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