RIFT VALLEY UNIVERSITY CHIRO CAMPUS

MAGNITUDE AND TREATMENT OUTCOME OF ACUTE

APPENDICITIS AT GELEMSO GENERAL HOSPITAL, OROMIA
REGION, EASTERN ETHIOPIA, 2024.

Research Proposal
BY
1. GURMESA SHERIF 0054/21
2. IBSA AHIMED 0070/21
3. KAZNO IDRIS 0078/21
4. MUSHEMAM NEZIR 0102/21

DEPARTMENT: NURSING
ADVISOR: KADIR ABDU (BSC, MSC)

JULY, 2024
CHIRO, ETHIOPIA
 RIFT VALLEY UNIVERSITY CHIRO CAMPUS
FACLUTY OF HEALTH SCIENCE

MAGNITUDE AND TREATMENT OUTCOME OF ACUTE

APPENDICITIS AT GELEMSO GENERAL HOSPITAL, OROMIA
REGION, EASTERN ETHIOPIA, 2024.

A Research Proposal to be Submitted to Rift Valley University Department

of Nursing in Partial Fulfillment of The Requirements for Degree of
Bachelor Science in Nursing

Research Proposal
BY
1. GURMESA SHERIF 0054/21
2. IBSA AHIMED 0070/21
3. KAZNO IDRIS 0078/21
4. MUSHEMAM NEZIR 0102/21

DEPARTMENT: NURSING
ADVISOR: KADIR ABDU (BSC, MSC)

JULY, 2024
CHIRO, ETHIOPIA
 ACKNOWLEDGEMENTS
Above all, we wish to express our gratitude to Allah, the Almighty. Secondly, the nursing
department at Rift Valley University's Faculty of Health Sciences has our deepest thanks for
this chance. We would especially want to thank our adviser, Mr. Kadir Abdu (BSc, MSc), for
all of his guidance, direction, and astute critique during the preparation of our study proposal.
We are appreciative to the Rift Valley University library and the administrative staff at
Gelemso General Hospital. Finally, we would like to sincerely thank our colleagues for
lending us ideas and vital information for our research.

TABLE OF CONTENTS

I
ACKNOWLEDGEMENTS........................................................................................................I

TABLE OF CONTENTS..........................................................................................................II

ABBREVIATION AND ACRONYM....................................................................................IV

LIST OF FIGURES...................................................................................................................V

LIST OF TABLES...................................................................................................................VI

SUMMARY............................................................................................................................VII

1. INTRODUCTION..................................................................................................................1

1.1. Back ground....................................................................................................................1

1.2. Statement of the Problem................................................................................................2

1.3. Significant of the Study...................................................................................................4

1.4. Objectives........................................................................................................................4

1.4.1. General Objective.....................................................................................................4

1.4.2. Specific Objectives...................................................................................................4

2. LITERATURE REVIEW.......................................................................................................5

2.3. Conceptual frame work.................................................................................................11

3. METHODOLOGY...............................................................................................................12

3.1. Study Area and Period..................................................................................................12

3.2. Study design..................................................................................................................12

3.3. populations....................................................................................................................12

3.3.1. Source of population..............................................................................................12

3.3.2. Study population....................................................................................................12

3.4. Sample size and sampling technique.............................................................................12

3.5. Criteria of Legibility.....................................................................................................12

3.5.1. Inclusion Criteria:...................................................................................................12

3.5.2. Exclusion Criteria:.................................................................................................13

3.6. Sampling technique.......................................................................................................13

3.7. Data collection processes..............................................................................................13

II
 3.7.1. Data collection instruments....................................................................................13

3.7.2. Data collection procedures.....................................................................................13

3.8. Variables.......................................................................................................................13

3.8.1. Dependent variables...............................................................................................13

3.8.2. Independent variables.............................................................................................13

3.9. Operational definitions..................................................................................................14

3.10. Data processing and analysis......................................................................................14

3.11. Data quality assurance.................................................................................................15

3.12. Ethical clearance.........................................................................................................15

3.13. Dissemination of result...............................................................................................15

4. TENTATIVE WORK PLAN...............................................................................................16

5. BUDGET BREAKDOWN...................................................................................................17

5.1. Personnel costs..............................................................................................................17

5.2. Transportation and Communication cost......................................................................17

5.3. Cost of supplies.............................................................................................................17

5.4. Summary of Budget Notification..................................................................................18

6. REFERENCES.....................................................................................................................19

7. ANNEXES...........................................................................................................................23

Annex 1: Consent form for head of Gelemso general hospital............................................23

Annex 2: Consent form for medical record room head........................................................24

Annex 3: Checklist for data collection.................................................................................25

III
 ABBREVIATION AND ACRONYM

AA Acute Appendicitis
GGH Gelemso General Hospital
ICU Intensive Care Unit
IESO Integrated Emergence Surgery and Obstetrics
LOS Length of Hospital Stay
MD Medical Doctor
OR Operation Room
RIF Right Iliac Fossa
RLQ Right Lower Quadrant
TAC Temporary Abdominal Closures
TAH Tikur Anbesa Specialized Hospital
UTI Urinary Tract Infection
WBC White Blood Cell
Y12MCH Yekatit 12 Medical College Hospital
ZHD Zonal Health Department
ZMH Zewditu Memorial Hospital

IV
 LIST OF FIGURES
Figure 1: Conceptual framework for study to assess magnitude and treatment outcome of
acute appendicitis at Gelemso general hospital, Oromia region, eastern Ethiopia, 2024. Which
is developed by reviewing different literatures........................................................................11

LIST OF TABLES

V
Table 1: Work plan schedule for activities to be implemented for study to assess magnitude
and treatment outcome of acute appendicitis at Gelemso general hospital, Oromia region,
eastern Ethiopia, 2024..............................................................................................................16
Table 2: Budget breakdown for activities to be implemented for study to assess magnitude
and treatment outcome of acute appendicitis at Gelemso general hospital, Oromia region,
eastern Ethiopia, 2024..............................................................................................................17

VI
 SUMMARY
Background: Appendicitis is a condition characterized by inflammation of the vermiform
appendix. It is classified as a surgical emergency and many cases require removal of the
inflamed appendix either by laparotomy or laparoscopy. Untreated, mortality is high, mainly
because of rupture leading to peritonitis and shock. However, there is scarcity of information
on the magnitude and treatment outcome of acute appendicitis in the current study area.

