Appendicitis

Good Evening Everyone,
Well we had our mass casualty event today. We had dignitaries from the Army and Air Force attend as well as a group of Iraqi physicians. The exercise went well and in the next few days I will post photo's and give a brief description of what we accomplished.

Today, however, I would like to discuss a medical topic. It is a rare day that I do not evaluate a patient with a complaint of abdominal pain. For those of you in the health care field know, abdominal pain is a pain to work up. So many illnesses can present with a complaint of abdominal pain. Most commonly I am asked by my patients, "Do I have appendicitis?" I even had a young lady who had already had an appendectomy as a child, ask me if I thought perhaps her recent abdominal pain was related to another case of appendicitis. I simply chuckled and reassured her.

Anyway, tonight I would like to discuss the all to common condition that is appendicitis.

Anatomy:
The appendix is actually called the Veriform Appendix and is located as a small pouch off of the Cecum portion of the large bowel. The small intestines connect the terminal portion of the stomach where the duodenal sphincer is located and the Cecum. The Cecum is the beginning portion of the large bowel and is part of the ascending colon. See Diagram below:

The appendix is an appx. 10 cm pouch that extends from the medial edge of the cecum and extend normally toward the midline portion of the abdomen. The appendix size can range from 2-20 cm in length and can extend in any direction depending on a persons anatomy. Because the fecal matter from the small intestions or more specifically the ilium portion of the small intestine, is emptied into the cecum in a liquid state, the appendix is prone to filling. Normally, this filling is not a problem, but there are times when the appendix pouch can become infected and inflammed. Weather the inflammation is secondary to stagnating fecal fluid or from a bacterial infection that infects the tissue of the appendix is not always known, but the result is the same. Abdominal pain will develop and this is what we call appendicitis.

Signs/Symptoms:
Appendicitis can present with a variety of clinical complaints. Most commonly a patient will experience, early on in the course, diffuse abdominal pain, nausea, anorexia and/or lack of appetite. As the infection progresses, the patient will begin to experience a localizing of the abdominal pain to the right lower quadrant of the abdomen. As the pain localizes, the patient will start to spike a fever, become diophoretic (begin to sweat), vomit, and have sharp abdominal pain with motion. Patients will be very guarded and will complain that even the ride over to the hospital caused abdominal pain, secondary to hitting bumps or potholes in the road.

Diagnosing:
A good clinical exam should point the provider in the right direction for appendicitis. So, a thorough evaluation should start the diagnostic process. Bowel sounds may or may not be decreased. Pain will be illicited on palpation of the abdomen, especially in the right lower quadrant. The odd finding of rebound tendernous or pain that is more severe with the releasing of palpation is often noted. The patient will have pain to the right lower quadrant by simply tapping firmly on the bottom of the right foot. This jarring sensation will irritate the inflammed appendix.
A rectal exam to check for rectal bleeding is appropriate. If the pt. has right lower quadrant pain upon the digital rectal exam, then appendicitis should most certainly be in the differential. A digital rectal exam will not only cause abdominal pain but a hemoccult or test for rectal bleeding can be assessed.

Fever and vomitting is often times the part of the presentation of appendicitis so a complete set of vitals should be obtained. If the patients, blood pressure suddently drops, then septic shock should be ruled out.
Labs should be drawn to assist with the diagnoses. A CBC (Complete Blood Count) should be drawn. A CBC contains a white blood cell count which will be elevated during an appendicitis. This is an indication of infection. The CBC also monitors the hemaglobin and hematocrit in the the blood. If either of these are low, then the patient is anemic, which could indicate a loss of blood, perhaps through rectal bleeding. A CMP or comprehensive metobolic panel should also be drawn. A CMP will assess kidney funtion through measuring of electrolytes. Electrolytes tells us the hydration status of the patient and assesses the sodium, potassium, chloride, and carbon dioxide of the patient. Additionally the CMP will assess the liver function and other kidney funtions through blood urea nitrogen and creatinine levels.
We assess the function of other vital abdominal organs to ensure that the cause of the pain and other symptoms are being caused by anything other than the inflammed appendix.

