Oh My Appendix!

Human beings ate raw grass, leaves, bark and uncooked cereals, like rabbits and other herbivorous animals, before they became refined carnivores who cooked and softened their food. And like these animals, we too had a long appendix.

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As the nature of our diet changed, we did not require this organ and it eventually became small and rudimentary. It still nestles in the lower part of the right side of the abdomen, an appendage loosely attached to the transition point between the small and large intestines. The organ does not serve any discernible useful function. But in almost 40 per cent of the population it gives trouble at some time in their lives.

Digested food gets pushed in and out of the appendix during its transit through the intestine. As long as the opening remains patent, this does not pose a problem. Sometimes the opening of the appendix becomes narrowed and obstructed. This can occur because of intestinal worms, a hard stony piece of stool called a fecolith, or even undigested food particles. Contrary to popular opinion, orange pits and other swallowed seeds have not been shown to block the appendix.

The appendix is lined by abundant lymphoid tissue. This can swell and secrete infected fluid if there is a bacterial or viral infection. If this is sufficient to partially or completely block the opening, there is pain and swelling. If the symptoms are neglected, the appendix can “burst”, spilling the infection fluid into the surrounding area. The entire abdominal cavity can then become infected, causing peritonitis. The infection may get localised, forming an appendicular abscess.

Appendicitis initially produces non-specific symptoms like fever, vomiting, diarrhoea and abdominal pain. The pain may eventually localise in the lower part of the right side of the abdomen. There may also be acute pain in an anatomical area called McBurney’s point, situated a little away from the umbilicus.

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The presentation of appendicitis may be atypical in the young (less than 10 years) and in the old (more than 60). The pain fails to localise in any particular area of the abdomen and may pose a diagnostic enigma. The symptoms may be confusing and the diagnosis missed if the appendix is situated in an abnormal location, too high, too low or at the back, or on the left side of the abdomen. Houdini, the magician, had an appendix on the left side. The diagnosis was missed and it perforated during a performance. He collapsed on stage, dying shortly afterwards.

Unfortunately, there are no confirmatory diagnostic blood tests for appendicitis as there are for other illnesses like typhoid or urinary tract infections. The suspicion of appendicitis can, however, become a certainty with an ultrasound or CT scan. But these procedures have an inherent latent period (waiting for the facility to become available) and the appendix can rupture in the interim.

Around 45 per cent of women are suspected to have appendicitis during their reproductive years. This is because the pain of appendicitis can be confused with tubal infection (salpingitis), urinary tract infection, ectopic pregnancy or even normal mittleschmerz, the mid-cyclic ovarian pain caused by rupture of the mature ovarian follicle and release of the ovum. In 30 per cent of surgeries, the diagnosis of appendicitis is wrong and a normal organ is removed. The mortality, however, is 50 per cent if the inflamed appendix is not treated surgically.

A laparoscopy clinches the diagnosis. The appendix itself can often be removed at the same time with a minimally invasive, no scar laparoscopic procedure, thus providing an investigation method that also cures. The appendix can also be removed through a classical incision.

Sometimes it is possible to control the infection with antibiotics, allowing the person to opt for an interval appendectomy at a convenient time. Some people have a “grumbling appendix” that causes repeated attacks of pain which can be managed conservatively. This delays the need for surgery. It is not a very wise course of action as the infection can flare up at inopportune moments. Women who have repeated attacks of appendicitis are also likely to develop adhesions and scars. This can distort the anatomy of the pelvic area and result in undesirable relative infertility.

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Sources: The Telegraph (Kolkata, India)

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