…….10 1.4.8 Diagnosis ……………………….………….……………………..11 1.4.9 Treatment and prevention ………………..…………………...…..12 1.5 Vermiform appendix ……………..……………..…………………..13 1.5.1 Anatomy …………………………………………….……………13 1.5.2 Appendix histologically …………………………….…………….15 1.5.3 Appendicitis ………………………………………..……………..17 vi 1.5.4 Etiopathogenesis ……………………………………….………...17 1.5.4.1 Obstruction ……………………………………..…….….17 1.5.4.2 Non obstructive ………………………………….………18 1.5.4.3 Recurrent appendicitis …………………………………..19 1.5.4.4 Sub-acute appendicitis……………………………………19 1.5.5 Symptoms of appendicitis …………………………...…………...19 1.5.6 Physicals sign ……………………………………….………....…20 1.5.7 Diagnosis …………………………………………………….......21 1.5.7.1 Medical history ………………………………………….21 1.5.7.2 Laboratory tests …………………………………………22 1.5.8 Differential diagnosis for acute appendicitis …………………..…23 1.5.9 Function of the human appendix ………..………………………..26 1.5.9.1 Embryological ………………………….…...……………26 1.5.9.2 Physiological ………………………...…………………...27 1.5.9.3 Bacteriological …………………….…….…………….....27 1.5.9.4 Biochemical ……………………….……………….…….28 1.5.9.5 Immunological ……………………………………………28 1.5.10 Treatment …….………………………………………………….28 1.5.10.1 Open appendectomy ……...………………………….....28 1.5.10.2 Laparoscopic appendectomy ……………………..…...29 CHAPTER TWO: LITERATURE ERVIEW …………...…………31 CHAPTER THREE: MATERIALS AND METHODS 3.1 Settings and sample size …………………………………………....36 3.2 Ethical considerations ………………………………………….......36 3.4 Methods ……………………………………………………….……36 3.3.1 Sampling ………………………………………………...…36 3.3.2 collection of appendices ………………………………..….36 vii 3.3.3 Histological examination ……………..……………..….….36 3.5 Photography …………………………………………………….…..39 3.6 Questioner ………………………………………………………….39 3.7 Statistical Analysis …………………………………………………39 CHAPTER FOUR: RESULT 4.1 Personal characters of the patients ………………………………….45 4.2 Complains of the patients with appendicitis …………...…………...46 4.3 Life style and behavior of the patients …………………………...…48 4.4 Clinical description of appendices by the surgeon …………………49 4.5 Personal characters associated with E. vermicularis ……………….49 4.6 Symptom associated with E. vermicularis ……………………...….51 4.7 Complains of the patients with appendicitis who positive for E. vermicularis ………………………………………………………….…52 4.8 Life style and behavior associated with E. vermicularis …...…..….54 4.9 Clinical description of appendix by the surgeon and E. vermicularis infection ……………………………………………………………..….55 4.10 The form of appendix associated with personal characters of the patients …………………………………………………………………56 4.11 The form of appendix associated with complains of the patients with appendicitis .......………………………………………………………...57 4.12 The histopathological examination of appendices ………...………58 CHAPTER FIVE: DISCUSSION …………………………………....63 viii CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions ………………………………………………………...70 6.2 Recommendations ………………………………………….………70 REFERENCES ………………………………...…...…………………71 ANNEXES Annex 1………………………………………………………………....87 Annex 2 ……………………………………………………………...…89 Annex 3 …………………………………………………..…………….91 Annex 4 ………………………………………………………………...92 Annex 5 …………………………………………..…………………….93 Annex 6 …………………………………………...……………………94 ix List of tables Table (4.1) Personal characters of the patients ……………..……...…...45 Table (4.2) Complains of the patients with appendicitis …………….....46 Table (4.3) Life style and behavior of the patients ……………..........…48 Table (4.4) Clinical description of appendices by the surgeon ….....…..49 Table (4.5) Personal characters associated with E. vermicularis …........50 Table (4.6) Symptom associated with E. vermicularis …………………51 Table (4.7) Complains of the patients with appendicitis who positive for E. vermicularis …………………………………………………………52 Table (4.8) Life style and behavior associated with E. vermicularis ………………………………………………………………………….54 Table (4.9) Clinical description of appendix by the surgeon and E. vermicularis infection …………………………………………………..55 Table (4.10) The form of appendix associated with personal characters of the patients …………………………………………………………..….56 Table (4.11) The form of appendix associated with complains of the patients with appendicitis…………………………………………….....57 x List of figures Figure (1.1) Life cycle of E. vermicularis …………………..………...…4 Figure (1.2) Morphology of E. vermicularis ……………….………..….6 Figure (1.3) Morphology of adult Enterobius vermicularis ………….….7 Figure (1.4) Appendix ………….……………………..……….….……13 Figure (1.5) The location of the rest of the appendix ...…………….......14 Figure (2.6) McBurney’s point …………………..…………....……..…15 Figure (2.7) Appendix histologically ………………….…….....………16 Figure (2.8) Appendicitis ………….….…………………………...……17 Figure (3.1) Preparation of sections ………………….…………..…….40 Figure (3.2) Length and greatest diameter of appendix ………….…..…40 Figure (3.3) Cutting a cross section and a longitudinal ………………...41 Figure (3.4) Processing of specimens by wax ……………...………..…41 Figure (3.5) Paraffin section ……………..…………………………..…42 Figure (3.6) Sectioning by Microtome ……………………………....…42 Figure (3.7) Staining ………………………………………………..…..43 Figure (3.8) Professor Abdel Monem Lubbad, Histopathologist, during examination of samples for histopathology ………...………………..…43 Figure (3.9) iScan system ………………………………….…………...44 Figure (3.10) Examination of samples in iScan system ………………..44 Figure (4.1) Normal appendix …………………………...……………..59 Figure (4.2) Perforated appendix ……………………………………….59 Figure (4.3) Whole worm in appendix tissue ………………………..…60 Figure (4.4) Inflamed calcified tissue and parts of degenerated worm …………………………………………………………………………..60 Figure (4.5) Calcified degenerated worm …………...………..…….…..61 Figure (4.6) Mucosa and E. vermicularis TS …………………………..61 Figure (4.7) Appendix and TS of E. vermicularis …….………………..62 Figure (4.8) Eggs and part of the adult worm ……………………....…..62 xi List of abbreviations APUD Amine Precursor Uptake and Decarboxylation CDC Centers for Disease Control and Prevention cm centimeters CT X-ray computed tomography g Immunoglobulin A IgA Immunoglobulin A IgG Immunoglobulin G IgM Immunoglobulin M kg kilogram mg milligrams mm millimeter NIDDK National Institute of Diabetes and Digestive NIH National Institutes of Health USA United States of America UTI Urinary Tract Infection vs versus WBC White Blood Cell WHO World Health Organization y year β-HCG Beta Human chorionic Gonadotropin xii CHAPTER ONE Introduction 1.1 Background Intestinal parasite incidence were reported by many studies in Gaza strip, including Giardia lamblia, Entamoeba histolytica/dispar, Ascaris lumbricoides, Trichuris trichiura, Enterobius vermicularis and Strongyloides stercoralis (Shubair et al., 2000; Al-Hindi, 2002). The prevalence rate of intestinal parasites ranged from 27.6%-32.3% in Palestine (Ali et al., 1989; Yassin et al., 1999). Gastrointestinal infection due to Enterobius vermicularis occurs worldwide and is considered to be the most common helminthes infection (Aydin, 2007). It was estimated that 400 million persons are infected by pinworm worldwide (Stephen et al., 2006). The prevalence of E. vermicularis among preschool children in nursing setting in Gaza strip reached to 46.3% (Al-Hindi et al., 2013). The main source of contamination inside the house by the environmental dust and carried by children. The teen-age, the rates of infection in boys increase than among girls, because the girls start observing hygienic practices with higher precocity than boys (Yoon et al., 2000; Kim et al., 2001). Among adults, the infection frequency in the males similar in the females, (Smolyakov et al., 2003). Waste disposal decrease affected of the distribution infection (Nithikathkul et al., 2001). Appendicitis is the most common acute surgical condition of the abdomen emergency in the western world occurring in 7%–12% of the general population (Baert, 1999). Approximately 7% of the population will have appendicitis in their life time, with the peak incidence occurring 8 between the age of 10 and 30 years (Haren, 1999). The initial event in the pathogenesis of acute appendicitis is obstruction of the lumen by factors like fecaliths, foreign bodies, intestinal parasites, tumors, or lymphoid follicular enlargement due to viral infections (Silen, 1987). The simple presence of E. vermicularis in the appendix usually produces symptoms which resemble acute appendicitis although the mechanism for this does not involve mucosal invasion by the parasite (Sah and Bhadani, 2006). While Gutierres, (2000) maintains that there exists a consensus that pinworms do not produce the inflammatory reaction. Cook, (1994) stated that it is controversial whether pinworms are causatively related to acute appendicitis, and Burkhart and Burkhart, (2005) reported that pinworm infection causes symptoms of appendicitis to surface. 1.2 Objectives 1.2.1 General objectives To determine the role of E. vermicularis in appendicitis through histopathological examination. 1.2.2 Specific objectives 1. To determine a relationship between E. vermicularis infection and appendicitis. 2. To search for the presence of E. vermicularis in the appendix grossly and histologically 3. To study the social economic status of patients with association to appendicitis. 2 1.3 Significance Enterobius vermicularis prevalence is very high in Gaza strip. Appendicitis is also one of the common conditions among Gaza population. According to the knowledge of the author, no studies have been carried out on such topic in Gaza strip. There is no determination or identification of the reasons of appendicitis in case of appendectomy. As usual the patients complain from abdominal pain and other related symptoms considered as suspected with appendicitis and there was an observation and diagnostic methods for each patient before surgical remove. 1.4 Enterobius vermicularis E. vermicularis is called a pinworm due to its long pointed tail that resembles a straight pin in the adult worm (Ridley, 2012). Infection rates very up to 40%, depending on age and race (Bowman, 2009). E. vermicularis has a worldwide distribution and is one of the most common childhood helminthes infections in the developed world (Cook and Zumla, 2003). 1.4.1 Taxonomy Taxonomic Classification Kingdom Phylum Class Order Family Genus Species Animalia Nematoda Rhabditea Oxyurata Oxyuridae Enterobius vermicularis (http://www.wikipedia.org/wiki/Enterobius) 3 1.4.2 Life cycle Figure (1.1): Life cycle of E. vermicularis. (CDC, 2013) 1. Eggs are deposited at night by the gravid females. 2. Eggs are ingested via person-to-person transmission through the handling of contaminated surfaces (such as clothing, linen, curtains, and carpeting), or airborne eggs may be inhaled and swallowed. Self-infection may also occur if eggs are transferred from to the mouth by fingers that have scratched the perianal area (CDC, 2013). 3. After ingestion, larvae hatch from the eggs in the small intestine, and grow rapidly to a size of 140 to 150 micrometers in length, and migrate through the small intestine towards the colon (Cook, 1994). 