|
|
|
Operations
Appendectomy -- for appendicitis
What is the appendix?
The appendix is a
closed-ended, narrow tube
that attaches to the cecum
(the first part of the
colon) like a worm. (The
anatomical name for the
appendix, vermiform
appendix, means worm-like
appendage.) The inner lining
of the appendix produces a
small amount of mucus that
flows through the appendix
and into the cecum. The wall
of the appendix contains
lymphatic tissue that is
part of the immune system
for making antibodies. Like
the rest of the colon, the
wall of the appendix also
contains a layer of muscle.
What is appendicitis?
Appendicitis is inflammation
of the appendix. It is
thought that appendicitis
begins when the opening from
the appendix into the cecum
becomes blocked. The
blockage may be due to a
build-up of thick mucus
within the appendix or to
stool that enters the
appendix from the cecum. The
mucus or stool hardens,
becomes rock-like, and
blocks the opening. This
rock is called a fecalith
(literally, a rock of
stool). At other times, the
lymphatic tissue in the
appendix may swell and block
the appendix. Bacteria which
normally are found within
the appendix then begin to
invade (infect) the wall of
the appendix. The body
responds to the invasion by
mounting an attack on the
bacteria, an attack called
inflammation. (An
alternative theory for the
cause of appendicitis is an
initial rupture of the
appendix followed by spread
of bacteria outside the
appendix.. The cause of such
a rupture is unclear, but it
may relate to changes that
occur in the lymphatic
tissue that line the wall of
the appendix.)
If the inflammation and
infection spread through the
wall of the appendix, the
appendix can rupture. After
rupture, infection can
spread throughout the
abdomen; however, it usually
is confined to a small area
surrounding the appendix
(forming a peri-appendiceal
abscess).
Sometimes, the body is
successful in containing
("healing") the appendicitis
without surgical treatment
if the infection and
accompanying inflammation do
not spread throughout the
abdomen. The inflammation,
pain and symptoms may
disappear. This is
particularly true in elderly
patients and when
antibiotics are used. The
patients then may come to
the doctor long after the
episode of appendicitis with
a lump or a mass in the
right lower abdomen that is
due to the scarring that
occurs during healing. This
lump might raise the
suspicion of cancer.
What are the complications
of appendicitis?
The most frequent
complication of appendicitis
is perforation. Perforation
of the appendix can lead to
a periappendiceal abscess (a
collection of infected pus)
or diffuse peritonitis
(infection of the entire
lining of the abdomen and
the pelvis). The major
reason for appendiceal
perforation is delay in
diagnosis and treatment.
A less common complication
of appendicitis is blockage
of the intestine. Blockage
occurs when the inflammation
surrounding the appendix
causes the intestinal muscle
to stop working, and this
prevents the intestinal
contents from passing. If
the intestine above the
blockage begins to fill with
liquid and gas, the abdomen
distends and nausea and
vomiting may occur. It then
may be necessary to drain
the contents of the
intestine through a tube
passed through the nose and
esophagus and into the
stomach and intestine.
A feared complication of
appendicitis is sepsis, a
condition in which infecting
bacteria enter the blood and
travel to other parts of the
body. This is a very
serious, even
life-threatening
complication. Fortunately,
it occurs infrequently.
What are the symptoms of
appendicitis?
The main symptom of
appendicitis is abdominal
pain. The pain is at first
diffuse and poorly
localized, that is, not
confined to one spot.
(Poorly localized pain is
typical whenever a problem
is confined to the small
intestine or colon,
including the appendix.) The
pain is so difficult to
pinpoint that when asked to
point to the area of the
pain, most people indicate
the location of the pain
with a circular motion of
their hand around the
central part of their
abdomen.
