Published in "Panorama"
Diagnosing and treating appendicitis
Appendicitis is the most common reason for abdominal surgery among children and its peak incidence is between the ages of 11 to 30. Though no age is exempt, chances of appendicitis reduce with age after the peak incidence, says Dr.Qurban Hatim Pamina, General and Laparoscopic surgeon, Zulekha Hospital, Sharjah.
What is appendicitis and what are its causes? Appendicitis is an inflammation of the appendix, a worm-like pouch about 3½ inches long located at the beginning of the large intestine, where it dangles from the intestine. The cause of appendicitis is usually obliterative, explains Dr.Qurban. That is, there could be obstruction of the lumen in the appendix as a result of which there is distension of the appendix and accumulation of intra-luminal fluid. Consequently there is ineffective lymphatic drainage and bacterial invasion of the wall of the appendix. In advanced cases, this could lead to rupture of the appendix and spilling of pus into the peritoneum leading to a medical emergency.
How does the lumen become obstructed? The appendix could become plugged with a hard piece of fecal matter, inspissated food, thread worms, enlarged lymph follicles and tumours. But these are not related to certain kinds of foods (guavas and spicy, oily foods, for instance) eaten, as is commonly believed, clarifies Dr.Qurban. “Neither is there any perceptible gender bias in appendicitis, nor is there any regional or climatic correlations. Also there is no known link between appendicitis and dietary habits, smoking or alcohol intake or heredity,” emphasizes the specialist.
Appendicitis may be acute, sub-acute or chronic. “Usually it is acute or sub acute; some people develop sudden abdominal pain coming over a few hours, with vomiting. This is the acute form,” explains Dr.Qurban. “Alternatively, the pain may be manifest from a few hours to a few days in the sub acute case and the patient may experience a vague pain with no other symptoms and sometimes, mild fever. Chronic appendicitis has pain which is recurrent, lingering for days to weeks.”
Appendicitis is an illness with protean manifestations, with symptoms overlapping with other medical conditions and significant morbidity. Explaining the symptoms, Dr.Qurban clarifies, “A typical clinical presentation of the ailment begins with pain usually originating around the navel and then spreading down the abdomen to the right. The nerve supply of the appendix is similar to the nerve supply around the navel. Hence the pain is felt in the navel due to the distension of the appendix, its tightening. Alternatively, it can also be felt in the epigastrium – an upper abdominal pain, in which case it could be mistaken for a heart burn. It’s a known entity that people may actually have appendicitis for a long time but mistake it for indigestion!”
As the whole appendix gets involved, it abuts the anterior abdominal wall, the peritoneum. When this happens, Dr.Qurban explains, “one feels local pain in the right lower quadrant of the abdomen. The pain may worsen on moving, taking deep breaths, coughing, sneezing. However, if the inflammation is very fast, the patient might feel the local pain in the first instance without having felt the pain around the navel.”
Children may have vomiting associated with the pain and adults may experience nausea without vomiting. However, the vomiting and nausea are not a must in every child or adult with appendicitis. There is usually tenderness in the local area and the pain increases with touch. When the infection has spread enough, there may be chills, fever and progressively intense pain. However, not everyone has all the symptoms. Variations in the position of the appendix, age of the patient, and degree of inflammation make the clinical presentation of appendicitis pretty inconsistent, says Dr.Qurban. “Because the position of the appendix may be different in different individuals, the patients may show Atypical presentations. For instance if the appendix is in the pelvis, the person might have increased frequency of urination and movement of the leg will aggravate the pain; when the appendix is placed high, he will have pain in the upper abdomen, around the gall bladder region; if the appendix is hidden behind the ileum (one segment of the small intestine), the pain may be late in coming and there may be associated low back pain; sometimes the patient will come down directly with peritonitis. Whenever a child has appendicitis, he/she will walk bent so as to relax the hurting muscles. Pressing against that area increases discomfort, and there is usually difficulty in walking upright because of the pain.”
Is constipation a symptom of appendicitis? Dr.Qurban is emphatic: “Constipation is not related to appendicitis. It is neither a symptom of appendicitis, not does it lead to it. On the other hand, a person might have frequent stools or mild diarrhoea as a symptom of appendicitis. Because the tip of the appendix is lying free, when it gets inflamed, it can touch the bladder or the colon. When this happens, there is either frequent urination or it’ll trigger diarrhoea.”