4 4. During this migration they moult twice and become adults (Burkhart and Burkhart, 2005). The time interval from ingestion of infection eggs to oviposition by adult females is one month. The life span of the adults is about two months. The estimations of the number of eggs in a gravid female pinworm ranges from about 11,000 (Cook, 1994) to 16,000 (Burkhart and Burkhart, 2005). 5. Gravid females migrate nocturnally and oviposit while crawling on the skin of the perianal area. Larva developed (i.e. the eggs become infective) in 4 to 6 hours under optimal condition (CDC, 2013). 6. Newly hatched larvae may also migrate back into the anus, and this is known as retroinfection, and while moving on the skin near the anus, the female pinworms deposit eggs either through: - contracting and expelling the eggs. - dying and then disintegrating, or - bodily rupture due to the host scratching the worm. 7. After depositing the eggs, the female becomes opaque and dies. The reason the female emerges from the anus is to obtain the oxygen necessary for the maturation of the eggs (Cook, 1994). 1.4.3 Morphology The pinworm appears as a white, small and delicate nematode (i.e., roundworm) (Gutiérrez, 2000). E. vermicularis has a cylindrical body, and a cuticle with three main outer layers made of collagen and other compounds, secreted by the epidermis. The cuticle layer protects the nematode so it can invade digestive tracts of animals. The worms molt four times, the first two before hatching, and then before their adult stage (Barnes, 1987; Bogitsh and Cheng, 1998). Female E. vermicularis, measuring 8 to 13 mm long by 0.4 mm wide, are characterized by the 5 presence of wing like expansion (alae) of the body wall at the anterior end, distension of the body due to the large number of eggs in the uteri, and a pointed tail. Males, smaller in size, are 2 to 5 mm long and possess a curved tail (Bogitsh et al., 2012). The egg measures 50 to 54 micrometer in length by 20 to 27 micrometer in width and has a characteristic shape, flattened on one side. It is almost colourless, with a bean-shaped double contour shell a fully formed embryo (Cook and Zumla, 2009). The eggs have five membranes: one inner, lipoidal layer, three middle layers known as membrana lucida, and one outer, albuminous membrane which coats the egg. This membrane makes the eggs sticky and therefore itchy to the host, which is important in the life cycle (Garcia and Bruckner, 1997; Brusca and Brusca, 2003). The larvae may be visible inside the egg due to the colorless shell of the embryonated eggs (Gutiérrez, 2000; Ridley, 2012). The larvae grow to 140–150 micrometers in length (Cook, 1994). Figure (1.2): Morphology of E. vermicularis. )http://www.stanford.edu/class/humbio103/ParaSites2006/Enterobius/gen eral%20information.htm) 6 Figure (1.3): Morphology of adult Enterobius vermicularis (a) male (b) female. (Bogitsh et al., 2012) 1.4.4 Geographic distribution and epidemiology E. vermicularis has a worldwide distribution. It is acquired by contamination and thus is common among persons living in closed contact. It occurs with equal frequency in both sexes. Enterobiasis has been shown repeatedly to be an infection that tends to occur in all persons within a household. Deworming of a population with a single does of medication resulted 10 months later in a higher prevalence rate and higher worm burdens (Haswell et al., 1987). It has been repeatedly suggested that the prevalence of enterobiasis is lower in the tropics (WHO, 1981), but this conclusion appears to be due to poor survey methodologies (Haswell et al., 1987). In several studies, the prevalence of enterobiasis has been shown to decrease with increasing age (Hayashi et al., 1959; Rahman, 1991), suggesting that it is an infection mostly of children. However, in surveys 7 made in India, the prevalence of the infection was similar in all age groups (Haswell et al., 1987). Enterobius occurs in 24% of Eskimos and Aleutians, as shown by a study of appendices removed surgically (Ashburn, 1941). In a shantytown in Lima, Peru, the prevalence in school children was 42% (Gilman et al., 1991), comparable to the 40% rate found in a similar group in Indonesia (Norhayati et al., 1994). The prevalence of enterobiasis is significantly lower in blacks than in whites; the reason for this difference is unknown (Cram, 1943; Cherubin and Shookhoff, 1963). In an orthopedic ward of a children's hospital in Liverpool, England, the prevalence of E. vermicularis was 55% (Ashford et al., 1988). The parasite is transmitted from person to person through contamination hands, clothes, and fomites. In a study of children from two elementary schools in southern California, the prevalence of Enterobius was 12% to 22%, but these rates represented a significant decline from those found in a study performed two decades earlier. Extrapolation of these data to the country at large indicates that there are at least 4.5 million children with enterobiasis in the United States (Wagner and Eby, 1983). Infections occur in one of four ways: (1) retroinfection when hatched larvae migrate back into the large intestine; (2) self-infection when patient is re-infected by hand to mouth transmission; (3) cross-infection when infective eggs are ingested, either with contamination food or from fingers that have been in contact with a contaminated surface or body parts from infected humans; or (4) inhalation of airborne eggs. In households with heavily infected individual eggs have been found in samples of dust taken from chairs, tabletops, dresser tops, floors, baseboard, etc. in a survey to determine the distribution of airborne pollen 1 in public places, such as theaters, pollen and pinworm eggs were found on sample plates not only from arm rests and baseboards but also from chandeliers high above the seats; most of these eggs, however, were no longer viable (Bogitsh et al., 2012). 1.4.5 Behavior E. vermicularis neither aggregate (clump) nor swarm (coordinated population movements) while in the host, two characteristics that occur somewhat frequently in nematode. E. vermicularis optimal temperature is around 33°C, showing reduced activity at temperatures higher than 40°C and inactivity at 46°C. When the temperature drops, E. vermicularis again becomes less active. The optimal temperature of 33°C is close to the temperature of a human intestine. Movement seems to favor right angles, like most nematodes. This movement may be a leftover evolutionary trait from when its ancestors had to penetrate a host's skin (Croll, 1970). 1.4.6 Habitat E. vermicularis inhabits the colon, especially the cecal portion, but whether it lives within the intestinal contents or within the mucus close to the wall. Members of the oxyurida have only one host in their life cycles. After infective eggs are ingested by a susceptible host. The larva develop to adults in the intestine, probably within the mucosal crypts of the ileum, cecum, and appendix. These are immature worms, which after maturation leave the mucosa and location in the lumen (Duran, 1957). In the lumen, the normal habitat of the parasites, they ingest colonic contents (Mya, 1955). The entire cycle is reportedly complete within 4 to 6 weeks, within 30 days being the best estimate (Cho et al., 1981). 9 1.4.7 Pathology There are usually no histologic change in the large intestine associated with Entrobius. The parasites are often found in the lumen of the appendix (Sinniah et al., 1991); in rare cases, they are buried in the mucosa. The second most common location is the abdominal cavity, especially the pelvic peritoneum. On occasion, worms are found within the mucosa of the small intestine, colon, and the appendix, generally with no inflammatory reaction; in a few instance, they are found within an acute abscess (Gutiérrez, 2000). Symptoms are caused when gravid females migrate out of the anus to deposit eggs on to perianal skin, where they cause pruritus. E. vermicularis may also be responsible for non-specific colitis in children (Jardine et al., 2006). Occasionally, ectopic infections occur in the female genital organs or urinary tract, and chronic pelvic peritonitis and ileocolitis has been described (Macedo and MacCarty, 2000 ). The route by which E. vermicularis gains access to these organs is not clear but may be via the fallopian tubes or haematogennous spread. A case of ectopic infection in the male genital tract has been reported, with assumed entry through the urethra (Zahariou et al., 2007). Aberrant infections may also occur in the liver, ovary, kidney, spleen and lung as well as appendix; however, their role in the pathogenesis of acute appendicitis remains unclear (Arca et al., 2004). The granuloma which forms around the female and eggs consists chiefly of lymphocytes with a few eosinophils but no giant cells (Cook and Zumla, 2009). 81 1.4.8 Diagnosis The diagnosis of Enterobius is usually clinical, based a history of perineal itching. In the clinical laboratory, the diagnosis is confirmed by finding the eggs (color plate) or the adults in perianal samples taken with the Scotch tape anal swab usually at night. No recommendations exist concerning the number of anal swabs needed for the diagnosis of 100% of infections. In one study, six swabs were enough (Sadun and Melvin, 1956). Pinworms do not lay eggs in the feces (Caldwell, 1982), but sometimes eggs are deposited in the intestine (Garcia and Bruckner, 1997). As such, routine examination of fecal material gives a positive diagnosis in only 5 to 15% of infected subjects (Cook, 1994), and is therefore of little practical diagnostic use (Cook et al., 2009). In a heavy infection, female pinworms may adhere to stools that pass out through the anus, and they may thus be detected on the surface on the stool (Garcia and Bruckner, 1997). Adult E. vermicularis are occasionally found in tissue sections from appendices removed surgically or at autopsy. The estimated percentage of this finding varies from less than 1% (Collin, 1965) to 3% (Ashburn, 1941). However, if the appendiceal contents are examined together with the tissue section, the prevalence rises to about 8% (Ashburn, 1941). In many of these cases the appendix is normal, but in others a histologic picture of appendicitis may be found (Bouree and Dubourdieu, 1984); in either case, worms may be embedded in the wall of the appendix. The relationship between the worms and appendicitis has been explored many times; the consensus is that the worms do not produce the inflammatory reaction and are only innocent bystanders (Budd and Armstrong, 1987). 