Carbapenems versus ciprofloxacin/metronidazole for decreasing complications and hospital stay following complicated acute appendicitis surgery: A prospective cohort in an Ecuadorian population.

BACKGROUND: After appendectomy due to complicated acute appendicitis (CAA), there are some alternatives as antibiotic scheme: ciprofloxacin/metronidazole; as well as monoscheme based on carbapenems: ertapenem, meropenem, and imipenem. AIM: This study aims to prove the efficacy of carbapenems versus ciprofloxacin/metronidazole in CAA post-operative management in terms of preventing complications during post-operative period and decreasing hospital stay. MATERIALS AND METHODS: This was an observational, analytical, longitudinal, and prospective cohort study (March 2014-November 2016). Patients were classified into two groups, according to the prescribed antibiotic scheme: some carbapenems or ciprofloxacin/metronidazole. RESULTS: Ninety-eight patients were enrolled. There was an requirement for antibiotic therapy rotation only in the ciprofloxacin/metronidazole (7/49, 14.3%; p = 0.004). Carbapenems reached a mean hospital stay of 4.45 days, in contrast with ciprofloxacin/metronidazole, 8.29 days (p = 0.020). In post-surgical follow-up, there were more cases of curative resolution in the group in the carbapenems group (35/49 vs. 15/49 p < 0.001) as well as a greater number of cases with some late infection in the ciprofloxacin/metronidazole group (1/49 vs. 10/49, p = 0.010). CONCLUSION: In the post-operative management of CAA, carbapenems represent an important indication to be considered as first-line antibiotic therapy.

ANTECEDENTES: Tras la cirugía por apendicitis aguda complicada existen varias alternativas de esquema antibiótico, entre las que destacan ciprofloxacino/metronidazol, o bien monoterapia con algún carbapenémico, como ertapenem, meropenem e imipenem. OBJETIVO: Determinar la eficacia de los carbapenémicos en comparación con ciprofloxacino/metronidazol en el manejo posquirúrgico de la apendicitis aguda complicada, en términos de prevención de complicaciones durante el ­posoperatorio y de reducción de la estancia hospitalaria. MÉTODO: Estudio observacional, analítico, longitudinal, prospectivo y de cohorte, de marzo de 2014 a noviembre de 2016. Los pacientes fueron clasificados en dos grupos según el esquema antibiótico prescrito: un carbapenémico o ciprofloxacino/metronidazol. RESULTADOS: Se seleccionaron 98 pacientes. Solo hubo necesidad de rotación de antibiótico en el grupo de ciprofloxacino/metronidazol (7 de 49, 14.3%; p = 0.004). En el grupo de carbapenémico, la media de estancia hospitalaria fue de 4.45 días, y en el grupo de ciprofloxacino/metronidazol fue de 8.29 días (p = 0.020). En el seguimiento posquirúrgico hubo más casos de resolución curativa en el grupo de carbapenémico (35 de 49 vs. 15 de 49; p < 0.001), así como un mayor número de casos con alguna infección tardía en el grupo de ciprofloxacino/metronidazol (1 de 49 vs. 10 de 49; p < 0.001). CONCLUSIÓN: En el manejo posquirúrgico de la apendicitis aguda complicada, los carbapenémicos representan una importante indicación que debe considerarse como antibioticoterapia de primera línea.

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Increased risk of appendectomy in patients with gastroesophageal reflux disease: A nested case-control study using a national sample cohort.

