One in seven Americans suffered it. Appendicitis. What is it? – Part 2

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Next they try to image what is going on in your belly. An abdominal x-ray may detect the fecalith as the cause of appendicitis (5%). Free air due to perforation can might be seen on the plain film.

A barium enema may be used. It is an x-ray test where liquid contrast is used from the anus to fill the colon. Sometimes it show an impression on the colon in the area of inflamed appendix. Barium enema also can exclude other intestinal problems that mimic appendicitis.

Ultrasound shows an enlarged appendix or an abscess. Ultrasound is painless, but the appendix can be seen in only half of patients. Ultrasound also is helpful in excluding the problems with ovaries, fallopian tubes and uterus. Ultrasound machine usually looks like a small thumb on wheels that they bring into your room. Technician puts gelly on and drives the probe over you belly.

Often they go straight to CT Scan (computer tomography). Especially if the patient is not pregnant. CT scan gives relatively high irradiation of your body by x-rays. However benefits of prompt diagnose of appendicitis outweigh the risk of radiation. CT scan gives slicing images of your body.

What do they look for? As any inflamation causes edema, the wall of the appendix will be thickened. This is actually a defensive mechanism – by edema the organism try to wall of, to seal off the area of infection and inflamation.

But it is useful for us because we can surely say there is an inflammation. The same goes for ultrasound.

CT scan is expensive – around 1000 dollars in an American hospital, though 40 dollars in Russia.

If the CT scan is taken during the night, CT image may be send to Australia Russia or India.

An American radiologist is paid around 40 dollars to read just an X-ray film. I guess he gets more for reading the CT scan. It is only 5 dollars in India. This is why even such clinics as Harvard and Yale adopt this model of work – they send the CT scans to the cheap labor abroad. Especially during the night. Half an hour later the fax from Australia arrives. “Inflammatory pericecal mass in the right iliac fossa consistent with the diagnosis of severe acute appendicitis.” Any doctor can read an x-ray film or CT scan. Radiologists are doctors who specialize in the reading of the films. They may find what was missed by others.

At this point diagnosis is usually clear. In cases if it is not, there is Laparoscopy. Laparoscopy is a surgical procedure. Small fiberoptic tube with a camera is inserted into the abdomen through a small puncture in abdominal wall.

Yet there is no test that will diagnose appendicitis with 100% certainty.

The position of the appendix may vary. If it is longer than normal, appendix may go deep down into the pelvis. It also may move behind the colon (called a retro-caecal appendix). From one hand it is better because retro-caecal appendix has less chances to burst into peritoneal cavity, from the other it is difficult to diagnose and it is difficult to approach surgically. Inflammation of other organs, for example, female pelvic organs, may resemble inflammation of the appendix. Pregnant women may have appendix pushed up in abdomen by the enlarged uterus. Athletic young adults may tolerate more pain and may have not so obvious symptoms of appendicitis. Old patients may have vague symptoms as well.

Other inflammatory problems may mimic appendicitis. Surgeons often observe patients with suspected appendicitis for a period of time to see if the problem will resolve or suggest appendicitis more strongly versus another condition. Conditions that mimic appendicitis are:

1) Meckel’s diverticulitis. 2) Pelvic inflammatory disease -infection of tube and ovary. It is treated with antibiotics alone 3) Fluids from the right upper abdomen may drip into the lower abdomen and cause inflammation resembling appendicitis. Then, for example, patient has gallbladder disease or liver abscess, but all symptoms suggest acute appendicitis. 4) Diverticulitis that occur on the right side. 5) Inflammation of right kidney. 6) Crohn’s disease or ulcerative colitis 7) Yersinia enterocolitica infection – the bacteria that comes form certain food – like unpasteurized milk. – may cause appendicitis 8) passing kidney stone 9) ectopic pregnancy 10) ovarian cyst rupture. And so on. There are some other conditions.

Appendectomy is performed urgently usually. Thomeo is Latin for dissect or cut. Lapar – is abdomen (belly) in medical Latin. Laparotomy is opening of belly. Appendectomy is cutting of appendix. Laparoscopy is looking (by scope) into belly. Antibiotics almost always are given prior to surgery as soon as appendicitis is suspected.

Few patients have mild “confined appendicitis” localized to a small area. These patients may improve during several days of observation when treated with antibiotics alone. Doctors may or may not removed the appendix later. Chances are you are not one of this patients.

If a person has not seen doctor for many days while appendicitis ruptured (yeah, sometime happens; there are some tough guys), an abscess may form, and the perforation may close. Initially it can be treated with antibiotics; however, that will require drainage later. A drain is guided under ultrasound or CT scan and appendix is removed after the abscess resolves.

In modern days surgeons offer laparoscopic appendectomy. They insert laparoscope (it is like a small telescope with a video camera) and remove appendix with special instruments through small puncture wounds.

If you had this type of surgery, you will probably have four 1-cm size scars and you will go home in one or two days.

But if your case is complicated or there is just no laparoscopy in the hospital, they will do classical appendectomy. Surgeon cuts 10-cm incision in the area of the appendix. Appendix is removed form the right lower abdomen or where it is. Area is checked for other problems. In the case of abscess the purulent stuff will be drained with rubber tubes through the skin. With that kind of surgery you will probably stay for four to seven days. Antibiotics will help to resolve the abscess.

This is why you sign the consent: “laparoscopic appendectomy, possible conversion to an open appendectomy”.

The most common complication of appendectomy is wound infection. If it is severe, the surgeon will postpone incision closure for several days.

Ok, now you have those four small scars or one big scar, you go home and visit that party that you missed.

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Author: Piyawut Sutthiruk

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