| It's 10 pm. Severe pain in your belly. You are in ER. | | | | abdomen looking like tumor.Diagnostic problem with |
| Previous day you had a nice party with your friends. | | | | appendicitis is that some other conditions may mimic |
| Then pain started around your umbilicus (navel). You | | | | it.Abdominal cavity is packed with different organs. |
| thought first: aha, probably you ate something bad, it | | | | Other sources could cause pain in right lower |
| will go away. But it doesn't. You have vomited once | | | | quadrant. Females may have ovarian torsion or |
| and lost appetite. Pain did not improve but worsened. | | | | tuboovarian abscess or extrauterine pregnancy (this |
| After a day of suffering you decided to visit the | | | | is why doctors persistently ask: when was your last |
| hospital. Long taxi trip. Pain is shooting every time the | | | | menstrual period? Are you taking contraceptive |
| car bumps into a pot. Nurses ask you bunch of | | | | hormones? Did you have vaginal bleeding?), etc. They |
| questions and place in an available room. There is a | | | | also check your chorionic hormone, trying to find if |
| confused 90 something years old women in the | | | | you are pregnant.Scrupulous doctor asks your |
| neighbor room. She mumbles something | | | | permission to perform rectal exam. Many people |
| incomprehensibly. The woman has come from a | | | | refuses to do it. I can understand that. Who would |
| nursing home. She suffers Alzheimer disease and yells | | | | like that somebody sticks fingers into his ass. I |
| every night for the past 7 years. She has history of | | | | wouldn't. But the rectal exam gives a lot of |
| multiple medical problems. They brought her in the ER | | | | information. Rectum - is the part of gut that is |
| after she developed fever. Nurses draw your blood. | | | | closest to the back orifice. Back orifice is named anus |
| You pain is getting gradually worse. Change your | | | | in Latin or anal canal. Surgeons say that there are |
| position, pull your legs. Pain doesn't go away. When | | | | only two contra-indications for avoiding rectal exam: 1. |
| the ... doctor comes? At last ER physician sees you. | | | | patient does not have anus 2. Surgeon does not |
| He writes H+P and ER orders. A stretcher is rolled in. | | | | have fingers.Rectal exam in appendicitis is usually |
| They take you to a radiology department and put | | | | unremarkable. Maybe you can cause pain by palpating |
| into a big machine looking like a gate. Everybody | | | | the side wall of the rectum that is close to the |
| leaves you and the machine drives you into the big | | | | appendix. But the rectal exam allows to distinguish |
| metal doughnut. They bring you back into the | | | | other disorders. During the rectal exam you may |
| ER.Surgical intern comes. He did not rest since 5 AM. | | | | palpate hemorrhoids, uterus, nodules in prostate or |
| He asks bunch of the same questions again and | | | | enlarged prostate, you may feel fluid in lower part of |
| pokes your belly. A tired resident comes. He pokes | | | | peritoneal cavity, etc. You may see blood on the |
| your belly again. You still wait, become bored, | | | | finger telling you about internal bleeding. You may |
| complain on delay, call your relatives. It's already 2 | | | | check the stool for small amount of blood (named |
| AM. At last the resident discuss your symptoms with | | | | fecal occult blood test - FOBT - or Guaiac test by |
| attending over the phone. He tells you that you have | | | | the name of the dye that turns blue in the presence |
| appendicitis and CT scan confirmed it. History and | | | | of blood. At last rectal exam may help in |
| physicals are written. Admission orders are written. | | | | dis-impaction of rectum. That is when hard stool |
| Pre-op orders are written. Antibiotics are prescribed. | | | | causes bowel obstruction.Usually a rectal exam is |
| IV fluid is running 80 ml an hour. You sign consent for | | | | more or less normal. But every surgeon will tell you a |
| operation. Transporting guys take you upstairs - | | | | war story about how once in while, once in five |
| depending on severity of your symptoms - straight | | | | years he found something significant on rectal exam, |