The purpose of this study is to confirm and complement previous data regarding an association between gastroesophageal reflux disease and appendectomy.The Korean National Health Insurance Service-National Sample Cohort includes data from people ≥ 20 years old collected from 2002 to 2013. A total of 13,484 participants who received an appendectomy were matched with 53,936 controls at a 1:4 ratio. We analyzed the previous histories of gastroesophageal reflux disease (GERD) in the appendectomy and control groups. Appendectomies were identified using operation codes (Q2860-Q2863) exclusive for appendicitis (International Classification of Disease-10 (ICD-10): K35). GERD was defined using the ICD-10 (K21), and patients who were treated ≥ 2 times and were prescribed a proton pump inhibitor (PPI) for ≥ 2 weeks were included. Crude (simple) and adjusted odds ratios (ORs) for GERD and appendectomy were analyzed using conditional logistic regression analyses.A higher GERD rate was detected in the appendectomy group (11.4% [1,713/15,062]) than in the control group (8.2% [4,947/60,248], P < .001). Adjusted ORs for GERD were 1.37 (95% confidence interval [CI] = 1.30-1.45) (P < .001). Subgroup analyses stratified according to age and sex revealed consistent findings. The adjusted OR for GERD in participants prescribed PPIs for ≥ 30 days was 1.31 (95% CI = 1.20-1.43), and the adjusted OR for GERD in participants prescribed PPIs for ≥ 60 days was 1.30 (95% CI = 1.15-1.48).The Odds for GERD were higher in the appendectomy group than in the control group.

Pediatric incidental appendectomy: a systematic review.

Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis. It is generally performed to eliminate the risk of future appendicitis. The risks and benefits of incidental appendectomy during various operations in children have been debated for over a century, but need to be revisited in light of innovations in medical practice, including minimally invasive surgery, improved imaging techniques, and use of the appendix as a tubular conduit for reconstruction. A detailed review was undertaken of the techniques, pathology, risks of appendectomy, utility of the appendix, and incidental appendectomy in the treatment of specific pediatric medical conditions. A comprehensive literature search was performed, and retrieved results were reviewed for relevance to the topic. The decision to perform a pediatric incidental appendectomy relies on informed consideration of the individual patient's co-morbid conditions, the indication for the initial operation, the future utility of the appendix, and the risk of future appendiceal pathology. The discussion includes a variety of situations and comorbid conditions that may influence a surgeon's decision to perform incidental appendectomy.

Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis.

Preoperative samples in the context of complicated appendicitis (CA) are rarely collected, and there is no consensus regarding the optimal antibiotic therapy in children. To help optimize empirical preoperative treatment, we studied clinical and bacteriologic data from a prospective cohort of 93 children with CA in a French hospital. All the bacteria isolated from peritoneal fluids were identified, using phenotypic and/or molecular techniques. The most commonly recovered species were Escherichia coli (71%), Streptococcus group milleri (34%), anaerobes (20%), and Pseudomonas aeruginosa (19%). The association piperacillin-tazobactam is an accurate choice of empirical therapy as it is active against 97% of bacteria. A third-generation cephalosporin with metronidazole in association with an aminoglycoside is a good alternative. Although antibiotic use may be considered as an adjunct to surgical intervention of CA, the appropriate use of preoperative antibiotics is essential and must be constantly reevaluated according to the bacterial epidemiology.

Does access to care affect outcomes of appendicitis in children?--A population-based cohort study.

BACKGROUND: The annual number of pediatric appendectomies in Ontario was stable throughout the study period, but with a significant level of regional variations across regions. The objective of this study is to use population-based data to measure the associations and to explain the variations of appendectomy rates with population socio-demographic indicators. METHODS: Appendectomy rates in children aged less than 19 years were calculated from Ontario hospital discharge data from 1993 to 2000. Small area variations in appendectomy and correlations between socio-demographic indicators were studied. Multiple logistic regression was used to measure the risk of negative appendectomy and perforation while adjusting for socio-demographic factors. RESULTS: The rate of positive primary appendectomy has been stable since 1993 with an average rate of 93.2 per 100,000 children. The negative appendectomy rates showed a significant decline over time from a high of 16.0 in 1994 to 10.2 per 100,000 in 2000 (p < 0.0001). There was a 4-fold regional variation in negative appendectomy with the highest rate of 26.0 per 100,000 in the northern regions of Ontario. After adjusting for socio-economic status, areas of higher percentages of rural living remained a single significant factor associated with a higher chance of negative and perforated appendectomy (OR = 1.28, 95% CI: 1.01, 1.61, p < 0.01 and OR = 1.11, 95% CI: 0.96, 1.28, p = 1.682 respectively). Areas with higher ultrasound use were associated with a lower risk of perforated appendectomy (OR = 0.83, 95% CI: 0.72, 0.95, p < 0.05). CONCLUSION: The higher rates of negative and perforated appendectomy in rural populations underpin the influence of access to preventive and primary health care in modifying the odds of appendicitis resulting in surgery.