As appendiceal inflammation
increases, it extends
through the appendix to its
outer covering and then to
the lining of the abdomen, a
thin membrane called the
peritoneum. Once the
peritoneum becomes inflamed,
the pain changes and then
can be localized clearly to
one small area. Generally,
this area is between the
front of the right hip bone
and the belly button. The
exact point is named after
Dr. Charles
McBurney--McBurney's point.
If the appendix ruptures and
infection spreads throughout
the abdomen, the pain
becomes diffuse again as the
entire lining of the abdomen
becomes inflamed.
Nausea and vomiting also
occur in appendicitis and
may be due to intestinal
obstruction.
How is appendicitis
diagnosed?
The diagnosis begins with a
thorough history and
physical examination.
Patients often have an
elevated temperature, and
there usually will be
moderate to severe
tenderness in the right
lower abdomen when the
doctor pushes there. If
inflammation has spread to
the peritoneum, there is
frequently rebound
tenderness. This means that
when the doctor pushes on
the abdomen and then quickly
releases his hand, the pain
becomes suddenly but
transiently worse.
White Blood Cell Count
The white blood cell count
in the blood usually becomes
elevated with infection. In
early appendicitis, before
infection sets in, it can be
normal, but most often there
is at least a mild elevation
even early. Unfortunately,
appendicitis is not the only
condition that causes
elevated white blood cell
counts. Almost any infection
or inflammation can cause
this count to be abnormally
high. Therefore, an elevated
white blood cell count alone
cannot be used as a sign of
appendicitis.
Urinalysis
Urinalysis is a microscopic
examination of the urine
that detects red blood
cells, white blood cells and
bacteria in the urine.
Urinalysis usually is
abnormal when there is
inflammation or stones in
the kidneys or bladder which
sometimes can be confused
with appendicitis.
Therefore, an abnormal
urinalysis suggests that
there is a kidney or bladder
problem while a normal
urinalysis is more
characteristic of
appendicitis.
Abdominal X-Ray
An abdominal x-ray may
detect the fecalith (the
hardened and calcified,
pea-sized piece of stool
that blocks the appendiceal
opening) that may be the
cause of appendicitis. This
is especially true in
children.
Ultrasound
An ultrasound is a painless
procedure that uses sound
waves to identify organs
within the body. Ultrasound
can identify an enlarged
appendix or an abscess.
Nevertheless, during
appendicitis, the appendix
can be seen in only 50% of
patients. Therefore, not
seeing the appendix during
an ultrasound does not
exclude appendicitis.
Ultrasound also is helpful
in women because it can
exclude the presence of
conditions involving the
ovaries, fallopian tubes and
uterus that can mimic
appendicitis.
Barium Enema
A barium enema is an x-ray
test where liquid barium is
inserted into the colon from
the anus to fill the colon.
This test can, at times,
show an impression on the
colon in the area of the
appendix where the
inflammation from the
adjacent inflammation
impinges on the colon.
Barium enema also can
exclude other intestinal
problems that mimic
appendicitis, for example
Crohn's disease.
CT Scan
In patients who are not
pregnant, a CT Scan of the
area of the appendix is
useful in diagnosing
appendicitis and
peri-appendiceal abscesses
as well as in excluding
other diseases inside the
abdomen and pelvis that can
mimic appendicitis.
Laparoscopy
Laparoscopy is a surgical
procedure wherein a small
fiberoptic tube with a
camera is inserted into the
abdomen through a small
puncture made on the
abdominal wall. Laparoscopy
allows a direct view of the
appendix as well as other
abdominal and pelvic organs.
If appendicitis is found,
the inflamed appendix can be
removed at the same time.
The disadvantage of
laparoscopy compared to
ultrasound and CT scanning
is that it requires a
general anesthetic.
There is no one test that
will diagnose appendicitis
with certainty. Therefore,
the approach to suspected
appendicitis may include a
period of observation, tests
as previously discussed, or
surgery.
Why can it be difficult to
diagnose appendicitis?
