Tuesday, September 19, 2006

Tales From the Right Lower Quadrant, Part four


I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually.

There are several ways to handle an appendiceal abscess, most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of draining the abscess, surgically or by placing drainage catheters into it with Xray guidance. Typically this leads to rapid resolution of the immediate problem, but leaves on the table the question of how -- or whether -- to deal with the offending appendix in the future. But before we get to that, let's talk a bit about draining that abscess.

Mainly risking incredulity and recommending finding another surgeon by the patients' friends, I've on a couple of occasions treated small abscesses only with antibiotics. When a person comes into the office complaining of a month's worth of somewhat annoying illness, and the workup shows mostly swelling in the appendix's homeland with only a small fluid collection, it's seemed reasonable to take a pretty conservative approach. But in most cases, the patient is sicker than that, and the abscess is bigger, so drainage is best. Of course, I've always leaned toward the surgical approach, because it's the most definitive: especially for a large and loculated collection. You can get big drains in there, wiggle your finger around in the hole to break down the septations, and get it done all at once. Radiologists are getting better and braver at approaching intra-abdominal fluid collections, and it's become the preferred approach in lots of situations. The one area that until fairly recently many of them like to avoid, however, is a deep pelvic abscess. I liked it, if the anatomy was just right, because even in busy operating rooms, it seems I could always surprise a person or two with how I did it. Guess it must be an old-timer thing.

When the appendix is long and low-lying, and its tip sits way down in the pelvis, it's not rare for it to rupture by the time its particular form of appendicitis is figured out. That's in large measure because it tends to present with diarrhea, as opposed to most cases, in which bowel shut-down is the norm. The abscess that forms sits on the front of the rectum and bulges inward into it. You can put the victim up in stirrups, spread open the anus, confirm you can reach the abscess, poke a little needle through the rectal wall to prove the pus is there, and then, grossly, ram a clamp through the same point, through the entire thickness of the rectal wall and into the cavity. Pus ensues; fragrant, copious, gratifying pus. Guide a rubber drain into the area, and you're done: no skin incision, no consequences. You'd think poking a hole through the rectal wall into the abdominal cavity would lead to disaster; but it's well walled-off, it drains, it heals, and everyone is happy. The drain falls out in short order.

I drained silly George, and he got well promptly. He followed up as suggested, in the office, and I told him (as I had in the hospital) that I recommended he have his appendix removed after an appropriate amount of time had passed for healing. It's become controversial -- more now than a few years ago. The concern is that left in there, appendicitis will eventually happen again, and it's one of those things passed down from generation to generation of surgeons. It's only quite recently that studies have been done that raise questions about the need (these are all "retrospective" studies, meaning analyses of existing data, rather than "prospective" studies, meaning randomizing current patient to groups who'd have it done and who'd not have it done, and seeing what happens. Prospective studies are better. None have been done; but the papers have, rightly, gotten the attention of surgeons.)

Trained in the dark ages, I've done quite a few "interval appendectomies," and it's interesting how they have varied: in some cases it's as if the person had never had appendicitis. Everything normal, easy as pie. In others, the worm has been plastered to various entrails and exceedingly difficult to remove. Once or twice, it had been so fried by the original infection that there was nothing left but a thread; clearly incapable of causing further trouble. One time the pathology report came back "acute appendicitis with rupture," months after the actual event. But the need for the surgery was not what troubled George. He was worried about having his appendix removed, fearing the loss of it would lead to some sort of future health consequences.

That's not an unreasonable concern, and it's been addressed in many ways. I liked to refer to a study done by the Mayo Clinic (can't find it now. Didn't try real hard.) that compared around 4000 people who'd had appendectomy with the same number of ones that hadn't, similar in all other ways, and found no difference in incidence of health problems over many years of observation. But George brought an article, published in a journal of alternative medicine. It had actual photomicrographs of the appendix, showing lymphoid tissue (well-known.) The article pointed out the appendix's location between the small and large intestine (close enough) and stated that given the location and the lymphoid tissue, it clearly had an immune-surveillance function. There were no data, no studies. Just a conclusion out of thin air. Now this is not really a big deal, and I don't mean to hijack my own post. But it was the first time I'd seen an educated person show a complete lack of ability to judge data. Pretty picture, shiny paper = conclusion must be correct. Imagine. George rejecting reams of scientific and peer-reviewed data in favor of pseudo-data that served his purposes...