Apendicitis aguda: formas de presentación clínica y casuística del Hospital San Juan de Dios / Acute appendicitis: clinical presentation and caseload of San Juan de Dios Hospital

La apendicitis aguda es el trastorno quirúrgico más común del abdomen y es uno de los cuadros clínicos a los que, con mayor frecuencia, se ven enfrentados los cirujanos. En el presente trabajo se analizan los distintos factores involucrados en su etiopatogenia y la importancia del diagnóstico clínico para decidir la conducta terapéutica adecuada. Se estudian 100 casos de pacientes con diagnóstico de apendicitis aguda intervenidos quirúrgicamente en el Servicio de Urgencia del Hospital San Juan de Dios entre los meses de Enero y Abril del año 2004. Se analizan datos correspondientes a identificación; forma de presentación clínica; tiempo de evolución, correlacionándolo con los hallazgos intraoperatorios; estudios complementarios de laboratorio; complicaciones; controles y evolución postoperatoria.

Perforated appendicitis in children: is there a best treatment?

PURPOSE: This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors' hospital. METHODS: This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital. RESULTS: The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management. CONCLUSIONS: Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm3. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.

Appendiceal disease in women with endometriosis and right lower quadrant pain.

STUDY OBJECTIVE: To evaluate the frequency and range of appendiceal disease in women with endometriosis and right lower quadrant (RLQ) pain, and to estimate the value of preoperative gastrograffin enema (GGE) as a screen for the disease. DESIGN: Nonrandomized clinical trial (Canadian Task Force classification II-2). SETTING: University-affiliated hospital with a private practice setting. PATIENTS: A subpopulation of 65 women from a group of 337 patients undergoing laparoscopy for symptomatic endometriosis. INTERVENTION: Preoperative GGE was performed whenever possible in these women. At laparoscopy, the appendix was removed if it appeared abnormal or if the preoperative GGE was positive. MEASUREMENTS AND MAIN RESULTS: Of 65 women (19%) with symptomatic endometriosis and preoperative RLQ pain, 52 (80%) underwent appendectomy as part of surgery. Of these 52 excised appendixes, 39 (75%) had histologically confirmed pathology including appendicitis or periappendicitis, endometriosis, fibrous obliteration, lymphoid hyperplasia, and carcinoid tumor. Preoperative GGE had sensitivity of 74% and specificity of 83% for appendiceal disease. Its positive predictive value was 95% and negative predictive value was 42%. No complications from laparoscopic appendectomy occurred. CONCLUSION: Disease of the appendix is common in women with endometriosis and RLQ pain. Appendectomy is particularly likely if preoperative GGE is positive.

Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory.

BACKGROUND/PURPOSE: The authors compared 3 quantitative methods for assisting clinicians in the differential diagnosis of abdominal pain in children, where the most common important endpoint is whether the patient has appendicitis. Pretest probability in different age and sex groups were determined to perform Bayesian analysis, binary logistic regression was used to determine which variables were statistically significantly likely to contribute to a diagnosis, and recursive partitioning was used to build decision trees with quantitative endpoints. METHODS: The records of all children (1,208) seen at a large urban emergency department (ED) with a chief complaint of abdominal pain were immediately reviewed retrospectively (24 to 72 hours after the encounter). Attempts were made to contact all the patients' families to determine an accurate final diagnosis. A total of 1,008 (83%) families were contacted. Data were analyzed by calculation of the posttest probability, recursive partitioning, and binary logistic regression. RESULTS: In all groups the most common diagnosis was abdominal pain (ICD-9 Code 789). After this, however, the order of the most common final diagnoses for abdominal pain varied significantly. The entire group had a pretest probability of appendicitis of 0.06. This varied with age and sex from 0.02 in boys 2 to 5 years old to 0.16 in boys older than 12 years. In boys age 5 to 12, recursive partitioning and binary logistic regression agreed on guarding and anorexia as important variables. Guarding and tenderness were important in girls age 5 to 12. In boys age greater than 12, both agreed on guarding and anorexia. Using sensitivities and specificities from the literature, computed tomography improved the posttest probability for the group from.06 to.33; ultrasound improved it from.06 to.48; and barium enema improved it from.06 to.58. CONCLUSIONS: Knowing the pretest probabilities in a specific population allows the physician to evaluate the likely diagnoses first. Other quantitative methods can help judge how much importance a certain criterion should have in the decision making and how much a particular test is likely to influence the probability of a correct diagnosis. It now should be possible to make these sophisticated quantitative methods readily available to clinicians via the computer.