88 1.4.9 Treatment and prevention Complete eradication of pinworm infection from a population is highly unlikely. Personal hygiene is the most effective deterrent. Fingernails should be cut short, and hand should be washed thoroughly after toilet use and before food is prepared or eaten. Since infection is most prevalent in urban areas where relatively large population intermingle, education of parents has proven most effective. Parents should be informed that it is a self-limiting non-fatal infection, widespread among children and that no social stigma should be attached to it. There is no evidence that dogs can transmit the infection. Infected children as well as other members of the household should be treated promptly. Bedclothes, towels, and washcloth from infected homes should be carefully laundered in hot water and aired in sunlight (Bogitsh et al., 2012). Mebendazole is the drug of choice (100 mg as a single dose in adult) except for children under 1 year of age, for whom it is not recommended (Strobel et al., 2006; Sangeeta et al., 2009). Or Piperazine, Pyrantel pamoate 11 mg/kg body weight as a single dose. And Albendazole 400 mg as a single dose more than 2 years. Children (1-2 years) Albendazole 200 mg as a single dose (Sangeeta et al., 2009; Cook and Zumla, 2009). The whole family should be treated and treatment repeated two to four weeks later to eradicate any worms hatched since first treatment (Strobel et al., 2006). 82 1.5 Vermiform appendix The vermiform appendix (from the Latin vermis, meaning "worm," and forma, meaning " shape" ) is as it implies, a wormlike tubular organ. It averages 8 to 10 cm (3 to 4 inches) in length (Thibodeau and Patton, 1999). The diameter is usually between 7 and 8 mm (Guinness world records, 2011). Its usually located in the lower right side of the abdomen near the right hip bone (Paterson, 2007). Figure (1.4): Appendix. (http://www.webmd.com/digestive-disorders/picture-of-theappendix) 1.5.1 Anatomy The appendix is a narrow, hollow tube connected to the cecum. Its point of attachment to the cecum is consistent with the visible free taenia leading directly to the base of the appendix (Drake et al., 2005). The location of the rest of the appendix varies considerably. It may be : Posterior to the cecum or the lower ascending colon, or both, in a retrocecal or retrocolic position. Suspended over the pelvic brim in a pelvic brim in a pelvic or descending position. Below the cecum in a susbcecal location. 83 Anterior to the terminal ileum, possibly contacting the body wall, in a preileal position or posterior to the terminal ileum in a postileal position. Figure (1.5): The location of the rest of the appendix. (http://www.hakeem-sy.com/main/node/20136) The base of the appendix thus lies in the right iliac fossa, close to (McBurney’s point). This is two- third of the away along a line drawn from the umbilicus to the anterior superior iliac spine. In most cases, the appendix is mobile within the peritoneal cavity, suspended by its mesentery (meso-appendix) with the appendicular artery in its free edge. This is effectively an end-artery, with anastomotic connection only proximally (Burkite et al., 2007). The appendiceal layers are similar to those of the large bowel. However, in some locations the muscular coat may be so minimal that only a thin layer of connective tissue separates the mucous membrane and peritoneum; thus infection can easily spread. With or without infection, diverticulation of the mucosa is not rare (Davis and Sheldon, 1995). 84 Figure (1.6): McBurney’s point. (http://appendicitis-symptoms.com/acute-appendicitis) 1.5.2 Appendix histologically The appendix has the same basic structure as the large intestine. Its glandular mucosa is separated from a loose vascular submucosa by the delicate muscularis mucosa. External to the submucosa is the main muscular wall. The appendix is covered by a serosal layer (the visceral layer of peritoneum) which contains the large blood vessels and becomes continuous with the serosa of the meso-appendix. When the appendix lies retroperitoneally, there is no serosal covering. A prominent feature of the appendix is its collections of lymphoid tissue in the lamina propria. This lymphoid tissue often has germinal centers and is prominent in childhood but diminishes with increasing age. The mucosa contains a large number of cells of the gastrointestinal endocrine amine precursor uptake and decarboxylation (APUD) system. These secrete mainly serotonin and were formerly known as argentaffin cells (Burkite et al., 2007). The appendix is longest in childhood and gradually shrinks throughout adult life. The wall of the appendix is composed of all layers typical of the intestine, but it is thickened and contains a concentration of lymphoid tissue. Similar to the tonsils, the lymphatic tissue in the appendix is typically in a constant state of chronic inflammation, and it is generally 85 difficult to tell the difference between pathological disease and the "normal" condition (Fawcett and Raviola, 1994). The internal diameter of the appendix, when open, has been compared to the size of a matchstick. The small opening to the appendix eventually closes in most people by middle age. (Scott, 1980; Fisher, 2000). Figure (1.7): Appendix histologically. (http://appendicitis-symptoms.com/acute-appendicitis; http://www.hakeem-sy.com/main/node/20136) 1.5.3 Appendicitis Acute appendicitis is an abdominal emergency (Drake et al., 2005), and is the most common causes of acute abdomen (Roy, 2011), if the mucous lining of the appendix becomes inflamed, the resulting condition is well known affliction, appendicitis. The appendix is very close to the rectal wall. For patient with suspected appendicitis, a physician often evaluates the appendix by digital rectal examination. 86 The opening between the lumen of the appendix and the cecum is quite large in the children and young adults a fact (Thibodeau and Patton, 1999). Figure (1.8): Appendicitis. (http://www.hitechsurgery.com/laparoscopic_surgery.htm; http://www.medicinenet.com/appendicitis/page2.htm) 1.5.4 Etiopathogenesis 1.5.4.1 Obstruction Obstruction of the lumen is the dominating factor in acute appendicitis. Fecoliths are usual cause of appendiceal obstruction, feces, parasites, or growths that clog the appendiceal lumen, enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body, inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, trauma to the abdomen (NIH Publication, 2008). Less common is hypertrophied tissue, inspissated barium from previous X-rays, vegetable, fruit seed, worms (Entrobius vermicularis, Balantidum coli, Schistosoma haematobium) (Fernder et al., 2002; Duzgun et al., 2004). Due to this blockade closed loop obstruction results and the secretions continuously produce distension that stimulates nerve 87 endings of visceral afferent pain fibers producing vague, dull, diffuse pain in the mid abdomen or lower epigastrium. Distension also stimulates peristalsis that results into crampy abdominal pain superimposing visceral pain. Distension continues and pressure in organ increases and exceeds venous pressure, thereby, occluding capillaries and venules but arterial inflow continues, resulting in engorgement and vascular congestion. Distension of this magnitude usually causes reflex nausea and vomiting and diffuse visceral pain become more severe. The inflammatory process involves the serosa of appendix, thereby, involving parietal peritoneum that produces tenderness as well as rebound tenderness. Progressive distension increases arterial pressure and the area with poorest blood supply suffers most; ellipsoidal infarcts develop in the antimesentric border. As the distension, bacterial invasion, compromise of vascular supply and infarction progress, perforation occurs through one of the infracted areas on antimesentric border (Bhasin et al., 2007). An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomen a potentially dangerous condition called peritonitis (Thibodeau and Patton, 1999). 1.5.4.2 Non obstructive In this type the inflammation usually commences in the mucous membrane and less in the lymph follicles. Like all other inflammatory process it terminates in any of the following ways: (a) Resolution, (b) Ulceration, (c) Suppuration, (d) Fibrosis , (e) Gangrene. This type is less serious than the obstructive type. In the non obstructive type the mucopurulent products of the inflammation get an opportunity to escape along the lumen. The organ becomes turgid, dusky red and haemorrages occur into the mucus membrane. The vascular supply of the distal part of the 81 appendix is often in jeopardy because it is intramural and liable to occlusion by inflammation or thrombosis. This may lead to gangrene to the tip. In the non obstructive type the inflammation progresses sufficiently slow for protective adhesion to form and the resulting peritonitis is localized. As the tip suffers most; the fibrosis usually occur therein and this is a classical finding in recurrent appendicitis (Majumdar and Majumdar, 2005). 1.5.4.3 Recurrent appendicitis Repeated attacks of non obstructive appendicitis lead to fibrosis, adhesions causing recurrent appendicitis . 1.5.4.4 Sub-acute appendicitis Is milder from of acute appendicitis (Roy, 2011). 1.5.5 Symptoms of appendicitis The abdominal pain usually: • occurs suddenly, often causing a person to wake up at night • occurs before other symptoms • begins near the umbilicus and then moves lower and to the right • is new and unlike any pain felt before • gets worse in a matter of hours • gets worse when moving around, taking deep breaths, coughing, or sneezing (NIDDK and NIH, 2008). Other symptoms of appendicitis may include • loss of appetite (Drake et al., 2005) • nausea 89 • a low-grade fever that follows other symptoms (Kahan and Raves, 2004). • vomiting: due to reflex pylorospasm . • constipation: is the usual feature but diarrhea can occur if appendix is in post-ileal or pelvic position • urinary frequency inflamed appendix may come in contact with bladder and can cause bladder irritation (Bhat, 2006). 1.5.6 Physicals sign 1.5.6.1 Rovsing’s sign In this case the left iliac fossa is pressed down in order to find out whether the patient experiences a pain in the right iliac fossa. In this case, loops of the small intestine have pushed to the right ilic fossa, thus interfering with the position of the inflamed appendix (Saha, 2011). There are two explanation for this: (a) Retrograde displacement of colonic gas, striking the base of the inflamed appendix. (b) Displacement of ilial loops to the right side of the abdomen, irritating the inflamed appendix (Nan, 2007). 1.5.6.2 Hyperextension In case of retrocaecal appendix Copes psoas test or internal rotation (in case of pelvic appendix – obturator test) of right hip causes pain in right iliac fossa due to irritation of psoas muscle and obturator internus muscle respectively (Bhat, 2006). 21 1.5.6.3 Hyperaesthesia It may occur on the right side of the abdomen in the (Sherrens triangle) bounded by anterior superior iliac spine, umbilicus, public and symphysis (Roy, 2011). 1.5.6.4 Rebound and tenderness Is pain produced by the movement of viscera against the inflamed parietal peritoneum. Any maneuver that produces relative movement of the underlying viscera against the parietal peritoneum suffices to elicit rebound (Davis and Sheldon, 1995). 1.5.6.5 Rectal examination Shown tenderness in the recti-vesical pouch of douglas, especially on the right side (Majumdar and Majumdar, 2005). 