I'll finish this series (for now) with another prejudice, for the heck of it: I'm not a big lover of laparoscopic appendectomy. I think laparoscopy is a fabulous innovation, and there are several operations for which the laparoscopic approach is clearly superior to the open one. Appy, in my opinion, ain't one of them. Why? Properly done, an open appy takes fifteen or twenty minutes, uses a small incision that isn't very painful (much less so than the original disease was!) and from which the patient recovers rapidly; often in the hospital only a day or so postop. Admittedly, this isn't always so: appendectomy can be an extremely difficult operation. But we're talking typical, here. Come in to do an appy in the middle of the night, get a crew not so familiar with all the laparoscopic tools of the trade, and you've turned a simple thing into a time- and money-consuming circus. But tool-makers are very talented at marketing (there are some great technologies out there, just waiting for a disease.) High profile, big-ticket lasers gather dust in OR hallways as we speak. But that's for another post, another time.

21 comments:

Assrot said...

Very interesting reading your blog. I just discovered it about a week ago. I don't suppose you'd like to give a discourse on Upper Right Quadrant Pain and any experience you may have had with it?

Sid Schwab said...

Come on back! I'll have lots to say about things living in the right upper quadrant in the future: gallbladders R Us, after all..

Dr. W said...

If you'd been in psychiatry, I daresay you'd have found LOTSA people, educated and not, that would gladly disregard the data because of a glossy picture and emotional appeal.

Some of them even call themselves mental health care providers!!!

Elizabeth said...

In late July 2006, 50% of Americans thought Iraq had weapons of mass destruction when the United States invaded the country and 64% of Americans polled by Harris stated that Saddam Hussein had "strong links" with al Qaeda.

Yet, you're surprised "an educated person" would "show a complete lack of ability to judge data". Jeez!

(BTW, I love your blog!)

Sid Schwab said...

You noted the name I gave the man, I take it?

Elizabeth said...

Oh my, how did I miss that...

melissa b. said...

Thank you very much for the information you've published on your blog! My appendix ruptured nearly five years ago and because the infection had gotten into my blood stream (septic I think was the official term they used)I was kept in the hospital (mind you this was a county hospital) for nine days and given Cipro and some other antibiotic. They released me with more antibiotics and without having removed my appendix informing me that because of the rampant infection it would cause additional complications. They did advise me to return to a physician after the antibiotics were gone and the infection cleared to have the appendix removed. Well, I still have yet to do so after all these years, feel fine, but lately have been wondering if am walking about with a ticking bomb inside. Thus far your blog has been the only site I've found that even touches on the issue.

enrico said...

I don't know the numbers off the top of my head, but isn't 10% or so supposed to be the acceptable "norm" for false positive appys (or the converse, if you don't have any false positives, you've let some real ones go). What is the latest on that?

And what's with general surgeons and butt pus anyway? :P

Anonymous said...

Can you explain why surgeons wait to remove a gallbladder, if someone has severe or marked pancreatitis as evidenced by ct,RUQ sonogram, or elevated liver enzymes. Does the pancreatitis result from a blocked bililary duct by a stone or inflammation, or both? Thanks.

Sid Schwab said...

gallstone pancreatitis (there are other causes, too: you could read my posts about pancreatitis) is caused when a stone passes from the gallbladder into the bile duct and sticks at the opening long enough to force bile up into the pancreas (it makes more sense if you look at those posts of mine -- maybe you did and just asked this question in the appendix section!).