Objective: The aim of this study is to assess magnitude and treatment outcome of acute
appendicitis at Gelemso general hospital, Oromia region, eastern Ethiopia, from July 28 to
August 28, 2024.

Methods: A facility based cross-sectional study design will be carried out from July 28 to
August 28, 2024. Lottery method will be used to select the first patient card. Purposive
sampling will be employed to recruit a total all patient medical record and the data will be
collected using the checklist that is adopted from previous study. Descriptive statistics will be
computed to determine frequencies and summary statistics (mean, standard deviation, and
percentage) to describe the study population in relation to socio-demographic and other
relevant variables. Data are presented using tables, graphs, and figures. The collected data
will be entered and analysis by Microsoft excel.

Budget: 18,458.0 ETB will be a total expected cost to carry out the research.

Work Plan: This study will take place from July, 2024 to September, 2024.

Keywords: Acute appendicitis, magnitude, Gelemso general hospital, east Ethiopia.

1. INTRODUCTION
1.1. Back ground
Appendicitis is a condition characterized by inflammation of the vermiform appendix it is
classified as a surgical emergency and many cases require removal of the inflamed appendix
either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of rupture
leading to peritonitis and shock (Hoblerk, 2018). It is recognized as a surgical disease when

VII
the Harvard University pathologist Reginald Heber Fitz read his analysis of 257 cases of
perforating inflammation of the appendix at the 1886 meeting of the Association of American
Physicians (Abdus SA., et al., 2019), and it has been recognized as one of the most common
causes of the acute abdomen worldwide. The vermiform appendix is a blind muscular tube
with mucosal, submucosal, muscular and serosal layers. The relationship of the base of the
appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic,
sub cecal, perineal, or right pericolic position. These anatomic considerations have significant
clinical importance in the context of acute appendicitis. The appendix is an immunologic
organ that actively participates in the secretion of immunoglobulins, particularly
immunoglobulin A (Jaffe BM and Berger DH, 2020).

With more than 250, 000 appendectomies performed annually, appendicitis is the most
common abdomens surgical emergency. Peak incidence on acute appendicitis is to the second
and third decades of life. It is relatively rare at the extremes of ages however, perforation is
more common in infancy and in the elderly, during which periods mortality rates are highest.
Males and females are equally affected, except between puberty and age 25, when males
predomination a 3:2 ratio. The incidence of appendicitis has remained stable in the United
States over the last 30 year, while the incidence of appendicitis is much lower in under
developed countries, especially pants of Africa, and lower socioeconomic groups (Anderone
RE, 2017, Jaffe BM and Berger DH, 2020, Merlin MA., 2020, Morino M., 2016).

Appendicitis is the most common surgical cause of abdominal pain worldwide (Chamisa I.,
2019, Magadi FA., et al., 2014), Difference in incidences, sex, age, and seasonal variations
has been reported widely, with paucity of information from Nigeria. The incidence is higher
among the Caucasians and also in peoples living in the developed world, although this
appears to be declining (Weaker A. and Segal I. 2015, Blomqvisit P., et al., 2018, Addis DG.,
et al., 2020, Al-Omran M., et al., 2023).

Report of increasing incidence in African countries has been reported by some authors in the
last few decades (Bekele A. and Makasha A., 2016, Abdelrahman I.H. and Doumi E.A.,
2017, Offili OP., 2017, Mangete ED. and Kombo BB., 2014). Changing to western lifestyle,
including diets have been held responsible for this (Hill A.G. and Willmore W.S., 2021). It is
generally reported to be more common in males (Addis DG., et al., 2020, Freud E., et al.,
2019, Luckmann R. and Davis P., 2021) and usually occurs in the age range of 10-30 years,
VIII
(Addis DG., et al., 2020, Noudeh YJ., et al., 2017, Ayoade BA., et al., 2016), although
Magnate form Port- Harcourt in Nigeria, founded a significantly higher incidence in females
(Mangete ED. and Kombo BB., 2014), Higher incidences have been reported in the summer
months by many authors (Gallerani M., et al., 2016, Wolkomir A., et al., 2017, Abdul J., et
al., 2022). Sanda et al, have suggested intense challenge to the mucosa associated lymphoid
tissue from allergens in the dust, during the sandstorm of the spring months, the Arabian
Peninsula (Sanda RB., et al., 2018).

At Gelemso general Hospital there is no study conducted on the magnitude and treatment
outcome of acute appendicitis. Thus, the aim of this study is to assess the magnitude and
treatment outcome of acute appendicitis with age, sex, and treatment outcome, contributing to
show the burden of the disease for those who are responsible to health care service.

