Review of Histopathological Diagnoses of One Year Appendectomy Specimens in Sulaimani City

: Objective: To review and see the pattern of histopathological diagnoses of one year appendectomy specimens. Methodology: This retrospective study was carried in Sulaimani Teaching Hospital over the period of one year (from 1 st of January to 31 st of December 2009). All pathological reports were reviewed retrospectively for patient’s age, sex, histopathological diagnosis and operative findings (if present). Histopathological diagnoses then were classified into either positive or negative for acute inflammation. Any associated findings or any surgical specimen removed with the appendix was recorded. The obtained data were analyzed by using the statistical package social sciences ( SPSS) version 19; with Chi square to test for significance between data. Results: Hospital pathological reports of 2052 appendectomy cases were reviewed, (47.12%) were males and (52.88%) were females. 61.9% of all appendectomy cases were positive for acute inflammation (32.9% had acute appendicitis; 26.1 % had acute suppurative appendicitis , and 4.5% had gangrenous appendicitis), while 38.1% were negative (28.5 % had reactive follicular hyperplasia, 6.2% were normal, and 0.2% had carcinoid tumors). Negative for acute inflammation cases were generally significantly more common in females e.g. periappendicitis, Reactive Follicular Hyperplesia and carcinoid tumor but eosinophilic appendicitis cases like acute appendicitis were more common in males. Normal appendixes versus Reactive Follicular Hyperplesia (without associated appendicitis) are two entities that intermingle. Chronic appendicitis is controversial entity. Out of 20 cases with Entrobius vermicularis (95%) cases were associated with reactive follicular hyperplasia and it shows non significant association with acute appendicitis. Recommendation: We recommend that the pathologists must be strict to histological criteria for each pathological entity before the diagnosis.


Introduction:
istologically a distinguishing feature of the appendix is the extremely rich lymphoid tissue of the mucosa and submucosa, which in young individuals forms an entire layer of germinal follicles and lymphoid pulp. Muscularis mucosa and submucosa may be inconspicuous; muscularis propria contains complete longitudinal and circular layers and prominent ganglion cells (1) .
The appendix of the newborn is almost devoid of lymphoid tissue. This lymphoid tissue reaches its height of development in late childhood or adolescence (2) . In the elderly some histological changes occur: the lymphoid tissue undergoes progressive atrophy during life to the point of complete disappearance in advanced age, the appendix, particularly the distal portion, sometimes undergoes fibrous obliteration with presence of plasma cells and eosinophils infilteration (1) .
Acute appendicitis is the most common general surgical emergency (3) .
The incidence of acute appendicitis roughly parallels to that of lymphoid development, with the peak incidence in late teens and twenties. Obstruction of the lumen is the dominant factor for acute appendicitis. Although fecoliths and lymphoid hyperplasia are the usual factors of obstruction, some unusual factors could also be the reason e.g. intestinal worms, malignant or benign tumors, foreign body, parasite or anatomic variance (4) .
Despite the advances in surgery over the past century, the diagnosis of acute appendicitis continues to present clinicians with problems, especially in young females (5) . The gold-standard for diagnosis of acute appendicitis is histopathology (6) . There are no definite guidelines as to whether all appendices should be sent for histopathology as a routine; however many of appendiceal tumors are diagnosed on appendectomy specimens (7) .

Methodology:
This retrospective study was carried in Sulaimani Teaching Hospital, over the period of one year (from 1 st of January to 31 st of December 2009).
All pathological reports of patients who underwent appendectomy were reviewed retrospectively for patient's age, sex, histopathological diagnosis and operative findings (if present).

