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 Table of Contents  
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 572-574

Is there a seasonal distributionof acute appendicitis in Iraqi children?

1 Department of Paediatrics, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq
2 Department of Pediatric Surgery, Children's Welfare Teaching Hospital, Baghdad, Iraq

Date of Submission19-May-2016
Date of Acceptance20-Oct-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Mahmood D Al-Mendalawi
Baghdad Post Office, PO Box 55302, Baghdad, 1111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.215442

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The aim of this study was to define the seasonal distribution of acute appendicitis(AA) in Iraqi children, if any, test the significant effect of age and sex on this distribution, and compare our results with those reported previously.
AA is one of the most common causes of abdominal pain and indication for emergency abdominal surgery in children. The few anecdotal published studies have shown variable association of seasonality with AA in children.
Patients and methods
We carried out a retrospective study on 1091 pediatric appendectomies at Children's Welfare Teaching Hospital in Baghdad between 2009 and 2014. Data of age, sex, and monthly and seasonal distribution were obtained from medical files. Descriptive statistics and the c2-test were used to describe and analyze data, respectively.
The highest rates(30.7 and 30.4%, respectively) were found in the winter and summer months, whereas the lowest rates(20.6 and 18.2%, respectively) were found in the spring and fall. Seasonality was not statistically associated with age(P=0.120) or sex(P=0.251).
The results indicate a seasonality of AA in the population studied. Pediatricians and pediatric surgeons should take into account this seasonality when evaluating children with acute abdominal pain. Further large-scale multicenter studies are recommended to confirm our observation.

Keywords: acute appendicitis, children, seasonal distribution

How to cite this article:
Al-Mendalawi MD, Lattuf MA. Is there a seasonal distributionof acute appendicitis in Iraqi children?. Menoufia Med J 2017;30:572-4

How to cite this URL:
Al-Mendalawi MD, Lattuf MA. Is there a seasonal distributionof acute appendicitis in Iraqi children?. Menoufia Med J [serial online] 2017 [cited 2020 Oct 29];30:572-4. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/572/215442

  Introduction Top

Acute appendicitis(AA) is the most common indication for emergency abdominal surgery in children, with 80000cases diagnosed per year and a lifetime risk for developing appendicitis of 7%[1]. The etiology of AA is complex, with the basic pathology of appendiceal luminal obstruction caused by reactive lymphoid tissue hyperplasia, fecaliths, foreign bodies, or parasites. Diet, seasonal factors, and family history could influence the development of AA[2]. Its accurate preoperative diagnosis remains difficult in children[3]. Early diagnosis and surgical intervention are essential to reduce the risk of perforation, mortality, and hospital stay[4],[5], hence the significant burden on the healthcare budget[6].

The seasonal rhythm of AA has been studied extensively in adults[7],[8],[9],[10]. In children, the few published studies have shown variable association of seasonality with AA. Yet, this factor has not been evaluated in Iraqi children. We, therefore, aimed in this study to define the seasonal distribution of AA in Iraqi children, test the significant effect of age and sex on that distribution, and compare our results with those reported previously.

  Patients and Methods Top

As national registry data on AA are not yet available, we retrospectively retrieved cases of pediatric appendectomies at the Department of Pediatric Surgery, Children's Welfare Teaching Hospital in Baghdad from 1 January 2009 to 31 December 2014. Age, sex, and month of admission of all the histologically proven cases of AA were obtained from the medical files. Seasons were categorized as follows: winter(December–March), spring(April–May), summer(June–September), and fall(October–November). The study proposal was approved by the Scientific and Ethical Committee at Al-Kindy College of Medicine, Baghdad University.

Statistical analysis

Descriptive statistics were used to describe data and c2 was used to test the significant effect of age and sex variables on AA seasonality. Statistical significance was set at P value less than 0.05. The statistical analysis was carried out using the statistical package for social sciences, version17 software(SPSS Inc., Chicago, Illinois, USA).

