Difficulties with appendicitis

This is a substantial list. Fortunately most of them are rare. We have divided them into those involved in diagnosing appendicitis, those you will meet while you are removing an appendix, and those which occur afterwards.

DIFFICULTIES [s7]DIAGNOSING APPENDICITIS If the patient is VERY YOUNG beware, because: (1) a good history will be difficult to get in a child, (2) his abdomen will be difficult to examine, (3) gastroenteritis may cause tenderness and cramps. If he does have appendicitis, he needs early surgery. Don't leave him overnight. The most common mistake is to misdiagnose lobar pneumonia as appendicitis, so count his respirations and see if his alae nasi move as he breathes.

If he is asleep, try to feel his abdomen, even for a few seconds, before he wakes up yelling. If he resents any attempt to examine it, there is probably something serious inside it. Examine him repeatedly at intervals of a few hours, until you have enough evidence to justify a laparotomy. If abdominal pain, vomiting, and fever persist, and he is tender in his right iliac fossa, he has appendicitis.

If he is OLD or FAT beware, because infection is poorly localized, complications are frequent and he may present atypically: (1) Tenderness and rigidity may be minimal. If you wait for them to become marked, he may develop ileus and distension while you wait. (2) He may have no fever. As with a child, examine him at intervals of a few hours.

If she is PREGNANT don't be afraid to operate if you think she may have appendicitis. Early in pregnancy, hyperemesis may confuse her symptoms. Narrowly localized tenderness will often provide the diagnosis. Later, her caecum and appendix move upwards, and so does the tenderness of appendicitis. Appendicectomy is unlikely to upset her pregnancy in the first two trimesters. The third is the dangerous one; she is more likely to die from peritonitis (which increases the risk of premature labour) than from having her appendix out.

DIFFICULTIES [s7]AT APPENDICECTOMY If you find GREENISH FLUID in his peritoneal cavity, it has probably escaped through a perforated duodenal ulcer, and tracked down his right paracolic gutter. Remove his appendix if appendicitis is fairly common in your area, close the wound, and repair the perforation through a paramedian incision.

If his APPENDIX LOOKS NORMAL, and appendicitis is common in your area, excise it and look for other pathology, as listed above under ''Differential diagnosis': (1) If he has enlarged mesenteric nodes, and a clear yellowish serous exudate, suspect mesenteric adenitis (common). (2) If you find a purulent exudate, suspect PID in a woman (common) and other causes of peritonitis. These include Meckel's diverticulitis (rare). Look for an inflamed diverticulum about a metre from the ileocaecal junction (28-4). If it is inflamed, excise it with a wedge of tissue on either side; if it is normal, leave it. Another possibility is primary peritonitis (rare, 6.2). (3) If you can feel a tensely distended gall bladder when you pass your finger up through the incision, he has cholecystitis. (4) If he has a tensely distended caecum, he has some large gut obstruction. Enlarge the incision and feel for its cause. (5) If there is pure blood in the abdominal cavity, the possibilities include ectopic pregnancy, a leaking ovarian follicle, and trauma[md]see below. (6) If there is blood-stained fluid, consider pancreatitis, or intestinal infarction. (7) If you find distended small gut, consider strangulation of a hernia[md]perhaps an internal one, or a femoral or an obturator hernia.

If his CAECUM IS MUCH THICKENED, suspect amoebiasis.

If his appendix is inflamed, but is so TIED DOWN BY ADHESIONS that it is difficult to remove safely, insert a drain and close the wound. Do an interval appendicectomy.

If the BASE OF HIS APPENDIX IS NECROTIC, you cannot tie it. If his caecum is healthy, insert a purse string suture. If it is unhealthy, and will not take a suture, infold it with some Lembert sutures, and tack some omentum over it. Put a drain down to it, close the muscles of his abdominal wall, but leave his skin open.

If his APPENDIX IS BURIED in a mass of adhesions and pockets of pus, avoid spreading the infection. Enlarge the incision, lift its medial side forwards, isolate the mass with warm packs, suck out the pus, and remove his appendix if this is not too difficult. Otherwise, leave it and do an interval appendicectomy.

If he has GENERALIZED PERITONITIS, remove his appendix as above if this is not too difficult, and manage his peritonitis as in Section 6.2.

DIFFICULTIES [s7]FOLLOWING APPENDICECTOMY These include ileus (10.13), respiratory complications (9.11), and acute dilatation of his stomach (very rare).

If he goes into SHOCK some hours after the operation, suspect that he is bleeding from his appendicular artery (rare). Transfuse him, reopen his wound and tie it.

If he VOMITS, his ABDOMEN DISTENDS, and he becomes constipated, suspect: (1) intestinal obstruction (10.12) due to an abcess or to kinking of his gut. If necessary, drain the abscess, otherwise manage him as in Section 10.13. (2) Intussusception (10.8). (3) Gram-negative septicaemia and septic shock (53.4).

If he develops a FAECAL FISTULA, it will probably heal spontanously in 2 or 3 weeks[md]provided there is no distal obstruction (9.14). If it persists, suspect obstruction, or amoebic colitis or actinomycosis (rare). Give him amoebecides. Wait several weeks before referring him.

If his TEMPERATURE RISES IN THE SECOND WEEK, accompanied by malaise and local symptoms, there is probably pus somewhere. (1) He may have a metastatic abscess in his liver, or a subphrenic abscess. (2) If he has a mucous rectal discharge or diarrhoea, suspect that there is pus in his rectovesical pouch. Feel for a hard inflammatory mass above his prostate, or in a woman's rectovaginal pouch. (3) Feel also for an inflammatory mass in the abdomen.

If a PELVIC ABSCESS FORMS, monitor him carefully, do a daily rectal examination, and, if he is not very toxic, wait until it drains into his rectum or into an adjacent loop of gut. 95% of pelvic abscesses drain spontaneously, and do not need surgery. If he is no better after a week of non-operative treatment, drain the abscess rectally or vaginally. This applies only to abscesses following appendicitis, not those following PID, which should be drained vaginally as soon as they form (6.6).

If his wound CONTINUES TO DISCHARGE, you may have left a faecolith behind. Explore the track and remove it. He may have: (1) amoebiasis, (2) actinomycosis (rare), or (3) Crohn's disease (rare).

13 The gall-bladder, pancreas, and spleen