International Journal of Surgery Open 26 (2020) 154e160

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International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Review Article

Prevalence of acute appendicitis among patient admitted for acute abdomen in

Ethiopia: Systematic review and meta-analysis
Mohammed Suleiman Obsa a, *, Bulcha Guye Adema b, Getahun Mola Shanka c, Eyasu Alem Lake b,
Gedion Asnake Azeze d, Robera Olana Fite b
a
Department of Anesthesia, College of Health Science, Wolaita Sodo University, Wolaita, Ethiopia
b
Departments of Nursing, College of Health Science, Wolaita Sodo University, Wolaita, Ethiopia
c
Departments of Surgery, College of Health Science, Wolaita Sodo University, Wolaita, Ethiopia
d
Departments of Midwife, College of Health Science, Wolaita Sodo University, Wolaita, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Acute abdomen is an acute onset of abdominal disease entities that require immediate
Received 20 August 2020 surgical intervention. It is one of the commonest surgical emergencies encountered both in developed
Accepted 19 September 2020 and developing nations. This systemic review and meta-analysis was aimed at determining the pooled
Available online 23 September 2020
prevalence of acute appendicitis among acute abdomen patients in Ethiopia.
Materials and methods: PubMed, Science Direct, Google Scholar and Excerpta Medica Database
Keywords:
(EMBASE), AJOL, Web of Science, Mednar, and Chocrane library were searched. The data were extracted
Acute appendicitis
using Microsoft Excel and analyzed by using STATA version 14. Publication bias was checked by funnel
Acute abdomen
Prevalence
plot and more objectively through Egger's regression test, with P > 0.05 considered to indicate absence
publication bias. Heterogeneity of studies was checked using the I2 test. Pooled analysis was conducted.
Subgroup analysis was done by region. Leave out one sensitivity analysis was employed to see the effect
of single study on the overall estimation. STATA version 14 statistical software was used for meta-
analysis.
Results: The overall prevalence of acute appendicitis was 44.272% (95% CI: 38.366, 50.18.503; I2 ¼ 93.9%).
Based on the subgroup analysis, the prevalence of acute appendicitis was 53.2% in Tigrai, 46.54% in
Oromia, 44.26% in SNNPR, 41.30% in Addis Ababa, and 36.81% in Amhara.
Conclusion: The prevalence of acute appendicitis among acute abdomen patients is high. Therefore, close
monitoring of the patient prognosis and appropriate prevention techniques is essential.
© 2020 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Background many cases require removal of the inflamed appendix either by

laparotomy or laparoscopy, untreated mortality is high, mainly
Acute appendicitis is one of the commonest surgical emergen- because of rupture leading to peritonitis and shock [7e9].
cies encountered both in adults and children. Acute abdomen is an Intestinal obstruction (IO) is defined as obstruction of the pas-
acute onset of abdominal disease entities that require immediate sage of the intestine for its contents, continues to be a major
surgical intervention in most of the case and Acute abdomen is a problem for human being since it was first recognized and treated
commonly encountered illness both in developed and developing in 350 Before Christ. It occurs when the normal flow of intestinal
nations [1e6] Acute appendicitis commonly presents as an acute contents is interrupted. Intestinal obstruction is one of the most
abdomen and a condition characterized by inflammation of the common causes of acute abdomen worldwide [10,11].
vermiform appendix it is classified as a surgical emergency and Acute appendicitis is the commonest cause of surgical acute
abdomen and it is estimated that 10% of the population will have
appendicitis during their lifetime. For instance, in Europe, America,
* Corresponding author. and Australasia up to 16% of the population underwent appen-
E-mail addresses: msuleiman43@gmail.com (M.S. Obsa), bulchaguye@gmail. dectomy for appendicitis. The presence of verities of clinical con-
com (B.G. Adema), shankamolla@yahoo.com (G.M. Shanka), eyasumsc2008@
ditions that resemble acute appendicitis creates diagnosis
gmail.com (E.A. Lake), dearged2011@gmail.com (G.A. Azeze), rolana2000@gmail.
com (R.O. Fite). difficulties even in most experienced clinicians [12].

