Medical Minute – 99 Problems but Appendix Aint One!

By: Dr. James Lee

A hospital director catches up with a patient running barefoot from the building.

“Why did you escape from the operating room and run away?” asked the director.

The patient replies, “Because the nurse was saying, ‘It’s okay be brave, it’s just an appendicitis, it’s a simple operation.’

The director says, “So what? She was just trying to reassure you.”

The patient says, “She was talking to the surgeon!”

Haha, a little humor to start off never hurts! But, now on to the serious matter of Acute Appendicitis.

Appendicitis is the inflammation of the appendix. The appendix is a small, hollow, worm-like organ that is attached to the first part of the colon (large intestine) called the cecum. The cecum is usually located low in the abdomen on the right side. The exact function of the appendix is debatable. Most accept that it may have some immunoprotective function, like a lymphoid organ, others argue that it is a developmental remnant that has no real function. Regardless, appendicitis is diagnosed in approximately 300,000 people each year in the U.S. Males are slightly more likely to get appendicitis than females, with 8.6% of men and 6.7% of women developing appendicitis in their lifetime. Appendicitis can occur at any age but is most common between the ages of 10-45. The incidence of appendicitis is highest among patients 10-19 years of age and lowest in children 9 or under.

Appendicitis happens when the lumen of the appendix gets blocked, either by fecal material, foreign bodies, or the lymphoid tissue inside the appendix swells up. The result is that mucous production inside the appendix has nowhere to drain and pressure builds up. The pressure exerted on the wall of the appendix blocks off the lymph drainage first, then the venous drainage next. This results in a further build of pressure on the wall of the appendix. When the pressure inside the appendix exceeds the pressure of the arteries delivering blood to the appendix, the blood supply to the appendix is cut off. When this happens, the wall of the appendix begins to weaken and that is when perforation or rupture occurs.

Acute appendicitis often begins with vague discomfort around the belly button or upper center of the abdomen. Over time, usually 6-12 hours, it travels to the right lower abdomen. After the pain has localized to the right lower quadrant, the point of maximum tenderness, where it hurts the patient most, is located 2/3 along a line between the belly button and the right hip pointer (anterior-superior iliac spine). This point is called McBurney’s point after the doctor who first described it. This pain is constant and associated with nausea and sometimes vomiting. Most people with appendicitis want to lay quietly and do not move around easily. The pain is worse with movement, and it hurts to walk. A low-grade fever is common, but high temperatures are usually not seen unless the appendix ruptures. Patients usually have a low-grade white blood cell count, but a high white count can indicate perforation of the appendix. Many patients are not hungry or interested in eating. Diagnosis is usually suggested by history and physical examination. Confirmation of the diagnosis is usually made with a CT scan or Ultrasound.

The treatment for acute appendicitis traditionally is surgery. The first recorded successful appendectomy was done in 1735 by Claudius Amyand. This involved an 11-year-old boy with acute appendicitis located in an inguinal hernia. However, it would be 150 years before appendectomy would be more widely described. It was in 1887, that the first successful operation deliberately performed for appendicitis would be done by Thomas Morton. Interestingly, Dr. Morton’s brother and son both died of acute appendicitis.

Other interesting historical cases of appendicitis include Dr. Walter Reed, whose work on yellow fever identified the mosquito as the vector of this deadly virus and allowed the completion of the Panama Canal. He would not see this as he developed acute appendicitis in 1902 and initially declined surgery, only to undergo surgery later and die from perforated appendicitis. Prince Albert Edward was set to be coronated King after his mother Victoria’s death in 1901. He developed abdominal pain 12 days before his scheduled coronation. After 10 days of symptoms and refusing to delay the coronation, he relented to have his appendiceal abscess drained and delay the coronation by six weeks. Prince Albert Edward was reported to have been told by his physician that if he did not delay his accession, “Then Sir, you will go as a corpse.” Brigham Young and Harry Houdini also died of acute appendicitis.

Today, appendectomy for acute appendicitis is one of the most common emergency abdominal surgeries, with excellent outcomes. Today this can mostly be accomplished with three small incisions using the laparoscopic approach. This results in less time in the hospital and less post-operative pain over the open technique of a single larger incision.

Recently there is interest in the non-operative management of appendicitis, where patients are given antibiotics alone to resolve appendicitis. This was initially studied by the U. S. Navy, during the Cold War, on submariners. As you may imagine, given the incidence of appendicitis in young men, there was a need to evaluate treatment options as it was difficult to get sailors to surgery before rupture from a deployed submarine. Currently, non-operative treatment is possible for patients who show no signs of peritonitis or sepsis, have stable vital signs, do not have compromised immune systems, are pregnant, or have other bowel diseases. The disadvantage of non-operative treatment of appendicitis is the recurrence rate. 10-20% of patients will recur within 30 days, 30-40% recur at 1 year and 40-5-% at 5 years.

So if there is one thing to impart about appendicitis, it is that if you or someone you know has persistent pain in the lower right side of the abdomen, do not wait to go to the doctor. Get seen right away. Risk of perforation increases with the amount of time from the onset of pain. After 24-36 hours of pain risk of rupture increases dramatically.

Dr. James Lee serves as the Coroner of Winn Parish. He is a General Surgeon and Surgical Oncologist who has been practicing in Winnfield for over ten years. Dr. Lee attended the University of Colorado for his medical degree. He completed his residency in Surgery at the University of Oklahoma before completing a fellowship in Surgical Oncology and Endoscopy at Roswell Park Cancer Institute in Buffalo, NY. Dr. Lee and his wife Scarlett live in Winnfield with their son and are active in the community.

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