1.5.6.6 Guarding and rigidity May be demonstrated depending upon whether the appendix is perforated or not, guarding, rigidity over the lower abdomen which subsequently may spread to all over the abdomen. However, in-patients with early retrocaecal appendix and pelvic appendicitis symptoms and signs may be minimal (Koch, 2000). 1.5.7 Diagnosis 1.5.7.1 Medical history Classically, appendicitis present with dull, generalized, abdominal pain that slowly migrates to the right lower quadrant over the course of 12 to 24 hours. Poorly localized pain is due to luminal distention, whereas right lower quadrant pain result from irritation of the overlying parietal 28 peritoneum by a necrotic appendix. Nausea and vomiting are common, through they typically follow the onset of pain. Patient with appendicitis are typically anorexic even in the absence of nausea (Mick et al., 2006). 1.5.7.2 Laboratory tests Routine laboratory studies are helpful in diagnosis acute appendicitis, largely through exclusion of other condition. Perhaps the only truly routine is the leukocyte count. It is well recognized that the white blood cell (WBC) count is usually elevated in bona fide cases of appendicitis. However, a substantial number of patients have the diagnosis and a normal WBC count. Many times, in retrospect, a normal WBC count can be attributed to early stage of the illness, and elevation might have been anticipated as the illness progressed. For this reason, serial measurements of the WBC count would undoubtedly improve the accuracy of the test (Thompson et al., 1992 ). Depending on the clinical circumstances, three other types of studies should be performed routinely. First, urine analysis with microscopic examination should be performed in all patients with suspected appendicitis (Scott et al., 1983; Puskar et al., 1995). The goal of performing the test is to exclude ureteral stones (hematuria) and to evaluate the possibility of urinary tract infection (UTI) (pyuria, bacteruria) as a cause of lower abdominal pain, particularly in elderly diabetic patients. Lower UTI is not infrequent among patients with acute appendicitis, especially women. The presence of UTI thus does not exclude acute appendicitis but does need to identified. The newer "dipsticks" contain indicators for bacterial infection and can be used to supplant to microscopic examination. 22 Second, measurement of serum liver enzymes and amylase levels can be helpful in diagnosing liver, gallbladder, or pancreatic inflammation if the pain is described as more in the midabdomen or even right upper quadrant. Serum amylase level are reported elevated in 3% to 10% of patients with acute appendicitis or acute lower abdominal pain not attributable to pancreatitis (Swensson and Maull, 1981; Gumaste et al., 1993). If pancreatitis is the cause, the pattern of amylase elevation is usually higher and is accompanied by elevation of serum lipase. Elevation of the latter, especially if it is more than threefold grater than normal, strongly indicates pancreatitis. Measurments of serum amylase are not recommended for all patients with abdominal pain but should be considered in patient atypical clinical features. Third, serum β-HCG (human chorionic gonadotropin) levels should be measured in women of childbearing years if there is any possibility of pregnancy. It is currently standard practice in many hospital emergency departments to use such as tests to exclude the possibility of ectopic or concurrent pregnancy in patients with acute abdominal pain. This practice has not been systematically scrutinized for cost-effectiveness, but it makes sense because the stakes are so high if a pregnancy is not recognized before a fetus is exposed to ionizing radiation or the mother is explored under general anesthesia (Norton et al., 2008). 1.5.8 Differential diagnosis for acute appendicitis Many conditions mimic acute appendicitis. It differs in children, adult, elderly, and females. 23 1.5.8.1 Perforated duodenal ulcer In duodenal ulcer perforation, fluid trickles down along right paracolic gutter and mimics appendicitis. Upper abdominal pain, obliterated liver dullness, gas under diaphragm in X-ray and CT scan differentiate it from acute appendicitis. 1.5.8.2 Right ureteric colic Pain is colicky in nature which often refers to genitalia. Haematuria, urinary symptoms are common. It mimics retrocaecal/pelvic acute appendicitis. Often in ureteric stone, abdomen is soft and nontender. CT is the important way to differentiate. 1.5.8.3 Acute bacterial enterocolitis It presents with pain abdomen, diarrhea, toxaemia, dehydration, often it is difficult to differentiate from acute appendicitis. 1.5.8.4 Pelvic inflammatory disease Like salpingo-oophoritis mimics acute appendicitis. Twisted /haemorrhagic/ ruptured ovarian cyst/ ruptured ectopic gestation/ endometriosis/ tubo-ovarian abscess mimics acute appendicitis. Laparoscopy helps to differentiate it from others. (mittelschmerz) is lower abdominal pain due to rupture of follicular cyst during mid cycle. It subsides on its own. There are no systemic features. 1.5.8.5 Worm infestation (Round worm bolus/ ball): It often presents as pain in right iliac fossa. Features of intestinal obstruction are common here (Bhat, 2006). 24 1.5.8.6 Acute cholecystitis Murphy's sing, Boa's sign, radiating pain to scapula. Retching and noisy vomiting are commonly present in the cholecystitis (Majumdar and Majumdar, 2005). 1.5.8.7 Urinary tract infection (cystitis or pyelonephritis) Unlikely if nitrites are absent from dipstick testing of the urine and can be excluded if there are not significant numbers of white blood cells or bacteria on urine microscopy. 1.5.8.8 Mesenteric adenitis Common in children and often associated with an upper respiratory infection or sore throat. Inflammation and enlargement of the abdominal lymph nodes, probably viral in origin. Fever is typically higher than in appendicitis (i.e. greater than 38.5°C) and settles rapidly. A firm diagnosis can only be made at laparotomy or laparoscopy, but gradual resolution favours this diagnosis. 1.5.8.9 Large bowel disorders Constipation may cause colicky abdominal pain and iliac fossa tenderness. There is no fever and the rectum is loaded with faeces. Diverticulitis affecting the caecum or the sigmoid colon (when lying in the right iliac fossa) is usually diagnosed only at operation. 1.5.8.10 Small bowel pathology An inflamed or perforated Meckel's diverticulm may present exactly like appendicitis. Terminal ileitis due to Crohn's disease (or, more rarely, Yersinia pseudotuberculosis). Necrotic small bowel from strangulation usually present with intestinal obstruction. 25 1.5.8.11 Acute pancreatitis Pain is predominantly central. If there is tenderness in the right iliac fossa, it will also be present in the epigastrium. If in doubt, the serum amylase should be measured. 1.5.8.12 Gastroenteritis Vague abdominal pain and tenderness which may be associated with vomiting and diarrhea. Usually improves steadily during a period of observation (Burkite et al., 2007). 1.5.9 Function of the human appendix The appendix completes most of its functions at the early end of the spectrum of life. The vital aspects of these are probably complete at least by early infancy. While it is freely admitted that the precise functions of the human vermiform appendix are still unclear, so much more is now known that clarification is at hand. It discuss this further under the following headings: 1. Embryological 2. Physiological 3. Microbiological (Bacteriological) 4. Biochemical 5. Immunological (Sleisenger and Fordtran, 1983; Schwartz, 1984) 1.5.9.1 Embryological During the fifth foetal week it is the appendix which develops from a bud at the junction of the small and large bowel and undergoes rapid growth into a pouch. In the sixth week there is a transient nubbin surmounting the pouch indicative of being involved in the rapid development of the pouch 26 which is very strategically placed near the apex of the highly significant mid-gut loop. It is only after the fifth foetal month that the proximal end of this pouch, which has appeared to be a very insignificant structure up until this stage, starts growing differentially to give rise to the true caecum which continues to develop into infancy. The embryonic appendix has finger-like projections (villi) on its inside surface and it is only around birth that the long ribbons (taeniae) causing the sacculation of the large bowel start to develop. These ribbons, of course, converge on the base of the appendix (England, 1983; Glover, 1984). 1.5.9.2 Physiological The goblet cells lining the appendix and adjacent caecum and colon secrete a special type of mucus which can be regarded as an antibacterial paint controlling the organisms which develop in the bowel in the region. The paint contains a high concentration of IgA type immunoglobulins, secretory antibodies produced for mucosal or surface immunity and part of the bowel-blood barrier (Chadwick and Phillips, 1982; Glover, 1984). 1.5.9.3 Bacteriological Through the cells within and overlying the lymphoid follicles and their production of secretory and humoral antibodies the appendix would be involved in the control of which essential bacteria come to reside in the caecum and colon in neonatal life. As well it would be involved in the development of systemic tolerance to certain antigenic agents within the alimentary tract whether they are derived from bacteria, foodstuffs or even the body's own proteolytic enzymes (Alexander and Binder, 1983; Doe, 1986). 27 1.5.9.4 Biochemical One in three hundred or so appendicectomy specimens contains a carcinoid tumour composed of a highly specialised type of cell rich in vaso-active peptides such as serotonin. The exact function of such agents in the entire bowel is still being elucidated, but the fact that the majority (Schwartz, 1984) of such tumours occur within the appendix is indicative that the appendix could well be involved in some way with such substances (Glover, 1984). 1.5.9.5 Immunological This is the area where the appendix would seem to have its predominant functions due to its content of lymphoid follicles, which are highly specialized structures. Although it was thought the appendix itself could be the site for B-lymphocyte induction (a Bursa of Fabricius equivalent) (Perey et al., 1968) the latest opinions favour this programming being more centralised in the bone marrow. The appendix may still have a role in this highly significant function, but not alone, and its lymphoid tissue is known for certain to be involved in antibody production (the function of B type lymphocytes). These antibodies are of two types: (i) IgA type immunoglobulins for secretory or mucosal surface immunity, and (ii) IgM and IgG immunoglobulins for humoral or bloodstream immunity (Toma and Retief, 1978; Wheater et al., 1982). 