[Acute appendicitis at the National University Hospital in Bangui, Central African Republic: epidemiologic, clinical, paraclinical and therapeutic aspects]. / Les appendicites aiguës au Centre National Hospitalier Universitaire de Bangui, Centrafrique: aspects épidémiologiques, cliniques, paracliniques et thérapeutiques.

We carried out a retrospective study to analyse clinical, paraclinical and therapeutic aspects of acute appendicitis cases as the National University Hospital (CNHU) at Bangui in the Central African Republic. We compared our findings with those for other African countries and for industrialized countries. From September 15 1990 to February 15 1992, 285 patients underwent laparotomy to treat acute appendicitis. We carried out a study of clinical, paraclinical and therapeutic aspects on 57 patients with complete case histories (20% of the patients undergoing surgery). The appendices of these patients were sent to the Laboratory of Pathological Anatomy of the Faculty of Medicine at Marseille, France, for analysis. The frequency of appendectomy among patients undergoing visceral surgery by laparotomy with no acute traumatic abdominal syndrome was 42.3%. The incidence of appendectomy for the city of Bangui in 1991 was 36.5 per 100,000 inhabitants. These cases of appendicitis were diagnosed essentially on clinical grounds. Leukocyte counts exceeded 10,000 per mm3 in 30% of the patients. Histological examination revealed the presence of parasites in 10 cases : Schistosoma mansoni eggs (seven cases) and Ascaris lumbricoides eggs (one case) in patients with acute appendicitis and one case each of Schistosoma mansoni eggs and Ascaris lumbricoides eggs at the time of diagnosis but normal histological results for the removed appendix. Most of the patients consulted late, a mean of four days after the onset of symptoms. The frequency of appendectomy on principle was 12.7% and parenteral antibiotic treatment was prescribed systematically follow- ing surgery. The mean duration of hospital stay after surgery was 7.6 days. No early postoperative complications were noted. However, two late postoperative complications resulting in the death of the patient were observed, giving a mortality rate of 3.5%. These complications were one case of peritonitis after appendectomy involving intestinal resection and one case of occlusive syndrome with septic shock. The frequency of acute appendicitis at the CNHU at Bangui was similar to that reported in another tropical African country (~ 1%). However, the incidence of appendectomies at Bangui is lower than generally reported for western countries (15 to 40%). Positive diagnosis was made on classic data obtained on clinical examination and on associated biological data, if available. Parasites were identified on histological examination in some cases of acute appendicitis, but it is unclear whether these parasites were actually responsible for the appendicitis. Efficient examinations for the exploration of acute nonspecific abdominal pain, such as the measurement of inflammation indicators, particularly serum activated protein C levels, graded-compression ultrasound scans and celioscopy, should be made available in the hospitals of African countries to increase the precision of diagnosis and to decrease the still too high frequency of appendectomies performed on principle. The postoperative mortality rate at the CNHU of Bangui is higher than the low rates (0.1 to 0.25%) reported for industrialized countries but is close to those reported for African countries. This high rate of mortality results partly from the lateness of consultations, because patients in tropical Africa often consult a traditional healer before resorting to modern medicine, and partly from misdiagnoses.

Tc-99m-HMPAO white blood cell scan for diagnosis of acute appendicitis in patients with equivocal clinical presentation.

