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30 May 2008

A Bengali Woman's Missing Appendix*

(Click on the headline for a surgeon's prescription describing genuine cases of appendicitis)
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Surajit Dasgupta
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Anywhere in India, if someone suffers from stomach pain, the ailment could be anything. If it's West Bengal, and it's a woman, chances are high she will be diagnosed with 'appendicitis'. How reliable is this diagnosis?

Background:
This article was written in December 2004. However, none of the two newspapers I worked with during the period September 2004-March 2008 had enough space to accommodate it, even as it's difficult to do away with any of its technical details. The Pioneer had published an abridged version (about 800 words) of this exposition in 2006; the article was not uploaded on to the newspaper’s Internet version.
Four years after writing this article, as I heard last week from friends and acquaintances from Kolkata and its suburbs and the towns Burdwan, Durgapur and Asansol, the scourge of doctors prescribing unnecessary appendectomy all over West Bengal continues with impunity. The capital of the state is the worst hit, as readers will find in this survey which I had started as diary entries in 1989 (and wrapped up in 2005) on my own volition, disturbed by the sheer percentage of cases of appendicitis among Bengalis — a problem one rarely comes across while socialising with other communities in India.
You meet a girl from West Bengal. In a few days as you get to know her better, while chatting on sundry issues of life, she tells you she has had an appendectomy after being diagnosed with appendicitis. It's been about a month that I have joined a new organisation; and in its Kolkata branch I have already knocked into two women out of three who have had appendectomy. Now I have acquired a seemingly funny habit of inquiring if people I have met with in the recent past have had appendicitis. And the answers to these inquiries are emboldening the theory that a native Bengali woman is a typical victim of appendicitis!
Why is the rate of occurrence of appendicitis so high in West Bengal, especially amongst girls? What's more worrisome, those domiciled in the state have virtually accepted appendicitis to be an integral part of a girl's life! Are unscrupulous hospitals advising surgical intervention eyeing a fat bill? Isn't an alternative therapy possible? I came up with the following answer.
Appendix is a closed-ended, narrow tube that attaches to the caecum (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 caecum. 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.

Appendicitis is inflammation of the appendix. It is largely understood that appendicitis begins when the opening from the appendix into the caecum 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 caecum. 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. Living in Kolkata for five years, I never came across any patient in Kolkata to whom the doctors said that the appendicitis would heal this way; whereas in thousands of cases in the US, the UK, France, Netherlands, Germany and Japan, the inflammation, pain and symptoms had disappeared**.

The rate of self-recovery was higher in elderly patients and when antibiotics were used. In only 14% of the cases, he patients came to the doctor long after the episode of appendicitis; with a lump or a mass in the right lower abdomen that was due to the scarring that occurred during healing. This lump raised the suspicion of cancer, which was found baseless in most diagnoses.

Complications:
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. Then nausea and vomiting may occur. It may be necessary, then, to drain the contents of the intestine through a tube passed through the nose and oesophagus 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, that seldom occurs.

Symptoms:
The main symptom of appendicitis is abdominal pain. The pain is at first, diffuse (not ‘diffused’) and poorly localised, that is, not confined to one spot. Poorly localised 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 localised clearly to one small area. Generally, this area is between the front of the right hipbone 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.

Diagnosis:
The diagnosis begins with a thorough history and physical examination. Only 1 in 7 patients interviewed by me said the physician had asked for her medical history. 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.

WBC 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. Potential victims of nursing homes' greed beware : If the doctor advocates surgery right after reading your WBC count, seek a second, even a third opinion.

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 per cent 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. Only 48 per cent of the operated were asked for an ultrasound.

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 anaesthetic.

There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis might include a period of observation, tests as previously discussed, or surgery.

Difficulty in diagnosis:
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.

Mimicry of appendicitis:
The surgeon faced with a patient suspected of having appendicitis always must consider and look for other conditions that can mimic appendicitis. India does not have a culture of informed patients. Not only is it the patient's handicap, most doctors generally consider a patient intellectually challenged. Among those interviewed, the ones who are post graduate students of biology, said the doctor lost his/ her temper when the compulsion of surgical intervention was questioned by the learned patient. Among the conditions that mimic appendicitis are (ref: photographs and captions below):

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



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 that mimics appendicitis



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



Kidney diseases — The right kidney is so close to the appendix that inflammatory problems in the kidney, eg., an abscess, can mimic appendicitis


Treatment:
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 localised 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. But 72 of the interviewed said the operation was suggested within two days of reporting abdominal pain. 19 said it was suggested on the very frist visit to the 'specialist'.

Occasionally, a person may not see the 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 got jammed. 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. None of the 153 interviewed belonged to this category.

Appendectomy:
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.

Modern 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 cyst may mimic appendicitis. In case of 23 girls, this procedure was not followed although the menstrual cycle coincided with the time of surgery. Moreover, till 2000, only 7 major hospitals had inculcated this technique but almost all nursing homes offered appendectomy.

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.

Once in a while, 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.

Complications:
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.

Long-term implications:
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.

So, next time, God forbid, if you complain of any of the symptoms of appendicitis, better carry a cut-out of this page to cross check one doctor's prognosis with another's diagnosis.

* Based on the works of gastroenterologist Dr Jay W Marks
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** Sample of survey in Kolkata : 153 undergraduate and post-graduate students, 38 of them personally known to this correspondent; the rest are acquaintances of these 38. Colleges :- Dinabandhu Andrews, Netajinagar, Ashutosh, J C Bose, Presidency, Jaipuria, Gokhale, City (south) and Vijaygarh Jyotish Ray, 1989-94; 2000-05.
Those interviewed between 1989 and 1994, and then between 2000 and 2003 didn't know the interlocutor would, one day, become a journalist. The study was concluded in August 2005. Respondents that year appeared inhibited, talking to a journalist.
The 2008 batch of interviewees were quite forthcoming.
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The writer is a mathematician and linguist, now a corporate communicator and has been a science journalist, a teacher and marketing manager (in reverse chronological order) in his previous vocations

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Surajit Dasgupta treats no individual, organisation or institution as a holy cow.