It's 10 pm. Severe pain in your belly. You are in ER. Previous
day you had a nice party with your friends. Then pain started around
your umbilicus (navel). You thought first: aha, probably you ate
something bad, it will go away. But it doesn't. You have vomited once
and lost appetite. Pain did not improve but worsened. After a day of
suffering you decided to visit the hospital. Long taxi trip. Pain is
shooting every time the car bumps into a pot. Nurses ask you bunch of
questions and place in an available room. There is a confused 90
something years old women in the neighbor room. She mumbles something
incomprehensibly. The woman has come from a nursing home. She suffers
Alzheimer disease and yells every night for the past 7 years. She has
history of multiple medical problems. They brought her in the ER after
she developed fever. Nurses draw your blood. You pain is getting
gradually worse. Change your position, pull your legs. Pain doesn't go
away. When the ... doctor comes? At last ER physician sees you. He
writes H+P and ER orders. A stretcher is rolled in. They take you to a
radiology department and put into a big machine looking like a gate.
Everybody leaves you and the machine drives you into the big metal
doughnut. They bring you back into the ER.
Surgical
intern comes. He did not rest since 5 AM. He asks bunch of the same
questions again and pokes your belly. A tired resident comes. He pokes
your belly again. You still wait, become bored, complain on delay, call
your relatives. It's already 2 AM. At last the resident discuss your
symptoms with attending over the phone. He tells you that you have
appendicitis and CT scan confirmed it. History and physicals are
written. Admission orders are written. Pre-op orders are written.
Antibiotics are prescribed. IV fluid is running 80 ml an hour. You sign
consent for operation. Transporting guys take you upstairs - depending
on severity of your symptoms - straight to or to the floor. Attending
will operate you first thing in the morning.
Classically
appendicitis starts as a pain that began in the periumbilical region
(around navel - you belly pot). Then pain moves to the right lower
quadrant of the abdomen. Nausea and vomiting often present after the
onset of the pain. Classically, patient has low grade fever (this means
around 37-38 C or 101-102 F), positive psoas sign (you stretch your leg
and this movement increases your pain), positive Rovsing sign (Doctor
pokes in your left lower quadrant of the abdomen, and you fill the pain
in you right lower quadrant), Leukocytosis. Leukocytes are the white
blood cells - WBC. Usually there are around 4000-9000 white cells per
micro liter of you blood. When you have inflammation in you body the
count goes up.
Your pain during appendicitis classically localizes
in Mc Burney's point. That is one third between your umbilicus and
anterior superior iliac spine (this is the bony point that is sticking
most prominently from your pelvis - you can palpate it yourself on the
side of your belly). For confirmation a doctor also may try to elicit
obturator sign - he will ask you to bend you knee and bring your heel to
your groin - this manoeuver increases the pain during appendicitis.
Similar test is the raising of the leg while you lie on the stretcher.
That movement also increases your pain.
Appendicitis is the
inflammation of appendix supposedly due to narrowing of this lumen. That
narrowing may be caused by hyperplasia of appendix (means too big
growth, overgrowth of the tissue) . That variant happens in children
mostly. Another variant - is fecalith (small stony fecal material) that
impacts into the appendix lumen. That is seen in young adults mostly.
Appendix
itself is a small part of gut . It is pencil-size sticking out gut. Gut
is a continuos tube. Mouth is entry. Anus is exit. Appendix sticks out
from the wall and ends blindly. It has only one entrance. Appendix is
attached to the Caecum (part of gut - literally means blind colon in
Latin). Appendix of ruminating animals (animals that chew grass, like
cow) is very long and big. Appendix in humans is reduced to the
pencil-size. However it doesn't disappear. There is a theory that
appendix plays role in immune response. The walls of appendix are
actually filled with lymphatic tissue containing lymphocytes (those are
subtype of White Blood Cells). Lymphatics is responsible for immunity.
The
removal of appendix doesn't really change immunity significantly.
Nonetheless, it is not something redundant. Unless it is inflamed there
is no good reason to remove it .
Now, acute appendicitis is the
acute inflammation of appendix. Suffix "-itis" means inflammation in
Latin. Appendicitis is also the most common cause of acute abdomen.
Acute abdomen in surgery is a condition in abdomen that requires urgent
actions, usually surgical.