| to or to the floor. Attending will operate you first | | | | something that every other doctor missed. Just by |
| thing in the morning.Classically appendicitis starts as a | | | | putting the finger into the butt. I saw how a surgeon |
| pain that began in the periumbilical region (around | | | | put a finger into an old, demented women and pulled |
| navel - you belly pot). Then pain moves to the right | | | | out a pessarium. It was an apple-size pink plastic |
| lower quadrant of the abdomen. Nausea and vomiting | | | | membrane , that should go into vagina, but |
| often present after the onset of the pain. Classically, | | | | somebody (at home?) put it (by mistake?) into the |
| patient has low grade fever (this means around | | | | rectum of that woman. You really need to push hard |
| 37-38 C or 101-102 F), positive psoas sign (you | | | | to get such big object into the anus. The poor lady |
| stretch your leg and this movement increases your | | | | suffered bowel obstruction for a week and would |
| pain), positive Rovsing sign (Doctor pokes in your left | | | | probably die if it stayed long enough.OK, lets return |
| lower quadrant of the abdomen, and you fill the pain | | | | to appendicitis. So, doctors will check you White |
| in you right lower quadrant), Leukocytosis. | | | | Blood Cell Count Any infection or inflammation may |
| Leukocytes are the white blood cells - WBC. Usually | | | | cause this count to be abnormally high. It is not |
| there are around 4000-9000 white cells per micro liter | | | | specific for appendicitis, but it confirms other |
| of you blood. When you have inflammation in you | | | | findings.Next, doctors check Urinalysis - microscopic |
| body the count goes up.Your pain during appendicitis | | | | examination of the urine. That detects red blood cells, |
| classically localizes in Mc Burney's point. That is one | | | | white blood cells and bacteria in the urine. When |
| third between your umbilicus and anterior superior iliac | | | | there is inflammation or stones in the kidneys or |
| spine (this is the bony point that is sticking most | | | | bladder, the urinalysis is abnormal. A normal urinalysis |
| prominently from your pelvis - you can palpate it | | | | is more characteristic to appendicitis.Next they try to |
| yourself on the side of your belly). For confirmation a | | | | image what is going on in your belly. An abdominal |
| doctor also may try to elicit obturator sign - he will | | | | x-ray may detect the fecalith as the cause of |
| ask you to bend you knee and bring your heel to | | | | appendicitis (5%). Free air due to perforation can |
| your groin - this manoeuver increases the pain during | | | | might be seen on the plain film.A barium enema may |
| appendicitis. Similar test is the raising of the leg while | | | | be used. It is an x-ray test where liquid contrast is |
| you lie on the stretcher. That movement also | | | | used from the anus to fill the colon. Sometimes it |
| increases your pain.Appendicitis is the inflammation of | | | | show an impression on the colon in the area of |
| appendix supposedly due to narrowing of this lumen. | | | | inflamed appendix. Barium enema also can exclude |
| That narrowing may be caused by hyperplasia of | | | | other intestinal problems that mimic |
| appendix (means too big growth, overgrowth of the | | | | appendicitis.Ultrasound shows an enlarged appendix or |
| tissue) . That variant happens in children mostly. | | | | an abscess. Ultrasound is painless, but the appendix |
| Another variant - is fecalith (small stony fecal | | | | can be seen in only half of patients. Ultrasound also is |
| material) that impacts into the appendix lumen. That | | | | helpful in excluding the problems with ovaries, fallopian |
| is seen in young adults mostly.Appendix itself is a | | | | tubes and uterus. Ultrasound machine usually looks like |
| small part of gut . It is pencil-size sticking out gut. Gut | | | | a small thumb on wheels that they bring into your |
| is a continuos tube. Mouth is entry. Anus is exit. | | | | room. Technician puts gelly on and drives the probe |
| Appendix sticks out from the wall and ends blindly. It | | | | over you belly.Often they go straight to CT Scan |
