Bowel movement patterns in children with acute appendicitis

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Article Information:

Group: 2007
Subgroup: Volume 9, Issue 2
Date: April 2007
Type: Original Article
Start Page: 86
End Page: 92


  • MH Imanieh
  • Departments of Pediatric Gastroenterology,Gastroenterohepatology Research Center, Shiraz, Fars, Iran
  • SA Banani
  • Pediatric Surgery,Nemazee Hospital,Shiraz University of Medical Sciences, Shiraz, Fars, Iran
  • SM Dehghani
  • Departments of Pediatric Gastroenterology,Gastroenterohepatology Research Center, Shiraz, Fars, Iran
  • R Khajeh
  • Departments of Pediatric Gastroenterology Research Center I, Gakurya,
  • D Mehrabani
  • Gastroenterohepatology Research Center ,
    • Correspondence:

      Affiliation: Departments of Pediatric Gastroenterology,Gastroenterohepatology Research Center
      City, Province: Shiraz, Fars
      Country: Iran
      Tel: +98-711-624-2534
      Fax: +98-711-626-5024


Background: Acute appendicitis is currently one of the most important causes of acute abdominal peritonitis and emergency laparatomy. Despite its low mortality, it remains a cause of concern for surgeons due to the postoperative complications of wound infection, sepsis, intrabdominal abscess and even bowel obstruction resulting from adhesions. High incidence of acute appendicitis provides a strong impetus for further studies. This study was conducted to determine the bowel movement patterns and dietary fiber consumption in pediatric patients with appendicitis in Shiraz, southern Iran.


Methods: The study included 202 pediatric patients under the age of 18 years at Nemazee Hospital affiliated to Shiraz University of Medical Sciences, who had undergone appendectomy with the preoperative diagnosis of acute appendicitis from March 2003to March 2004. Using a written semi-standard questionnaire, the variables recorded were age, gender, stool consistency, number of bowel movements, type of bread consumed, habit of fruit and vegetable consumption, clinical presentation (signs and symptoms) and the time taken from the onset of symptoms to arrival in hospital, the date of patients admission to the emergency room to the time of surgery, and the duration of postoperative hospitalization. The pathology of appendicitis was clarified and recorded.


Results: The patients aged from 3–18 years (mean: 11.2±3.6 years), with a male to female ratio of 2:4. Anorexia was the most common symptom, affecting 78.7% of patients. Of 31 patients with constipation, 58% did not report daily regular intake of fruits while the others had regular fruit intake. Only 3 patients (9.7%) had regular daily consumption of vegetables, and 27 patients (87.1%) had pathology reports of fecalith, while in the nonconstipated patients, only 1.2% had such reports. The abdominal pain was periumbilical in many patients (42.6%), which shifted to McBurny point in most (96%) patients. 134 patients (66.3%) visited a health center within 24 hours after the first symptoms. Surgeries were performed on 132 patients (65.3%) within 6 hours, on 67 patients (33%) within 6–12 hours, and on 3 patients (2%) in more than 12 hours.


Conclusion: Our findings suggest a high rate of constipation in patients with lower fiber intake, which is consistent with the hypothesis indicating the role of dietary fibers in lowering the incidence of appendicitis.

Keywords: Acute appendicitis; Children; Dietary fiber; Constipation

Manuscript Body:


Acute appendicitis is currently one of the most important causes of acute abdomen, peritonitis and emergency laparatomy. Although mortality due to appendicitis has been significantly reduced, it remains a source of concern for surgeons because of its postoperative complications such as wound infection, sepsis, intra-abdominal abscess and even bowel obstruction arising from adhesions. The high incidence of acute appendicitis provides a high potential for further studies of the disease. The etiology of acute appendicitis has interested researchers worldwide.1,2 In spite of the fact that the etiology of acute appendicitis and several etiologic factors have been subject of speculation and discussion, multiple factors are probably involved in pathophysiology of the disease. These include non-specific factors, as well as viral, bacterial, and fungal infections and fiberdeficient dietary regimens, etc.

The evidence for the association of acute appendicitis with fiber deficient diets is based on epidemiologic studies, mostly conducted in Africa. In addition, the rising incidence of the disease in Europe during 19th century was due to decreasing fiber content of the diet. Ironically, little changes in the total fiber content of the dietary regimen in the past 30 years, have not shown any significant increase in the incidence of acute appendicitis.3-6

