By Tedler D. Depaynos, MD
It was the wee hours of the morning when the patient went to the hospital because of pain in the right lower quadrant of his abdomen. As a rule, when a patient comes at a very unholy hour and from a distant place specially an elderly one, there is really something wrong. The impression made by the admitting surgical resident was acute appendicitis because of the location of the pain but since the patient was 67 years old other considerations were entertained.
The appendix is a “vestigial organ” found at the beginning of the large intestines called the ceacum. It is “vestigial” in the sense that it has no practical use anymore. It originally contains 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. There are exceptions to the rule however because more than a decade ago we operated on a 78 years old female patient because of the same acute disease.
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 appendiceal 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 terms, 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. In this patient, emergency operation was done and true enough his appendix was gangrenous, foul smelling and fecal matter was obstructing the lumen.
Classically, acute appendiceal pain occurs initially 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 usually continuous and increasing in severity. With worsening infection, fever occurs with flu-like symptoms. Diagnosis may be confusing sometimes because it may be accompanied by vomiting and diarrhea and/or difficulty of urination. In cases where the manifestations are not classical, the patient is admitted and placed under close observation for at least 24 hours.
The patient manifested the classical signs and symptoms but what was intriguing was the rapidity of the process. He insisted that it was only a few hours earlier when he felt the epigastric pain which shifted later to the right lower quadrant of his abdomen. This simply emphasized that the process of acute appendicitis maybe rapid and complications may occur fast especially in the pediatric patients where the omentum in the abdomen that limits the spread of the infection is still minuscule.
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 will just buttress the clinical diagnosis by ruling out other abdominal conditions that could cause pain at the lower right side. In elderly patients like this patient, lesions in the colon like cancer is always entertained specially by more experienced surgeons.
Treatment is mainly removing the inflamed appendix, cleaning the abdominal cavity under appropriate anesthesia and of course giving of appropriate antibiotics. With no complications, the operation is a simple one.
Because the patient was operated early and had no complications, the patient was with all smiles even when he came back for follow-up and removal of his wound staples.
BBMS INDUCTION
Our CONGRATULATIONS to the new set of excited officers of the Baguio-Benguet Medical Society led by their president, Dr. Danilo Flores Jr, a young upcoming Ophthalmologist and their vice-president for administration, Dr. Justiniano Bai ,an Orthopedic surgeon with a sub-specialty in hand surgery. They were solemnly inducted at the Fortune Restaurant last July 27, 2016 by the national Philippine Medical Association president, Dr. Ireneo C. Bernardo, III.
Dr. Flores surely will be assisted unofficially by his wife, Myra, a well trained Oncologist. He ambitions to initially upgrade the projects of the previous administration like the continuing Medical Education with the aid of the different Medical Sub-Specialty Associations, conduct environmental and charitable service projects not only within the hospital each member is connected to but also in the community and to strengthen the fellowship and camaraderie of the association.**