To diagnose appendicitis you need to have right lower quadrant pain.
The
pain should be present together with either appropriate history (all
those classical signs and lack of appetite) or Leukocytosis (increase in
white blood cells in the blood).
Patients often ask questions:
Can I avoid surgery? Can you treat me with antibiotics alone? You told
me that it is possible to treat the appendicitis with antibiotics alone.
Please, I do not want surgery, my mother (father, brother, fiancee)
said that I can avoid surgery.
The answer is: you can try to avoid
it probably, but the odds of death are much higher if you treat
appendicitis without surgery. Untreated appendicitis may lead to
perforation in less than a day. Sun rises. Sun sets. Appendix bursts.
So, the prompt surgical intervention is the main solution. On occasion,
the surgeon may even find a normal-appearing appendix and no other
problem explaining the symptoms. He may remove the appendix anyway
because it is better to remove a normal-appearing appendix than to miss
mild case of appendicitis.
To cool down the infection before
surgery doctors use antibiotics. Antibiotics may convert acute
appendicitis into more chronic type. However the removal of the appendix
is the choice.
With modern technology it becomes much easier to
distinguish appendicitis and other causes of pain in right lower
quadrant. Yet there is no 100% proof diagnostics. Sometime doctors treat
with antibiotics alone, when they are not sure. Though, modern CT-scan
shows appendicitis almost close to 100%.
What would happen if you
miss the appendicitis and appendix bursts? You will get one of the most
dreaded surgical complication - peritonitis. Again, "-itis" equals
inflammation. Peritoneum means the peritoneal cavity.
It is
difficult to describe the shape of the peritoneal cavity . That shape is
very complex. Simple explanation: peritoneal cavity is like a closed
bag. It is completely closed in males
Female have small holes in
the peritoneum. Oocytes (future babies) go from ovaries first to
peritoneal cavity. The holes in the peritoneum allow oocyte to go into
Fallopian tubes. Fallopian tubes lead into the uterus (womb in English
or hyster in Latin or uterus in Greek). Organs that are covered by
peritoneal cavity linings are named intra-peritoneal. There are also
melo-peritoneal, extra-peritoneal or retro-peritoneal organs that
covered partially or not covered at all. It looks like the main function
of peritoneum (peritoneal cavity) is to give some lubrication to your
guts. Though there are other functions as well.
Now, take a
plastic bag, pour a little bit of water or oil into it and seal. Put one
hand on one side of the bag, another hand - on another side of the bag
and rub against each other. You can see your hands slide easily. This is
the idea of peritoneum - you bowels slide easily against each other
even when they are stretched by food and when they are pushing the
digested food down. When a bowel is punctured (perforated), the content
of the bowel will go into the peritoneal cavity. Colon (lower, bigger
bowl) has the fecal material. Fecal material consists of bacteria on 2/3
(yeah, there are so many of them). Now, that small puncture in one part
of the gut will cause spillage of the bacteria all around that closed
bag of peritoneum.
Guts on inside have several mechanisms protecting from bacteria. Peritoneal cavity doesn't' have such a protection.
Small
puncture in one part of gut will cause all of you guts be inflamed on
outside non-protected side (for the gut it is outside, but for the
peritoneal cavity it is the inside). This is the peritonitis (diffuse).
This what the surgeons are afraid of. Look at you. You belly is like
half of you body. So it is like half of you body is severely inflamed.
Eventually it may lead to sepsis, a condition in which bacteria enter
the blood and infect other parts of the body. This is life-threatening
complication.
Sometime inflammation stays local and seals off
forming an abscess. Abscess is the walled off accumulation of pus. Pus
is the mixture of dead and alive bacteria, dead white blood cells
(leukocytes; leukos = white, cyte = cell) that fought the infection and
honorably died, and dead tissue, that was digested partially by bacteria
and partially by the stuff from leukocytes. Inflamed peritoneum (the
lining of the peritoneal cavity is also named peritoneum) easily adhere
to each other and may seal of the infection - there will be local
peritonitis. Any adherence may cause problems in the future - guts do
not slide easily anymore and food or stool sticks. Blockage of the
intestine may occur in acute appendicitis as well. This is partially
responsible for the nausea and vomiting. Sometimes, when antibiotics are
used, appendicitis goes away without surgical treatment. It happens in
elderly patients. The patients may come to the hospital with a lump or a
mass in the right lower abdomen looking like tumor.
