By Tedler D. Depaynos, MD
The patient was a 16 years old female who had been complaining of abdominal pain for the past 3 days. She took some of the leftover “paracetamol” tablets in their house but the pain was increasing in severity. Her urine became “yellowish” and urination was becoming “difficult”. Because she was noticed to be bending from time to time and grimacing because of the pain, her mother brought her to an MD whose clinic is located in a drug store for consultation. Because of the difficulty of urination, she was diagnosed to have a UTI (urinary tract infection) with probably a “kidney complication”. Antibiotics and pain killers were prescribed but after 2 days, no relief was obtained and the pain appeared to have worsened. She was then referred by a neighbor to their family MD for a second opinion.
Just deep breathing alone and a little abdominal movement would stimulate her abdominal pain. On closer examination, the pain was localized at the right lower quadrant (RLQ) of her abdomen where the appendix is located. It was rigid even with a slight touch and when the left side or left lower quadrant (LLQ) was slightly depressed pain was felt at the opposite side. Apparently, the patient had an “acute abdomen” probably due to “acute appendicitis” which required immediate surgery.
The appendix is a “vestigial organ” found at the beginning of the large intestine called the ceacum. It is “vestigial” in the sense that it has no practical use anymore. It originally contained lymphatic tissues which are surmised to contribute to the immunity of children and young adults. In time, however, these tissues atrophy so the organ becomes non-functional. In elderly patients they are expected to be more atrophied so that the possibility of acute appendicitis is much less. The family MD who is also a surgeon could recall, however, that less than a decade ago he operated on a 79 years old female patient because of the same acute disease.
In this young patient, however, her appendix is probably not yet fully atrophied.
Inflammation sets in when obstruction occurs in the lumen of the appendix. This may be due to hard feces, undigested food like seeds or most commonly, swelling of the remnant lymphatic tissues due to non-specific infection. The infection may be due to simple infectious diarrhea so that the diarrhea may lead to acute appendicitis in rare cases.
With luminal obstruction, infection worsens with more swelling resulting in compression of the appendicial blood supply causing eventually gangrene and perforation of the appendix. The worst scenario is spillage of the pus, fecal material and bacteria into the abdominal cavity causing abdominal infection or peritonitis. This may be absorbed into the blood stream and it may cause sepsis or in layman’s term, blood poisoning. This is the main concern of surgeons – to prevent these complications to occur by operating early as soon as a definite diagnosis is made.
Classically, acute appendicitis occurs initially with pain at the epigastrium or just above the navel. After sometime, it shifts into the right lower side of the abdomen. What is characteristic is that the pain is continuous and increasing in severity. With worsening infection, fever occurs with flu-like symptoms. If pain becomes on and off or shifts to other sides of the abdomen, most probably the case is not appendicitis. Diagnosis may be confusing sometimes, because it may be accompanied by vomiting and diarrhea and/or difficulty of urination just like in this patient. In cases where the manifestations are not classical, the patient is usually admitted and placed under close observation for at least 24 hours.
Diagnosis of acute appendicitis is based mainly on the history and physical examination of the patient. Of course, the experience of the practicing surgeon counts a lot. Blood examination, urinalysis, x-rays and ultrasound of the abdomen which were done on this patient would just buttress the clinical diagnosis by ruling out other abdominal conditions that could cause pain at the lower right side of the abdomen. Examples are urinary tract infections, twisted ovarian cyst, right fallopian tube infections or even mid cycle of menstruation we call “Mettleschmertz”. In elderly patients, lesions in the colon like cancer are always entertained specially by more experienced surgeons.
Treatment is mainly removing the inflamed appendix, cleaning the abdominal cavity by profuse washing under appropriate anesthesia and of course giving of appropriate antibiotics. With no complications, the operation is a simple one.
Because the patient was operated on an emergency basis and had no complications, the young patient was discharged early and she was with all smiles especially when she came back after a week for follow-up and removal of her wound staples. Her mother even left a package which also made the family MD smile, when he opened it.**