https://doi.org/10.1016/j.ijso.2020.09.003
2405-8572/© 2020 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
M.S. Obsa, B.G. Adema, G.M. Shanka et al. International Journal of Surgery Open 26 (2020) 154e160

Clinically, it is a disease with an acute onset of pain, which is as patients' factors and institutional inadequacies. Efforts to reduce
initially per umbilical but later shifts to the right iliac fossa associated delay may reduce complications. Surgery is often the only solution
with anorexia, nausea and vomiting with a physical finding of to prevent death from surgical cause of acute abdomen [2]. In
marked tenderness at the right iliac fossa. The clinical evaluation of Ethiopia, very little is known about the general pattern and the
the patient has remained the mainstay of the diagnosis of acute relative incidence of the causes of acute abdomen [18].
appendicitis. Meticulous history and examination of the patient have Of the major gastrointestinal disorders, acute appendicitis was
direct relationship to diagnostic accuracy. The early surgical removal the most common condition, accounting for one third of the cases
of the appendix remains the best method of treatment for total cure in Black Lion Hospital (15). The study aimed at determining the
in addition to minimizing morbidity and mortality [12,13]. prevalence acute appendicitis among patient admitted for acute
The mortality rate following acute abdominal surgical emer- abdomen in Ethiopia.
gencies is still high. The overall mortality was 4.2% and the rate
increased significantly in patients aged >60 years. Postoperative 2. Method
mortality was 5.8% while mortality rate in non-operated patients
was 2.8%. The causes of preoperative death included perforated 2.1. Study design and search strategy
peptic ulcer, abdominal malignancies (15.4%) and urgent colonic
resections (9.4%). Emergency procedures generally are associated A systematic review and meta-analysis was conducted on the
with increased morbidity and mortality rate in elderly patients (the pooled prevalence of acute appendicitis among patient admitted
overall mortality was 22%) [14,15]. for acute abdomen in Ethiopia. PubMed, Science Direct, Google
Lack of health education, improper health care facilities and late Scholar, AJOL, Web of Science, Mednar, Chocrane library and
presentations are common factors for increased morbidity and EMBASE were accessed. The core search term and phrases were
mortality. Old age (>55- years) and duration of illness greater than “Prevalence”, “Acute appendicitis”, “Acute Abdomen”, “Ethiopia”,
two days were factors statistically associated with postoperative “Addis Ababa”, “Adama”, “Bahirdar”, “Dire Dawa”, “Gondar”,
complication. Emergency procedures generally are associated with “Mekelle”, “Hawassa”.
increased morbidity and mortality rate in elderly patients (the The following term with MeSH (Medical Subject Heading)
overall mortality reaches 22% [16,17]. Analyzing of pattern of acute Boolean operators were used to search PubMed.
abdomen has epidemiological and clinical benefits. It also helps for (((((((Prevalence) OR “Epidemiology"[Mesh]) AND Appendicitis)
early diagnosis and prompt treatment. Patients with acute OR Acute Appendicitis) OR Ruptured Appendicitis) OR Perforated
abdomen in Africa countries present late due to factors categorized Appendicitis) OR Acute Abdomen) AND Ethiopia.

Fig. 1. Flow chart of study selection for systematic review and met-analysis of Prevalence of acute appendicitis among patient admitted for acute abdomen in Ethiopia.

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M.S. Obsa, B.G. Adema, G.M. Shanka et al. International Journal of Surgery Open 26 (2020) 154e160

2.2. Reporting Articles excluded were:

The results of this review were reported based on the Preferred 1) Studies which were not fully accessed. An attempt was made to
Reporting Items for Systematic Review and Meta-Analysis state- contact the corresponding author
ment (PRISMA) guideline [19]. (Supplementary file-PRISMA 2) Studies with methodological problems.
checklist) and, it is not registered in the Prospero database.

2.3. Eligibility criteria 2.4. Study selection and extraction

The inclusion criteria were: Three independent reviewers screened the title and abstract.
Study Type: - All observational studies, which reported the The disagreement was handled based on established article selec-
prevalence of prevalence of acute appendicitis. tion criteria. Three reviewers conducted the abstract and full-text
Study area: Studies conducted in Ethiopia. review. Data were extracted using a standardized data extraction
Language: Studies published in English, were considered. format prepared in Microsoft Excel by two independent authors.
Study Period: Study conducted before 2020 G.C. Five independent reviewers extracted data using Microsoft Excel

Table 1
Descriptive summary of 13 studies included in the systematic review and meta-analysis of the prevalence of acute appendicitis in Ethiopia.