1.2. Statement of the Problem

Appendicitis is sufficiently common that appendectomy is the most frequently performed
urgent abdominal operation and is often the first major procedure performed by a surgeon in
training. Notwithstanding advances in modern radiographic imaging and diagnostic
laboratory investigations, the diagnosis of appendicitis remains essentially clinical, requiring
a mixture of observation, clinical acumen and surgical science. In an age accustomed to early
and accurate preoperative diagnosis, acute appendicitis remains an enigmatic challenge and a
reminder of the art of surgical diagnosis (O’Connell RP., 2018).

A study at Tikur Anbesa Specialized Hospital between the year 1999 to 2000, a total of 147
children’s under the age of 13 years admitted for acute appendicitis were analyzed. The mean
age was 9.3 years, and appendicitis occurred more commonly among males. Factors
independently found to be predictors of perforation by univariate analysis were; age
<10years, duration of illness for over 24 hours, history of treatments elsewhere before arrival
to TAH, generalized abdominal tenderness and or rigidity, hypoactive and or absent bowel
sound, RLQ mass, Leukocytosis with neutrophilia and presence of complications. However,
none of these was retained as significant factors in multiple logistic regression analysis. It is
concluded that there are many factors that are associated with perforation but there is no
single factor that independently predicted perforation of appendicitis. Delay in intervention
due to late presentation to hospital is an important preventable factor (Kotiso B. and
Abdurahman Z., 2017).

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Similarly, a total of 277 cases of acute appendicitis admitted from January 1st to December
31st 1998 at Zewiditu memorial hospital (ZMH) were reviewed. 16(5.8%) had presented with
a RLQ mass, which was managed conservatively while 261 (94.2%) had emergency surgery.
At operation, it was found that 184 (70.6%) had simple appendicitis, 45 (17.4%) had
perforated, and 25(9.5%) gangrenous appendices. Seven (2.5%) had appendicular abscess
with amputated stump left. The male to female ratio was 2.6:1. The patient’s age ranged b/n
13 and 75 with the peak occurring b/n 13-30 years. The most common symptoms were
abdominal pain, (100%) and Vomiting (76.9%), the commonest signs were localized
tenderness in the RLQ (92.4%) with rebound tenderness (70.4%). Digital rectal, examination
was done in 127 patients in whom tenderness was elicited in 80 (63%), of them the approach
to the appendix in 78.4% of operation was thorough a transverse incision at McBurney’s
point. In ZMH, appendectomy was found to be the most common emergency operations,
accounting for 46.7% of cases and carried a post- operative mortality rate of 1.2 % (Abrham
D., 2013).

In Ethiopia, very little is known about the general magnitude and treatment outcome of acute
appendicitis. This study will be conducted with the aim of assessing the magnitude and
treatment outcome of acute appendicitis at Gelemso general hospital and compare it with
other studies in the country, Sub-Saharan Africa and also the developed world. The study is
believed to have epidemiological and clinical benefits and would also serve as a base for
other studies. Therefore, the aim of this study is to assess the magnitude and treatment
outcome of acute appendicitis and also to contribute practicable recommendations based on
the study findings, so that proper planning, implementation and evaluation of the perspective
health activities will be conducted in the study area.
1.3. Significant of the Study
This study will help to indicate the magnitude of appendicitis in the study area. Since similar
studies were not conducted in this health institution (Gelemso general hospital) the study will
provide the current magnitude of the disease in the study area. The result of the study will
also help the local health institutions: regional hospitals, health centers, zonal health
departments and regional health bureaus so that proper planning, implementation and
evaluation of perspective health service activities will be conducted in the area. It will also
help the local health workers as baseline information to provide quality health care service
(early diagnosis and treatment) for those patients with acute appendicitis. It can also provide
X
basic information about the magnitude and treatment outcome of acute appendicitis that is
going on similar health institutions around selected countries in the world including Ethiopia.
The study will also use as aspiring board for those who need to conduct similar study in the
region and Gelemso general hospital.

1.4. Objectives
1.4.1. General Objective
 To assess magnitude and treatment outcome of acute appendicitis at Gelemso general
hospital, Oromia region, eastern Ethiopia, from July 28 to August 28, 2024.
1.4.2. Specific Objectives
 To determine the magnitude of acute appendicitis
 To identify treatment outcome of acute appendicitis

2. LITERATURE REVIEW
A study at Nottingham, UK in adult patients (>16 Yrs) undergoing an emergency
appendectomy at a university teaching hospital between Feb. 2004 and Jan.2005, a total of
199 patients with a median age of 31 years (range, 16 -89 years) were identified. Of these
29% of patients experienced a postoperative complication, 4% of patients were admitted to
the surgical high dependency unit or ICU postoperatively and there was one death (0.5%).
Comparison between patients with histological proven appendicitis (82%) and those patients
having a negative appendectomy (18%) showed no significant difference in the rate of
complication as defined (Al-Khyatt W. et al., 2017). However, patients with positive
histology were more likely to experience a septic complication and despite this patients with
a negative appendectomy were more likely to be readmitted, predominantly with persistent
abdominal pain. It is concluded that appendectomy is associated with significant morbidity in
patients with an inflamed appendix, were more likely to experience aseptic complication but
re-admission was more common in patients with a histopathologically normal appendix
because of unresolved abdominal pain (Simpson J. and Roxon A., 2018).