| has only one entrance. Appendix is attached to the | | | | (computer tomography). Especially if the patient is |
| Caecum (part of gut - literally means blind colon in | | | | not pregnant. CT scan gives relatively high irradiation |
| Latin). Appendix of ruminating animals (animals that | | | | of your body by x-rays. However benefits of prompt |
| chew grass, like cow) is very long and big. Appendix | | | | diagnose of appendicitis outweigh the risk of radiation. |
| in humans is reduced to the pencil-size. However it | | | | CT scan gives slicing images of your body.What do |
| doesn't disappear. There is a theory that appendix | | | | they look for? As any inflamation causes edema, the |
| plays role in immune response. The walls of appendix | | | | wall of the appendix will be thickened. This is actually |
| are actually filled with lymphatic tissue containing | | | | a defensive mechanism - by edema the organism try |
| lymphocytes (those are subtype of White Blood | | | | to wall of, to seal off the area of infection and |
| Cells). Lymphatics is responsible for immunity.The | | | | inflamation.But it is useful for us because we can |
| removal of appendix doesn't really change immunity | | | | surely say there is an inflammation. The same goes |
| significantly. Nonetheless, it is not something | | | | for ultrasound.CT scan is expensive - around 1000 |
| redundant. Unless it is inflamed there is no good | | | | dollars in an American hospital, though 40 dollars in |
| reason to remove it .Now, acute appendicitis is the | | | | Russia.If the CT scan is taken during the night, CT |
| acute inflammation of appendix. Suffix "-itis" means | | | | image may be send to Australia Russia or India.An |
| inflammation in Latin. Appendicitis is also the most | | | | American radiologist is paid around 40 dollars to read |
| common cause of acute abdomen. Acute abdomen in | | | | just an X-ray film. I guess he gets more for reading |
| surgery is a condition in abdomen that requires urgent | | | | the CT scan. It is only 5 dollars in India. This is why |
| actions, usually surgical.To diagnose appendicitis you | | | | even such clinics as Harvard and Yale adopt this |
| need to have right lower quadrant pain.The pain | | | | model of work - they send the CT scans to the |
| should be present together with either appropriate | | | | cheap labor abroad. Especially during the night. Half an |
| history (all those classical signs and lack of appetite) | | | | hour later the fax from Australia arrives. |
| or Leukocytosis (increase in white blood cells in the | | | | "Inflammatory pericecal mass in the right iliac fossa |
| blood).Patients often ask questions: Can I avoid | | | | consistent with the diagnosis of severe acute |
| surgery? Can you treat me with antibiotics alone? | | | | appendicitis." Any doctor can read an x-ray film or CT |
| You told me that it is possible to treat the | | | | scan. Radiologists are doctors who specialize in the |
| appendicitis with antibiotics alone. Please, I do not | | | | reading of the films. They may find what was missed |
| want surgery, my mother (father, brother, fiancee) | | | | by others.At this point diagnosis is usually clear. In |
| said that I can avoid surgery.The answer is: you can | | | | cases if it is not, there is Laparoscopy. Laparoscopy |
| try to avoid it probably, but the odds of death are | | | | is a surgical procedure. Small fiberoptic tube with a |
| much higher if you treat appendicitis without surgery. | | | | camera is inserted into the abdomen through a small |
| Untreated appendicitis may lead to perforation in less | | | | puncture in abdominal wall.Yet there is no test that |
| than a day. Sun rises. Sun sets. Appendix bursts. So, | | | | will diagnose appendicitis with 100% certainty.The |
| the prompt surgical intervention is the main solution. | | | | position of the appendix may vary. If it is longer than |
| On occasion, the surgeon may even find a | | | | normal, appendix may go deep down into the pelvis. |
| normal-appearing appendix and no other problem | | | | It also may move behind the colon (called a |
| explaining the symptoms. He may remove the | | | | retro-caecal appendix). From one hand it is better |
| appendix anyway because it is better to remove a | | | | because retro-caecal appendix has less chances to |
