God of the Appendix: Of Truth And Worms

[OK, here I go, stepping off a cliff. Can't say why I want to, exactly. ]

Of Design and Darwin, the appendix speaks to me. With my finger through a hole in the abdominal wall, I sense it, and at two in the morning it tells the truth.

In the appendix, we have a thing within us of no demonstrable value, but which is capable of doing us great harm. People may argue at the edges, but there are two things we know with central certainty: the presence of the appendix kills a lot of people or makes them real sick, and its absence is of absolutely no consequence. Evidently, that's a threat to the concept of intelligent design/creationism, and in a sort of endearingly weak effort, Ken Ham, a major ID guru, once tried to explain it away. Believe it away. Faith it away.

If you take a position in matters of science, says I, you need to keep at least one hand on the fact wall at all times; otherwise, you fall down. So whereas I'm not the first to address the appendix as religious icon, I'm only aware of a couple of people talking about it who've held a thousand or so in their hands. That's concrete: I assert my credibility. (The article to which I linked above has a reference to an article by a surgeon. It's from the same website, "Answers in Genesis," and is impaction-full of the same sort of pseudoscientific assertions. The author is an evolution denier and a creationist.) In the human body there's no other structure of any importance that feels and looks like a silly noodle, and which varies in people from a little stub to several inches long. (I hear one of you thinking something, and you should be ashamed of yourself.) I've removed a bunch of 'em, and I (nor anyone else) have never seen an adverse consequence of appendiceal non-existence. But I've seen a hell of a lot of carnage from appendicitis.

Here are examples of the arguments about appendicoloid importance in the article I cited.

"Today, the appendix is recognized as a highly specialized organ with a rich blood supply. This is not what we would expect from a degenerate, useless structure."

Highly specialized? As defined how? Recognized by whom? He offers as proof of the appendix's function, a statement that the appendix has function; lacking are any actual studies. And it hardly has a rich blood supply. It does have blood, alright: it's alive. But rich? The stomach has a rich blood supply: it's fed by several arteries, coming at it from all directions. You can hardly kill the thing. The appendix? A single artery, the bare minimum, I'd say.

"The appendix contains a high concentration of lymphoid follicles. These are highly specialized structures which are a part of the immune system. The clue to the appendix’s function is found in its strategic position right where the small bowel meets the large bowel or colon. The colon is loaded with bacteria which are useful there, but which must be kept away from other areas such as the small bowel and the bloodstream."

Like most of the intestinal tract, the appendix has lymphoid tissue. Which in and of itself proves nothing. Take out the appendiceal lymph tissue, it might cover the nail of your pinkie. From the rest of the GI tract, you could haul it away in a bucket. Nor is its location a "clue," absent any data to support the assertion. Mr. Ham shovels us an implication that the appendix has something to do with keeping bugs out of the bloodstream: a statement only, with no proof, no studies. A theory perhaps? To the contrary: take out an appendix and poof: no bugs in the bloodstream. Appendicitis, on the other hand, seeds the bloodstream with bugs in many a victim. Bacteria in the small bowel? Plenty of 'em, especially right next to the appendix. He implies the appendix keeps them out. It's simply silly to say such things.

"Through the cells in these lymphoid follicles, and the antibodies they make, the appendix is ‘involved in the control of which essential bacteria come to reside in the caecum and colon in neonatal life’. Like the very important thymus gland in our chest, it is likely that the appendix plays its major role in early childhood. It is also probably involved in helping the body recognize early in life that certain foodstuffs, bacterially derived substances, and even some of the body’s own gut enzymes, need to be tolerated and not seen as ‘foreign’ substances needing attack."

The quote within the quote is from the surgeon's treatise, on the same website -- so in effect, the article quotes itself. Again, an assertion, made up out of whole cloth. Not a demonstration, not an even an attempt. Why? No evidence. Couple of scientific words. He goes on to say the appendix is "probably" like the thymus. Probably? How so? PROBABLY?? What kind of science is that? We know a great deal about the thymus' function in early life. Removal in infancy has significant consequences, demonstrably. Removal of the appendix in infancy has none that have ever been shown. In fact, it's in infancy that the appendix is most deadly: because appendicitis is harder to diagnose in a babe, rupture before discovery is more common at that age than in older people. If I'd had a magic way to remove it from my newborn son, I'd have done it. But here's the best stuff:

"But if it has a function, why can it be removed without ill effects?

