It’s not unusual for many of us to get stomach aches from time to time; often due to the ingestion of contaminated food, usually prepared outside one’s own dwelling. Commonly associated with fever, loose stools and episodes of vomiting, gastroenteritis is not too difficult to recognise.

However, do you remember a time where you got a tummy pain on the right side or a pain around the belly button and this happening despite not eating from take-way food outlets?   

If you sought medical advice on such occasions, your doctor must have attempted to exclude the condition known as Appendicitis; which usually has a rather similar presentation, but is ‘mandatory’ to be excluded before thinking of a simple infection.   

This week’s Health Capsule dedicates the page to discuss this rather important surgical condition and our source person for the article is Professor Lionel Wijesuriya, Consultant Surgeon at Neville Fernando Teaching Hospital, Malabe. He counts many years of experience in diagnosing and managing patients with ‘appendicitis’; which usually presents as an emergency situation, and warrants speedy recognition and treatment.   

“Appendicitis is a painful medical condition in which an organ lying within our belly-known as the appendix- becomes inflamed and filled with pus-a fluid comprising dead cells and inflammatory tissue that results from an infection of that little organ. Being a disease that develops rather rapidly, it carries the adjective acute” says Professor Wijesuriya.   

It is not always clear as to what causes this condition. There is also no way of knowing if or when one might develop appendicitis, although the condition is often found to follow one of two underlying issues:   

•  An infection (viral or bacterial) in another organ within the belly that has spread to the appendix or   
•  An obstruction that blocks the opening of the narrow cavity within the appendix. Such a ‘blockage’ might result from several different sources. These include:   
•  Lymph tissue in the wall of the appendix that has swollen as a result of the infection it is associated with.   
• When a person’s appendix becomes infected or obstructed, bacteria within the organ multiply rapidly. This bacterial ‘take-over’ causes the appendix to swell with the pus within   
•  A pellet of hardened stool (technically known as ‘a faecolith), usually associated with constipation; rarely, a parasite (eg. a worm)   
•  Foreign objects such as pins, stones, the husk of the paddy grain (fore-runner of rice) or egg shell all swallowed with the food.   

A blunt injury to the belly   
According to the Professor, Appendicitis is undoubtedly more common in western countries where 5-7% of the population is likely to develop it; sometime during life, mostly during their childhood or teens.The incidence in Sri Lanka, as indeed it is in other countries in this region and the entire ‘third world’, is a little less. It is unusual to see Appendicitis in older adults, beyond the age of 35 to 40. The two sexes are affected equally although the diagnosis in young females of child-bearing age may pose a challenge, in that most of the other lower abdominal painful disorders in them may mimic Appendicitis.   

Presentation
“Most patients arrive at a medical facility with pain in the belly, more often than not associated with feeling generally unwell and usually with some fever. The initial ’ache’ associated with Appendicitis begins around the belly button, but within a matter of hours, shifts to the right lower part of the belly. Usually constant in nature, the pain sharpens with the passing of several hours and can worsen during any movement, including walking, deep breathing, coughing and sneezing. Other common features associated include the lack of desire for food, nausea, vomiting, constipation and a low-grade fever.   

“Many a patient gets the feeling that a bowel movement would bring them relief, but find that they are unable to achieve that” he further mentioned.   

In addition to this common presentation, there can be atypical presentations as well where the diagnosis is not necessarily ‘cut and dry’.   
The location of the pain may vary depending upon the actual position of the appendix, which itself is not all that constant; e.g. the patient might feel pain in the back, the flank, just above the pubic region or even the left side of the belly. In a male patient, the pain may be interpreted as arising in the right testis when the inflamed appendix is placed astride the ureter, the tube carrying urine to the bladder from the patient’s right kidney.   

If the patient happens to be pregnant when she develops appendicitis, the location of the pain may lie higher than usual and in fact be rather misleading. In patients with chronic underlying disease (eg. Diabetes) the intensity of the belly ache may be reduced so much that the diagnosis might be totally missed.   

Belly aches are very common. In schoolchildren and young adults any belly ache that persists in spite of home-remedies should be treated with respect and medical advice must be sought without undue delay, particularly if the patient is found to have fever and ‘refuses food’.   

Diagnosis
As far as the diagnosis of appendicitis is concerned, the sequence of presentation in almost 3/4 of patients is with loss of appetite, followed by abdominal pain and then vomiting.   

According to the professor, Acute Appendicitis is essentially a ‘clinical diagnosis’: ie. the doctor who sees the patient makes the diagnosis based mostly on the story gathered from the patient (or parent/guardian in the case of a child) and the bed-side clinical examination that follows. An experienced surgeon usually gets the diagnosis ‘right’ almost 75% of the time. A simple blood-test (full blood count) could improve the diagnostic accuracy.   

Where there is any further doubt, the clinician might order imaging tests (ultrasound or CT scan) for further confirmation.   

Treatment
“Once you are diagnosed with Appendicitis - you will almost always have the operation known as appendicectomy, under anaesthesia (where the entire organ will be removed – with no risk of residual disability as the human appendix does not have any definitely recognized function)” he highlighted.   

Although there are reports appearing on the virtues of treating selected patients with antibiotics alone, it is not a generally accepted practice world-wide as yet.   

“A commonly asked question is whether all these patients diagnosed with appendicitis require surgery. The answer is yes, even though there might be the occasional exception. The surgeon dealing with the patient might occasionally delay surgery if it is felt that the patient has already developed an ‘appendicular mass’, where such delayed action proves safer”.   

The other important fact-although rare- that merits mention is appendicitis-related deaths!   
According to the professor, a ruptured appendix may result if the surgery for its removal is delayed unduly resulting in the condition of general peritonitis from seepage of pus from inside the organ into the cavity of the belly-at-large. In most cases of suspected peritonitis, the surgeon will remove the organ soon after suspecting the event and clean the inside of the belly. If the patient is left untreated, peritonitis can quickly spread, resulting in septicemia (the presence of bacteria in the blood) which might make the patient ‘dangerously ill’ and he or she may even succumb to the disease.   

An overall mortality rate of less than 1% is attributable to complications of the disease rather than to surgical intervention. This figure, in fact, tends to be higher in patients above the age of 70.   

Care after surgery
The after-care following removal of the appendix usually tends to be straight-forward. While in hospital, the medical and nursing staff will ensure the comfort of the patient by ensuring adequate intake of fluids, as instructed by the medical personnel, into a vein followed shortly after by fluids by mouth and later solid food, pain-killing medication as prescribed as well as basic wound care. The discomfort related to the wound lasts no more than 2-3 days. Most patients can expect to leave hospital by the 2nd or 3rd day, to recuperate thereafter at home.   
Return to normal physical activity should happen in less than a fortnight since most patients are relatively young!