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Another study in UK study analyzed 816 children diagnosed with acute appendicitis over a
decade, with 4.5% under five years old. Abdominal pain was the most common symptom, but
not invariable. Vomiting was present in 28 children, and localized tenderness in the RIF was
present in 21 children. In five children, diagnosis was delayed by over 18 hours. The overall
operation rate was 50%, inversely proportional to the child's age. No mortality occurred, and
the wound sepsis rate was 16.6%. The low incidence of acute appendicitis in young children
means it is often overlooked, but a high index of suspicion may lead to earlier diagnosis and
reduced mortality. (Hall N.J. et al., 2021). A study in New York examined the incidence and
epidemiological factors of acute appendicitis in various ethnic groups in an urban minority
community. The study involved 278 consecutive patients who underwent appendectomy at
the Bronx Lebanon Hospital center between 1998 and 2015. Acute appendicitis constituted
3.1% of all emergency surgical admissions, with Hispanics, African Americans, whites, and
Asians having higher incidences. There were no significant differences in pathological
findings regarding the diseased appendix in different racial groups. High WBC counts
indicated inflammation of the appendix but had no predictive value for the type of pathology
(Albo E., et al., 2017).

A study by Mohamedian at Clarksburg WVa found that nine pregnant patients had
appendectomy due to appendicitis complicating pregnancy. Seven had acute appendicitis,
pyuria, and UTI symptoms. Abdominal pain, nausea, and tenderness in the RLQ were present
in all patients. No fetal or maternal loss was reported. The study found that perinatal
mortality was 4.8% in acute inflammation only and 19.4% in perforated appendicitis.
Diagnosis relied on clinical documents, and prompt surgical intervention was crucial for good
outcomes (Mohamedians S., 2022).

Another study analyzed 210 pediatric appendectomy cases and 744 adult cases of suspected
acute appendicitis from 2005 to 2012. Pediatric patients had similar pain durations to adult
patients but required less time for emergency room evaluation. Classic, migrating pain was
the most predictive factor in children and adults, followed by a WBC count over 12x109/L.
The overall negative appendectomy rate was 10.0% for children and 19.0% for adults, with
perforation rates of 19.0% and 13.8%, respectively. Mortality and morbidity were similar in
both groups, and diagnosing acute appendicitis in children was similar to adults (Lee SL.,
2016).

XII
A study at Guthrie Medical Center in Pennsylvania found a 31% rate of perforated
appendicitis in 1984, an increase from previous rates of 13% and 0% in 1964 and 1944.
Perforation accompanied 18.3% cases of appendicitis, with diagnostic accuracy at 81.4%.
Patients in the first decade of life and those 50 years of age were at risk. Perforation rates
were inversely related to accuracy, with poorest in women in the second to fourth decade or
mid-menstrual cycle. Increased public and physician awareness is crucial to reduce
perforations (Ricci MA., et al., 2021).

In 2014, a study in California found that age- and sex-specific incidence rates and case
fatality rates for acute appendicitis were lower than previously reported. In persons aged 60
and older, the fatality rate for non-perforated appendicitis with appendectomy was 0.7%,
while for perorated appendicitis with appendectomy and abscess was 2.4%. Surgery was
delayed in 21% of individuals aged 40-59, 29% of those aged 60-79, and 47% of those aged
80 years. The proportion of cases with perforation increased from 22% to 75% between ages
20-80. Most elderly in California receive timely surgery and tolerate it better than previously
reported (Luckman R., 2019).

A study conducted at King Khalid University Hospital in Saudi Arabia found that 61.3% of
preschool children had complicated appendicitis, while 35.3% had acute appendicitis and
3.7% had normal appendix. Classic symptoms were present in most patients, but atypical
ones were found in some. Symptom duration was longer in complicated appendicitis patients.
73.4% of patients suspected a diagnosis other than appendicitis. Complicated appendicitis
was associated with longer hospital stays and more post-operative complications (Mallick
MS., 2018).

A study by Turkey's department of surgery found that acute appendicitis, the most common
cause of surgical emergencies, has different pathogenesis, clinical courses, and outcomes in
the elderly. The study reviewed 109 older patients aged 50 or older, analyzing demographic
features, preoperative clinical diagnosis, abdominal interventions, postoperative morbidity,
and mortality. The elderly had a higher perforation rate than pediatrics and adults, with a
higher proportion of elderly patients in perforated cases. The precise diagnosis of appendicitis
is relatively low in the elderly (Gurleyit G., 2023). Another similar study at New Delhi, India,
a total of 348 cases of acute suppurative appendices removed because of clinical suspicion of
acute appendicitis. Male to female ratio 2.6:1 with highest number of cases in the age group

XIII
21-30 years;282 specimens out of 348 showed that features consistent with acute appendicitis
with an overall higher occurrence in male statistically significant association was obtained
between perforation and male sex, older age, and acute suppurative appendicitis (Singhal R.,
2017).

A study conducted at the National University Hospital in Bangui, Central Africa, analyzed
the clinical, paraclinical, and therapeutic aspects of 285 patients who underwent laparotomy
to treat acute appendicitis. The study found that the frequency of appendectomy was 42.3%
among patients undergoing visceral surgery by laparotomy without acute traumatic
abdominal syndrome. The incidence of appendectomy in Bangui was 36.5% per 100,000
inhabitants in 2019. The cases were diagnosed based on clinical grounds, with 30% having a
leukocyte count exceeding 10,000 per mm3. Histological examinations revealed the presence
of parasites in 10 cases. Negative appendectomy was the most common, with parenteral
treatment prescribed systematically after surgery. The mean hospital stay was 6.7 days, and
no early post-operative complications resulted in patient death. However, two late post-
operative complications led to patient death, resulting in a mortality rate of 3.5% (Zoguerch
DD., 2021).

