By Tedler D. Depaynos, MD
It was in the wee hours 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, 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 69 years old, other considerations were entertained.
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 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. I could recall, however, that less than a decade ago we operated on a 79 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 worse 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 appendicitis occurs initially with pain at the epigastrium or just above the navel. After sometime, it shifts to 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. 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 day before he felt the epigastric pain and shifted abruptly to the right lower quadrant of his abdomen. This simply emphasize that the process of acute appendicitis maybe rapid and complications may occur fast especially in pediatric patients where the omentum in the abdomen that limits the spread of the infection is still miniscule.
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 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 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 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 early and had no complications, the patient was with all smiles especially when he came back after a week for follow-up and removal of his wound staples. He even left an envelope which also made the surgeon smile when he opened it.**
