Appendicitis on the front lines; drama and irony close to home


For the patient who hurts low and right,

And suffers from lost appetite

    Search high and low

    The appendix must go

Would a CAT scan help? Well, it might.

Appendicitis has afflicted so many patients since my arrival that I can write about the disease without identifying anyone in particular.

The classic appendicitis patient will complain of abdominal pain starting near the umbilicus (navel), increasing over the course of three days, and moving to the right lower quadrant, aggravated by jarring, and accompanied by loss of appetite.

I always ask the patient what they had for lunch, and whether they enjoyed it.

People with appendicitis come with a back story and a social context.  Some had serious medical problems before their appendix went bad.  They may use illegal or legal things to excess.  They may have good or bad relationships with their family members; they may have no family members at all.  They may not possess the ability to speak for themselves. 

The physician must rely on the information available.

Eighty percent of appendices live near a spot two-thirds of the way along a line from the belly button to the front point of the hip bone, called McBurney’s point; a patient who points there brings immediate suspicion for appendicitis.

If I call a surgeon, he or she will want to know about rebound (increased pain on sudden release of pressure on the abdomen), psoas sign (pain on pulling the right leg back when the patient lies on his or her left side), bunny hop (pain on jumping on the right foot), bowel sounds (presence or absence of normal gurgling in the abdomen), and guarding (tenseness of the abdominal wall muscles).

None of these signs or symptoms makes the diagnosis by itself.  I have had appendicitis patients come with pain low on the right, low on the left, high on the right, and high on the left.  Some had pain in the leg or the back, and a few had no pain at all.

Not one enjoyed their lunch.

When I worked in Navajoland, my appendicitis patients complained of not being able to eat rather than pain.

CT scans help if the history and physical don’t paint a clear picture but characteristic history and physical trump a normal CT scan.  “I operate on patients,” I heard a surgeon say, “Not images.”

Six years ago, while Bethany and I got ready to go out, I told her about the twinge I’d just had at McBurney’s point.  She asked me if I’d enjoyed lunch, which I had, and if I had pain when I hopped on my right foot, which I didn’t.  I ignored the mild zing which came and went over the next six months while my gallbladder went from bad to worse.  I set a convenient date for its removal, and as I walked to the OR with the surgeon, I said, “Listen, Mike, while you’re in there, take out my appendix.  I really don’t want to get back on this table.”

Ten days later, to my unpleasant surprise, the pathology report showed carcinoid, a low-grade cancer.

More things can go wrong with the appendix than just appendicitis.

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