It can be difficult to
diagnose appendicitis. The
position of the appendix in
the abdomen may vary. Most
of the time the appendix is
in the right lower abdomen,
but the appendix, like other
parts of the intestine, has
a mesentery. This mesentery
is a sheet-like membrane
that attaches the appendix
to other structures within
the abdomen. If the
mesentery is large, it
allows the appendix to move
around. In addition, the
appendix may be longer than
normal. The combination of a
large mesentery and a long
appendix allows the appendix
to dip down into the pelvis
(among the pelvic organs in
women). It also may allow
the appendix to move behind
the colon (called a
retro-colic appendix). In
either case, inflammation of
the appendix may act more
like the inflammation of
other organs, for example, a
woman's pelvic organs.
The diagnosis of
appendicitis also can be
difficult because other
inflammatory problems may
mimic appendicitis.
Therefore, it is common to
observe patients with
suspected appendicitis for a
period of time to see if the
problem will resolve on its
own or develop
characteristics that more
strongly suggest
appendicitis or, perhaps,
another condition.
What other conditions can
mimic appendicitis?
The surgeon faced with a
patient suspected of having
appendicitis always must
consider and look for other
conditions that can mimic
appendicitis. Among the
conditions that mimic
appendicitis are:
*Meckel's diverticulitis. A
Meckel's diverticulum is a
small outpouching of the
small intestine which
usually is located in the
right lower abdomen near the
appendix. The diverticulum
may become inflamed or even
perforate (break open or
rupture). If inflamed and/or
perforated, it usually is
removed surgically.
*Pelvic inflammatory
disease. The right fallopian
tube and ovary lie near the
appendix. Sexually active
women may contract
infectious diseases that
involve the tube and ovary.
Usually, antibiotic therapy
is sufficient treatment, and
surgical removal of the tube
and ovary are not necessary.
*Inflammatory diseases of
the right upper abdomen.
Fluids from the right upper
abdomen may drain into the
lower abdomen where they
stimulate inflammation and
mimic appendicitis. Such
fluids may come from a
perforated duodenal ulcer,
gallbladder disease, or
inflammatory diseases of the
liver, e.g., a liver
abscess.
*Right-sided diverticulitis.
Although most diverticuli
are located on the left side
of the colon, they
occasionally occur on the
right side. When a
right-sided diverticulum
ruptures it can provoke
inflammation they mimics
appendicitis.
*Kidney diseases. The right
kidney is close enough to
the appendix that
inflammatory problems in the
kidney-for example, an
abscess-can mimic
appendicitis.
How is appendicitis treated?
Once a diagnosis of
appendicitis is made, an
appendectomy usually is
performed. Antibiotics
almost always are begun
prior to surgery and as soon
as appendicitis is
suspected.
There is a small group of
patients in whom the
inflammation and infection
of appendicitis remain mild
and localized to a small
area. The body is able not
only to contain the
inflammation and infection
but to resolve it as well.
These patients usually are
not very ill and improve
during several days of
observation. This type of
appendicitis is called
"confined appendicitis" and
may be treated with
antibiotics alone. The
appendix may or may not be
removed at a later time.
On occasion, a person may
not see their doctor until
appendicitis with rupture
has been present for many
days or even weeks. In this
situation, an abscess
usually has formed, and the
appendiceal perforation may
have closed over. If the
abscess is small, it
initially can be treated
with antibiotics; however,
the abscess usually requires
drainage. A drain usually is
inserted with the aid of an
ultrasound or CT scan that
can determine the exact
location of the abscess. The
appendix is removed several
weeks or months after the
abscess has resolved. This
is called an interval
appendectomy and is done to
prevent a second attack of
appendicitis.
How is an appendectomy done?
