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
*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.
Comments
probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.
it was better if you mentioned that his pain was acute onset or not