A prospective audit at Endale hospital in South Africa found that 200 patients with acute
appendicitis were operated, with 64% being male. The mean duration of illness before
medical intervention was 3.7 days. Surgical access was by midline laparotomy in 62.5% and
Lanzes incision in 35.5%. Major complications included hospital acquired pneumonia in
12.5%, wound dehiscence in 7%, and renal failure in 3%. Post-operatively, 89.5% were
admitted directly to the general ward, with 11% requiring ICU admission. Overall mortality
was 2% (Victor YK., 2019). Another prospective study in Lagos, Nigeria, analyzed 250 cases
of acute appendicitis, focusing on presentation, management, operative findings, and
treatment outcomes. The majority of cases (42.8%) occurred in the third decades of life, with
common symptoms including abdominal pain, fever, and vomiting. Common signs included
RIF direct tenderness, rebound tenderness, localized tenderness, localized guarding, and right
rectal wall tenderness. The mean WBC count was elevated, and 63% of appendices were
retrocecal. 98% of patients with acute appendicitis had appendectomy, with wound infection
being the most common post-operative complication. The overall complication rate was
13.5%, and negative appendectomy rate was 13.4% (Fashina IB., 2019).

XIV
Between 1998 and 2014, a retrospective study at Kumasi Ghana involved 628 patients, with a
male to female ratio of 1.7:1. The majority of patients were admitted with abdominal pain,
with vomiting, fever, and anorexia being the most common symptoms. The mean duration of
illness was 74 hours, with 89.22% of patients experiencing RIF pain and tenderness. The total
WBC count was significantly raised, and 628 appendices were performed, with 39%
perforated at operation. Wound infection was the most common complication, with an
average stay of 7 days. The mortality rate was 1.9%, mostly elderly patients (Ohene Y.,
2016). Another similar study in Nigeria studied 603 consecutive patients with acute
appendicitis over a 5-year period. The majority were females, with a male-to-female ratio of
1.8:1. The patients were aged 4-65 years, with a median age of 22.1 years. The most common
symptoms were abdominal pain and tenderness. Supportive lab and radiological services
were not regularly available, but Leukocytosis with left shift was useful. At surgery, 70% had
acutely inflamed appendix, 20% gangrenous or perforated appendicitis, and 3% an appendix
abscess. Wound infection complicated surgery in 3% of patients, and there were no operative
deaths. Acute appendicitis was the second most common surgical abdominal emergency
during the study period (Oguntola AS., et al., 2020).

A review of 277 cases of acute appendicitis admitted to Zewiditu Memorial Hospital in

Ethiopia from January 1st to December 31st 2012 revealed that 5.8% had a RLQ mass, which
was managed conservatively, while 94.2% required emergency surgery. The majority of
cases (70.6%) had simple appendicitis, 17.4% had perforated, and 9.5% had gangrenous
appendices. The patient population ranged from 13 to 75 years old, with the peak occurring
between 13-30 years. Common symptoms included abdominal pain, vomiting, localized
tenderness in the RLAQ, and rebound tenderness. Digital rectal examinations were performed
in 127 patients, with 78.4% of the appendix approach through a transverse incision at Mc
Burney's point. Appendectomy was the most common emergency operation, accounting for
46.7% of cases, with a post-operative mortality rate of 1.2% (Abrham D., 2013).

Acute appendicitis was the most common cause of acute abdomen in a study, with 87.5% of
cases. The majority of patients were boys, with a male to female ratio of 1.6:1. The most
common symptoms were abdominal pain, anorexia, vomiting, and fever. Right lower
quadrant tenderness was the leading physical finding in 83.9% of patients. Children with non-
perforated appendicitis had a longer duration of symptoms, with a mean duration of 2.5 days.
The mean length of hospital stay was 3.6 days for non-perforated appendicitis and 8.4 days
XV
for perforated appendicitis. Leucocytosis was observed in 74.5% of children, with a mean
leucocyte count of 13150/mm3. Perforation incidences were 4.1%, 10.2%, and 45.3%.
Postoperative wound infection was observed in 1.9% and 31% of children with non-
perforated and perforated appendicitis, respectively. Two children died in the hospital
(Assefa Z., 2014).

Another study at Dil Chora hospital reported that acute appendicitis was the most frequent
cause of acute abdomen, which was followed by intestinal obstruction and gastro-duodenal
ulcer rupture. The 20–29 age range was when it peaked in occurrence. The mortality ratio for
acute abdomen was 10.9%. Results of acute abdomen were shown to be statistically
significantly associated with fewer than two days of sickness (AOR=3.89, 95% CI=1.094-
13.84), age between 18 and 50 (AOR=5.06, 95% CI=1.327-19.349), and season of
presentation (September to November) (OR=3.6, 95% CI=1.296-10.108) (Melkie A. et al.,
2016).

A research including 402 patients at public referral hospitals in the Harari region found that
268 (66.7%) had uncomplicated appendicitis and 134 (33.3%) had severe appendicitis.
Compared to the groups with uncomplicated appendicitis, more individuals with complex
appendicitis had a history of visiting another medical facility (Bayissa B.B. et al., 2022). A
study at Dessie Comprehensive Specialized Hospital found that 12% of 300 patients who
underwent acute appendicitis surgery had unfavorable outcomes. The most common
postoperative condition was wound infection, despite one sepsis-related death. Independent
predictors of unfavorable outcomes included female gender, living outside the hospital
setting, length of illness prior to hospital arrival, more than three days in the hospital, and
mass in the right lower quadrant (Melese Ayele W., 2021).

A study in Addis Ababa, Ethiopia, found a male majority (63.9%) among 18-25-year-olds
with abdominal discomfort as the most common symptom. The most common sign was
tenderness in the right lower quadrant (93.4%). Abdominal ultrasonography was performed
in 81% of participants, with sensitivity and specificity of 95.7% and 33.3%, respectively. The
remaining 74.4%) had simple appendicitis (74.4%). The study found an average hospital stay
of 3.2 days, with a 3.8% morbidity rate and 0.4% fatality rate (Gebre Selassie H. et al., 2021).