During an appendectomy, an
incision two to three inches
in length is made through
the skin and the layers of
the abdominal wall in the
area of the appendix. The
surgeon enters the abdomen
and looks for the appendix,
usually located in the right
lower abdomen. After
examining the area around
the appendix to be certain
that no additional problem
is present, the appendix is
removed. This is done by
freeing the appendix from
its attachment to the
abdomen and to the colon,
cutting the appendix from
the colon and sewing over
the hole in the colon. If an
abscess is present, the pus
can be drained with drains
(rubber tubes) that go from
the abscess and out through
the skin. The abdominal
incision then is closed.
Newer techniques for
removing the appendix
involve the use of the
laparoscope. The laparoscope
is a thin telescope attached
to a video camera that
allows the surgeon to
inspect the inside of the
abdomen through a small
puncture wound (instead of a
larger incision). If
appendicitis is found, the
appendix can be removed with
special instruments that can
be passed into the abdomen,
just like the laparoscope,
through small puncture
wounds. The benefits of the
laparoscopic technique
include less post-operative
pain (since much of the
post-surgery pain comes from
incisions) and a speedier
recovery. An additional
advantage of laparoscopy is
that it allows the surgeon
to look inside the abdomen
to make a clear diagnosis in
cases in which the diagnosis
of appendicitis is in doubt.
For example, laparoscopy is
especially helpful in
menstruating women in whom a
rupture of an ovarian cysts
may mimic appendicitis.
If the appendix is not
ruptured (perforated) at the
time of surgery, the patient
generally is sent home from
the hospital in one or two
days. Patients whose
appendix has perforated
generally are sicker than
patients without
perforation. After surgery,
their hospital stay often is
prolonged (four to seven
days), particularly if
peritonitis has occurred.
Intravenous antibiotics are
given in the hospital to
fight infection and assist
in resolving any abscess.
Occasionally, the surgeon
may find a normal-appearing
appendix and no other cause
for the patient's problem.
In this situation, the
surgeon may remove the
appendix. The reasoning in
these cases is that it is
better to remove a
normal-appearing appendix
than to miss and not treat
appropriately an early or
mild case of appendicitis.
What are the complications
of appendectomy?
The most common complication
of appendectomy is infection
of the wound, that is, of
the surgical incision. Such
infections vary in severity
from mild, with only redness
and perhaps some tenderness
over the incision, to
moderate, requiring only
antibiotics, to severe,
requiring antibiotics and
surgical treatment.
Occasionally, the
inflammation and infection
of appendicitis are so
severe that the surgeon will
not close the incision at
the end of the surgery
because of concern that the
wound is already infected.
Instead, the surgical
closing is postponed for
several days to allow the
infection to subside with
antibiotic therapy and make
it less likely for infection
to occur within the
incision.
Another complication of
appendectomy is an abscess,
a collection of pus in the
area of the appendix.
Although abscesses can be
drained of their pus
surgically, there are also
non-surgical techniques, as
previously discussed.
Are there long-term
consequences of
appendectomy?
It is not clear if the
appendix has an important
role in the body in older
children and adults. There
are no major, long-term
health problems resulting
from removing the appendix
although a slight increase
in some diseases has been
noted, for example, Crohn's
disease.
Appendectomy At A Glance
*The appendix is a small,
worm-like appendage attached
to the colon.
*Appendicitis occurs when
bacteria invade and infect
the wall of the appendix.
*The most common
complications of
appendicitis are abscess and
peritonitis.
*The most common
manifestations of
appendicitis are pain,
fever, and abdominal
tenderness.
*Appendicitis usually is
suspected on the basis of a
patient's history and
physical examination;
however, a white blood cell
count, urinalysis, abdominal
x-ray, barium enema,
ultrasonography, CT, and
laparoscopy also may be
helpful in diagnosis.
*Due to the varying size and
location of the appendix and
the proximity of other
organs to the appendix, it
may be difficult to
differentiate appendicitis
from other abdominal and
pelvic diseases.
*The treatment for
appendicitis usually is
antibiotics and appendectomy
(surgery to remove the
appendix).
*Complications of
appendectomy include wound
infection and abscess. |
|
