Appendicitis:What to do?
Appendicitis is a common disease that has an uncomplicated course when diagnosed and treated early with a short hospital stay but can also be life-threatening when it is complicated by perforation and vital organ failure with a prolonged spell in the hospital. Appendicitis can affect any age group and both sexes. This article gives you information about the illness, the current trends of how to go about after suspecting appendicitis in simple terms that are easy to understand.
Appendix often called a vestigial organ in humans can be the seat of infection in a young child, an adult or the elderly. The diagnosis at times is difficult because of the other confusing conditions that resemble appendicitis. With the advances in investigations, antibiotics, anesthetics and surgical techniques, the morbidity and mortality related to appendicitis have reduced over the last couple of decades.
The appendix is a small tube-like organ that is located in the area where the small intestine meets the large intestine. It measures about 5-7 cms. Because it is free on one end, the location can be variable, hanging down like a clapper in a bell, or tucked behind the caecum or the large intestine on the right side.
Often appendicitis starts as a generalized abdominal pain that is noticed around the umbilical area. Over the period of few hours, the patient develops nausea and vomiting. By the end of 12-14 hours, the abdominal pain usually moves from the umbilical site to the right lower abdomen. Many patients lose their appetite until the infection is resolved. Over the next day or two, patients develop fever also. Some patients have loose stools or constipation, an increased frequency of micturition or burning sensation while passing urine.
- Clinical findings: Many doctors go by the clinical history and findings to diagnose appendicitis but it would be prudent to have some basic investigations, an ultrasound because of the other illness that can present like appendicitis but would not need an operation (food poisoning/enteritis). In female patients who have their monthly cycles delayed and women in the reproductive age group before being subjected to an ultrasound or a CT scan, would often have a urine pregnancy test.
- Abdominal Ultrasound:A USG abdomen and pelvis is often done to look for evidence of appendicitis and at the same time to look for other diseases of the urinary system( ureteric stone), the reproductive system in female (torsion of the ovaries, ovarian cyst, ectopic pregnancy).
- CT scan:A CT scan is done in doubtful cases that help to rule out a ureteric stone, intestinal obstruction, perforation or growth arising from the caecum (the beginning of the large intestine).
- Blood tests:The basic blood tests include complete blood counts, kidney function tests and sometimes liver function tests. A serum B-HCG (blood test for pregnancy hormone) is done in patients suspected to have an ectopic pregnancy that can present with similar right sided lower abdominal pain.
- Diagnostic Laparoscopy:In some patients despite all the tests, it would be difficult to find the cause of the right lower abdominal pain. In such cases, surgeons would decide on or offer the choice of a surgical procedure known as 'Diagnostic laparoscopy'. This is a keyhole surgical procedure that gives a chance to 'look into the abdomen' to find out what is wrong. Based on the abnormality that is found, the surgeons would manage appropriately (if the appendix is inflamed, it would be removed; if an ovarian cyst is twisted, then the cyst would be removed; if there is an intestinal problem then that would be addressed).
- Initial care:The initial treatment that would be given by medical teams would be to start intravenous fluids (ensures that the patient is hydrated well), a dose of antibiotics, a painkiller and stabilization while the next plan is formulated with the help of the emergency medicine doctors, surgeons, radiologists, and anesthetists.
- Medical treatment or Surgical treatment:Many patients would want to avoid an operation and would ask for medicines only. Appendicitis cannot be always treated with antibiotics. A few patients respond well to antibiotics when the infection is at a very early stage when there is no other major illness and the patient is fit and healthy. It would be difficult for the doctors or surgeons to say who would improve, who would not improve. Postponing surgery, carries a risk of worsening of infection, rupture of the inflamed appendix and abscess formation. Once the surgery is decided, the surgeons would offer an open appendectomy or a laparoscopic (keyhole) surgery.
- Open Appendectomy :This surgery is performed under general or spinal anesthesia, wherein a cut(incision) is made in the right lower abdomen above the right groin fold.The muscle layers are divided/split, the appendix removed and the stump of the appendix(the end attached to the intestine or where the appendix begins) is ligated. If there is perforation and or pus, surgeons often place a drain tube that stays in for a couple of days.