1.5.10 Treatment 1.5.10.1 Open appendectomy A transverse right lower quadrant skin crease incision is recommended. The muscular layers are split in the direction of their fibers. The peritoneum is opened and fluid sent for culture. Recent studies have 21 suggested it is unnecessary to send routine peritoneal fluid cultures (Celik et al., 2003). The mesoappendix is divided and appendiceal base clamped and ligated. Stump inversion is optional. Engstrom and fenyo found no difference as regards to wound infection and postoperative fever between one group in which the appendix was ligated and doubly invaginated and another group in which it was simply ligated (Engstrom and Fenyo, 1985). If pus is present, the abdomen should be irrigated with saline. The abdominal wall is closed in layers. The skin is usually closed by subcuticular absorbable sutures even in the case of perforation. Primary wound closure after perforated appendicitis is safe, economical and advantageous in pediatric practice (Surana and Puri, 1994; Rucinski et al., 2000). 1.5.10.2 Laparoscopic appendectomy An infraumbilical port is inserted using an open than percutaneous technique. Two 5 mm infraumbilical incisions are paced on either side of the midline. A third right lower quadrant incision is optional. After mobilization of the appendix, the mesoappendix is divided, the appendiceal stump is ligated with endoloops or an endoscopic stapler, and the appendix is removed. In recent years, laparoscopic appendectomy has emerged as a safe alternative in the pediatric age group (Moir, 1995; Humphrey and Najmaldin, 1995). Although the rate at which laparoscopy is utilized in the treatment of appendicitis varies dramatically from center to center (range 0%-95%) (Newman et al., 2003), it is undoubtedly a reasonable surgical alternative to open appendectomy for the treatment of acute appendicitis in children. 29 Recent studies have demonstrated that laparoscopic appendectomy is at least as safe and effective as open appendectomy (Canty et al., 2000; Lintula et al., 2002). Despite the fact that laparoscopic appendectomy takes longer to perform (57 minutes vs. 34 minutes) compared to open appendectomy, it has multiple advantages (Vegunta et al., 2004). A large database study of adults in the children in the United States showed laparoscopic appendectomy to be associated with a shorter median hospital stay and lower rates of wound infection, gastrointestinal complications and overall complications (Guller et al., 2004). The increased operative expanse of laparoscopic appendectomy appeared to be offset by an earlier return to normal daily activities (Stringer et al., 2006). 31 CHAPTER TWO Literature review The association between parasitic infection of the appendix and acute appendicitis has been widely investigated. The retrospective study was to evaluate the prevalence of parasitic infection of the appendix in a tropical area at southeast Brazil and to assess its possible relation to acute appendicitis in surgically removed appendices. Of the 1,600 appendectomies performed during a 10-year period, 24 (1.5%) were found to have helminths within the appendix. Enterobius vermicularis was observed in 23 of the 24 specimens (95.8%), and Taenia sp. was detected in only one case (Silva et al., 2007). Some intestinal nematodes such as Ascaris vermicularis, lumbricoides, Ancyclostomidae Trichuris duodenale, trichuria, Necator Enterobius americanus, Strongyloides stercoralis and some species of Schistosoma as well as Entamoeba histolytica have been incriminated in the cause of appendicitis. They are large intestinal worms of man and are by far known to be the most widespread and commonest parasites of man in tropical Africa (Cheesbrough, 1998; Ukoli, 1990). Human infection with E. vermicularis has been recognized for thousands of years (Fry and Moore, 1969). The first reported about the presence of the parasite in the appendix by Fabrius in 1634 (Fry and Moore, 1969). E. vermicularis is most commonly found in the lumen of the appendix (Sinniah et al., 1991). The role of parasitic infection in the etiology of acute appendicitis has been discussed for more than 100 years (Yildirim et al., 2005). In various reports, the association between E. vermicularis infestation and acute appendicitis varies from 0.2-41.8% worldwide (Arca et al., 2004; Efraimidou et al., 2008). E. vermicularis can cause 38 symptoms resembling true appendicitis (Bredesen et al., 1988). Despite this fact, there is still controversy as to whether the parasites may cause appendicitis or not (Ajao et al., 1997). Retrospective studies have indicated that E. vermicularis is the commonest worm found in the appendix and that its presence can cause pathologic changes ranging from lymphoid hyperplasia to acute phlegmonous inflammation with lifethreatening complications like gangrene and peritonitis (Silva et al., 2007). Several authors have looked at the relationship of pinworm infestation and appendicitis. Studies carried out in England have demonstrated a prevalence of pinworm appendicitis from 1.5% to 4.2% in specimens removed for presumptive acute appendicitis (Budd, 1987). A retrospective analysis conducted in Turkish population found among 190 appendectomies, 6 specimens (3.15%) to contain parasites, 4 of them were E. vermicularis (Aydin, 2007). Similar percentage (3.8%) reported other studies from Turkey, as well. (Yidirim et al., 2005; Isik et al., 2007). In Nepal E. vermicularis was identified in 1.62% among patients with clinical diagnosis of appendicitis (Sah and Bhadani, 2006). In one Brazilian study, 24 cases out of 1600 appendectomies (1.5%) with helminthes within the appendix were recorded during a 10-year period (Silva et al., 2007). One recent study from Iran confirmed the relationship between E. vermicularis and the occurrence of acute appendicitis in 2.9% cases (Ramezani and Dehghani, 2007). Slightly higher incidence (4.1%) was described in another study from Denmark which also concluded that there was a highly significant difference in the incidence of E. vermicularis in normal appendices and in inflamed which may indicate that the presence 32 of this parasite in the appendix can give the symptoms of acute appendicitis or this parasite leaves or does not enter an inflamed appendix (Wiebe, 1991). The histological findings revealed, however, that the pin worms were most commonly seen in association with chronic inflammatory changes and not with acute inflammation. Other histological characteristics include prominent eosinophilia and granulomatous inflammation which must be distinguished from chronic changes seen in inflammatory bowel disease. Occasionally, worms lodge in ectpopic sites, such as the fallopian tubes or the ovaries and in peritoneal granulomatous nodules (Muller, 2002). It is also well accepted that, one of the possible causes of “acute abdomen” in children may be parasitic infections. E. vermicularis is the most common parasite occurring in man infecting about 10% of population in developed countries, the infection rate in children is even higher (Hwang et al., 2002). There was a significant difference in the incidence of E. vermicularis in males and females; females had a higher rate of infestation. The mean age of the infested group was significantly lower than the non-infested group. Infestation was more frequent in females than in males in other studies (Bredesen et al., 1988; Wiebe, 1991; Dahlstrom and Macarthur, 1994). Bredesen et al., (1988) reported that the infestation occurred in lower ages, especially in the pediatric age group. In studies there was rarely associated between E. vermicularis and histological changes of acute appendicitis. And discovered E. vermiculans may have a causal role in 33 appendicular pain and chronic inflammation, but it is rarely related to acute appendicitis (Budd and Armstrong, 2005). The relationship of pinworm infection to acute appendicitis has not been demonstrated, although E. vermicularis has been found in many patients with symptoms of appendicitis and where no other cause has been found (Muller, 2002). However, in a variety of studies carried out in different parts of the world, the parasite has been found in removed appendices (Rueda et al., 1993; Khiruriia, 2001). For example, in one study done in Venezuela, 3500 surgerically-removed appendices were examined and E. vermicularis was found in 11% of the cases (Dorfman et al., 1995). Histopathologically, increased eosinophils, focal eosinophilic microabscesses, purulent exudates, and granulomatous inflammation are the most frequent findings seen in most cases. The histological findings revealed, however, that the pinworms are most commonly seen in association with chronic inflammatory changes and not with acute inflammation (Syavashi, 1997). Enterobius is not directly involved in the inflammatory process, but its presence evokes irritation (Ramezani and Dehghani, 2007). An association between histological findings of intramural parasites is recognized (Mogensen et al., 1985). Budd and Armstrong reviewed 1419 appendicitis removed from cases of clinical appendicitis and 110 in other surgical procedures, E. vermicularis was identified in 2.7% of patients with clinical appendicitis (Budd and Armstrong, 1987). Enterobiasis could not necessarily be claimed as the causative agent of acute appendicitis. Although pinworms are usually considered to be asymptomatic inhabitants of the intestine, when they do cause symptoms 34 there can be a spectrum of non-specific gasterointestinal complaints. It has been proposed that possibly E. vermicularis is the cause of appendicitis- like symptoms (pseudo-appendicitis) or, on the other hand, worms may leave an appendix that is inflamed (Addiss et al., 1986). However, the clinical signs in the patients below 6-year old are uncertain making them difficult to interpret. In some cases, even the sophisticated diagnostic methods may be insufficient to apply in infection diagnosis (Iranian Public Health, 2004). 35 CHAPTER THREE Subjects and Methods 3.1 Settings and sample size Two hundred appendix specimens were collected from three hospitals (Kamal Edwan, Al Shifa, European) in Gaza strip. 3.3 Ethical considerations An approval from the Ministry of Health, and consent form from each patient participated in the study were obtained before the starting of the study. (Annex 3, Annex 4, Annex 5, Annex 6) 3.4 Methods 3.4.1 Sampling The arrangement of with each surgical operation department in the three hospitals carried out to collect appendices. Where the researcher obtained the appendix after the surgical operation. 3.4.2 Collection of appendices In the morning or night after appendectomy each appendix was preserved in 10% formalin in a clean container labelled and transported to private laboratory (Specialized Medical Center). 3.4.3 Histological examination (Luna, 1992; Cormack, 2001). Each fresh tissue was cut out from the examined organ immediately from patient after the surgical operation. Fixation of tissues prevent their autolysis, the obtained tissue is put quickly fixative 10% formalin. 