XVI
From meta-analysis study that included a total of 15 studies with 6886 study subjects. The
pooled prevalence of acute appendicitis was 46.95 % (95% CI, 41.62 to 52.28 %). Based on
the subgroup analysis, the Tigray region ranked first (51.98 %), followed by Addis Ababa
(49.35%), and the lowest prevalence of appendicitis is reported from Oromia region (47.57%)
(Adu A. and Birhanu Y., 2021). Another systematic review and meta-analysis study reported
that the overall prevalence of acute appendicitis was 44.272% (95% CI: 38.366, 50.18.503; I2
= 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 (Obsa M.S. et al., 2020).

2.3. Conceptual frame work

This conceptual framework is developed based on review of different literatures and
textbooks.

Demographic Factors
Treatment Related Factors:
 Age
Procedure performed
 Sex
 Address
 Marital status
 Educational status

Magnitude of Acute
Appendicitis

XVII

Disease Related Factors:

 Duration of illness
Figure 1: Conceptual framework for study to assess magnitude and treatment outcome of
acute appendicitis at Gelemso general hospital, Oromia region, eastern Ethiopia, 2024. Which
is developed by reviewing different literatures.

3. METHODOLOGY
3.1. Study Area and Period
This study will be conducted at Gelemso General Hospital, which is found in Oromia
National Regional State, and located 376 kms from Addis Ababa. The hospital has a
catchment population of 1,540,354, with 208 beds distributed in medical, pediatrics, surgical,
gynecology, and obstetrics wards. Monthly, an estimated average of 1025 clients attend the
hospital for different reasons. Out of 208 beds, 30 were found in surgical ward. Some of the
services which given by this department were in patient service, emergency and elective
minor and major surgical operations and blood transfusion. The total number of staff in the
hospital are 351. Out of these 190 of them are health professionals including specialists,
General practitioners, Midwifery, Nurses, Lab professional, Anesthesia, Pharmacist, and
others. Numbers of health professionals in the surgical ward are 2 surgeon, and 5 BSc., 7
clinical nurses (Gelemso general hospital HR). The study will be conducted at Gelemso
general hospital from July 28 to August 28, 2024 G.C.
3.2. Study design
Facility based cross sectional study will be conducted on the records review in all patients
who had appendectomy at Gelemso general hospital in the study period.
3.3. populations
3.3.1. Source of population
Records of all patients who were operated for surgical acute abdomen at Gelemso general
hospital from January 01, 2023 - December 31, 2023.

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3.3.2. Study population
Selected records of patients who have had appendectomy at Gelemso general hospital from
January 01, 2023 - December 31, 2023.
3.4. Sample size and sampling technique
The study will be retrospective review, all patients operated for acute appendicitis during the
period from January 01, 2023 - December 31, 2023, will be included.
3.5. Criteria of Legibility
3.5.1. Inclusion Criteria:
Patients, who have gotten operative management for acute appendicitis at GGH from January
01, 2023 - December 31, 2023, will be included in the study.
3.5.2. Exclusion Criteria:
All records of patients, who have undergone appendectomy of a normal appendix having an
initial different diagnosis other than an acute appendicitis, will be excluded from the study.
3.6. Sampling technique
The records of all patients who had emergency appendectomy will be retrieved and analyzed.
3.7. Data collection processes
3.7.1. Data collection instruments
Data collection tools is adopted from similar studies. Those tools include a special patient
Performa which includes socio-demographic characteristics, signs and symptoms, physical
findings, outcomes, complications encountered, and other relevant items related to disease.
The structured checklist will be documented from each patient card and surgery registration
books.
3.7.2. Data collection procedures
The data collected by four graduated clinical nurses (Diploma) who are not employed in any
health institution and will spend their full time in data collection. Training will be given for
two days for data collectors regarding the purpose of the study and the procedures to be
followed for data collection and the principal investigator will supervise them.
3.8. Variables
3.8.1. Dependent variables
Magnitude of acute appendicitis
3.8.2. Independent variables
 Age
 Sex
 Address
XIX
  Length of hospital stay
 Duration of illness
 Clinical signs
 Clinical Symptoms
 Types of abdominal incision
 Intra-operative finding
 Procedure done
3.9. Operational definitions
 Classic presentation of acute appendicitis:
 Patients presenting with the following symptoms:
 Right lower quadrant (right iliac fossa) abdominal pain
 Anorexia
 Nausea and/or vomiting
3
 Leukocytosis – laboratory finding of WBC >10,000/mm
 Negative appendicectomy is defined as one which is performed for a clinical diagnosis of
acute appendicitis but where the appendix is found to be grossly normal.
Favorable outcome:
 Patients with a clinical diagnosis of acute appendicitis improved and discharged from the
hospital and developed no postoperative complication
Length of Hospital stay:
 Number of days elapsed while the patient is in the hospital
Unfavorable outcome:
 Patients with a clinical diagnosis of acute appendicitis who improved but developed one
or more postoperative complication(s), e.g., wound infection, intestinal obstruction, or
 Patients with a clinical diagnosis of acute appendicitis who have died in the intra- or post-
operative period
Outcome:
 Condition of the patient at discharge (either improved and developed no postoperative
complication or improved but developed one or more complication(s), or dead.

3.10. Data processing and analysis

The quantitative data entered in Microsoft excel, the frequency distribution of variables will
be examined to check for data entry errors (e.g., unrecognized of missing codes, out of range

XX
values). Descriptive analysis will be used to describe socio-demographic variables. The data
will be described and presented using text, tables and graphs.