OBJECTIVE: The authors' goal was to evaluate the accuracy of Technetium 99m-HMPAO-labeled leukocyte imaging for screening patients with atypically presenting appendicitis and to determine how availability of this test affected practice patterns of surgeons at the authors' medical center. SUMMARY BACKGROUND DATA: Appendicitis can be difficult to diagnose and in equivocal cases usually requires inpatient observation. The delay may increase morbidity and costs. A test that rules out acute appendicitis could be cost effective if it allowed early discharge from the emergency department. Previously, there have been no simple, rapid, accurate noninvasive methods for improving diagnostic accuracy in patients with equivocal presentations of appendicitis. METHODS: Patients referred to rule out appendicitis were analyzed. Patients were imaged up to 3 hours after injection of 10-mCi 99mTc-HMPAO-labeled autologous leukocytes (Tc-WBC), and when the scans became positive, imaging was terminated and the requesting physician notified of the results. Diagnostic accuracy was established by surgical and histopathologic findings or by absence of symptoms after 1 month clinical follow-up. The source of referral, hospital length of stay, disposition of patients, and ancillary tests (ultrasound, computed tomographic scan, and barium enema) were analyzed. RESULTS: One hundred twenty-four patients were studied from November 1991 through December 1995. Fifty-eight percent of positive scans showed uptake within 1 hour of injection and 73% by 2 hours. The Tc-WBC scan correctly identified an inflammatory source of abdominal pain in 65 of 66 cases (sensitivity = 98%) and was correctly negative in 55 of 58 cases (specificity = 95%). The scan correctly diagnosed appendicitis in 50 of 51 cases (sensitivity = 98%) and correctly excluded appendicitis in 62 of 73 cases (specificity = 85%). Outpatient referrals increased from 38% to 87%. In those patients with negativescans, inpatient observation, number of adjunctive tests, and length of stay decreased significantly. CONCLUSIONS: The high sensitivity and negative predictive value of Tc-WBC imaging may permit patients to be screened and discharged from the emergency department. Focally positive scans often indicate disease requiring operation but not in all cases. The Tc-WBC imaging reduced the negative laparotomy rate to 3.9% while reducing admission rates and hospital length of stay.

[The value of imaging techniques in the diagnosis of non-specific abdominal pain in young patients]. / Wertigkeit bildgebender Verfahren bei der Diagnostik unspezifischer abdomineller Beschwerden junger Patienten.

In a retrospective study the use of imaging modalities in the diagnosis of non-specific abdominal pain in patients under 31 years was evaluated. 253 patients with primarily non-specific abdominal complaints were analysed. For further investigation one of the following methods had to be applied: abdominal sonography and/or upper gastrointestinal tract roentgenograms and/or enteroclysis and/or barium enema. In 66% (167/253) of all cases abdominal pain remained non-specific. Clinical history and physical examination led to the final diagnosis in 66/86 (76.7%) of patients with pathologic findings. 21/561 (3.7%) radiographic examinations revealed abnormalities of clinical importance. In 10/253 (4%) patients the final diagnosis could be established only with the help of radiologic and/or endoscopic examinations. The low efficacy of conventional radiology justifies the demand for a stricter indication in the young patient suffering from non-specific abdominal pain.

[Antibacterial and detoxification therapy in acute appendicitis]. / Antibakterial'naia i dezintoksikatsionnaia terapiia pri ostrom appenditsite.

An analysis of clinical effectiveness of antibacterial therapy, photomodification of autoblood, hemosorption and their combinations was made in 395 patients with acute appendicitis. It was established that no antibacterial and desintoxicating therapy is required in catarrhal appendicitis. The prophylactic application of photomodification of autoblood is thought to be most expedient for phlegmonous appendicitis at the postoperative period, a combination of antibacterial therapy and photomodified autoblood--for gangrenous appendicitis, a combination of antibacterial therapy, photomodification of autoblood and hemosorption--for appendicular diffuse suppurative peritonitis.

Barium enema in the diagnosis of acute appendicitis.

