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Appendicitis: Pain at the heart of your gut


The first time Olu, a 23-year-old undergraduate male noticed he was becoming  pale, he thought nothing of it, until he was not able to make himself better. The paleness turned to jaundice. His bilirubin level was 29 (normal is two).  He had intolerable upper abdominal pain once or twice a month. His father took him to a doctor who dismissed it as gastritis.

But after a month, the pain became worse. “We went to a renowned doctor’s clinic. A video x-ray indicated that I had significant stones in my gallbladder. The doctor said I needed to have my gallbladder removed. He gave me a week, but that night, the pain increased. Olu could not sleep. “I was too weak to stand. My stomach was tender, swollen, with no bowel activity. I cannot describe the pain, except, if a gunshot in the head, the bullet in your body, is as bad as it gets, this is worse than that.”

Olu was screaming with pain. Unable to get in a comfortable position, he crawled all over the floor, sweating profusely. He could not breathe.

Hearing his screams, his family rushed to his room. They were shocked, seeing him twisted in pain. Barely able to speak, he cried, “take me to the hospital.” No one ever imagined these were symptoms of such a dreadful disease, but is some acute pain and would subside with a simple Cholecystectomy.

At the emergency room, the physician examined him and was  given injections to decrease the pain. The pain was so severe that Olu did not get any initial relief. Finally, after five ‘adult’ dosages, the pain subsided enough that the doctor could do further tests, x-rays, and blood work.  The doctor suspected appendicitis. He was to be proved right later.

“When I woke up, I realised I was in the hospital and had a naso-gastric tube going through my nose and into my stomach. I was still in pain, but it was not as severe as the night before. That morning the doctors came in to see me, did an examination, and then scheduled me for immediate surgery. What followed next happened so fast, it is a blur.   The staff prepped me for surgery, shaved my abdomen, and wheeled me to the theatre.

Olu had an appendectomy (removal of the appendix) and few days later, returned home and has been fine ever since.

Olu is one of the several thousands whose appendices get inflamed and require removal. Basically, the appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked.

The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. At other times, it might be that the lymphatic tissue in the appendix swells and blocks the opening. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation.

If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

Sometimes, the body is successful in containing (“healing”) the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used.

 The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion of cancer.

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localised, that is, not confined to one spot. The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen.

A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localised clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button.

The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his or her hand after gently pressing on the abdomen over the area of tenderness.

White Blood Cell Count – In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early in the process.

Urinalysis –  A microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. A normal urinalysis suggests appendicitis more than a urinary tract problem.

Abdominal X-Ray – May detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.

Ultrasound  – A painless procedure that uses sound waves to provide images of identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess.

Barium Enema – An x-ray test in which liquid barium is inserted into the colon from the anus to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon.

Computerised tomography (CT) Scan – Useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.

Laparoscopy – A surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery.

Why it can be difficult to diagnose appendicitis?
The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery,  a sheet-like membrane that attaches the appendix to other structures within the abdomen. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women). It also may allow the appendix to move behind the colon (called a retro-colic appendix).

The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis.

Conditions that mimic appendicitis
Meckel’s diverticulitis – A small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate (break open or rupture). If inflamed and/or perforated, it usually is removed surgically.

Pelvic Inflammatory disease – The right fallopian tube and ovary lie near the appendix. Sexually active women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary.

Inflammatory diseases of the right upper abdomen – Fluids from the right upper abdomen may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis.

Right-sided diverticulitis – Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures -it can provoke inflammation – they mimics appendicitis.

Kidney diseases-  The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic appendicitis.

Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected.

There is a small group of patients in whom the inflammation and infection of appendicitis remain mild and localised to a small area. The body is able not only to contain the inflammation and infection but to resolve it as well. These patients usually are not very ill and improve during several days of observation. This type of appendicitis is referred to as “confined appendicitis” and may be treated with antibiotics alone. The appendix may or may not be removed at a later time.

On occasion, a person may not see their doctor until appendicitis with rupture has been present for many days or even weeks. In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. The drain allows pus to flow from the abscess out of the body. The appendix may be removed several weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack of appendicitis.

How an appendectomy is done
During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed.

Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt.

Complications of treatment
The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment.

Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. Wound infections are less common with laparoscopic surgery.

Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques.

Complications of non-treatment
The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse periotonitis (infection of the entire lining of the abdomen and the pelvis).

The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15 per cent. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.

A less common complication of appendicitis is blockage or obstruction of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing.

One other feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

Long-term consequences
It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example, Crohn’s disease.

Recently it has been hypothesized that some episodes of appendicitis-like symptoms, especially recurrent symptoms, may be due to an increased sensitivity of the intestine and appendix from a prior episode of inflammation.


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