It is absolutely vital to rule out intrauterine or tubal pregnancy in this age group by performing a urine for gravindex examination as well as careful pelvic ultrasonography. Previous tubal ligation does not rule out possible tubal pregnancy.
History of spotting and missed periods will have to be actively investigated. Ultrasonogram will indicate other problems like tubo-ovarian pathology, mass, fluid collection etc. Some ultrasonographers are capable of demonstrating abnormal appendix filled with purulent material.
Ureteric stones could also present like acute appendicitis and it is advisable to look into the urinalysis and also perform appropriate investigations for the same.
Elderly people who are not able to communicate their problems well and paralyzed patients may not show all the signs of acute appendicitis the way others do. But every attempt has to be made to carefully assess these situations. More often, these are picked up after the appendix has perforated and at times with para-appendiceal inflammatory mass changes. When such patients are sick, and has vomiting, particularly with an elevated white count, appendicitis should be a consideration.
In infants the only history that may be available is that the child is sick, refusing feeds and is vomiting. Almost always the diagnosis is made only after the appendix is perforated and there is evidence of peritonitis with abdominal distension. More often these children are operated for peritonitis and the presence of perforated appendicitis is noted. But it is important for the family practitioner to be aware of this diagnosis every time he examines a sick child with abdominal symptoms and signs. One of the useful signs that may indicate symptoms of presence of peritonitis is to gently palpate the lower abdomen and in particular right side and one will find the child briskly flexing the knees and bending the hips towards the abdomen. This self-protective reaction indicates the presence of peritonitis and when it happens on palpation of the right lower quadrant of the abdomen, possibility of acute appendicitis has to be seriously considered. The presence of acetone in the urine and no sugar, would indicate the level of dehydration requiring rapid fluid administration. Children in particular, when they vomit and refuse feeds acetone in the urine is not uncommon.
In dealing with pregnant women diagnosis of acute appendicitis is extremely difficult. In early pregnancy if acute appendicitis is not rapidly diagnosed and taken care of, complications may even lead to abortions. On the other hand, ignoring the pregnancy and going ahead with appendicectomy under general anesthesia has to be done only after careful consideration. The family practitioner will be better off inviting the opinion of an obstetrician as well as a general surgeon. In early pregnancy the elevation of white count may not be a useful sign and cannot be depended upon totally unless the number is significant.
During advanced pregnancy performing appendicectomy is somewhat of a challenge to the surgeon and here again the idea of general anesthesia will require to be carefully planned out keeping the interest of the fetus in mind. Although rare, when appendicitis complicates pregnancy, it is a serious situation and requires to be dealt with by multiple disciplines.
How do we avoid unnecessary surgery for appendicitis? Adolescent patients, particularly men, when they come with symptoms of
acute appendicitis, the possibility of acute appendicitis is very high. In these cases, when there are convincing signs and symptoms along with elevated white count as also in a nonpregnant female adolescent early operative procedure and appendicectomy is likely to give a very high rate of positive appendicitis. But the same is not true in other groups. Unlike the olden days due to the current levels of management, including judicious utilization of antibiotics, the disastrous complications of delayed diagnosis of appendicitis have come down significantly. So in most hospitals a strict diagnostic regimen is being followed by many practicing surgeons. If the signs and symptoms are clear cut with evidence of reproducible direct tenderness in the right iliac fossa with point-tenderness over McBurney’s area and an elevated white count, with no other complicated history, no major work-ups are necessary. Ultrasonographic examination of the pelvic area, to rule out other pathologies, particularly in women and a plain x-ray of the abdomen to look at the presence of faecalith or segmental right lower quadrant intestinal ileus, will be of help in making a diagnosis. When such convincing findings are not there and the ultrasonography and plain x-rays are noncontributory, patients are generally admitted and are kept on I.V. fluids. No oral intake is allowed and antibiotics are not started. In a few hours, the surgeon reexamines the patient and if any of the symptoms and signs show significant worsening or a repeated white cell count shows appreciable elevation patient is taken to surgery. This judicious wait, watch, reevaluate and proceed approach does not add to the morbidity and mortality of acute appendicitis in the hands of such experienced people. Most often, on the second examination with hydration and support, the patient is already feeling better and many of the symptoms are not present and signs not reproducible. It allows the clinician to wait for some more time like another six hours and reexamine the patient before a final decision is taken. In order to prove that it is not acute appendicitis some aggressive radiologists and surgeons proceed with barium enema examination and repeated ultrasonographic examination.
||*These extensive work ups should be limited to special circum-stances only and barium enema examination is certainly not a consideration while dealing with pregnant woman.|
*This improved new approach to acute appendicitis has saved a lot of patients from unnecessary surgery and needless waste of time and money not to mention the complications following surgery.