Acute appendicitis is still a difficult diagnosis to make. Reports place the rate of incorrect diagnosis--the rate of negative laparotomy--at 15 to 42 per cent. This study is a prospective analysis of barium enema (BE) examinations performed upon 101 patients who presented with a history accompanied by signs and symptoms suggestive of, but not clearly diagnostic of, acute appendicitis. The over-all accuracy rate was 91.5 per cent. Sensitivity and specificity rates were 83 and 96 per cent, respectively. BE had a positive predictive value of 88 per cent and a negative predictive value of 95 per cent in this study. No complications resulted from the use of BE in this study, which included three instances of perforated appendicitis. We conclude that emergent BE is an inexpensive, safe and readily available adjunct to the diagnosis of acute appendicitis. Its use in the presence of a clear-cut presentation of acute appendicitis is not necessary. When clinical data were equivocal, BE reduced the rate of negative laparotomy to 7.2 per cent.

What causes appendicitis?

Appendicitis was rare in the past and still is in traditional Third World populations. It began to increase a century ago, peaked about 1950, and has now fallen to about half its previous incidence. As to causation, dietetically, it was contended that the increase was promoted primarily by an associated fall in dietary fiber intake. The recently advanced hygiene hypothesis considers the increase to have stemmed from improvements in hygiene, generally; these limited exposure to enteric infections and modified response to virus infections, thereby triggering appendicitis. Major uncertainties still prevail over the promotive and precipitating factors of the disease. It is doubtful whether individuals can take any action to avoid appendicitis.

The geography of chronic digestive disease in southern Africa.

Lifestyle and dietary patterns are in the process of rapid transformation in Soweto. Comparisons with whites indicate differences in bowel behaviour, lactase deficiency and breath methanes. The association between smoking pipe tobacco and cancer of the oesophagus is confirmed, but home-brew consumption has been found to be the major risk factor in this cancer. A recent swing to Western-type alcohol has led to the emergence of alcohol-induced pancreatitis in blacks. Urbanisation and westernisation have also affected the influence of the traditional healer and the incidence of duodenal ulcer disease. The fundamental environmental influence which determines non-infective large-bowel disease is diet. A dietary survey of Sowetans indicates that their present diet is low in fat and fibre. Despite the latter, appendicitis is still relatively uncommon. Other significant differences are observed in colorectal cancer and diverticular disease.

Diet, infection, and acute appendicitis in Britain and Ireland.

During 1979-82 hospital discharge rates after emergency admission for acute appendicitis were higher in Eire (17.4 per 10,000 population) than in England (10.3), Scotland (11.1), or Wales (12.3). Comparison of food consumption between the four countries, and between the health board areas of Eire and regions of Scotland, shows that appendicitis rates are highest in communities that consume more potatoes, sugar, and cereals, and less non-potato vegetables and fruit. The rates are also related to mortality from enteric and respiratory infections, to general practice consultations for infective disease, and to postneonatal mortality. This is evidence in favour of the hygiene hypothesis for the aetiology of appendicitis.

Diet and bowel diseases--past history and future prospects.

Changes in diet from ancient times until the present are described. Previously relatively low in energy and animal products yet high in fibre-containing foods, diets are now high in energy and animal products (particularly fat), yet contain less fibre. The changing incidences of bowel disorders and diseases are described, with assessments of the role of diet. Clearly, diet is implicated as regards predisposition to constipation, appendicitis, colorectal cancer and diverticular disease; however, a meaningful dietary role in irritable bowel syndrome, ulcerative colitis and Crohn's disease is doubtful. In South Africa the rarity of bowel diseases in rural blacks compared with whites affords valuable aetiological information about some bowel diseases. The low occurrence thereof (except inflammatory bowel disease) in Indian and coloured populations is not readily explicable. While dietary changes in whites are being widely urged in order to combat degenerative diseases, the magnitude of changes made is unlikely to reduce the occurrence of bowel diseases. The progressive westernization of the diets and lifestyles of less-privileged populations is likely to be associated with increases in the incidences of these diseases.