3.11. Data quality assurance

The following measure will be undertaken so as to control the quality of the data. The data
collectors were trained. Before data collection started patient’s cards and surgery registration
books will be collected and cross matched. The checklist will be pretested on selected 15
patients’ documents and checked to avoid printing errors before data collection started. The
name of the data collectors will be recorded so as to enhance the responsibility to any
incomplete data. Data collectors will submit the collected data to supervisor on daily basis
and the supervisor checked the completeness of the data.

3.12. Ethical clearance

Before the data collection period, ethical clearance and approval will be obtained from Rift
Valley University ethical board, and a supportive letter will be given. The data collection will
begin after permission and co-operation obtained from Gelemso general hospital
administration. An informed written and signed voluntary consent will be obtained from
medical record room head after the objectives of the study are explained. A thumbprint or
signature will be used on the consent form. Confidentiality of response will be maintained
throughout the research process by giving code for each patient record.

3.13. Dissemination of result

The report of the study will first be submitted and presented to Rift Valley University, and
then the copies of the report will be given to Gelemso general hospital administrators, west
Hararghe zone health offices. Attempt will be made to present the finding on national and
international conference and workshops. Besides, publication on peer-reviewed journal will
be considered.

XXI
 4. TENTATIVE WORK PLAN
Table 1: Work plan schedule for activities to be implemented for study to assess magnitude
and treatment outcome of acute appendicitis at Gelemso general hospital, Oromia region,
eastern Ethiopia, 2024.
July, 2024
Responsible
No Activities
body

August
March
April

May

June

July
1 Topic selection PI
2 Proposal writes up PI
3 Submission of first draft proposal to advisors PI
4 Submission of second draft proposal to PI
advisors
5 Final proposal submission PI
6 Getting ethical clearance from university EC
7 Data collection, Analysis and report writing PI & DC
8 Submission of first draft report to advisors PI
9 Submitting final report to Department PI
10 Final defense PI
11 Monitoring of the overall activities PI & Advisor

Key: DC- Data collector, EC- Ethical committee and PI- Principal investigator.

XXII
 5. BUDGET BREAKDOWN
Table 2: Budget breakdown for activities to be implemented for study to assess magnitude
and treatment outcome of acute appendicitis at Gelemso general hospital, Oromia region,
eastern Ethiopia, 2024.
5.1. Personnel costs
S. No. Item/ activity Number Multiplier Unit Cost Total cost (Birr)
1 Data clerk 1 10 days 110.0 1,100.0

2 Peridium for data collectors 2 20 days 100.0 4,000.0

3 Peridium for supervisors 1 10 days 230.0 2,300.0

Subtotal: 6

5.2. Transportation and Communication cost

S. No. Item/ activity Number Multiplier Unit Cost Total cost (Birr)
4 Transportation cost 4 5 days 150.0 3,000.0

5 Mobile cards for communication - - 800.0 800.0

Subtotal: 9

5.3. Cost of supplies

S. No. Item/ activity Number Multiplier Unit Cost Total cost (Birr)
Desta(1)
6 A 4 Paper 3.0 680.0 2,040.0

7 Note book Each(3) 3.0 150.0 450.0

8 Pen Each(10) 15.0 20.0 300.0

9 Pencil Each(5) 10.0 15.0 150.0

10 Backup material Each(1) 1.0 1,000.0 1,000.0

11 Duplicating service Page(37) 4.0 5.0 740.0

12 Printing and binding services Page(30) 3.0 300.0 900.0

Subtotal: 63
Total: 16,780.0
Contingency (10 %): 1,678.0
Grand total: 18,458.0

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5.4. Summary of Budget Notification
 Personal cost = 7,400 birr

 Transportation & Communication cost = 3,800 birr

 Cost of supplies = 5,580 birr

 Grand total with 10% contingency = 18,458.0 birr

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Abdus SA, Shahidul A, SM Quamruzzaman, M. Anisur Rahma. Diagnosis of Acute
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Abrham D. Incidence, patterns and clinical presentation of acute appendicitis in adults at
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Addis DG, Shaffer N, Fowler B.S, Tauxe RV. The epidemiology of acute appendicitis
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Anderone RE. The natural history and traditional management of appendicitis revisited
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Assefa Z. 2014. Acute appendicitis in children admitted to Zewditu memorial hospital.
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Bekele A, Makasha A. Clinical Profile and Risk Factors for Perforated Acute
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Blomqvisit P, jung H, Nyren O, Ekbom A. Appendectomy in Sweden 2009- 2016
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Chamisa I. A Clinicopathological Review of 324 Appendices Removed for Acute
Appendicitis in Durban, South Africa: A Retrospective Analysis. Ann R Coll Surg
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Gebre Selassie H., Tekle Selassie H. & Ashebir D. 2021. Pattern and Outcome of Acute
Appendicitis: Observational Prospective Study from a Teaching Hospital, Addis
Ababa, Ethiopia. Open Access Emergency Medicine, 13, 265-271.
Gelemso General hospital Human resource report 10th of May, 2024.
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Turky Eur J Emerg med 2023 Sep; 10(3):200-3
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Medical Journal, 2021 July, 78(7): 355 – 357
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Schwartz SI, Brunicardi CF (Ed), McGraw-Hill Health Pub. Division, New York
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Merlin MA. Evidence based appendicitis; the initial workup. Post grad Med 2020;
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7. ANNEXES
Annex 1: Consent form for head of Gelemso general hospital.
Good morning/afternoon ____________________________________________
Our names are Gurmesa Sherif, Ibsa Ahimed, Mushemam Nezir and Kazno Idris. We are
from Rift Valley University Chiro Campus, we are going to conduct a study on the
assessment of magnitude and treatment outcome of acute appendicitis in Gelemso general
hospital, Oromia region, eastern Ethiopia, from July 28 to August 28, 2024.