The impact of dietary fiber on human health has intrigued both the medical community and the public. In the US, several groups have recommended inclusion of fiber in the diet. Moreover, whole grain products are known to be beneficial to normal colon functioning.7,8 Despite the fact that most dietary elements are absorbed by the small intestine, fibers are the only components that enter the colon largely unchanged. This forms the basis for the belief that fiber content of the diet affects all conditions and functions of the intestine.7,8 Pattern, consistency and number of bowel movements have been the subject of studies for many years. A significant difference has been noted between the incidence of diseases of the colon in the industrialized communities with low dietary fiber intake and non-industrialized communities with fiber-riched diet.9,10 The industrialized nations have registered increased incidences of constipation, irritable bowel syndrome (IBS), diverticulitis, colon cancer, and appendicitis. Given that the water content of dietary fiber is three times its density, it forms softer and heavier stools with a larger volume and reduced passage time, thus lowering the probability of contracting appendicitis as compared to stools with lesser fiber. However, there is a need for further enquiry into the effect of dietary fiber. Unexpectedly, the incidence of cute appendicitis in the US has decreased despite low dietary fiber content. The incidence of acute appendicitis in industrialized states is still much higher than that of non-industrialized nations.11,12 The present study was performed to determine the importance of bowel movement patterns in relation to acute appendicitis in pediatric patients in Shiraz, southern Iran.



Materials and Methods


The present study included a total of 202 pediatric patients with acute appendicitis, and aged from 3-18 years (11.2±3.6) with 143 males, and 59 females, who referred to Nemazee Hospital affiliated to Shiraz University of Medical Sciences from March 2003 to March 2004. A written semi-standard questionnaire was completed by each patient and/or their parents. The pathology of appendicitis was clarified and recorded in each case. The questionnaire provided information on the variables of age, gender, stool consistency,  number of bowel movements, duration of constipation if any, type of consumed bread, whether whole or bran, habit of fruit and vegetable consumption. Further information recorded in the questionnaire included the chief complaint and its initial site, pattern of spread of the abdominal pain, the presence of signs and symptoms such as fever, anorexia, nausea, vomiting, diarrhea, and rebound tenderness. Account was also taken of the time from the beginning of symptoms to arrival in hospital, the interval between patients admission to the emergency room and surgical operation, and the duration of postoperative hospitalization. The statistical analyses of the results were carried out using SPSS software (version 11.5, Chicago, IL) and P <0.05 was considered significant.





Of 202 patients with acute appendicitis, 31 subjects complained from hard stools, 169 had normal stools and 2 experienced loose stools. On the average, bowel movements were reported from one to three times in every 24 hours, in 171 and less than three times per week in 31 patients. Furthermore, in 140, 29 and 2, subjects, the bowel movements were once, twice, three times every 24 hours respectively. On the other hand, the corresponding bowel movements reported in 23 and 28 patients were once every 72 and 96 hours. Pathology examination of 202 patients showed fecalith material in 118, fecalith in 29, pussy or bloody material in 38 and mucosal or lymphoid tissue hyperplasia in 9 patients with no specific pathologic diagnosis in 8 subjects (Table 1). Of 31 patients with acute appendicitis, constipation, mucosal or lymphoid tissue hyperplasia and fecalith material were reported in 27, 2 and 1 respectively, with undetermined pathology in one case (Table 1). The daily consumption of whole bread was reported in only 7 of 202 patients (Table 2). All the 31 patients who experienced appendicitis had histories of constipation and did not consume whole bread. Except 14 cases, of 171 patients with acute appendicitis and without the history of constipation, 157 had regular daily intake of fruit (Table 2). Out of the 31 patients with concurrent appendicitis and constipation, only 18 patients had regular daily intake of fruit (Table 2). Among the 171 patients without constipation, 105 patients had a regular daily intake of green vegetables; while 66 patients had not such history (Table 2). Among the 31 patients with constipation, only 3 patients had a positive history of regular daily vegetable intake (Table 2). The frequency and percentage of distinct signs and symptoms associated with acute appendicitis are shown in Table 3.











One-hundred and thirty-four patients (66.3%) visited a health center within 24 hours after the first symptoms, 39 (19.3%) presented within 24-48 hours and 29 (14.4%) presented after 48 hours of beginning of symptoms. The shortest time interval between beginning of symptoms and their arrival at a health facility was about one hour, while the longest time interval was about 120 hours. The mean time was about 29 hours. The shortest duration between arrival at the center and the carrying out of surgery was about 2 hours, and the maximum time was 12 hours. The mean time between patient’s arrival and surgery was six and a half hours. The minimum period of hospitalization after surgery was 24 hours, and the maximum period was about 58 hours. The pathology report showed that 130 patients had simple inflammation, 18 patients had suppurative appendicitis, 25 patients had gangrenous appendicitis, 27 patients had perforated appendicitis, and 2 patients had appendicular abscess.