Diagnostic problem with appendicitis is that some other conditions may mimic it.
Abdominal
cavity is packed with different organs. Other sources could cause pain
in right lower quadrant. Females may have ovarian torsion or tuboovarian
abscess or extrauterine pregnancy (this is why doctors persistently
ask: when was your last menstrual period? Are you taking contraceptive
hormones? Did you have vaginal bleeding?), etc. They also check your
chorionic hormone, trying to find if you are pregnant.
Scrupulous
doctor asks your permission to perform rectal exam. Many people refuses
to do it. I can understand that. Who would like that somebody sticks
fingers into his ass. I wouldn't. But the rectal exam gives a lot of
information. Rectum - is the part of gut that is closest to the back
orifice. Back orifice is named anus in Latin or anal canal. Surgeons say
that there are only two contra-indications for avoiding rectal exam: 1.
patient does not have anus 2. Surgeon does not have fingers.
Rectal
exam in appendicitis is usually unremarkable. Maybe you can cause pain
by palpating the side wall of the rectum that is close to the appendix.
But the rectal exam allows to distinguish other disorders. During the
rectal exam you may palpate hemorrhoids, uterus, nodules in prostate or
enlarged prostate, you may feel fluid in lower part of peritoneal
cavity, etc. You may see blood on the finger telling you about internal
bleeding. You may check the stool for small amount of blood (named fecal
occult blood test - FOBT - or Guaiac test by the name of the dye that
turns blue in the presence of blood. At last rectal exam may help in
dis-impaction of rectum. That is when hard stool causes bowel
obstruction.
Usually a rectal exam is more or less normal. But
every surgeon will tell you a war story about how once in while, once in
five years he found something significant on rectal exam, something
that every other doctor missed. Just by putting the finger into the
butt. I saw how a surgeon put a finger into an old, demented women and
pulled out a pessarium. It was an apple-size pink plastic membrane ,
that should go into vagina, but somebody (at home?) put it (by mistake?)
into the rectum of that woman. You really need to push hard to get such
big object into the anus. The poor lady suffered bowel obstruction for a
week and would probably die if it stayed long enough.
OK, lets
return to appendicitis. So, doctors will check you White Blood Cell
Count Any infection or inflammation may cause this count to be
abnormally high. It is not specific for appendicitis, but it confirms
other findings.
Next, doctors check Urinalysis - microscopic
examination of the urine. That detects red blood cells, white blood
cells and bacteria in the urine. When there is inflammation or stones in
the kidneys or bladder, the urinalysis is abnormal. A normal urinalysis
is more characteristic to appendicitis.
Next they try to image
what is going on in your belly. An abdominal x-ray may detect the
fecalith as the cause of appendicitis (5%). Free air due to perforation
can might be seen on the plain film.
A barium enema may be used.
It is an x-ray test where liquid contrast is used from the anus to fill
the colon. Sometimes it show an impression on the colon in the area of
inflamed appendix. Barium enema also can exclude other intestinal
problems that mimic appendicitis.
Ultrasound shows an enlarged
appendix or an abscess. Ultrasound is painless, but the appendix can be
seen in only half of patients. Ultrasound also is helpful in excluding
the problems with ovaries, fallopian tubes and uterus. Ultrasound
machine usually looks like a small thumb on wheels that they bring into
your room. Technician puts gelly on and drives the probe over you belly.
Often
they go straight to CT Scan (computer tomography). Especially if the
patient is not pregnant. CT scan gives relatively high irradiation of
your body by x-rays. However benefits of prompt diagnose of appendicitis
outweigh the risk of radiation. CT scan gives slicing images of your
body.
What do they look for? As any inflammation causes edema, the
wall of the appendix will be thickened. This is actually a defensive
mechanism - by edema the organism try to wall of, to seal off the area
of infection and inflammation.
But it is useful for us because we can surely say there is an inflammation. The same goes for ultrasound.
CT scan is expensive - around 1000 dollars in an American hospital, though 40 dollars in Russia.
If the CT scan is taken during the night, CT image may be send to Australia Russia or India.