The purpose of this study is to assess magnitude and treatment outcome of acute appendicitis
in Gelemso general hospital, Oromia region, eastern Ethiopia, from July 28 to August 28,
2024.

XXVIII
Declaration of informed voluntary consent:
I have read the participant information sheet. I have clearly understood the purpose of the
research, the procedures, the risks and benefits, issues of confidentiality, the rights of
permitting and the contact address for any queries. I have been given the opportunity to ask
questions for things that may have been unclear. I am also informed that the hospital has the
right to stop this study from being conducted in the hospital if any misdeeds and unethical
procedures are observed during the data collection process in the hospital premises.
Therefore, I declare my voluntary consent on behalf of _____________management to allow
this study to be conducted in the Gelemso general hospital with my initials (signature).
Name and Signature of Head of Gelemso general hospital:
_____________________________

Name and Signature of Data Collector: __________________________________

NB: This is to be signed face to face in the presence of data collector and the copy is
provided to the CGH head.

Thank you for your cooperation!

Annex 2: Consent form for medical record room head.

Good morning/afternoon ____________________________________________
Our names are Gurmesa Sherif, Ibsa Ahimed, Mushemam Nezir and Kazno Idris. We are
from Rift Valley University Chiro Campus, we are going to conduct a study on the
assessment of magnitude and treatment outcome of acute appendicitis in Gelemso general
hospital, Oromia region, eastern Ethiopia, from July 28 to August 28, 2024.

The purpose of this study is to assess magnitude and treatment outcome of acute appendicitis
in Gelemso general hospital, Oromia region, eastern Ethiopia, from July 28 to August 28,
2024.

Declaration of informed voluntary consent

I have read/ was read to me the participant information sheet. I have clearly understood the
purpose of the research, the procedures, the risks and benefits, issues of confidentiality, the

XXIX
rights of permitting and the contact address for any queries. I have been given the opportunity
to ask questions for things that may have been inappropriate. I am also informed that the
hospital has the right to stop this study from being conducted in the hospital if any misdeeds
and unethical procedures are observed during the data collection process in the hospital
premises. Therefore; I declare my voluntary consent that this study to be conducted with my
initials (signature) as indicated below.

Æ Contact address if you have any question related with this study
Gurmesa Sherif Phone number_________________
Ibsa Ahimed Phone number_________________
Kazno Idris Phone number_________________
Mushemam Nezir Phone number_________________
Æ Please let you sign this form if you are agreeing that this study be conducted.
Name of MRR head:__________________ Signature of MRR head: ________________
Name of data collector:__________________ Signature of data collector:
________________

NB: This is to be signed face to face in the presence of data collector and the copy is provided
to the participant.
Thank you for your cooperation!
Annex 3: Checklist for data collection.
Checklist
Rift Valley University Chiro Campus, Faculty of Health Science, Department of Nursing:
Checklist for research activity on magnitude and treatment outcome of acute appendicitis in
Gelemso general hospital, Oromia region, eastern Ethiopia, from July 28 to August 28, 2024.

Part I: Demographic Pattern

S/No. Questions Response

Code number _____________________

101 Age in years _____________________

1. Male
102 Sex
2. Female

XXX
 1. Rural
103 Residence
2. Urban

XXXI
Part II: Pattern of Clinical Profile
S/No. Questions Coding Category
1. <24 Hours
201 Duration of illness prior to admission 2. > 24 Hours
1. Periumbilical pain shifting to the RLQ
202 Abdominal pain location 2. RLQ
3. Unspecified sites
1. Yes
203 Decreased or loss of appetite 2. No
1. Yes
204 Vomiting 2. No
1. Yes
205 Nausea 2. No
1. Yes
206 Fever 2. No
3. Diarrhea
207 Associated symptoms 4. Other(s)
1. RLQ (McBurney’s point)
208 Abdominal tenderness location 2. Unspecified
3. Generalized
1. Yes
209 RLQ mass 2. No
210 Raised white blood cells count (> 10,000 1. Yes
3
cells/mm ) 2. No
1. Yes
211 Wound infection 2. No
1. Yes
212 Paralytic ileus 2. No
1. Yes
213 Peritonitis 2. No
1. Yes
214 Chest infections 2. No
1. Yes
215 Fecal fistula 2. No

32
Part III: Management Profile

S/No. Questions Coding Category

1. Rockey Davis/ RLQ transverse/ Lanz
2. Grid iron
301 Type of abdominal incision
3. Lower midline
4. Others*
1. Inflamed/ Phlegmonous appendix
2. Gangrenous appendix
3. Perforated/ Ruptured appendix
302
Intraoperative findings 4. Appendiceal abscess
5. Appendiceal mass
6. Normal appendix
1. Appendectomy
2. Abscess drainage
303 Procedure performed 3. Negative /Prophylactic appendectomy
4. Negative laparotomy
5. Peritoneal lavage
1. Surgical wound infection / Wound dehiscence
2. Fistula
304 Post-operative complications 3. Chest infections
4. Bowel adhesions
5. No complication
1. < 3 days
305 2. 4 – 7 days
Length of hospital stay
3. > 7 days
1. Alive
306 Outcome of patient
2. Dead
*Others include paramedian, Pfannenstiel, midline, transverse sub-umbilical

33