Our body has been brilliantly designed, with plenty in reserve, and the ability for some organs to take over the function of others. Thus there are a number of organs which everybody agrees have a definite function, but we can still cope without them. Some examples:

*Your gall bladder has a definite function—it stores bile from the liver, and squirts it into the intestine as required to help with the digestion of fat. However, it can be removed and the body will cope—for instance, by secreting more bile continuously.
*You can cope with having a kidney out, because there is still enough kidney tissue left in the other one. (In the same way, a part of the Gut Associated Lymphoid Tissue, which includes the appendix, can be removed, and the remaining lymphoid tissue will usually be enough to carry on the total function). You won’t suffer from having your thymus out (if you’re an adult), because this extremely important gland, which ‘educates’ your immune cells when you are very young, is then no longer required. This is likely to be very relevant to the appendix."

Yipes. Except for the appendix, there's no organ out with which we can do without some chance of problems. Removing the gallbladder, while tolerated by most people, is associated with known and specific problems in a number of patients. It even has a name: post-cholecystectomy syndrome. He might have mentioned the spleen: you can live without it. But there are known risks: increased chance of blood clots, and increased susceptibility to certain life-threatening infections. Without flim-flam, we know the exact functions of these organs. The kidney analogy is so self-evidently stupid as to require no comment at all. And the "likely to be very relevant to the appendix" statement pretty much speaks for itself: another assertion ex cathedra. Because the appendix threatens his world-view, he's making stuff up: no function has ever been demonstrated, and no adverse consequence of its absence has ever been shown. There's no other organ about which it can be said. Face it, guys: the appendix is useless. (I mean it no offense. After all, it's put bread on my table.) That's just what the facts are: the sun rises in the East, and the appendix is useless. Assimilate it.

The study I cited most often to my patients when asked about adverse consequences of appendectomy is one done by the Mayo Clinic: they studied records of thousands of patients who'd had appendectomy, and compared them with equal thousands who hadn't. (Back in the day, it was very common during any abdominal operation to remove the appendix. Like flicking a bug off your shoulder. No extra charge: just did it to prevent further problems: took an extra couple of minutes, is all.) The groups were statistically similar in every way other than presence of the worm. There were no differences in incidence of any disease. It's as convincing as it gets, given the impossibility of doing a prospective double-blind study.

That the appendix has no unique or physiologically important function is as certain as it can be, based on what we can easily observe. I know it from direct observation, from operating countless times. Maybe if it weren't for us surgeons saving fertile people from their vermiformera, the little rascals would be gone by now. But the existence of a vestigial organ which, when it does anything at all, only does harm, is a threat to certain narrow religious views. Vestigial bespeaks evolution, so let's make something up. I find that interesting. And I find the attempts to will it away amusing. If you don't like certain facts, make up some new ones. If the facts don't fit your faith, change the facts. That sort of thinking has been known to start wars. And it gives faith a bad name.

By its existence, the lowly and useless appendix would seem to deal a fatal blow to the idea (at least Ken Ham's version) of Intelligent Design. Slain, by that ignoble worm, that surgeons'sidekick, my midnight mistress. If you deny evolution, then you have to say the designer wasn't paying attention, says the appendix to my scalpel; or the designer acted deliberately to stick within us something which serves only to harm. Even more scary. Unless, of course, you're a general surgeon.

Addendum: a study in Sweden found an increase in Crohn's disease after appendectomy (we're talking very small numbers here). What's not clear is whether we're seeing chicken or egg: ie, is it that people who will develop Crohn's are more susceptible to appendicitis, or does appendectomy somehow increase susceptibility to Crohns? Interestingly, appendectomy has been associated with a lower incidence of ulcerative colitis. And appendectomy before age ten, in this study, seemed to have no impact at all. To me, that suggests that the Crohn's link, if real, is indeed that Crohn's disposition is causing the appendicitis in that small subset of people. In other words, as you get more toward the age when Crohn's occurs, you'll see more of the connection. If appendectomy caused Crohn's, you'd expect the effect to show in the young kids as they grew up. Or at least I would.