Our results showed that, out of 202 children with acute appendicitis, 31 patients reported passing hard stools. These patients had an average frequency of bowel movement of less than three times a week. In accordance with the primary definition of constipation, 15.3% of all the patients proved to be suffering from this entity.7 A clear-cut definition of constipation, based on stool consistency and frequency of bowel movements, has not been described in previous studies. Therefore, it was not practical for researchers to uniformly evaluate the occurrence of constipation either in their patients or control groups.7

Among 31 the patients with a history of constipation, 18 patients (58%), did not report any daily regular intake of fruits while the remaining subjects had regular fruit intake. Statistical analysis showed a meaningful difference between the two groups (P=0.0001).

Of patients with a history of constipation, only 3 (9.7%) had a regular daily consumption of vegetables, whereas a significant majority did not consume vegetables (P=0.0001).

In regard to whole bread consumption, no significant difference was found between patients with constipation and control group. In majority of patients, the accurate measurement of dietary fiber intake was made in terms of grams per day.1 In our study, such estimation was not practical, and therefore, the patients with clinical history, were evaluated on the basis of their daily intake of fruit and vegetables. In fact, this per se has a solid basis and is a reliable and rapid method.3-5

Volz was the first to describe the relationship between the presence of fecalith and inflammation of the appendix. The belief that luminal obstruction is an important factor in the pathogenesis of acute appendicitis is based on the finding of fecalith in many patients with advanced disease.1

In this study and on the basis of pathology report, of 31 patients with constipation, 27 cases (87.1%) had fecalith, compared with 2 patients(1.2%) in the non-constipated group (P=0.0001), which was consistent with that of previous study.3-6 However, because of the small number of patients with constipation in our study, a conclusive generalization was not possible. Several authors found a logical relationship between acute appendicitis and decreased fiber intake.6,9,11 In connection with dietary fiber intake, Nelson investigated children with lower fiber intake who underwent appendectomy compared with their control.11 This supports the statement that a relationship existed between dietary fiber intake and the incidence of acute appendicitis. Despite the absence of control in our study, the agreement of our findings with that of above authors strongly suggested the possibility of such a relationship in our study population. History taking is an effective means for the evaluation of nutritional status in children, especially in recent past. This is more reliable when both children and their parents were included.3-5 This is an accurate method that was used in our study for the evaluation of dietary habits.

Our results showed that the rate of constipation was higher in patients with lower fiber intake, a finding consistent with the hypothesis that the dietary fibers reduced the incidence of appendicitis.9 Some studies also indicate that deficient dietary fiber per se does not lead to appendicitis, and other co-existent factors including bacterial, viral or fungal infections ,which were not looked for in our study, may be involved in the pathogenesis of appendicitis.4,5 A retrospective study carried out by Coughlin on 220 patients with cystic fibrosis during 1965–1989 showed 60 patients were appendectomized due to acute appendicitis. The study demonstrated that appendicitis in patients with cystic fibrosis ranged from simple mucosal swelling to severe inflammation of the vermix appendix. Our study fell short of taking pertinent history of organic etiologies of constipation and we therefore recommend that future studies incorporate this important component. Of 220 patients in the foregoing study, 143 were male and 59 female, with an approximate M/F ratio of 2.4. Other studies reported a ratio of 1.5, and showed male predominance.2,3 In our study, however, the size of the sample and the age limit of 3–18 years make the generalization of this finding impractical. In our sample, anorexia was the most common symptom, affecting 78.7% of patients. The initial abdominal pain was peri-umbilical in majority of the patients (42.6%) and its intensity in 96% of cases were highest at McBurny point. Other signs and symptoms including rebound tenderness, vomiting, fever and diarrhea prevailed as 85%, 71.3%, 59.9% and 8.9%, respectively.

In all, 134 patients (66.3%) visited a health center within 24 hours after the first symptoms, 39 (19.3%) presented within 24–48 hours and 29 (14.4%) presented after 48 hours of beginning of symptoms. Minimum and maximum times from beginning of symptoms to seeking medical care were 1, and 120 hours respectively. As seen, majority of patients visited hospital within the first 24 hours, which shows an acceptable level of awareness and concern about the symptoms of the disease. On arrival at the hospital, 132 (65.3%) patients underwent surgery within 6 hours, 67 (33%) cases were appendectomized between 6 to12 hours, and less than 2% spent more than 12 hours before they were operated upon. This finding indicated the promptness with which patients with acute appendicitis were treated in our health system. Finally, upon completion of surgery, 119 (58.9%) patients were hospitalized for 48 hours; 73(36.1%) for 72 hours and 8 (4%) patients for 96 hours. Our findings showed the appropriateness and efficiency of the post operative care of patients with acute appendicitis, provided by health service system.]





The authors would like to thank the office of the Vice Chancellor for Research of Shiraz University of Medical Sciences for financial support and the Center for Development of Clinical Studies of Nemazee Hospital for typing assistance.

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