Discussion:
The histopathological examination of the appendix serves two purposes, first it allows the diagnosis of acute appendicitis to be confirmed. Second histopathological examination may disclose additional pathologies that may not be evident intraoperatively which may impact patient management (8) . Age This study shows that the highest occurrence (69.4%) of acute inflammation is in 2nd and 3rd decade. This is the same finding as observed by Zulfikar I et al who did 2 years review of 323 cases (9) and Ojo et al in their study from Nigeria (10) . But Ngodngamthaweesuk et al who did a 5-year review of 449 patients found that young children (<10 years old) were statistically more significantly affected (11) . In this study 3 cases were ‹6 months while in many other studies on appendectomy in children the least age was onehalf year (12) . Sex: is the other important clinical feature in appendicitis. In this study males positive for acute inflammation were significantly more (56.3%) affected than females, this is highly consistent with Ngodngamthaweesuk N, et al who found that male patients operated upon for lower abdominal pain had histological feature of acute appendicitis significantly more than females (11) .
In this study normal appendix was observed in 6.2% of total 2052 cases which is less than that observed by other studies; 10.8% (9), and 10% (12) . Hyperplasia of the lymphoid tissue is a common normal feature in those younger than 20 years. Duzgun AP et al in Ankara reviewed 2458 cases in six years and divided the patients with lymphoid hyperplasia into two groups: younger and older than 20 years. Those below 20 years 5.3% were accepted as normal, whereas in those older 20 years the lymphoid hyperplasia was considered as important cause in the pathogenesis of acute appendicitis (8) . In the present study 585 (28.5%) of total cases showed RFH, 299 cases were ≤ 20 years if this number is added to 128 normal appendectomies then the percent of normal appendices rises to 20.8% (427 cases) which is higher than that observed by other studies (9,12) .
Other studies on appendicial lymphoid hyperplasia in children did not regard RFH as normal since it causes severe abdominal pain indistinguishable from AA. The increase and swelling of the lymphoid elements, together with the inelasticity of the peritoneal sheath of the appendix, is the most likely explanation of this pain (13) . Furthermore, as the majority of these cases conform to a recognizable syndrome, lymphoid hyperplasia should be considered as a clinical entity among diseases of the appendix (2) .
The ability of the lymphatic system and its ready response to a wide variety of stimuli, especially infection, is well known. Some studies considered that abdominal symptoms suggestive of and frequently indistinguishable from acute appendicitis occur in association with upper respiratory infections. Varicella, oxyuriasis and perhaps a high fat diet may evoke a lymphoid response in the appendix (2) .
It is believed that chronic appendicitis is rare; about 1.5 to 10% of all appendix inflammations ( 14,15) . Its existence is disputed clinically and pathologically. Falk et al report fibrosis, chronic inflammatory infiltrates, and neural cell proliferation is the most specific pathologic features in chronic appendicitis (16) . Lai DH et al in 2006 reviewed 16 cases having appendicitis with symptoms over few weeks. Histopathology revealed that all 16 patients proved to have acute inflammation of appendix. No chronic inflammation was found.
They suggest that it is better to use the name of "recurrent appendicitis" but not "chronic appendicitis" (17) . This study showed 0.8% patients had chronic appendicitis and only one case (0.05%) had granulomatous appendicitis. But in Zulfikar I et al study 10% patients had chronic granulomatous changes consistent with tuberculosis (9) . Periappendicitis referred to inflammation of the appendiceal serosa, with no inflammation in the mucosa. It means spread of inflammation from nearby organs. It could be acute or chronic. But it should be remembered that surgical manipulation may induce neutrophilic infiltration of the periappendix (1) . In this study periappendicitis is a much less finding, it is found in 28 cases only and the majority (57.1%) were found in females. Five cases had other associations; 3 cases were associated with ovarian cyst, 1 case with orchiectomy and one case with perforated sigmoid.. In eosinophilic appendicits there should be no neutrophils.
Eosinophils are the only inflammatory cells, between muscle fibers with odema separating muscle fibers (the Eosinophil -Edema lesion) or (E-E lesion) (18) .
It may be associated with helminthes infection like schistosomaiasis, strangyloides or enterobius. It is possible that the disease is triggered by Type I Hypersensitivity (19) . It could be part of eosinophilic gastroenteritis which is a rare and heterogeneous condition characterized by patchy or diffuse eosinophilic infiltration of gastrointestinal (GI) tissue, first described by Kaijser in 1937. Peripheral blood eosinophilia and elevated serum IgE are usual but not universal (20) . In this study 18 cases (0.9%) had esinophilic appendicitis. As in other types of acute appendicitis esinophilic appendicitis were found more common in males (2/3). KP Aravindan et al in 2010 in India studied 8 cases of eosinophilic appendicitis also found that the male/female resembled classical acute appendicitis ( 75%), with a mean age 24.3 years (18) . Carcinoid tumors are the most common appendiceal tumor; make up 51% of all malignant tumors of the appendix. The reported incidence of appendiceal carcinoids in several studies ranges from 0.02 to 1.5% of surgically removed appendices. A large female preponderance is reported in all series (2-3:1). Incidence peaks at ages 20-39 years (21)(22)(23) . This study showed 0.2% of specimens had carcinoid, 75% of cases were females, similar to other series (24) . Three were of solid pattern, & 1 adenocarcinoid. Duzgun AP, et al. found carcinoid tumor in 3 cases out of 2458 cases (0.1%) and all of them were females (8) . Zulfikar I et al found 0.6% specimens with carcinoids (9) .
Meckel's diverticulitis can mimic acute appendicitis in clinical history, physical findings and operative findings. It is always important to consider this as possible cause of acute abdomen (25) , in this study 5 cases (0.24%) had Meckel's diverticulitis and none of them associated with AA, Zulfikar I et al found 1.2% of cases presented as acute appendicitis and had Meckel's diverticulitis as coexisting pathology (9) . Entrobius vermicularis (Oxyuriasis) is associated with: • normal appendix, • esinophilic infilteration, • RFH • Granuloma formation (26) .
The association of E. vermicularis infection and acute appendicitis is controversial. It has also been noted that parasites may be incidental findings in cases where inflammation is already present (27) .
In the present study E. vermicularis was found in 20 cases, and 95% of them associated with RFH and only 1case associated with AA. Duzgun AP, et al. found 4 (0.4%) cases had E. Vermiclaris and none of them had acute appendicitis on histology (8) which is in correlation with the literature (28) . In a similar study in Hamadan province, western Iran, the reactive follicular hyperplasia and acute suppurative appendicitis were the most observed pathologic findings associated with E. Vermiclaris (29) .
Gh Mowlavi et al., in their study mentioned that E. vermicularis causes reactive follicular hyperplasia in most cases; and could not necessarily be claimed as the causative agent of acute appendicitis, they showed that E.vermicularis was likely to be involved partly in the etiology of appendicitis in young children (26) . H Kazemzadeh et al concluded that, parasitic infestation rarely causes acute appendicitis (30).