Epidemiology of appendicitis in Ecuador, 2004–2024: a national time-series analysis of incidence, trends, geographic variation, and case-fatality rates

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Background: Appendicitis is a common surgical emergency and a leading cause of gastrointestinal hospital admission in Ecuador. However, its long-term national patterns have not been comprehensively characterized. We aimed to describe appendicitis-related hospital discharge rates, temporal and geographic variation, and in-hospital case-fatality in Ecuador during 2004-2024. Methods: We conducted a nationwide descriptive ecological study using publicly available, anonymized hospital discharge records from the Ecuadorian National Institute of Statistics and Censuses. The unit of temporal and geographic analysis was the canton-year. Discharges with a primary ICD-10 diagnosis of K35-K37 were included. Annual population denominators were used to calculate crude and age- and sex-specific hospital discharge rates per 100,000 population. In-hospital case-fatality was calculated as deaths among appendicitis-related discharges. Comparisons were descriptive and unadjusted. Findings: We identified 717,639 appendicitis-related discharges, including 378,080 (52.7%) among males and 339,559 (47.3%) among females, and 1179 in-hospital deaths (case-fatality 0.164%). Recorded ethnicity was Mestizo in 602,817 (84.0%), Indigenous in 12,918 (1.8%), other in 9329 (1.3%), White in 3588 (0.5%), and Afro-Ecuadorian in 2153 (0.3%); 23,682 (3.3%) were recorded in additional categories, including Montubio, and 63,152 (8.8%) were unknown or unrecorded. Discharge rates increased until 2018-19, declined in 2020, and only partially recovered by 2024. Rates were highest mainly among adolescents and young adults, and crude case-fatality varied across health-system characteristics. Interpretation: Appendicitis represents a substantial surgical burden in Ecuador. The observed temporal, geographic, and health-system variation supports strengthening timely diagnosis, referral pathways, and equitable surgical access. Findings are ecological and should not be interpreted causally.