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