36 Gross examination: The appendix was examined by naked eye, then measurement was taken for each one (length and greatest diameter) (Figure 3.1) (Figure 3.2). Each appendix was divided in two by cutting a cross section 2 cm from tip, cut cross section of proximal fragment at 5 mm intervals, divide distal fragment in two by a longitudinal cut (Figure 3.1). The fixed tissue was washed in running tap water to remove the fixative . Dehydration it is the process of gradual extraction and removal of water from the fixed tissue. The following steps: were done putting the fixed tissue in 50% alcohol for one hour, then in 70% alcohol for two hours, finally in 100% alcohol Twice for two hours every once (absolute alcohol). Clearing by this process, the tissue becomes translucent. The tissues was treated with clearing agents as xylol or benzol twice for one hour every time to remove alcohol. Impregnation, iInfiltration of the fixed tissue with melted soft paraffin twice each for two hours every once (60-65 °C). The tissue was infiltrated with soft paraffin, to form a block that need for three things (1- put sample in paraffin 2- dispenser 3- cold place 4°C gradual cold) then blocks were put in freeze to save it, a block ready for sectioning (Figure 3.5). Sectioning or cutting, the paraffin block was by the microtome. Mounting, the obtained thin paraffin sections was then put in water bath then on clean glass slides smeared with glycerin then sample was keep in incubator (60-65°C) for (30-60) minutes (Figure 3.6). 37 The sections are now ready to be stained. Paraffin was removed by xylol by putting the slide in xylol solution for 3 minutes for every once. Xylol was replaced by putting the slid in absolute alcohol for 3 minutes. Putting the section in descending grades of alcohol (in 100% alcohol, then in 90% alcohol, then in 70% alcohol and finally in distilled water) 3 minutes in each step. This process is called hydration of the section. The slide was put in tap water (indirect) for 2 minutes. The section was stained in Hematoxylin Harris for 7 minutes. This basic stain will stain the nuclei and the basophilic structures of the cytoplasm with a blue color. The slide was put in tap water for 2 minutes in order to blue the section, then Differential (acid 1% in alcohol 70% ) use HCL (to remove excess Hematoxylin) then washing in tap water for 5 minutes. The slide was put in Eosin for one minutes. This is an acidic stain, it stains the acidophilic structures of the cytoplasm with red color. Washed in tap water for 3 minutes. The slide was dehydrated in ascending grades of alcohol. Put it for one minute in 70% alcohol, then for 3 minutes in 90% and for another 3 minutes in 100% alcohol. The slide was put in xylol twice for 3-5 minutes for every once in order to clear it from alcohol and to allow it to be miscible with Canada balsam on a clean cover slip (Figure 3.7). The section was mounted in Canada balsam by removing quickly the slide from xylol with its face upwards and put on the cover slip. Each slides was examined for the presence of E.vermicularis by under light microscope. 31 3.5 Photography Each appendix section was scanned and photographed using iScan Coreo. Ventana medical system, Inc. Sunnyvale California, USA (Figure 3.8). 3.6 Questionnaire Each patient was interviewed to obtain the required information. The questionnaire included: 1. Personal characters (sex of the patient, age, education, residence, occupation). 2. Complains of the patients of appendicitis (abdominal distension, pain degree, vomiting, nausea, diarrhea, constipation, frequent urination, low grade fever, wake up at night, gets worse when moving, inability to pass gas, insomnia, defecation will relive discomfort). 3. Clinical description of appendix by the surgeon (form of appendix, presence of abscess, diagnosis). 4. Life style and behavior (fiber-rich food, sugar-rich food, lipidrich food, meat-rich food, take a lot of antibiotic, smoking, nervous behavior). (Annex 2) 3.7 Statistical analysis Data were entered to computer and analyzed using SPSS/PC (Statistical package for social science inc. Chicago, Illinois USA, version 13.0). Chi-square (χ2) was used to identify the significance of the relations and associations among various variables. The results in the mentioned procedures were accepted as statistically significant when the p-value was less than 5% (p>0.05). 39 Figure (3.1): Preparation of sections. Figure (3.2): Length and greatest diameter of appendix. 41 Figure (3.3): Cutting a cross section and a longitudinal. Figure (3.4): Processing of specimens by wax. 48 Figure (3.5): Paraffin section. Figure (3.6): Sectioning by Microtome. 42 Figure (3.7): Staining. Figure (3.8): Professor Abdel Monem Lubbad, Histopathologist, during examination of samples for histopathology. 43 Figure (3.9): iScan system. Figure (3.10): Examination of samples in iScan system. 44 CHAPTER FOUR Result The present study included 200 patients who attended the three hospitals (Kamal Edwan, Al Shifa, European) in Gaza strip. Those patients complained from different symptoms and underwent appendectomy . 4.1 Personal characters of the patients Patients age was between (8-54 years old), male were 121 (60.5%) and female were 79 (39.5%). Patients education was divided to two groups, the high education 79 (39.5%) and the low education 121 (60.5%). Patients were from three regions as follows: Gaza north 85 (42.5%), Gaza 52 (26.0%) and Gaza south 63 (31.5%). Occupation of patients included, employee 22 (11.0%), non employee 12 (6.0%), house wife 27 (13.5%), and it was found that 139 (69.5%) of patients with appendicitis were students. Table (4.1): Personal characters of the patients (n=200) Variable No. % Age > 18y < 19y 99 101 49.5 50.5 Sex Males Females 121 79 60.5 39.5 Education > 12y < 12y 121 79 60.5 39.5 Residence North governorate 85 42.5 45 Gaza governorate South governorate Occupation Employee Non employee House wife Student 52 63 26.0 31.5 22 12 27 139 11.0 6.0 13.5 69.5 4.2 Complains of the patients with appendicitis From table (4.2) found that patients who had getting worse when moving followed the abdominal pain were (72.5%). Both diarrhea and constipation had similar prevalence (15.0%). Table (4.2): Complains of the patients with appendicitis (n=200) Variable No. % 93 107 46.5 53.5 88 49 63 44.0 24.5 31.5 Vomiting Yes No 98 102 49.0 51.0 Nausea Yes No 123 77 61.5 38.5 Diarrhea Yes No 30 170 15.0 85.0 Abdominal distension Yes No When the pain began Before one day Before three days Before more than three days Constipation 46 Yes No 30 170 15.0 85.0 Frequent urination Yes No 67 133 33.5 66.5 Low grade fever Yes No 96 104 48 52 Wake up at night Yes No 69 131 34.5 65.5 Gets worse when moving Yes No 145 55 72.5 27.5 Inability to pass gas Yes No 79 121 39.5 60.5 Insomnia Yes No 124 76 62.0 38.0 136 64 68.0 32.0 5 195 2.5 97.5 195 5 97.5 2.5 Defecation will relive discomfort Yes No Taking antibiotic to treat appendicitis Yes No Emergency case Yes No 47 4.3 Life style and behavior of the patients In the present study 163 (81.5%) of patients reported that they eat fiberrich food, 164 (82.0%) sugar-rich food, 63 (31.5%) lipid-rich food, while 190 (95.0%) meat-rich food. Table (4.3): Life style and behavior of the patients (n=200) Variable No. % Fiber-rich food Yes No 163 37 81.5 18.5 Sugar-rich food Yes No 164 36 82.0 18.0 63 137 31.5 68.5 190 10 95.0 5.0 10 64 79 47 5.0 32.0 39.5 23.5 21 179 10.5 89.5 31 169 15.5 84.5 112 88 56.0 44.0 Lipid-rich food Yes No Meat-rich food Yes No How many time eat meat in a week Don't eat Once Twice Three times or more Take a lot of antibiotic Yes No Smoking Yes No Nervous behavior Yes No 41 4.4 Clinical description of appendices by the surgeon The form of appendix for each patients was reported by the surgeon. As shown in table (4.4), there was 13 (6.5%) of normal appendices. The results showed that high prevalence of acute appendicitis was found 170 (85.0%), while suspected were 17 (8.5%). Table (4.4): Clinical description of appendices by the surgeon (n=200) Variable Form of appendix Normal looking appendix Inflamed Presence of abscess Yes No Diagnosis Acute appendicitis Suspected appendicitis Normal No. % 13 6.5 187 93.5 5 195 2.5 97.5 170 17 13 85.0 8.5 6.5 4.5 Personal characters associated with E. vermicularis From table (4.5) it was found that patients with appendicitis with age > 18y were the highest group for E. vermicularis infection but no significant difference was found (χ2=1.557, p=0.147). It was found that 13 (16.5%) female, 17 (14.0%) male patients with E. vermicularis in appendices, but no significant difference was found (χ2=0.217, p=0.393). It was found that patients from south governorate had the highest infection with E. vermicularis (19.0%) compared to north governorate and Gaza governorate, but no significant difference (χ2=1.350, p=0.509). The present study showed that patients who had the highest infection with E. 49 vermicularis are students (17.3%) followed by house wife (11.1%), while the other occupation had low prevalence's (χ2=1.901, p=0.593). Table (4.5): Personal characters associated with E. vermicularis (n=200) Variable With E. vermicularis No % Without E. vermicularis No % Sex of the patient Males Females 17 (14.0) 13 (16.5) 104 (86.0) 66 (83.5) Age > 18y < 19y 18 (18.2) 11 (12.9) 81 (81.8) 89 (88.1) χ2, p-value 0.217, 0.393 1.557, 0.147 Education > 12y < 12y 0.004, 0.552 18 (14.9) 12 (15.2) 103 (85.1) 67 (84.8) Residence North governorate Gaza governorate South governorate 12 (14.1) 6 (11.5) 12 (19.0) 73 (85.9) 46 (88.5) 51 (81.0) Occupation Employee Non employee House wife Students 2 (9.1) 1 (8.3) 3 (11.1) 24 (17.3) 20(90.9) 11 (91.7) 24 (88.9) 115 (82.7) 1.350, 0.509 1.901, 0.593 51 4.6 Symptom associated with E. vermicularis It was found that 4 (13.3%) of symptomatic patients were infected with E. vermicularis while 26 (86.7%) have E. vermicularis without symptoms (χ2=0.127, p=0.485), with no significant difference. Also, who suffered for constipation had E. vermicularis 3 (10.0%), while 13 (17.6%) without E. vermicularis (χ2=192, p=0.442) no significant difference. Patients who had itching in anal area and infected by E. vermicularis were 3 (10.0%). On the other hand, patients who did not have itching in anal area and infected by E. vermicularis were 27 (90.0%). In case of the complain of abdominal pain, loss of appetite, diarrhea and weight loss patients without E. vermicularis infection had high level of these symptoms compared to patients with E. vermicularis as shown in table (4.6). Table (4.6): Symptom associated with E. vermicularis (n=200) Variable With symptoms Without symptoms Had constipation Yes No Had itching in the anal area Yes No Had abdominal pain Yes No With E. Without E. vermicularis vermicularis No % No % 4 (13.3) 26 (86.7) 27 (15.9) 143 (84.1) χ2, p-value 0.127, 0.485 0.192, 0.442 3 (10.0) 27 (90.0) 13 (7.6) 157 (92.4) 0.488. 