Can appendicitis be mistaken for some other disease or disorder? “Yes, this may be so,” agrees Dr.Qurban. These conditions include pelvic inflammatory disease, ovarian cysts, infections of the fallopian tube, fibroids and fibroid degeneration in women, which have symptoms similar to appendicitis. In children, enlarged lymph nodes due to some viral infection bring on pain and other symptoms resembling appendicitis. In men, apart from intestinal causes, kidney stones have to be ruled out since even the presence of urinary stones will come on with pain in the right lower abdomen, and vomiting similar to appendicitis. Many other conditions can mimic appendicitis such as gastroenteritis, urinary infections, and an inflammation of the intestine known as Crohn disease.
If left untreated, what can an inflamed appendix lead to? “The appendix will rupture or perforate, leading to a complicated condition called peritonitis, abscess formation, and bowel obstruction. However, the appendix can swell rapidly and in some cases may burst in a matter of hours. When this happens, it spreads pus and other infected material into the abdominal cavity and causes peritonitis. Though this condition can be handled adequately with advancement in the medical field, without medical treatment on time, this condition can cause serious illness or even death,” says Dr.Qurban.
While peritonitis is the major complication of appendicitis, wound infections are common, opines Dr.Qurban.
How is appendicitis diagnosed? Since appendicitis comes in such variable forms and may progress over several hours to several days, its accurate diagnosis is challenging. Further, patients may not be able to report the symptoms in the sequential order in which they appear. History and physical examination of the patient is the mainstay of diagnosis. However, to rule out other conditions which manifest symptoms similar to appendicitis, CT Scans and ultra sound must be done.
Once diagnosed, what is the treatment modality. Dr.Qurban explains, “It is not that the appendix has no function as is generally believed. It is called the abdominal tonsil. Just as the tonsil guards the upper alimentary tract from bacteria, so does the appendix guard the entrance from the almost sterile ileum into the normally bacteria-infested colon It is not that the appendix does not have a function; it’s only that we can do without it, like the tonsils. So the dictum is, in appendicitis, if there is a reasonable suspicion, it is better to surgically remove the appendix. This is required so as to avoid complications rising therefrom.
If the appendix burst, it causes peritonitis which is generalized pus within the peritoneal cavity. This in turn makes all the intestines stick together. In a woman, this can reduce fertility by making the tubes and the ovaries considerably scarred. Because wherever pus forms and it is treated, it will lead to scarring, intestinal adhesions and consequent intestinal obstruction and pus pockets. And these factors lead to sub-fertility. In women, therefore, we are usually more aggressive in treating appendicitis.”
Continuing on the treatment modality, Dr.Qurban explains, “If the appendix has not burst and there is no generalized peritoneal infection, then keyhole surgery or surgery by laparoscopy can be done. However, if the appendix has burst or you expect reasonable contamination in the peritoneal cavity, then we undertake surgery with the open standard technique. This involves a very small one inch incision which allows us to clean the abdomen, which process cannot be done with laparoscopy.”
Is surgery then the only solution to appendicitis? “It can be treated with conservative methods using medication, but this will depend on the stage of the appendicitis,” clarifies Dr.Qurban.
“If it’s early and you are sure that the chances of bursting are less, then the patient has to be admitted in the hospital and treated with antibiotics. This is then the mainstay of therapy and the person is under observation. The antibiotics are given to calm down the infection and the patient’s temperature and pulse are monitored. If the pain subsides, temperature is normal and pulse rate is stable and the patient makes a brisk improvement, the antibiotics are continued for 5-7 days and then the patient is discharged.”
But this may not be the end of the treatment according to Dr.Qurban. “Usually even if we are treating in this conservative fashion, it is better to get the appendix out surgically, after six weeks. Because at a later stage in life, you may develop appendicitis when you are on a holiday or so placed that you may not be able to get quick medical help, should an emergency arise and there is threat of a burst appendix.”
Dr.Qurban has a word of caution on surgery though. “If you are reasonably sure that it is appendicitis, get it removed. But if the outer surface of the inflamed appendix has become abscessed from infection, it can complicate the surgery further. In this case, it is advisable to first treat the infection with antibiotics and drain the abscess. Once the infection has subsided, go in for surgical removal.”
Are there any complications that can occur from the surgery itself? Wound infection is the most probable complication of surgery, says Dr.Qurban. “In rare circumstances you can get a fecal fistula because the organ is inflamed up to the base, even when you tie the stitches, because of the inflammation, the stitches tend to come out. So a fecal fistula may appear where the stools start coming out, though this will ultimately close on its own; very rarely you may need to go in again and repair it. Also, a very large incision in the area may lead to increased scarring, leading again to intestinal adhesions and sub-fertility in women.
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