Once a provider has a high index of suspicion that the patient has appendicitis then an ultrasound of the right lower quadrant of the abdomen or a CT scan of the abdomen should be performed to give a final diagnosis. Many people have asked my why we just don't go straight to the ultrasound or CT scan and avoid all of the other work ups? We don't do this because more times than not, abdominal pain is not due to appendicitis and other disease processes can be identified with the previously mentioned battery of test.

Differential Diagnosis:
Appendicitis doesn't alway present with textbook symptoms and so a list of differential or alternate diagnoses should be considered as the patient goes through the work up phase. Other pathology that should be considered are ovarian cysts, pelvic inflammatory disease or PID in a woman, kidney, bladder, or urinary tract infections, (always ensure a urinalysis is performed), Cholecyctitis or gallbladder inflammation, colitis, Crohn's disease, fecal impaction, and mesenteric ischemia or an obstruction of blood flow to the bowel.
Any of these illnesses could cause similar symptoms as that of appendicitis.

Treatments:
Once the diagnosis has been made then the patient needs to be sent to a surgeon for surgical intervention. Older protocols directed that a patient with abdominal pain should not be given pain medications as symptoms could be masked. Now, recent studies show that the usage of analgesics, to include narcotics, does not delay the diagnosis of appendicitis. So, be sure that the patients pain is adequately managed. Remember pain is that 5th vital sign and should be assessed and managed aggressively.

Surgical intervention is almost aways the treatment of choice of a confirmed appendicitis. Several method of removal are available. First method of surgery is the open abdominal approach. This method is where the surgeon makes an apprx. 15-20 cm incision in the lower right quadrant of the abdomen, exposes the bowel and removes the appendix. This method has fallen out of favor as abdominal wall muscle are cut and damaged, the risk of infection is higher than other procedures, and recovery time is prolonged.
The second and most common method is the laproscopic approach. This is where a surgeon will make three small incisions on the abdomen. One incision is in the right lower quadrant the other on the lower middle quadrant and then the middle portion of the mid abdomen. The incisions are small and a should only be large enough to insert a camera and instruments into the abdominal cavity. This should be apprx. 1-2cm in diameter. The abdomen is filled with carbon dioxide to inflate the belly to increase work area around the appendix site. Then instruments and a camera are inserted and the appendix is removed. When complete the surgeon may place one suture in each incision and the patient is sent to the recovery room. Sometimes sutures are not used at all as the incisions are so small that the wound edges approximate themselves.
Recovery time and risk of infection is quicker and lower for this procedure versus the open surgery.
Finally, a new technique for appendix removal is finding favor. This procedure is the incision free, alternate orifice removal. This is where the surgeon will take a camera and instruments down the throat and through the stomach into the duodenum. A small incision is made in the duodenal wall and the instruments and the camera are passed through and extended down to the appendix, by passing the small intestines. The appendix is removed and brought out of the abdominal cavity through the stomach, up the esophagus, and out of the mouth. No external incisions are made and the patient is sent home the same day.
Pain management post operatively and prevention of infection is a must following surgery. Often time the patient is treated with vicodin or similar strength narcotics and given an antibiotic. The use of narcotics should be kept to a minimal as dependency can occur and the bowel motility can be reduced causing a secondary complication of constipation.

Appendicitis is a very serious and painful condition. If left untreated the appendix can rupture and the patient will develop peritonitis and die if left untreated.

We will all have abdominal pain at some point in our lives, but hopefully, now you will be able, more easily, recognize the difference between abdominal pain caused by virus or some other etiology and a true appendicitis.

I am thinking about all of you a great deal lately and I pray that the Lord continues to bless you. If you have any prayer request, please pass it along and I will pray for your concerns.

God Bless You All,

Jeff