0.351 3 (10.0) 27 (90.0) 11 (6.5) 159 (93.5) 0.257, 0.421 4 (13.3) 26 (86.7) 29 (17.1) 141 (82.9) 58 Loss of appetite Yes No 4 (13.3) 26 (86.7) 25 (14.7) 145 (85.3) 0.039, 0.552 Had diarrhea Yes No 1 (3.3) 29 (96.7) 8 (4.7) 162 (95.3) Weight loss Yes No 2 (6.7) 28 (93.3) 12 (7.1) 158 (92.9) 0.112, 0.598 0.006, 0.649 4.7 Complains of the patients with appendicitis who positive for E. vermicularis Table (4.7) shows clearly that patients who have appendicitis are not necessary have E. vermicularis Table (4.7): Complains of the patients with appendicitis who positive for E. vermicularis (n=200) Variable Abdominal dentition Yes No When the pain began Before one day Before three days Before more than three days Vomiting Yes No With E. vermicularis No % Without E. vermicularis No % χ2, p-value 0.000, 0.569 14 (46.7) 16 (53.3) 79 (46.5) 91 (53.5) 10 (11.4) 6 (12.2) 14 (22.2) 78 (88.6) 43 (87.8) 49 (77.8) 3.782, 0.151 0.077, 0.469 14 (46.7) 16 (53.3) 84 (49.4) 86 (50.6) Nausea 2.087, 0.106 52 Yes No 22 (73.3) 8 (26.7) 101 (59.4) 69 (40.6) Diarrhea Yes No 5 (16.7) 25 (83.3) 25 (14.7) 145 (85.3) Constipation Yes No 5 (16.7) 25 (83.3) 25 (14.7) 145 (85.3) Frequent urination Yes No 12 (40.0) 18 (60.0) 55 (32.4) 115 (67.6) Low grade fever Yes No 15 (15.6) 15 (14.4) 81 (84.6) 89 (85.6) Wake up at night Yes No 12 (40.0) 18 (60.0) 57 (33.5) 113 (66.5) 0.077, 0.481 0.077, 0.481 0.669, 0.268 0.057, 0.483 0.472, 0.312 Gets worse when moving Yes No 18 (60.0) 12 (40.0) 127 (74.7) 43 (25.3) Inability to pass gas Yes No 13 (43.3) 17 (56.7) 66 (36.8) 104 (61.2) Insomnia Yes No 17 (56.7) 13 (43.3) 107 (62.9) 63 (37.1) Defecation will relive discomfort Yes No Taking antibiotic to treat appendicitis Yes No Emergency Yes No 2.766, 0.077 0.217, 0.393 0.426, 0.324 0.29, 0.510 20 (66.7) 10 (33.3) 116 (68.2) 54 (31.8) 0.101, 0.560 1 (20.0) 29 (14.9) 4 (80.0) 166 (85.1) 0.905, 0.440 30 (15.4) 0 156 (84.6) 5 (100) 53 4.8 Life style and behavior associated with E. vermicularis From the present study, it was found that patients who eat fiber-rich food, sugar-rich food and meat-rich food did not show any sign of E. vermicularis infection. On the other hand it was found that patients who eat lipid-rich food are more likely to be infected by E. vermicularis. Table (4.8): Life style and behavior associated with E. vermicularis (n=200) Variable Fiber-rich food Yes No Sugar-rich food Yes No Lipid-rich food Yes No Meat-rich food Yes No How many time eat meat in a week Don't eat Once Twice Three times or more Take a lot of antibiotic Yes With E. Without E. vermicularis vermicularis No % No % χ2, p-value 0.547, 0.304 23 (14.1) 7 (18.9) 140 (85.9) 30 (81.1) 0.521, 0.333 26 (15.9) 4 (11.1) 138 (84.1) 32 (88.9) 3.763, 0.045* 14 (22.2) 16 (11.7) 49 (77.8) 121 (88.3) 0.206, 0.459 28 (14.7) 2 (20.0) 162 (85.3) 8 (80.0) 5.378, 0.146 2 (20.0) 14 (21.9) 11 (13.9) 3 (6.4) 8 (80.0) 50 (78.1) 68 (86.1) 44 (93.6) 2 (9.5) 19 (90.5) .552, .358 54 No Smoking Yes No Nervous behavior Yes No 28 (15.6) 151 (84.4) 2 (6.5) 28 (16.6) 29 (93.5) 141 (83.4) 2.103, 0.115 20 (17.9) 10 (11.4) 92 (82.1) 78 (88.6) 1.630, 0.140 * p< 0.05 = significant 4.9 Clinical description of appendix by the surgeon and E. vermicularis infection Patients who had normal looking appendix were positive for E. vermicularis 3 (23.1%), while those who had inflamed appendix were positive for E. vermicularis 27 (14.4%). This result clearly indicate that there is no significant difference (χ2=0.711, p=0.306). Table (4.9): Clinical description of appendix by the surgeon and E. vermicularis infection (n=200) Variable Form of appendix Normal looking appendix Inflamed Presence of abscess Yes No Diagnosis Acute appendicitis Suspected appendicitis Normal With E. Without E. vermicularis vermicularis No % No % 3 (23.1) 10 (76.9) 27 (14.4) 160 (85.6) 1 (20.0) 29 (14.9) 4 (80.0) 166 (85.1) 27 (15.9) 0 3 (23.1) 143 (84.1) 17 (100) 10 (76.9) χ2, p-value 0.711, 0.306 0.101, 0.560 3.769, 0.152 55 4.10 The form of appendix associated with personal characters of the patients Table (4.10), shows us that males have a high range of inflamed appendix (92.6) comparing with those with normal ones (7.4%). Female have a high range of inflamed appendix (94.9%) comparing with those with normal ones (5.1%) Patients less than 18 years old have a higher range of inflamed appendix (93.9%) than those who are over 19 years old (93.1%). Patients over 19 years old have a higher range (6.9%) of normal appendix than those who are less than 18 years old (6.1%). Table (4.10): The form of appendix associated with personal characters of the patients (n=200) Variable Normal No % Inflamed No % Sex of the patient Males Females 9 (7.4) 4 (5.1) 112 (92.6) 75 (94.9) Age > 18y < 19y 6 (6.1) 7 (6.9) 93 (93.9) 94 (93.1) Education > 12y < 12y 7 (5.8) 6 (7.6) 114 (94.2) 73 (92.4) χ2, P-value 0.443, .362 0.062, 0.515 0.258, 0.409 56 4.11 The form of appendix associated with complains of the patients with appendicitis The results showed that patients who gave vomiting, nausea and insomnia have the highest of complains in case of normal and inflamed appendix. So we can conclude that complains do not give us a firm judgment of the inflammation of the appendix. Table (4.11): The form of appendix associated with symptom of complains of the patients of appendicitis (n=200) Variable Normal No % Inflamed No % Vomiting Yes No 7 (53.8) 6 (46.2) 91 (48.7) 96 (51.3) Nausea Yes No 22 (73.3) 8 (26.7) 101 (59.4) 69 (40.6) Diarrhea Yes No 2 (15.4) 11 (84.6) 28 (15.0) 159 (85.0) Constipation Yes No 2 (15.4) 11 (84.6) 28 (15.0) 159 (85.0) Frequent urination Yes No Insomnia Yes No χ2, P-value 0.131, 0.470 0.002, 0.610 0.002, 0.610 0.002, 0.610 2.048, 0.128 2 (15.4) 11 (84.6) 65 (34.8) 112 (65.2) 1.482, 0.178 6 (46.2) 7 (53.8) 118 (63.1) 69 (36.9) 57 4.12 The histopathological examination of appendices The present study showed a possible relationship between E. vermicularis and appendicitis. The histopathological processing of appendices showed the normal appendix (Figure 4.1). The presence of E. vermicularis either as a whole (Figure 4.3), parts (Figure 4.4) or eggs (Figure 4.8), is more likely to cause the inflammation of appendix. In a few cases (23.1% of studied cases), it was found that normal appendix have an E. vermicularis, but it did not cause any inflammation. Also most appendicitis showed the perforation in the tissue (Figure 4.2) E. vermicularis worms were detected within the lumens (Figure 4.7) 51 Figure (4.1): Normal appendix. Figure (4.2): Perforated appendix. 59 Figure (4.3): Whole worm in appendix tissue. Figure (4.4): Inflamed calcified tissue and parts of degenerated worm. 61 Figure (4.5): Calcified degenerated worm. Figure (4.6): Mucosa and E. vermicularis TS. 68 Figure (4.7): Appendix and TS of E. vermicularis. Figure (4.8): Eggs and part of the adult worm. 62 CHAPTUR FIVE Discussion Enterobius vermicularis (pinworm) is the most successful intestinal nematode to thrive among human populations with over 400 million infected people worldwide (Kucik et al., 2004). In rare instances, pinworms can cause serious gastrointestinal problems and ectopic infections (Petro et al., 2005; Quasem and Salam, 2007). The pinworm has the largest geographic distribution among human intestinal parasites. A part of the reasons for successful maintenance of its prevalence may include the mildness of symptoms in most infections, leading health officials to often focus their efforts on other relevant parasites instead (Kucik et al., 2004). The simple presence of E. vermicularis in the appendix usually produces symptoms which resemble acute appendicitis although the mechanism for this does not involve mucosal invasion by the parasite (Sah and Bhadani, 2006). In rare cases, enterobiasis has led to serious consequences such as appendicitis, eosinophilic colitis (Arca et al., 2004), intestinal obstruction, intestinal perforation, and ectopic infections (Quasem and Salam, 2007). Although seen in all ages and socioeconomic levels, there is a distinct predilection for children and the young (Aydin, 2007). Whilst most children are asymptomatic, the most common presenting symptom is pruritus ani, but infestation may present with ileocolitis, enterocutaneous fistula, urinary tract infection, mesenteric abscesses, salpingitis and appendicitis (Sodergren et al., 2009). Other extraneous sites have been described, including the lung, breast, Meckel’s diverticulum, liver, and spleen (Abramson, 1966). 63 Fecal sampling usually fails to reveal ova or adult worms; therefore, the diagnosis of pinworms is usually made by night-time application of cellophane tape in the perianal area of the child suspected to have pinworms (Liu and Weller, 1994). Since 1899, when the association of Enterobius infestation and appendicitis was first described (Still, 1899), the role of E. vermicularis as a cause of acute appendicitis has been controversial (Symmers, 1950). A review of the published reports over the last 30 years does not settle this controversy. Some studies confirm the findings of acute or chronic inflammation in appendix specimens also found to have pinworms (Saxena et al., 2001). However, the majority of studies report a lower incidence of inflammatory changes in patients with appendiceal pinworms (Batistatou et al., 2002). There have been several case reports and retrospective studies describing this entity (Marjorie et al., 2004). By histologically examination, we found that 30 appendices (15%) out of 200 have an E. vermicularis. All of the patients have clinical symptoms of appendicitis. Most studies in the world regarding this topic may support our results. The first study was in Thessaloniki, all 1085 surgical specimens removed at operation from patients with clinical appendicitis were evaluated. E. vermicularis was found in seven appendices, all of which were from patients with clinical symptoms of appendicitis. The prevalence of E. vermicularis was 0.65% in cases of clinical appendicitis (Gialamas et al., 2012). 64 Another study supports this results, Columbus, Ohio, twenty-one of 1,549 appendectomy patients (1.4%) were noted to have intraluminal pinworms within the appendix specimen (Marjorie et al., 2004). The presence of E. vermicularis or eggs inside the tissue of appendix has changed the morphology of appendix tissue and resulted in the inflammation of some of the samples. The present study found that the presence of E. vermicularis in acute appendicitis is 27, suspected appendicitis is 0, and normal appendices is 3. From these results we can conclude that E. vermicularis could be associated with appendicitis in Gaza strip. And these results are consistent with other studies conducted world wide. In ThessalonikiIn, the few cases where E. vermicularis is found in association with acute inflammation, it may be that the worm has been responsible for initiating the inflammatory reaction, although this and other studies suggest that its presence may be coincidental (Budd and Armstrong, 1987). Similarity to our results from Egyptian, 127 appendices specimens were examined, and it was found E. vermicularis worms were detected within the lumens of two appendices removed from patients having symptoms and signs identical of acute appendicitis but without detectable histopathological findings. E. vermicularis worms were present also in 4 cases out of 76 cases diagnosed as acute appendicitis (5.3%) and in 4 cases out of 28 cases diagnosed as chronic appendicitis (14.3%) (Helmy et al., 2000). E. vermicularis worms were detected in 5.3% of cases of acute appendicitis with some of them showed wall penetration by the worm suggesting the implication of these worms in