[Update, 8/09]: In another (and quite unrelated) thread I've been asked about this study, which argues that the appendix could function as a sort of storehouse to replenish bacteria in the gut. In fact, it's an interesting speculation, but is no more than that. Also, it states that appendicitis is due to defect of some sort in the immune system -- made with no data to confirm. The study makes plausible extrapolations from the evidence that the appendix has evolved at least twice in certain animal lines. To leap from that to the idea that there must be a function in humans, and to propose without evidence what that function might be is hardly dispositive. The fact remains that in many studies of the appendectomized among us, no real evidence has emerged of a negative impact. Not at a rate that is very suggestive. And the paragraph above this suggests if there are effects, they about cancel each other out. Given the numbers of appendectomies done around the world, it's logical to think something would have shown by now. Nor does the study in this paragraph give credence in ANY way to the out-of-the-orifice statements of Ken Ham.]

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.

Tales From the Right Lower Quadrant, Part three

She was among the sickest kids I've ever seen: as close to death as any who eventually made it. And I never figured out if her parents were just incredibly clueless, or criminally negligent. When I saw her in the ER, her pulse was thready, barely palpable, and slow -- as in nearly agonal. Undoubtedly, a day or two ago it had been rapid, a desperate staccato plea for help. She moaned a little to deep stimulation, but her eyes -- like a doll's, like a pathetic imitation of some cliched cartoon -- were rolled up with only the whites showing. Instead of flushed and hot, as would be consistent with the rigid abdomen that told me her likely diagnosis, she was dusky and cool. Temperature below normal, heart slowing down. Jesus Christ!!! This little girl is dying of a ruptured appendix. I was as shocked and angry as I was scared I couldn't save her.

It had started over a week ago, her parents said: upset stomach, vomiting, fever. They put her to bed, figuring, they said, it was the flu. They just planned on waiting it out, as she got more and more lethargic. OK, yeah, kids get sick, they get a bug; don't call the doc for every sniffle. But vomiting for a week, becoming unresponsive: this is cult-worshipping craziness. You have to be nuts, or a committed conspiracy theorist -- a believer that doctors plot to make people sick, a snake-oil consumer -- to ignore all that for so long. Their daughter was no more than hours from death.

Cleverly called "the policeman of the abdomen," the omentum is there for a reason: it hangs down in front of the intestines like an apron, sliding around looking for trouble. If it finds it, in the form of an infection or inflammation, it sticks to the area, sealing it off with its layer of fat, richly endowed with lymphocytes and fibroblasts. Plug holes, send in the repel and repair crews. It works quite well when it works quite well. I mentioned previously that rupture leads either to pus all over the place, or to an abscess. Which one, depends largely on the omentum. If it finds the appendix early in the process and sticks to it -- and if in the process the nearby intestines close in as well -- the area gets effectively walled off. In kids, the omentum is thin and can be small. In the case of this little girl, for whatever reason it didn't do the job: she had a belly as full of pus as I've ever seen. And see it I did.

With warm IV fluids, heating blankets, and having given broad-spectrum antibiotics and medications to improve heart function, we got her in shape to handle an operation. I made an incision in her pretty little belly, up and down, in the middle. It would be there as long as she'd be there. I never cared too much about putting a belly-scar on an adult: whatever the indication, they'd know it was worth it. But cutting into a child's belly always bothered me a lot, no matter the reason. The bigger the cut, the worse I felt. The thrill of being the cavalry, riding to the rescue, was and is absent. That perfect skin, the vulnerable little child.

It was as if someone had taken a gallon jug of ugly gruel and poured it in: her insides were literally afloat in it. Raw and red, her intestines bobbed in pus. Her liver and spleen, surrounded. Sickly consistent, the same soup in her pelvis, the lateral gutters (that's the term for the area to the right of the ascending colon, and to the left of the descending. Never more appropriate), under her diaphragms. I sucked it out with catheters, and irrigated and irrigated, flooded her over and over again with liter after liter of warm and clean saline. Lastly, with antiseptic-laden solution. Assuring an un-cosmetic scar, of necessity I left the edges of her skin apart, lest she get infection in her wound.

Oxygen has antibiotic powers, and I kept her on it postop, to the (only slight) consternation of the pediatrician, since her measured oxygen levels were fine without it. The irrigations, the antibiotics and oxygen, her youth and who-knows-what other factors combined to give her a remarkably easy recovery. I was even able to tape her skin edges together, and her scar wasn't, as these things go, too bad after all.

Miracle? Not to me. The miracle would have been giving her parents who'd not let it happen in the first place.