Authors Publication year Region Conducted year Study design Actual sample Sampling method Prevalence

Yohannes M et al. 2017 Ahmara 2015e2016 Cross-sectional 355 Systematic Random sampling 39.5
Tassew B et al. 2017 Oromia 2012e2014 Retrospective-cross-sectional study 299 simple random sampling 49.2
Gebrie A et al. 2019 SNNP 2017e2018 Prospective-cross sectional study 171 simple random sampling 48
Yilma Y et al. 2019 Oromia 2014e2016 Retrospective-cross sectional study 245 Systematic Random sampling 42.5
Ayenew Z et al. 2016 Oromia 2011e2013 Retrospective-cross sectional 295 Systematic Random sampling 47.4
Wossen MT 2019 Tigrai 2007e2010 Retrospective-study 439 Not stated 55.4
Negash et al. 2017 SNNP 2013e2015 Cross-sectional study 376 Not stated 60
Nega B 2009 SNNP 2004e2006 Longitudinal-cross sectional 143 Not stated 24.5
Berhane Y et al. 2016 Tigrai 2009e2012 cross -sectional study 255 Not stated 50.2
Kotiso B et al. 2007 Addis Ababa 2000 Retrospective-cross sectional 235 Systematic Random sampling 52
Tamrat G et al. 2018 Addis Ababa 2008e2009 Prospective-cross-sectional study 504 Not stated 44.4
Tsegaye S et al. 2007 Ahmara 1998e2002 Retrospective -study 511 Systematic Random sampling 34.6
Nebyou S et al. 2014 Addis Ababa 2010e2012 Retrospective-study 530 Not stated 28

Fig. 2. Funnel plot of publication bias.

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M.S. Obsa, B.G. Adema, G.M. Shanka et al. International Journal of Surgery Open 26 (2020) 154e160

Fig. 3. Forest Plot of the prevalence of acute with its 95% Confidence Interval.

2016 spreadsheet. Any discrepancy during extraction was solved calculated. I2 test was used to quantify between-study heteroge-
through discussion. The name of the first author, Publication year, neity. Pooled analysis was conducted using a weighted inverse
prevalence, sample Size included, region, sampling design, and data variance random-effects mode. Subgroup analysis was done by
collection method was extracted. region. We also conducted a leave one-out sensitivity analysis to
appraise the main studies that exert a most important impact on
2.4.1. Quality assessment between-study heterogeneity. STATA version 14 statistical software
Three independent authors appraised the quality of studies. The was used for meta-analysis. The result was presented in a form of
Joanna Briggs Institute (JBI) quality appraisal checklist was used table and figures.
[20]. The disagreement was resolved by the interference of third
Table 2
reviewer. The following items were used to appraise cross-sectional
Sensitivity analysis of pooled prevalence for each study being removed at a time.
studies, 1inclusion criteria, 2description of study subject and
setting, 3valid and reliable measurement of exposure, 4objective Study Omitted Estimated Pooled prevalence with 95% CI

and standard criteria used 5identification of confounder, 6strategies Yohannes M et al. 44.68 [38.27, 51.08]
to handle confounder, 7outcome measurement, and 8appropriate Tassew B et al. 43.86 [37.55, 50.17]
Gebrie A et al. 43.98 [37.73, 50.23]
statistical analysis. Studies were considered low risk when it scored
Yilma Y et al. 44.42 [38.08, 50.76]
50% and above of the quality assessment indicators. Ayenew Z et al. 44.01 [37.67, 50.36]
Wossen MT 43.32 [37.32, 49.33]
Negash et al. 42.93 [37.31, 48.56]
2.4.2. Statistical analysis
Nega B 45.84 [40.01, 51.67]
The data were extracted using Microsoft Excel and analyzed by Berhane Y et al. 43.79 [37.52, 50.05]
using STATA version 14. Publication bias was checked by funnel plot Kotiso B et al. 43.64 [37.43, 49.85]
and more objectively through Egger's regression test, with P < 0.05 Tamrat G et al. 44.26 [37.73, 50.80]
considered to indicate potential publication bias. To assess for sig- Tsegaye S et al. 45.11 [38.85, 51.36]
Nebyou S et al. 45.70 [40.38, 51.02]
nificant between-study heterogeneity, the Cochrane Q statistic was
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M.S. Obsa, B.G. Adema, G.M. Shanka et al. International Journal of Surgery Open 26 (2020) 154e160

