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Managing appendicitis

Written by Rotimi Adesanya - Nigeria

Dr. Rotimi Adesanya
A reporter with this newspaper featured a report on Saturday, August 8, 2015, entitled "A community where nine out of every 10 villagers have appendicitis." He wondered what could be the reason for a situation whereby almost nine out of 10 persons in a particular community had undergone surgery as a result of the illness.

The youths informed the reporter that appendicitis and hernia were common among members of their community. They disclosed that several persons have died as a result of the conditions.

The reporter deduced that this could be attributed to the villagers' travails on hardship, hard work, farming and absence of potable water in the community.
The import of this piece is to shed light on the medical condition called appendicitis, being one of the commonest abdominal emergencies seen anywhere in the world.
To start with, appendicitis is more common in females than in males. It used to be thought of as a cosmopolitan disease; but in the last two decades or so, evidence has suggested that this is not necessarily true. Indeed, there is no hospital, large or small, that does not have to deal with this condition in all parts of Nigeria, whether in the urban areas or in the hinterland.

The appendix is a small, thin pouch about five to 10cm long. It's connected to the large intestine, where faeces (stools) are formed. No one knows exactly why we have an appendix; and removing it is not harmful.

Appendicitis is a painful swelling of the appendix, which causes pain in the abdomen. There are four types of appendicitis: acute appendicitis, sub-acute appendicitis, recurrent appendicitis, and chronic appendicitis
Acute appendicitis is the commonest surgical condition of the abdomen. Acute appendicitis may occur at all ages, while sub-acute appendicitis may resolve with medications.

Signs and symptoms
Appendicitis typically starts with a pain in the middle of the abdomen (tummy). The pain may come and go. Within hours, the pain travels to the lower right-hand side, where the appendix usually lies, and becomes constant and severe.

Other symptoms are anorexia, nausea, and low grade fever. Pressing on this area, coughing or walking may all make the pain worse. The patient may lose appetite, feel sick and occasionally experience diarrhoea.

The single most important physical finding by the doctor is right lower abdominal pain on palpation of the abdomen. Other findings include low-grade fever, peritoneal signs, and guardedness.

It's not exactly clear what the causes of appendicitis are, although most cases are thought to occur when something, usually a small piece of seed, stone, faeces (stool) or a swollen lymph node within the wall of the bowel blocks the entrance of the appendix. This obstruction leads to the development of inflammation and swelling.
The overall diagnostic accuracy achieved by history, physical examination, and laboratory tests has been approximately 80 per cent.
The ease and accuracy of diagnosis varies by the patient's sex and age, and is more difficult in women, children, elderly persons and women of childbearing age because acute gynaecologic conditions (e.g., pelvic inflammatory disease) may cause symptoms similar to appendicitis.

If the diagnosis of appendicitis is clear from the patient's history and physical examination, no further testing is needed, and prompt surgical referral is warranted.
When the diagnosis is not clear, management options for suspected appendicitis include observation in a hospital, diagnostic imaging to clarify the diagnosis, laparoscopy, and appendectomy.
In atypical cases, ultrasonography and computed tomography (CT) may help lower the rate of false-negative appendicitis diagnoses, and reduce morbidity from perforation.

It may rupture with the escape of faecal material and various bacteria into the abdomen, thus causing more severe disease called peritonitis.
An abscess cavity forms around the appendix, with the development of severe illness, high-grade fever and considerable discomfort.

A mass is formed by a combination of certain structures within the abdomen, the intestines and the appendix itself, called an appendix mass.

In most cases of appendicitis, the appendix will need to be surgically removed as soon as possible. Removal of the appendix, known as an appendectomy or appendicectomy, has an excellent success rate.
Most people make a full recovery from an appendectomy in a couple of weeks, although strenuous activities may need to be avoided for up to six weeks after open surgery.

As the causes are not fully understood, there's no guaranteed way of preventing appendicitis. The risk of the disease may be reduced by the increasing consumption of high fibre diets and vegetables, since such foods make bowel movements regular and shorten the digestion transit time.

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