Speaking of God, at the opposite end of the spectrum of parental involvement was a girl of similar age I was asked to see after she'd been in the hospital for three or four days with abdominal pain and not much else. No fever, no vomiting, no abnormal blood tests (the white blood cell count, a reflector of infection under usual circumstances, is nearly always elevated in appendicitis), Xrays, tea-leaves all OK. Was an operation indicated, I was asked? Look around, see if it's her appendix or something else surgical? I reviewed all the data, examined the child, and was as certain as I've ever been that it was neither appendicitis nor any other surgical situation. "That's what they told us about my other daughter, in Colorado," her mother said. "And she had a ruptured appendix and nearly died." I told her I understood how scary it was, that I couldn't comment on how that situation might have differed from this, but I was as sure as I could be that her daughter didn't have appendicitis, and I didn't think surgery would be of value. I told her I'd keep seeing her daughter every few hours to be sure, and moved toward the door. At which point the mom took that other daughter by the arm, and they both knelt and prayed at the child's bedside.

I was young then. I don't know if it was wise or not, but then and there I decided the little girl would never be really well -- never free of her mom's fear -- until her appendix was removed. So I did. When I told the mom I'd go ahead, her relief filled the room like fresh air; she looked as if she'd sprout wings and fly. And here's the amazing thing: in the face of my certainty, the normal lab work, the Xrays, the repeated exams, when I got in there it was as obvious as could be: her appendix, that mysterious little worm, that innocent little stripe-cum-killer, was.... entirely, amazingly, completely..... normal and pure as the first snow.

I've got a few more of 'em....

Tales From the Right Lower Quadrant: appendixes I have known. Part two.

"Get a crew ready!! Guy coming in with a ruptured splenic artery aneurysm!! Order blood and a cutdown tray, be there in the ER. He's arriving by medevac in five minutes!!!"

Wow! This was a big deal. The only intern on the vascular surgery service, I was already swamped with work, but this was going to be an amazing case. As I sort-of knew, the splenic artery is a pretty big one, heading from a take-off point on the upper part of the abdominal aorta, across to the left behind the stomach and on the upper edge of the pancreas, to the spleen, which lies in the left upper abdomen. (Since I now have a search box on this blog, and since I'm sure you've read all my previous posts, in which I've mentioned those organs now and then, I'll assume you don't need hot-links to all of them. Gets a little showy, I suppose.) Splenic artery aneurysms are pretty uncommon: once in a blue moon you'll see an ovoid rim of calcification in the right spot on an Xray that clues you in that a person has one. In most cases, they're silent unless they burst. When that happens, you'd expect sudden onset of pain in the mid or leftish upper abdomen, and, most likely, the rapid descent into shock: clammy, rapid pulse, low blood pressure, mentally out of it.

Which is exactly the story behind this man's arrival: he'd been ambulanced to an ER across the Bay, where an Xray had shown the typical calcification pattern, and he'd been fired off to us, one of the pre-eminent vascular surgery departments in the country. Dr. Wylie himself, chief of service and famous, who rarely came in for emergencies, was on his way. (He was pretty much the guy who'd invented repair of abdominal aneurysms, and pioneered much of the modern world of vascular surgery. He didn't have to take call!) We got the man well-resuscitated and into the OR in short order. Bags of blood at the ready (strangely, he didn't show signs of much blood loss, although he definitely was in shock...), extra anesthesia personnel in the room to help if he crashed further, with the patient shaved from stem to stern, special vascular clamps shiny and in easy reach of the scrub nurse's hand, Wylie got the nod from the north end of the ether screen and opened the man up with his usual dexterity, despite lacking the tip of his index finger (boating accident.) Expecting to find blood filling the lesser sac, everyone was more than a little surprised to find the cecum rotated up to and plastered on top of the stomach and spleen, forming the front wall of an abscess cavity, central in which was a ruptured appendix. "I'll be goddammed," said Dr. Wylie as he walked out of the OR, leaving the disposition to the resident team. The shock, it turns out, had been due to sepsis, not blood loss.

Malrotation of the gut is moderately uncommon, and usually presents with obstruction of the bowel due to twisting on itself. That can be very serious; in fact a case of it early in my practice was my virgin entre' into the medico-legal system (sounds like a fruitful subject of a future post!) Presenting as a dislocated case of appendicitis is not common; especially when also associated with a previously-undiagnosed splenic artery aneurysm -- which the man did indeed have. The patient did fine. Dr. Wylie had to take some gleeful guff at weekly complication conference for an error in diagnosis and for venturing out of vascular surgery into general surgery.