An
American radiologist is paid around 40 dollars to read just an X-ray
film. I guess he gets more for reading the CT scan. It is only 5 dollars
in India. This is why even such clinics as Harvard and Yale adopt this
model of work - they send the CT scans to the cheap labor abroad.
Especially during the night. Half an hour later the fax from Australia
arrives. "Inflammatory pericecal mass in the right iliac fossa
consistent with the diagnosis of severe acute appendicitis." Any doctor
can read an x-ray film or CT scan. Radiologists are doctors who
specialize in the reading of the films. They may find what was missed by
others.
At this point diagnosis is usually clear. In cases if it
is not, there is Laparoscopy. Laparoscopy is a surgical procedure. Small
fiberoptic tube with a camera is inserted into the abdomen through a
small puncture in abdominal wall.
Yet there is no test that will diagnose appendicitis with 100% certainty.
The
position of the appendix may vary. If it is longer than normal,
appendix may go deep down into the pelvis. It also may move behind the
colon (called a retro-caecal appendix). From one hand it is better
because retro-caecal appendix has less chances to burst into peritoneal
cavity, from the other it is difficult to diagnose and it is difficult
to approach surgically. Inflammation of other organs, for example,
female pelvic organs, may resemble inflammation of the appendix.
Pregnant women may have appendix pushed up in abdomen by the enlarged
uterus. Athletic young adults may tolerate more pain and may have not so
obvious symptoms of appendicitis. Old patients may have vague symptoms
as well.
Other inflammatory problems may mimic appendicitis.
Surgeons often observe patients with suspected appendicitis for a period
of time to see if the problem will resolve or suggest appendicitis more
strongly versus another condition. Conditions that mimic appendicitis
are:
1) Meckel's diverticulitis. 2) Pelvic inflammatory disease
-infection of tube and ovary. It is treated with antibiotics alone 3)
Fluids from the right upper abdomen may drip into the lower abdomen and
cause inflammation resembling appendicitis. Then, for example, patient
has gallbladder disease or liver abscess, but all symptoms suggest acute
appendicitis. 4) Diverticulitis that occur on the right side. 5)
Inflammation of right kidney. 6) Crohn's disease or ulcerative colitis
7) Yersinia enterocolitica infection - the bacteria that comes form
certain food - like unpasteurized milk. - may cause appendicitis 8)
passing kidney stone 9) ectopic pregnancy 10) ovarian cyst rupture. And
so on. There are some other conditions.
Appendectomy is performed
urgently usually. Thomeo is Latin for dissect or cut. Lapar - is abdomen
(belly) in medical Latin. Laparotomy is opening of belly. Appendectomy
is cutting of appendix. Laparoscopy is looking (by scope) into belly.
Antibiotics almost always are given prior to surgery as soon as
appendicitis is suspected.
Few patients have mild "confined
appendicitis" localized to a small area. These patients may improve
during several days of observation when treated with antibiotics alone.
Doctors may or may not removed the appendix later. Chances are you are
not one of this patients.
If a person has not seen doctor for many
days while appendicitis ruptured (yeah, sometime happens; there are
some tough guys), an abscess may form, and the perforation may close.
Initially it can be treated with antibiotics; however, that will require
drainage later. A drain is guided under ultrasound or CT scan and
appendix is removed after the abscess resolves.
In modern days
surgeons offer laparoscopic appendectomy. They insert laparoscope (it is
like a small telescope with a video camera) and remove appendix with
special instruments through small puncture wounds.
If you had this type of surgery, you will probably have four 1-cm size scars and you will go home in one or two days.
But
if your case is complicated or there is just no laparoscopy in the
hospital, they will do classical appendectomy. Surgeon cuts 10-cm
incision in the area of the appendix. Appendix is removed form the right
lower abdomen or where it is. Area is checked for other problems. In
the case of abscess the purulent stuff will be drained with rubber tubes
through the skin. With that kind of surgery you will probably stay for
four to seven days. Antibiotics will help to resolve the abscess.
This is why you sign the consent: "laparoscopic appendectomy, possible conversion to an open appendectomy".
The
most common complication of appendectomy is wound infection. If it is
severe, the surgeon will postpone incision closure for several days.
Ok, now you have those four small scars or one big scar, you go home and visit that party that you missed.