- Laparoscopic appendectomy:The same surgery is done with two-three holes ( one - 1cm cut at the umbilicus, two more 5mm cuts in the lower abdomen right or left side). Using specialized long this instruments, the appendix is carefully detached from the rest of the tissues, the stump or the base will be ligated with a loop of thread. After completely disconnecting the appendix, it is put into a small bag and removed.
- Robotic Appendectomy:This is similar to the laparoscopic appendectomy but a robot does the procedure using instruments that are attached to robotic arms. The surgeon sits at the console and based on the live feed that he can see on his console screen, he makes movements with his hands that are converted by technology into actual steps of surgery inside the patient's abdomen.
- Post operative care :After surgery, antibiotics are continued or stopped depending on the severity of the infection, the presence of pus and signs of vital organ involvement with septicemia (blood poisoning).Patients are discharged the next day or in 3-4 days depending on the recovery and complexity of the case. Usually, one- two follow-up visits would be needed to check the progress, to discuss the biopsy results and the healing of the wounds.
Delayed presentations of Appendicitis
Some patients seek medical help a few days later, in such instances, the body tries to control the infection wherein the surrounding fat, intestine form a ball so that the infection or pus does not spread to other areas. In such cases, the doctors would be able to feel a lump in the right lower abdomen. In such cases, patients have further scans, if there is no pus, then antibiotics are given and surgery(removal of the appendix) is recommended about 4-6 weeks later, this is referred to as 'Interval Appendicectomy'.
If the lump(that the doctor has felt), shows evidence of pus(on the scans), then a surgery is done to drain the pus. Most patients settle with this, however, if there are going symptoms, then a further CT scan followed by surgery is recommended.
In advanced cases where the infected appendix has ruptured or burst, the patient would be sick, dehydrated with a low BP and fast pulse. In unusual cases, patients can have pain in the upper abdomen, jaundice etc. These patients are investigations and emergency surgery performed, such patients would need close monitoring and intensive care to help them recover soon. Patients of this group would spend more time being on antibiotics, being in the hospital for a longer duration.
Unusual appendicular diseases
In some patients the appendix can be very long, running along the right side of the large intestine. In such patients, the infection at the tip would mimic cholecystitis or hepatitis (liver infection). This is often found on the CT scan.
Rarely, a tumor or a cancerous growth of the caecum can block the beginning of the appendix causing appendicitis but would need a different surgery if encountered. Tumours( carcinoid, mucinous tumors) of the appendix are rare but well documented. Such patients would need an appendectomy or a right hemicolectomy (removal of the right part of the large intestine along with a segment of the terminal part of the small intestine) and would need close long-term follow-up like cancer patients.
Diseases mimicing appendicitis
- Common diseases:There are numerous conditions that can masquerade as appendicitis starting from an intestinal colic due to an infection, ileo-caecal TB, Inflammatory bowel disease of ileum or caecum, diseases of right ovary and fallopian tube, pyoslaphinx, mid-cyclical pain in women(in between monthly cycles) and others.
- Right ureteric stone:A stone in the lower ureter(that carries the urine from the kidney to the urinary bladder) can resemble appendicitis but a urinary examination, ultrasound or CT scan will help in diagnosis.
- Right ovarian pathology:Often ruptured cysts of the ovary, infections, torsion (twist) of a large cyst all can present like appendicitis but can be differentiated at ultrasound or at laparoscopy.
- Ectopic pregnancy:Sometimes, instead of a normal pregnancy, it can happen in the tubes and rupture causing similar symptoms with loss of blood. Such conditions need quick assessment and early timely surgical intervention to prevent too much loss of blood.
Complications of surgery for appendicitis
Patients can develop an infection of the wound at the site of operation, this would need antibiotics and dressings until the wounds heal. In some cases there would be a formation of an abscess in the lower abdomen, intestines can get obstructed, the appendicular stump (part of the appendix that is attached to the caecum) may not heal properly. All these conditions need expert assessment, investigations and at times a further operation.
Appendicitis can affect any age group, timely medical attention helps to avoid the potential complications that can be life-threatening. The diagnosis can be tricky in some situations and in women, necessitating further scans and assessment. Laparoscopic or Keyhole surgery is established well as a good surgical option to open surgery, it is wise to have at least one follow-up appointment with your doctor to check the recovery, the final biopsy report and to see that there is no complications.