| normal-appearing appendix than to miss mild case of | | | | burst into peritoneal cavity, from the other it is |
| appendicitis.To cool down the infection before | | | | difficult to diagnose and it is difficult to approach |
| surgery doctors use antibiotics. Antibiotics may | | | | surgically. Inflammation of other organs, for example, |
| convert acute appendicitis into more chronic type. | | | | female pelvic organs, may resemble inflammation of |
| However the removal of the appendix is the | | | | the appendix. Pregnant women may have appendix |
| choice.With modern technology it becomes much | | | | pushed up in abdomen by the enlarged uterus. |
| easier to distinguish appendicitis and other causes of | | | | Athletic young adults may tolerate more pain and |
| pain in right lower quadrant. Yet there is no 100% | | | | may have not so obvious symptoms of appendicitis. |
| proof diagnostics. Sometime doctors treat with | | | | Old patients may have vague symptoms as |
| antibiotics alone, when they are not sure. Though, | | | | well.Other inflammatory problems may mimic |
| modern CT-scan shows appendicitis almost close to | | | | appendicitis. Surgeons often observe patients with |
| 100%.What would happen if you miss the appendicitis | | | | suspected appendicitis for a period of time to see if |
| and appendix bursts? You will get one of the most | | | | the problem will resolve or suggest appendicitis more |
| dreaded surgical complication - peritonitis. Again, "-itis" | | | | strongly versus another condition. Conditions that |
| equals inflammation. Peritoneum means the peritoneal | | | | mimic appendicitis are:1) Meckel's diverticulitis. 2) Pelvic |
| cavity.It is difficult to describe the shape of the | | | | inflammatory disease -infection of tube and ovary. It |
| peritoneal cavity . That shape is very complex. Simple | | | | is treated with antibiotics alone 3) Fluids from the |
| explanation: peritoneal cavity is like a closed bag. It is | | | | right upper abdomen may drip into the lower |
| completely closed in malesFemale have small holes in | | | | abdomen and cause inflammation resembling |
| the peritoneum. Oocytes (future babies) go from | | | | appendicitis. Then, for example, patient has gallbladder |
| ovaries first to peritoneal cavity. The holes in the | | | | disease or liver abscess, but all symptoms suggest |
| peritoneum allow oocyte to go into Fallopian tubes. | | | | acute appendicitis. 4) Diverticulitis that occur on the |
| Fallopian tubes lead into the uterus (womb in English | | | | right side. 5) Inflammation of right kidney. 6) Crohn's |
| or hyster in Latin or uterus in Greek). Organs that are | | | | disease or ulcerative colitis 7) Yersinia enterocolitica |
| covered by peritoneal cavity linings are named | | | | infection - the bacteria that comes form certain food |
| intra-peritoneal. There are also melo-peritoneal, | | | | - like unpasteurized milk. - may cause appendicitis 8) |
| extra-peritoneal or retro-peritoneal organs that | | | | passing kidney stone 9) ectopic pregnancy 10) |
| covered partially or not covered at all. It looks like | | | | ovarian cyst rupture. And so on. There are some |
| the main function of peritoneum (peritoneal cavity) is | | | | other conditions.Appendectomy is performed urgently |
| to give some lubrication to your guts. Though there | | | | usually. Thomeo is Latin for dissect or cut. Lapar - is |
| are other functions as well.Now, take a plastic bag, | | | | abdomen (belly) in medical Latin. Laparotomy is |
| pour a little bit of water or oil into it and seal. Put one | | | | opening of belly. Appendectomy is cutting of |
| hand on one side of the bag, another hand - on | | | | appendix. Laparoscopy is looking (by scope) into belly. |
| another side of the bag and rub against each other. | | | | Antibiotics almost always are given prior to surgery |
| You can see your hands slide easily. This is the idea | | | | as soon as appendicitis is suspected.Few patients |
| of peritoneum - you bowels slide easily against each | | | | have mild "confined appendicitis" localized to a small |
| other even when they are stretched by food and | | | | area. These patients may improve during several |
