One in seven Americans suffered it. Appendicitis. What is it? part1 by Aleksandr Kavokin, MD/PhD

It's 10 pm. Severe pain in your belly. You are in ER. Previous day you had a nice party with your friends. Then pain started around your umbilicus (navel). You thought first: aha, probably you ate something bad, it will go away. But it doesn't. You have vomited once and lost appetite. Pain did not improve but worsened. After a day of suffering you decided to visit the hospital. Long taxi trip. Pain is shooting every time the car bumps into a pot. Nurses ask you bunch of questions and place in an available room. There is a confused 90 something years old women in the neighbor room. She mumbles something incomprehensibly. The woman has come from a nursing home. She suffers Alzheimer disease and yells every night for the past 7 years. She has history of multiple medical problems. They brought her in the ER after she developed fever. Nurses draw your blood. You pain is getting gradually worse. Change your position, pull your legs. Pain doesn't go away. When the ... doctor comes? At last ER physician sees you. He writes H+P and ER orders. A stretcher is rolled in. They take you to a radiology department and put into a big machine looking like a gate. Everybody leaves you and the machine drives you into the big metal doughnut. They bring you back into the ER.

Surgical intern comes. He did not rest since 5 AM. He asks bunch of the same questions again and pokes your belly. A tired resident comes. He pokes your belly again. You still wait, become bored, complain on delay, call your relatives. It's already 2 AM. At last the resident discuss your symptoms with attending over the phone. He tells you that you have appendicitis and CT scan confirmed it. History and physicals are written. Admission orders are written. Pre-op orders are written. Antibiotics are prescribed. IV fluid is running 80 ml an hour. You sign consent for operation. Transporting guys take you upstairs - depending on severity of your symptoms - straight to or to the floor. Attending will operate you first thing in the morning.

Classically appendicitis starts as a pain that began in the periumbilical region (around navel - you belly pot). Then pain moves to the right lower quadrant of the abdomen. Nausea and vomiting often present after the onset of the pain. Classically, patient has low grade fever (this means around 37-38 C or 101-102 F), positive psoas sign (you stretch your leg and this movement increases your pain), positive Rovsing sign (Doctor pokes in your left lower quadrant of the abdomen, and you fill the pain in you right lower quadrant), Leukocytosis. Leukocytes are the white blood cells - WBC. Usually there are around 4000-9000 white cells per micro liter of you blood. When you have inflammation in you body the count goes up.

Your pain during appendicitis classically localizes in Mc Burney's point. That is one third between your umbilicus and anterior superior iliac spine (this is the bony point that is sticking most prominently from your pelvis - you can palpate it yourself on the side of your belly). For confirmation a doctor also may try to elicit obturator sign - he will ask you to bend you knee and bring your heel to your groin - this manoeuver increases the pain during appendicitis. Similar test is the raising of the leg while you lie on the stretcher. That movement also increases your pain.

Appendicitis is the inflammation of appendix supposedly due to narrowing of this lumen. That narrowing may be caused by hyperplasia of appendix (means too big growth, overgrowth of the tissue) . That variant happens in children mostly. Another variant - is fecalith (small stony fecal material) that impacts into the appendix lumen. That is seen in young adults mostly.

Appendix itself is a small part of gut . It is pencil-size sticking out gut. Gut is a continuos tube. Mouth is entry. Anus is exit. Appendix sticks out from the wall and ends blindly. It has only one entrance. Appendix is attached to the Caecum (part of gut - literally means blind colon in Latin). Appendix of ruminating animals (animals that chew grass, like cow) is very long and big. Appendix in humans is reduced to the pencil-size. However it doesn't disappear. There is a theory that appendix plays role in immune response. The walls of appendix are actually filled with lymphatic tissue containing lymphocytes (those are subtype of White Blood Cells). Lymphatics is responsible for immunity.

The removal of appendix doesn't really change immunity significantly. Nonetheless, it is not something redundant. Unless it is inflamed there is no good reason to remove it .

Now, acute appendicitis is the acute inflammation of appendix. Suffix "-itis" means inflammation in Latin. Appendicitis is also the most common cause of acute abdomen. Acute abdomen in surgery is a condition in abdomen that requires urgent actions, usually surgical.

To diagnose appendicitis you need to have right lower quadrant pain.

The pain should be present together with either appropriate history (all those classical signs and lack of appetite) or Leukocytosis (increase in white blood cells in the blood).

Patients often ask questions: Can I avoid surgery? Can you treat me with antibiotics alone? You told me that it is possible to treat the appendicitis with antibiotics alone. Please, I do not want surgery, my mother (father, brother, fiancee) said that I can avoid surgery.

The answer is: you can try to avoid it probably, but the odds of death are much higher if you treat appendicitis without surgery. Untreated appendicitis may lead to perforation in less than a day. Sun rises. Sun sets. Appendix bursts. So, the prompt surgical intervention is the main solution. On occasion, the surgeon may even find a normal-appearing appendix and no other problem explaining the symptoms. He may remove the appendix anyway because it is better to remove a normal-appearing appendix than to miss mild case of appendicitis.

To cool down the infection before surgery doctors use antibiotics. Antibiotics may convert acute appendicitis into more chronic type. However the removal of the appendix is the choice.

With modern technology it becomes much easier to distinguish appendicitis and other causes of pain in right lower quadrant. Yet there is no 100% proof diagnostics. Sometime doctors treat with antibiotics alone, when they are not sure. Though, modern CT-scan shows appendicitis almost close to 100%.

What would happen if you miss the appendicitis and appendix bursts? You will get one of the most dreaded surgical complication - peritonitis. Again, "-itis" equals inflammation. Peritoneum means the peritoneal cavity.

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BIO:

Aleksandr Kavokin, MD1994 Russia,PhD1997 Russia - Immunology and Allergy, postdoc at Cancer Center at Med U of South Carolina, postdoc at Yale - Cardiology, Molecular Medicine. http://www.geocities.com/aging_rejuvenation/ http://www.appendicitis.uni.cc/, http://www.geocities.com/appendicitis_disease/

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