  Results Top

During the 6-year study period(2009–2014), 1091 pediatric appendectomies were recruited. The cohort included 699(64.1%) males and 392(35.9%) females, with a male-to-female ratio of 1.8: 1. The mean age of the patients was 6.5±4.8years. Their age distribution included 99(9.1%) patients younger than 4years of age, 286(26.2%) patients within the age group of 4–8years, and 706(64.7%) patients within the age group of 8–12years. The yearly distribution of admission cases was as follows: 2009=100(9.2%); 2010=117(10.7%); 2011=204(18.7%); 2012=202(18.5%); 2013=219(20.1%); and 2014=249(22.8%). The monthly distribution of admission cases was as follows: January=67(6.1%); February=84(7.7%); March=100(9.2%); April=108(9.9%); May=117(10.7%); June=92(8.4%); July=88(8.1%); August=85(7.8%); September=67(6.1%); October=105(9.6%); November=94(8.6%); and December=84(7.7%). Seasonal distribution of cases showed two peaks in winter 335(30.7%) and summer 332(30.4%) [Figure 1]. [Table1] showed no statistically significant association between AA seasonality and the variables of age(χ2=10.091; d.f.=6; P=0.120) or sex(χ2=4.096; d.f.=4; P=0.251).
Figure 1: Seasonal distribution of the patients studied.

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Table 1: Statistical correlation between the season and age and sex of the patients studied

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  Discussion Top

Studying the seasonality of a particular health problem in a giving population is important to obtain useful baseline data for the establishment of diagnostic, therapeutic, educational, and preventive strategies.

The seasonal distribution of AA cases in the present study indicated two peaks in winter(30.7%) and summer(30.4%) [Figure 1]. This might be partly related to reactive appendiceal lymphoid tissue hyperplasia because of antecedent respiratory and gastrointestinal infections prevailing in Iraq. This could be concluded from reviewing data published by the Ministry of Health in Iraq, where there was a significantly high rate of gastrointestinal diseases in children visiting healthcare centers in winter (212/1000 children) and respiratory tract infections in summer (457/1000 children)[11]. The seasonality of AA in the present study appears to be interesting on comparing it with the few published studies worldwide. Moore and Schneider[12], in their evaluation of 436 South-African children over an 11-year period, addressed summer seasonality of AA. They attributed this to the seasonal increase in lymphoid tissue in the appendix wall in that particular region. Rai etal.[13] pointed to the summer seasonality in their 1-year retrospective study on 957 Indian children with AA. However, Jangra etal.[14] studied 395 Indian children with AA over a 10-year period and reported that AA was more prevalent in the rainy season, a period of humidity, high incidence of bacterial and viral infections, and high prevalence of intestinal parasites. Arecently published search of the MEDLINE databases pointed to the presence of a seasonal pattern in the onset of appendicitis, which might be because of exposure to air pollution, decreasing fiber diet, and an increase in the incidence of gastrointestinal infections in summer[15]. The difference between our observation in the present study and the aforementioned studies might be because of methodological variations in terms of the number of patients studied and the study period.

Although the majority of our studied population(64.7%) fell within the age group of 8–12years, no statistically significant association was observed between AA seasonality and age(P=0.120)[Table1]. This appears to be interesting in view of the atypical presentation, the high incidence of complicated appendicitis, and significant morbidity and mortality in preschool children compared with older children. This will ultimately make the diagnosis of AA in young children a clinical challenge compared with the typical presentation in older children[16].

Although males outnumbered females (64.1vs. 35.9%) in the present study, statistical analysis showed no significant association between AA seasonality and sex (P=0.251) [Table1]. The preponderance of males in the present study might be attributed to the community preference of male children in Iraq, which leads parents to seek medical consultation for their sick male children earlier.

