Acute Abdomen and Appendicitis
Acute abdominal pain is one of the most frequently encountered symptoms in patients seeking emergency attention. It is also the most commonly presented complaint in patients with diseases warranting surgery.
Acute abdomen refers to the clinical situation in which a sudden change in the condition of the intra-abdominal organs – usually related to inflammation or infection – demands immediate and accurate diagnosis. From the surgical point of view, acute abdominal pain is the cardinal symptom of ‘acute abdomen’. Conditions resulting in an acute abdomen can cause serious complications, sometimes even death.
The condition tests the clinical acumen of the doctor. An accurate and comprehensive history of the events surrounding the onset of pain and knowledge of the nature of pain, its location and accompanying symptoms, are crucial in developing a differential
diagnosis. The vital signs may be normal during the initial phases of the illness with an elevated temperature and a fall in blood pressure occurring in the later stages. Information from the patient’s history, physical examination, laboratory tests and imaging studies, usually permits a reasonably correct diagnosis, but uncertainty can still remain.
The most common surgical cause of acute abdominal pain is acute appendicitis. Because appendicitis is a common disease, it must remain in the comprehensive diagnosis of any undiagnosed patient with persistent abdominal pain, particularly that in the
right lower abdomen. Appendicitis is the single most important cause of acute abdominal pain, causing great diagnostic difficulties, causing some doctors to wrongly go for an appendectomy (surgical removal of the vermiform appendix). The other major causes of acute abdomen are:
- Non-specific abdominal pain.
- Acute cholecystitis, caused by gallstones in the gallbladder.
- Intestinal obstruction.
- Perforated duodenal ulcer.
- Renal colic, the pain caused by kidney stones.
- Acute pancreatitis.
- Acute gynaecological disorders.
The range of diseases extends from the relatively trivial to the immediately life threatening, and attempts to reach a diagnosis is sometimes curtailed in the interests of immediate treatment.
- The classic history of anorexia and periumbilical pain (near the belly button) followed by nausea, Right Lower Quadrant (RLQ) pain, and vomiting, occurs in almost half of all cases.
- Migration of pain from the periumbilical area around the navel to the RLQ is the most discriminating feature of the patient’s history.
- Owing to concerns about the patient’s exposure to radiation during CT scans, ultrasonography (using the reflections of high-frequency sound waves to construct an image of a body organ) has been suggested as a safer primary diagnostic method for appendicitis, with CT scanning used secondarily when ultrasonograms are negative or inconclusive. The overall accuracy of ultrasonography in diagnosing appendicitis ranges from 85 to 95 percent. Ultrasonography performed in patients with suspected acute appendicitis improves patient care, both by averting unnecessary appendectomies and by averting delays before medical or surgical treatment, which consequently reduces hospital expenditure.
Although many antibiotics are available to control infections, appendicitis remains a surgical disease. In fact, appendectomy is the only rational therapy for acute appendicitis. It avoids clinical deterioration and may avoid chronic or recurrent appendicitis. Appendectomy, either open or laparoscopic (in common parlance termed keyhole surgery), currently remains the treatment of non-complicated appendicitis.
Laparoscopy has some advantages, including decreased post-operative pain, better aesthetic result, less time to return to usual activities, and lower incidence of wound infections or a splitting opening of the wound. This procedure is costeffective, but may require more operative time compared with open appendectomy. No contraindications to appendectomy are known for patients with suspected appendicitis, except in the case of those with a long history of symptoms and signs of a large phlegmon inflammation in tissue spaces spread over a large area). Thus, generally a person diagnosed with acute appendicitis, undergoes surgery. If a peri-appendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians
may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage by pricking the skin followed by appendectomy later.
There can be certain problems which force the doctors to reconsider, and possibly, not perform laparoscopic appendectomy.
These contraindications are:
- Extensive adhesions, radiation or immunosuppressive therapy.
- Severe portal hypertension.
- Coagulopathy (a disease that adversely effects the clotting of blood).
- The first trimester of pregnancy.
In the last few years though, the incidence and mortality rate of appendicitis has markedly decreased. The overall mortality rate of 0.2 to 0.8 percent is attributable to complications of the disease rather than to surgical intervention. Mortality rate rises above 20 percent in patients older than 70 years, primarily because of diagnostic and therapeutic delay. Appendiceal perforation, which involves complications arising from a hole or break in the organ, sharply increases the morbidity and mortality rates. Complications are higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis.