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