After a disaster or at a remote homestead, the medic may not have ready access to modern medical technology. As such, many conditions that are commonly identified with ultrasounds or CAT scans may be more challenging to diagnose. One of these challenges is abdominal pain. There are various medical issues that cause it, with the classic example of an abdominal emergency being appendicitis. Over 300,000 Americans have their appendix removed every year.
The “vermiform appendix”, as it is formally known, is a hollow tubular organ a few centimeters long and a centimeter wide. It looks like a worm (vermiform means worm-like). Attached at the entrance to the large intestine (the “cecum”), it resides in the lower right portion of the abdomen in almost all people. Inflammation of the appendix can become a medical emergency quickly; if ignored, it may represent a life-threatening situation.
ASIDE: When the appendix (or any other organ, for that matter) is inflamed, the suffix “-itis” is added; thus, inflammation of the appendix is called “appendicitis”.
What purpose does the appendix serve? Charles Darwin believed it was a left-over from an earlier time, as horses and some other animals have larger ones that help them digest vegetation. Today, it is thought by many that it serves an immune function for fetuses and children. It is also thought to be a reservoir for good gut bacteria. After a bout of, say, dysentery or cholera, it may help repopulate the gastro-intestinal tract with beneficial micro-organisms.
Having said that, there seems to be no major ill effects from having an appendix removed, although some studies suggest a small increase in diseases, such as Crohn’s Disease.
What Happens in Appendicitis
Appendicitis is related to an obstruction of the organ by, usually, calcified feces; it some cases, blockage can be caused by foreign objects, trauma, or even intestinal worms. How does this lead to a possibly life-threatening situation?
Once blocked, the mucus produced by the appendix is unable to drain into the cecum. The organ swells as a result. Once swollen enough, the ensuing pressure on the appendix walls prevents the circulation necessary to keep tissue alive. The dying tissue causes the appendix to fill with pus and, without treatment, will be either walled-off by the body’s defenses or will burst (a “ruptured appendix”).
Once ruptured, an inflammation of the lining of the entire abdomen called peritonitis occurs. From there, it can progress to an infection throughout the body (sepsis) if untreated. Death may be the final outcome.
How to Identify Appendicitis
Many illnesses will be difficult for the medic to diagnose in austere settings. Although ultrasounds and CAT scans help confirm suspicions, appendicitis can be identified with some reliability based on physical signs and medical history.
Classic signs and symptoms that suggest appendicitis as the cause of abdominal pain include:
Pain starting at or around the belly button, usually dull and aching
Loss of appetite, followed by nausea and vomiting
Inability to pass gas
Pain evolving to become sharper and migrates to the lower right abdomen
The pain tends to localize to a specific spot one-third of the way from the hip bone to the belly button, an area known as “McBurney’s Point”.
Once an appendix has ruptured, the pain becomes general throughout the abdomen in many cases. The belly may appear stiff and swollen, with tenderness on exam, both on pressing down (“guarding”) and when letting go (“rebound tenderness”, often worse).
It should be noted that other symptoms may present in a significant minority of patients. Cramping may occur, with some complaining of painful or otherwise difficult urination. As with any condition, signs and symptoms may vary from person to person.
Mimics of Appendicitis
Other conditions may lead you to erroneously suspect appendicitis when, in actuality, something entirely different is going on. Urinary infections, right-sided tubal pregnancies or ovarian cysts, diverticulitis, Crohn’s disease or ulcerative colitis, and pelvic inflammatory disease may mimic an inflamed appendix to one extent or another and must be ruled out. These topics will be discussed in future articles.
Treatment of Appendicitis
Appendicitis is the most common cause of abdominal pain treated by surgery today, and the procedure is usually curative. The earlier the surgery is performed, the faster the recovery and the less likely scarring will occur. Below is a video of a (bloodier than usual) open removal of a swollen appendix:
Appendectomy can be performed, using a very small incision, under sedation and local anesthesia off the grid. This procedure is not without difficulty for the inexperienced surgeon, as there is intervening small intestine and other structures that must be moved out of the way to visualize the inflamed area. Of course, patient discomfort is a major obstacle.
Recent studies have explored the possibility of using antibiotics to nip early appendicitis in the bud. The patient should be placed on bedrest and restricted to small amounts of clear liquids as soon as you make the diagnosis.
Intravenous treatment is the preferred way to deliver antibiotics to treat appendicitis, but may not be an option off the grid. In that case, a combination of Ampicillin and either Clindamycin or Metronidazole might be useful. In cases of Penicillin allergy, Ciprofloxacin may be a suitable alternative to Ampicillin. It should be noted that, although most of these antibiotics can still be found in veterinary equivalents, this may no longer be the case in the uncertain future.
Joe Alton MD
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