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  1. Appendicitis: Early Diagnosis and Treatment are Essential

    Posted by Dr. Jack Sacks, Esq.on December 01, 2015

    Appendicitis is a medical emergency that requires immediate surgery to remove the appendix.  If left untreated, an inflamed appendix will eventually rupture.  When this happens intestinal contents (stool and bacteria) spill into the abdominal cavity causing infectious peritonitis, a serious and toxic inflammation of the abdominal cavity’s lining (the peritoneum).  This condition can be fatal unless it is treated quickly with surgery and strong antibiotics.

    SYMPTOMS: Usually pain is the first symptom, starting in the mid abdomen around the navel, and except in children below 3 years old, the pain tends to localize in the right lower quadrant within a few hours.  The abdominal wall becomes sensitive to gentle pressure, and the pain can be elicited through various tests the physician will use to bring it out.  One such sign is when the abdomen is gently pushed down and quickly released.  This is known as rebound tenderness and is a clinical sign the peritoneum is inflamed.  If the appendix is located beneath the cecum (first part of the colon), it may fail to elicit tenderness (silent appendix).  And if the appendix lies entirely within the pelvis, the region below the addomen, there could be a complete absence of the abdominal signs and symptoms. In such cases, a digital rectal exam will cause discomfort localized to the region of the appendix in the right lower quadrant.  Also, if the abdomen on palpation is rigid, which is known as involuntary guarding, there should be a strong suspicion of peritonitis requiring urgent surgical intervention.  The physician can perform certain other maneuvers, such as bending and rotating the right hip, and extending the hip in the prone position, which will bring about pain consistent with inflammation caused by appendicitis.  The next symptoms usually experienced are naussea and vomiting, as well as constipation.  Eventually as the inflammation progresses, fever will occur.

    BLOOD TESTS: When appendicitis is suspected, blood tests such as a CBC need to be done to try to confirm the diagnosis.  More than 80% of adults with appendicitis have a white blood cell count greater than 10,500 cells/mm3.  Another blood test commonly used is the determination of C-reactive protein (CRP),an acute-phase reactant synthesized by the liver in response to infection or inflammation.

    DIAGNOSTIC IMAGING: The plain film of the abdomen, known as a KUB is typically taken. Visualization of an appendicolith (a white colored defect in the right lower quadrant) in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis, but this occurs in fewer than 10% of cases. Another X-ray that may be utilized is the single-contrast Barium enema, which can be performed on an unprepared bowel. Absent or incomplete filling of the appendix with contrast barium coupled with pressure effect or spasm in the cecum suggests appendicitis. Though cheap in cost, once thick barium contrast is instilled, other more definitive tests will not be able to be performed.

    The appendix may be evaluated via transabdominal sonography. Many physicians believe that ultrasonography should be the initial imaging test in pregnant women and in children due to its safety. Abdominal CT scanning has become the most important imaging study in the evaluation of patients with appendicitis.  Advantages of CT scanning include its superior accuracy when compared with other imaging techniques, as well as its ready availability, noninvasiveness, and potential to reveal alternative diagnoses. MRI plays a relatively limited role in the evaluation of appendicitis due to high cost, long scan times, and limited availability.  The lack of dangerous radiation exposure makes it an attractive modality in pregnant patients where ultrasound is not helpful in making a diagnosis.

    In today’s day and age, the diagnosis of appendicitis should generally not be missed by an emergency room physician.  If in doubt a surgeon should be called to evaluate and remove the appendix, which can be done laparoscopically, so long as it remains locally inflamed or walled off, and before there is free perforation into the abdominal cavity.  A delay in diagnosis can result in lifelong complications affecting bowel function due to the scarring of the peritoneal lining.