3. Results appendicitis (60%) was reported in a study from SNNP region and
the lowest (24%) reported from a study conducted in the same
3.1. Characteristics of included studies Region. The sampling method employed in 6 studies was sys-
tematic random sampling and two studies used simple random
Initially, 222 articles were retrieved. Of these articles, 122 were sampling (Table 1).
excluded due to duplication and 80 articles were excluded by title,
abstract and full text presence. Therefore, 22 articles were fully 3.2. Publication bias
accessed and assessed for eligibility. Ultimately, 13 articles met the
eligibility criteria and were included in the final meta-analysis (Fig. 1). Egger's regression test p-value was 0.322, which indicated the
Thirteen full text articles were included in this systematic absence of publication bias. Furthermore, a funnel plot showed a
review and meta-analysis. The studies showed low risk on symmetrical distribution (Fig. 2).
quality assessment. Overall information regarding the prevalence
was obtained from various areas in Ethiopia: 3 conducted in 3.3. Prevalence of acute appendicitis
Oromia [7,14,21], 2 conducted in Ahmara [11,22], 3 conducted in
SNNP [16,23,24], 2 conducted in Tigrai [4,25], and 3 conducted in The estimated overall prevalence of acute appendicitis is pre-
Addis Ababa [17,18,26]. The actual number of study participants sented in a forest plot. The overall prevalence of acute appendicitis
ranges from 143 to 504. The highest prevalence of acute was 44.272% (95% CI: 38.366, 50.18.503; I2 ¼ 93.9%) (Fig. 3).

Fig. 4. Forest Plot of the prevalence of acute appendicitis based on the region where the studies conducted.

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3.3.1. Leave out one sensitivity analysis research proposal, conducted the research, did data entry and
Leave out analysis was done to evaluate the effect of each study analysis and wrote the manuscript. All authors read and approve
on the polled estimated prevalence of Acute Appendicitis by final manuscript.
excluding each study step-by-step. The result showed that the
excluded studies did not show significant difference in the Preva- Conflict of interest statement
lence of Acute Appendicitis (Table 2).
We declared that we have no conflict of interest.
3.4. Subgroup analysis
Guarantor
The subgroup analysis based on the region was done. Accord-
ingly, the prevalence of acute appendicitis is found to be 53.2% in
Mohammed Suleiman Obsa.
Tigrai, 41.30% in Addis Ababa, 46.54% in Oromia, and 44.26% in
SNNP (Fig. 4).
Research registration number
4. Discussion
Not applicable.
This study reviewed the evidence on the prevalence of acute
appendicitis. Thirteen study was included into the analysis, Consent for publication
selected based on a series of inclusion criteria. To the best of our
knowledge, this systematic review and meta-analysis provides a Not applicable.
comprehensive estimation of the prevalence of acute appendicitis
in Ethiopia. Acknowledgement
In this systematic review and meta-analysis, the overall preva-
lence of acute appendicitis was 44.27%. This is study is low when We would like to acknowledge Wolaita Sodo University for
compare study conducted in India stated that (62.98%) in female providing materials used for the work.
[9]. This difference suggests that the study depend on seasonal.
This study is comparable with Prospective Observational Study
Appendix A. Supplementary data
on acute Appendicitis Worldwide (POSAW) which stated that 42.2%
[27]. This study was higher than study conducted in Taiwan, the
Supplementary data to this article can be found online at
department of pathology, B.P.K.I.H.S analyzed retrospectively and A
https://doi.org/10.1016/j.ijso.2020.09.003.
retrospective population-based cohort observational study con-
ducted in Cameroon which stated that 36.25%, 7.0% and 3.85%
respectively [28e30]. References
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