the process of appendicitis as well as there role in inducing obstruction of the 65 appendiceal lumen. E. vermicularis do invade the wall of the vermiform appendix, and related to these are inflammatory reactions. This invasion causes the symptoms that lead to appendectomy (Mogensen et al., 1985). In the study agreement with this results in Thessaloniki, Greece, there is only one of the 901 cases of acute appendicitis (0.11%) showing evidence of E. vermicularis infestation. It is important, however, to mention that all of seven patients, diagnosed eventually with E. vermicularis infection, presented symptoms of clinical appendicitis, whether the latter was typical or not (Gialamas et al., 2012). With regards to histopathology, E. vermicularis is rarely associated with the histological changes of acute appendicitis. Similarly, Wiebe et al. (Wiebe, 1991) recently revealed a highly significant difference in the incidence of E. vermicularis in normal appendices and in inflamed appendices. This study strongly supports the previous bibliographic data. Although E. vermicularis may have a causal role in appendiceal pain and chronic inflammation due to obstructive phenomena, the overwhelming majority of cases are not associated with acute inflammation. Interestingly ,the presence of pinworms in the appendix may cause a clinical "appendiceal syndrome" even without eliciting acute inflammation (Aydin, 2007). This “syndrome”, also mentioned as appendiceal colic, consists of chronic right lower quadrant and pelvic pain, intermittent in nature, and can be explained by the hypothesis of appendiceal lumen obstruction. The situation in acute appendicitis is less clear (Gialamas et al., 2012). 66 The consensus on the role of E. vermicularis in the pathogenesis of appendicitis supports that its presence in the appendix may lead to clinical signs of appendiceal colic irrespective of the presence of histological inflammation (Dahlstrom and Macarthur 1994). Another study showed disagreement with this results in Austruliun There were 1867 appendices, Enterobius vermiculuris was identified in 63 appendices. Of the appendices infested with pinworm, 23 were acutely inflamed, while the appendices infested with pinworm, 40 were acutely normal. So E. vermicularis was more often associated with normal than inflamed appendices, and mucosal invasion was not seen, and therefore it seems unlikely that this parasite causes acute appendicitis. However, E. vermicularis may be a cause of symptoms resembling appendicitis, because a significantly higher proportion of patients with symptoms had E. vermicularis compared with 147 patients who had an incidental appendicectomy. If E. vermicularis causes symptoms resembling appendicitis, the mechanism for this does not involve mucosal invasion by the parasite. Other possibilties include a hypersensivity reaction or luminal obstruction (Dahlstrom and Macarthur, 1994). In the present study the ages of patients with E. vermicularis in appendices with the highest incidence occurred in less than 18 years age group, this findings are contrast with a study in Thessaloniki, Greece, the ages of the patients with histologically proven E. vermicularis in appendices ranged from 15 to 33 years with a median age of 25 years (Gialamas et al., 2012). In another study that disagree with this results in Copenhagen, incidence 2267 appendices were examined, the highest age group from 6 to 15 year (Wiebe, 1991). 67 The results of the present study showed that the prevalence of E. vermicularis in appendices is higher in females (16.5%) than males (14.0%). Our results were consistent with the results from Iran, thirtyeight of 5981 appendectomy patients, they were found in 38 cases there is pinworm that 67% present of it relates to females and 33% of it relates to males (Fallah and Dehgani, 2011). It is acceptable that the correct diagnosis can be achieved after coassessment of the patient’s history, physical examination and laboratory findings, as well as radiological imaging. In many cases, the doctor has to overcome the difficulties arising from the ambiguity of the clinical symptoms and the significant variations of laboratory results. Laboratory exams may show leucocytosis, but in most cases the WBCs are normal, and diagnosis may be made by the eosinophilia and the positive stool examination. In equivocal cases, the diagnostic certainty can be improved by the addition of radiological imaging. In cases of suspected appendicitis, ultrasound and computed tomography (CT) have proven to be beneficial, with reported sensitivities of 95% and 96%, respectively, and with negative predictive values of 99%, and the negative appendectomy rate in current practice continues to decline. Some patients for whom appendectomy is not clinically indicated may also benefit from night-time application of cellophane tape in the perianal area (Sodergren et al., 2009). Concerning the differential diagnosis, it is true that an appendiceal colic caused by pinworm infestation cannot be differentiated from the right lower quadrant pain of usual acute appendicitis. In some cases a careful 61 history may point to antecedent symptoms and a time course incompatible with typical appendicitis, but physical examination is generally not specific enough to differentiate between parasitic and ordinary appendiceal pain. Patients should be clinically observed and reevaluated before being subjected to an emergency appendectomy. However, the abdominal discomforts that they present and missing the diagnosis leads to inevitable surgical operation. Appendectomy, open or laparoscopic, should proceed with caution if the appendix is observed not to be acutely inflamed. The surgeon must bear in mind the possibility of resident worms in the vermiform appendix (Aydin, 2007). The diagnosis of pinworm infestation can be generally reached only after the histopathologic observation of the resected appendices. In order to achieve the best therapeutic result, all patients should routinely receive antihelminthic treatment afterwards, because the appendectomy treats only the symptoms and not the primary cause of the disease (Nackley et al., 2004). 69 Conclusions and Recommendations Conclusions 1. The histopathology proved the presence of E. vermicularis in the appendices 2. The study showed that 30 (15.0%) of patients with appendix were infected with E. vermicularis. 3. The histopathology showed the tissue morphology of each appendix normal or inflamed. 4. The presence of E. vermicularis in appendix can cause inflammation of appendix. 5. And the normal appendix have an E. vermicularis, with no change of histological tissue, and may produce symptoms which resemble acute appendicitis 6. Eating food rich in lipid may be associated with appendicitis. 7. The surgeon has the final opinion in the appendectomy. Recommendations 1. 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J Med Case Reports, 1:137. . 16 ANNEX 1 االستبيان استبيان بءث الدودة الدبوسية والزائدة الدودية رقم االستبيان تاريخ ممأ العيطة المعلومات الشخصية: 1 8 االسم : 9 2 الجطس: 81 3 العمر: 88 4 تاريخ الميالد: 82 5 المستوي الدراسي: 83 6 مططةة السنن : الشمال ماطة األا : ماطة األم : 9 سب دخول المستشفي: 87 األعراض المتعلقة بالدودة الدبوسية: 87 خالل( الشارين الماضيين) ه سبق وأصبت بالديدان المعوية : ال اعرف ال نعم ه سبق أن أصبت بأحد الطفيليات أو الديدان ؟ انتاميبا _مارديا _اسنارس_ الدبوسية _الشريطية غير ال اعرف ال ذلك ه صاحبتك أعراض معيطة: ال نعم خروج الديدان مأ البراز: ال نعم اإلمساك: ال نعم حنة في مططةة الشرج: ال نعم مغص : ال نعم فةد الشاية: ال نعم إساال: 89 ه أصبيتي وأنت حام في الزائدة الدودية: ال نعم كم مرة أنجبت: 21 بعد أي والدة أصبتي بالزائدة الدودية: 28 ه أعراضاا كانت مشاباة ألعراض الءم : ال نعم ه تطاولت مضادات حيوية لمعالجة الزائدة الدودية: ال نعم ه تم إمراء العملية بشن طارئ: ال نعم أسئلة متعلقة بالطبيب: 8 شن الزائدة الدودية : غير طبيعي طبيعي ه تنون دمام حول الزائدة الدودية: ال نعم تعليةات أخري من الطبي 7 1 8 2 3 4 5 6 7 1 9 84 غزة الجطوا ماطة الزوج: ماطة الزومة: 85 86 22 23 2 3 17 حمي خفيفة : ال نعم ه أصبت بءادي في البطن: ال نعم ه تستيةظ ليال بشن غير طبيعي: ال نعم ه تشعر بتع عطد الءركة: ال نعم ه تشعر بعدم الةدرة علي إخراج رياح: ال نعم ه تشعر باألرق: ال نعم ه عطد التبرز تشعر بأنك مرتاح: ال نعم متى بدأت تشعر باأللم: درمة األلم : شديدة متوسطة ه أصي احد في العائلة بالزائدة الدودية: ال نعم نعم 81 88 82 8 2 3 4 5 6 7 ال فةدان للوزن: ال نعم ه تلةيت عالج لاه الديدان: ال نعم نوع العالج الهي تلةيته : 2 األعراض المتعلقة بالزائدة الدودية: 3 الم في البطن : نعم الةيء: نعم الغثيان: نعم انتفاخ البطن: نعم إساال: نعم إمساك: نعم كثرة التبول : نعم أسئلة متعلقة بالعادات 8 ه تتطاول أطعمة غطية باأللياف: ال نعم ه تتطاول أطعمة غطية بالسنريات: ال نعم ه تتطاول أطعمة غطية بالدهون: ال نعم ه تتطاول اللءوم : ال نعم عدد مرات تطاول اللءوم في األسبوع : ثالثة فأكثر مرتان مرة ه تتطاول المضادات الءيوية بنثرة : ال نعم ه أنت مدخن: ال نعم كم سطة وأنت مدخن: 9 ه تعرضت لمشاك نفسية أو ضغوطات نفسية: ال نعم ه أنت عصبي: ال نعم 4 ال 5 ال 6 ال 7 ال 1 ال ال 81 ال 11 ANNEX 2 Questionnaire Questionnaire research worm pinworm and appendicitis Date of sample collection questionnaire Personal information: 8 1 Name: 9 2 Sex: 10 3 Age: 11 4 Date of Birth: 12 5 Study level: 13 6 14 7 Residence: North governorate Gaza governorate South governorate Occupation Father: Occupation pair: 15 When the pain began? 8 Occupation mother: 16 9 Reason for hospitalization: 17 Symptoms related worm pinworms: 18 During the past two months have you infected with intestinal worm? Yes No Do not know Have you ever had one of these parasites? Entameba histolytica/ dispar Giardia lamblia Ascaris lumbricoides Enterobius vermicularis Tape worms Another No Don’t know Had symptoms Yes No Expel worms with stool 19 Pain degree Middle strong Has anyone of the family affected by appendicitis? Yes No Do you had appendicitis during pregnancy? Yes No How many times she had? 20 After birth was appendicitis? 21 Symptoms like pregnancy Yes No Taking antibiotic to treat appendicitis? 1 2 3 4 Occupation wife's: 19 22 Low grade fever Yes No Accident in abdomen Yes No Wake up at night Yes No Gets worse when moving Yes No Inability to pass gas Yes No Insomnia Yes No Defecation will relive discomfort Yes No 5 6 7 8 9 19 11 12 1 2 3 4 5 6 7 Yes No Had constipation Yes No Had itching in the anal area Yes No Had abdominal pain Yes No Loss of appetite Yes No 23 1 2 Had diarrhea Yes No Weight loss Yes No Did you receive a treatment for these worms? Yes No The type of treatment that you received 3 Symptoms related appendix: 3 Abdominal pain Yes No Vomiting Yes No 4 Nausea Yes No Abdominal swelling Yes No Diarrhea Yes No Constipation Yes No Frequent urination Yes No 6 Yes No Emergency Yes No Physician questions. Form of appendix Normal Inflamed Presence of abscess Yes No Diagnosis Questions related to the habits: 1 Fiber-rich food Yes No 2 Sugar-rich food Yes No Lipid-rich food Yes No Meat-rich food Yes No How many time eat meat in a week? don't eat once twice three times or more Take a lot of antibiotic Yes No Smoking Yes No How many years are you smoking? 5 7 8 9 10 91 Psychological problems or psychological pressure Yes No Nervous behavior Yes No