| when they are pushing the digested food down. | | | | days of observation when treated with antibiotics |
| When a bowel is punctured (perforated), the content | | | | alone. Doctors may or may not removed the |
| of the bowel will go into the peritoneal cavity. Colon | | | | appendix later. Chances are you are not one of this |
| (lower, bigger bowl) has the fecal material. Fecal | | | | patients.If a person has not seen doctor for many |
| material consists of bacteria on 2/3 (yeah, there are | | | | days while appendicitis ruptured (yeah, sometime |
| so many of them). Now, that small puncture in one | | | | happens; there are some tough guys), an abscess |
| part of the gut will cause spillage of the bacteria all | | | | may form, and the perforation may close. Initially it |
| around that closed bag of peritoneum.Guts on inside | | | | can be treated with antibiotics; however, that will |
| have several mechanisms protecting from bacteria. | | | | require drainage later. A drain is guided under |
| Peritoneal cavity doesn't' have such a protection.Small | | | | ultrasound or CT scan and appendix is removed after |
| puncture in one part of gut will cause all of you guts | | | | the abscess resolves.In modern days surgeons offer |
| be inflamed on outside non-protected side (for the | | | | laparoscopic appendectomy. They insert laparoscope |
| gut it is outside, but for the peritoneal cavity it is the | | | | (it is like a small telescope with a video camera) and |
| inside). This is the peritonitis (diffuse). This what the | | | | remove appendix with special instruments through |
| surgeons are afraid of. Look at you. You belly is like | | | | small puncture wounds.If you had this type of |
| half of you body. So it is like half of you body is | | | | surgery, you will probably have four 1-cm size scars |
| severely inflamed. Eventually it may lead to sepsis, a | | | | and you will go home in one or two days.But if your |
| condition in which bacteria enter the blood and infect | | | | case is complicated or there is just no laparoscopy in |
| other parts of the body. This is life-threatening | | | | the hospital, they will do classical appendectomy. |
| complication.Sometime inflammation stays local and | | | | Surgeon cuts 10-cm incision in the area of the |
| seals off forming an abscess. Abscess is the walled | | | | appendix. Appendix is removed form the right lower |
| off accumulation of pus. Pus is the mixture of dead | | | | abdomen or where it is. Area is checked for other |
| and alive bacteria, dead white blood cells (leukocytes; | | | | problems. In the case of abscess the purulent stuff |
| leukos = white, cyte = cell) that fought the infection | | | | will be drained with rubber tubes through the skin. |
| and honorably died, and dead tissue, that was | | | | With that kind of surgery you will probably stay for |
| digested partially by bacteria and partially by the stuff | | | | four to seven days. Antibiotics will help to resolve the |
| from leukocytes. Inflamed peritoneum (the lining of | | | | abscess.This is why you sign the consent: |
| the peritoneal cavity is also named peritoneum) easily | | | | "laparoscopic appendectomy, possible conversion to |
| adhere to each other and may seal of the infection - | | | | an open appendectomy".The most common |
| there will be local peritonitis. Any adherence may | | | | complication of appendectomy is wound infection. If |
| cause problems in the future - guts do not slide easily | | | | it is severe, the surgeon will postpone incision closure |
| anymore and food or stool sticks. Blockage of the | | | | for several days.Ok, now you have those four small |
| intestine may occur in acute appendicitis as well. This | | | | scars or one big scar, you go home and visit that |
| is partially responsible for the nausea and vomiting. | | | | party that you missed.Aleksandr Kavokin, MD1994 |
| Sometimes, when antibiotics are used, appendicitis | | | | Russia,PhD1997 Russia - Immunology and Allergy, |
| goes away without surgical treatment. It happens in | | | | postdoc at Cancer Center at Med U of South |
| elderly patients. The patients may come to the | | | | Carolina, postdoc at Yale - Cardiology, Molecular |
| hospital with a lump or a mass in the right lower | | | | Medicine. |