Appendicitis

The appendix is like a small dead-end street heading off from the bowel (see Diagram –Gastrointestinal System).ย  Nobody knows if it serves any purpose, or how it developed during evolution from tiny animals to humans.ย  We only know about it because it can become infected (appendicitis).ย  If a swollen infected appendix bursts (ruptures), germs (bacteria) from the bowel spread all over the abdomen, which is fatal if not treated (surgery & IV antibiotics).

Appendicitis begins as vague discomfort anywhere in the belly.  There’s almost always loss of appetite.  Then as the pain gets worse, it concentrates around the right lower part of the abdomen.  Nausea and often vomiting begin.  If the appendix ruptures, pain may ease up briefly, but then the patient gets really sick, doubled over, with fever, and an abdomen that feels “hard as a board.”

Sometimes a person’s appendix points in an uncommon direction, in which case the pain may be felt in untypical areas.  We usually find tenderness when pressing on the lower right abdomen, but maybe we have to do certain leg maneuvers or a rectal exam to find the strongest point.

We don’t have to send patients with possible early appendicitis to an ER, since the condition progresses gradually, so there’s always time.  We might treat for other conditions like indigestion, but give warning signs to go to the hospital if things get worse.  The key to diagnosis is suspecting the disease:

  • Abdominal discomfort begins & gets worse within a day (rarely 2 days)
  • Pain is located in, or moves to, the lower right part of the abdomen
  • The lower abdomen hurts when pressed on, especially in one spot on the right
  • Nausea & then vomiting develop, after the pain had already begun first.

CT scans are an excellent test to identify or rule-out appendicitis, but not 100%.  They’re helpful if  clinical exam by an experienced surgeon is uncertain (blood tests help only a little).  The disadvantage is that they use radiation, which has a fairly low but still real rate of causing cancer in the long run.  This is most dangerous for young people, with many years of life ahead to get cancer (see Radiation Risks of X-rays).

An MRI avoids radiation, but take longer to perform, cost more, isn’t available in all ERs, and a few people can’t have them done.  Ultrasounds are more useful in children than adults.  Patients who seem to obviously have appendicitis can usually be diagnosed & treated without any of these tests.  Tests are most useful in the elderly, and people with weakened immune systems, whose symptoms are usually vague & difficult.

Appendicitis usually gets operated on.  In Europe it’s common to treat with antibiotics.  Studies suggest this can sometimes work, but many people eventually wind up needing surgery anyway.  A ruptured appendix always needs surgery (antibiotics too).

In my rural clinic years ago, I once sent a patient to the ER for possible appendicitis.  And the family took him home en route to feed him first.  The surgeon was not happy.  Anyone who goes to an ER for any condition that might need surgery should never eat or drink anything.

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