It wasn't the only time in my experience that a floppy cecum fooled me: I once operated on a man with a diagnosis of strangulated left inguinal hernia. (Yes. Left!) He had a hernia, all right. But what was contained in it was not dead bowel but his appendix: infected and ruptured. He also did just fine, thanks. But it's one more instance in which I remembered that Dr. Dunphy (previous post) was a wise man. And hardly the only time I was impressed by the power of the appendix....

Tales From the Right Lower Quadrant: appendixes I have known. Part one.

Dr. Dunphy (J. Englebert "Bert" Dunphy, Chairman of the Surgery Dep't, UCSF, RIP) used to tell us: when evaluating abdominal pain, never have appendicitis lower than second on your differential. It's a good thought to keep close: whereas classic appendicitis is most often a fairly straightforward bedside-makeable diagnosis, it can do pretty strange things, and be a major diagnostic challenge. Not to mention being the cause of a few good stories.

First, some background: the appendix -- its spanking name is appendix vermiformis, which means wormlike thingy -- looks, in its normal state, like a little worm, 'bout half a night-crawler. Doing nothing that any (reliable) research has ever identified, it hangs down from the cecum like a sad little rat-tail in the right lower part of your belly. Most people never have any reason to know it's there. When they do, in by far the most of cases, it's because it becomes infected: infection of the appendix is called appendicitis.

Your mom may have told you if you swallow cherry pits you'll get appendicits. I know your mom: she wasn't wrong often, but this is one of the times. That rumor may have gotten started because of an item called an appendicolith, which means a stone in the appendix. ("I gave my love a cherry, without a stone... I gave my love a chicken...." etc.) The other, less impressive, name is fecalith. What it is is a piece of stool that got stuck in there and become so inspissated it's like stone. This is one presumed cause of appendicitis; it also can lead to a rare situation of recurring appendicits (more, later.) But the fact is, in most cases there's not an identifiable reason when it happens; and in the vast majority of instances, it's a one-time deal. (I always made a point of telling kids with appendicitis, and their parents, that it's no one's fault: it's nothing they ate, nothing they did. It just happened.)

The gut doesn't have a large trick-bag; meaning, it only has a few ways it can respond to illness, and it doesn't have the sort of pain nerves that allow localization. If I pinch you on your skin, you'd know exactly where, with your eyes closed. Pinch a spot on your intestines, and you'd likely only muster a "yuck." So the early signs of infection or inflammation of one part of the gut have a way of sounding like and feeling like those in another. When appendicitis starts, therefore, it's usually with a vague yucky feeling, loss of appetite, nausea. Pain is hard to put a finger on, at first. It's only when the inflammation progresses to the point that it involves surrounding tissues -- specifically, the parietal peritoneum, which has LOTS of nerves, of the kind the brain can pinpoint -- that the pain begins to localize where the appendix is (or is supposed to "is"), in the right lower abdomen. Typically it takes a half a day or a day for the symptoms to localize. Appendicitis can happen at any age, but is significantly more common in kids (around five years old to teenage, and there's another spike of frequency in us senior citizens.) Luckily, it's rare in babies, which is good: it's hard as hell to diagnose early in them.

As the infection evolves, the appendix gets red and swollen, going from worm-size to -- sometimes -- finger-size. And left to its own devices, the infection eventually rots away all or part of the appendix (gangrenous appendicitis) and it falls apart, allowing the pus inside to leak out. Ruptured appendix, as you've no doubt heard. When that happens, things generally go in one of two ways, depending on several factors, including the location of the tip-end of the appendix: either pus flows all over the place, causing generalized peritonitis, or it gets walled off into an abscess. In the former case, you'll get sick as hell; in the latter, you won't feel great but it's possible to limp along without disaster.

The cecum is always the starting point, anatomically, of the appendix, and the cecum is nearly always situated in the right lower part of the abdomen. But the tip of the appendix can be in a lot of places, depending on its length, and resting place. Some far ends of the thing are way down in the pelvis; some are across to the left, or aiming north. Quite a few take off from the cecum and run backwards behind it, and can go as high as the liver in that "retro cecal" orientation. Major bummer for the victim and his/her surgeon.

OK. So now, assuming you didn't already, you have a background for a few stories I'm going to tell.