Timing of operation to remove the gallbladder is tricky: ideally, it's nice to wait until the pancreas simmers down: the surgery is easier, and things go better when a patient is healthy. In most cases, gallstone pancreatitis settles down fairly quickly, because the stone passes on through to the gut. If it doesn't then the first option often is to try to get the stone out with a scope rather than surgery. It's all a matter of judgment based on how the patient is doing.

The sonogram, per se, isn't a big part of the decision making, in terms of timing. It's more about the clinical status, and the pancreatic (not liver) enzymes. Persistently elevated liver enzymes is a different issue, although it might be due to a stone in the bile duct, also. Such stones may or may not cause pancreatitis when they are causing biliary obstruction.

Anonymous said...

Thanks for taking your time to respond, I found the information useful. I will go back and read your post on the pancreas, and pancreatitis. Sorry about mis-posting. Later-

Anonymous said...

IS it true that certain foods are more likely to get caught in the appendix and cause it to become inflammed? Such as popcorn kernals, or seeds. If so what foods are suggested to avoid? I always had this fear, but I love popcorn too much to give it up.

Sid Schwab said...

Short answer: there's no evidence of any diet that affects risk of getting appendicitis.

Anonymous said...

I thought I read somewhere that a high fiber diet was a good way to prevent appendicitis, among other things.I could be wrong, there is alot of misinformation out there. Now when the appendix ruptures, a part of the intestine could possibly must be removed, and viable ends reattached d/t spread necrosis?

Sid Schwab said...

High fiber is recommended for people with diverticular disease; there's no evidence it prevents appendicitis.

It's rare to have to remove more than the appendix itself, even when it's ruptured.

Anonymous said...

im sorry when i said intestine, i meant like hemicolectomy if someone had ruptured their appendix if tissues have become necrotic. thx

Sid Schwab said...

I'm not sure I understand entirely, and I don't know what d/t means. Sometimes it's necessary to do a cecectomy with appendicitis. If you're asking if it's always possible to reattach the ends immediately, it would depend on the status of the patient and the degree of necrosis/infection. Pretty rare to do a resection for appendicitis without being able immediately to reanastomose.

Anonymous said...

D/t means do to, another way of making writing or typing faster. The reason I ask I remember an occasion when a pt had a ruptured appendix found when surgeon opened up pt. t had peritonitis. It was noted that inflammation was so severe, that removal alone of appendix was not enough and had to reanastomosed, and a portion of the ascending colon was resected in the process. young pt too, pt waited too long before seeking medical attention, but was fine in the long run. I don't understand it myself, that's why I was curious. thanks for your response.

Anonymous said...

I would like to ask a question about right upper quadrant masses. Im a 28 year old female with history of crohns disease. I have gallstones and on ocassion I have experinced pain from them. I recently discovered a mass in the right upper quad, just below my rib cage.Its about the size of a golf ball and I can minipulate it. Its only pallaple when I lie to the side and when I lie down it seems to settle in my right side somewhere.I cant seem to obtain any answers. My PCP says gallbladder. My GI says maybe gallbladder. The suregon I saw today says that a gallbladder is not a pallaple organ and doesnt make since because I am not experincing any pain. I have no idea where to go from here with this. What could this be? Thanks!I would be SO greatful to learn anything about this.

Sid Schwab said...

There are several possibilities. Gallbladder is on the list, and whereas it's true that in most cases where it's palpable it's because of acute inflammation and is therefore painful, it's not 100% true. On the other hand, in those instances it's likely you'd be jaundiced. It could be something in your colon, possibly related to Crohn's, or in your small bowel, for the same reason. It seems to me that further investigation is warranted, starting either with ultrasound or CT scan. But being so far away, you'll undoubtedly get better info from you own docs.

Anonymous said...

In reguard to my message , I would just like to say thank you for your response in my quest for anwers with my crazy mass. I will continue to stay on the search for answers and Im sure more tests are to come. I have enjoyed reading your blogs.Thanks!