To the best of our knowledge, this is the first work in Iraq on AA seasonality involving a sizable study cohort (n=1091) that was carried out over an extended study period(6years). The present study has many limitations. First, it was retrospective, with all the inherited biases from this type of study. This could have been overcome if a national registry had been established and if the data had been collected from all over the country. However, the absence of a national registry on AA in Iraq has curtailed our attempt to study the seasonal distribution of AA at the national level. Second, this was a single-center experience, which might cast shadows on the results as certain characteristics at the studied center might affect the rate, for example, the threshold to diagnose AA at that center, number of clinically diagnosed AA that were not surgically operated on, or the number of pediatric surgeons on leave during a particular season.

  Conclusion Top

Our results pointed to the seasonal distribution of AA in the population studied. Pediatricians and pediatric surgeons should be aware of the seasonality of AA to soundly evaluate children with acute abdominal pain. Amulti-institutional, prospective study representing all regions within Iraq is warranted to verify our results.


The authors thank the Department of Medical Records at Children's Welfare Teaching Hospital for access to and help in retrieving patients' records.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910–925.  Back to cited text no. 1
Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol 2000; 4:46–58.  Back to cited text no. 2
Hennelly KE, Bachur R. Appendicitis update. Curr Opin Pediatr 2011; 23:281–285.  Back to cited text no. 3
Ozguner IF, Buyukayavuz BJ, Sava MC. The influence of delay on perforation in childhood appendicitis; a retrospective analysis of 58cases. Saudi Med J 2004; 25:1232–1236.  Back to cited text no. 4
Papandria D, Goldstein SD, Rhee D, Salazar JH, Arlikar J, Gorgy A, etal. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. JSurg Res 2013; 184:723–729.  Back to cited text no. 5
Flum DR, Koepsell T. The clinical and economic correlate of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002; 137:799–804.  Back to cited text no. 6
Noudeh YJ, Sadigh N, Ahmadnia AY. Epidemiologic features, seasonal variations and false positive rate of acute appendicitis in Shahr-e-Rey, Tehran. Int J Surg 2007; 5:95–98.  Back to cited text no. 7
Lee JH, Park YS, Choi JS. The epidemiology of appendicitis and appendectomy in SouthKorea: national registry data. JEpidemiol 2010; 20:97–105.  Back to cited text no. 8
Wei PL, Chen CS, Keller JJ, Lin HC. Monthly variation in acute appendicitis incidence: a 10-year nationwide population-based study. JSurg Res 2012; 178:670–676.  Back to cited text no. 9
Ilves I, Fagerström A, Herzig KH, Juvonen P, Miettinen P, Paajanen H. Seasonal variations of acute appendicitis and nonspecific abdominal pain in Finland. World J Gastroenterol 2014; 20:4037–4042.  Back to cited text no. 10
Ministry of Health, Republic of Iraq. Annual Health Report; 2010. Available at: http://www.moh.gov.iq/upload/upfile/ar/rep2010.pdf. [Last accessed on 2016 Apr 15].  Back to cited text no. 11
Moore SW, Schneider J. Acute appendicitis in childhood: experience in a developing country. Pediatr Surg Int 1995; 10:71–75.  Back to cited text no. 12
Rai R, D'Souza RC, Vijin VV, Sudarshan SH, Aithala PS, Pai JR. An evaluation of the seasonal variation in acute appendicitis. JEvol Med Dental Sci 2014; 3:257–260.  Back to cited text no. 13
Jangra B, Jangra MS, Rattan KN, Kadian YS. Seasonal and day of week variations in acute appendicitis in north Indian children. JIndian Assoc Pediatr Surg 2013; 18:42–43.  Back to cited text no. 14
[PUBMED]  [Full text]  
Fares A. Summer appendicitis. Ann Med Health Sci Res 2014; 4:18–21.  Back to cited text no. 15
[PUBMED]  [Full text]  
Mallick MS. Appendicitis in pre-school children: a continuing clinical challenge: a retrospective study. Int J Surg 2008; 6:371–373.  Back to cited text no. 16


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