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June 10, 2011 9:54 pm

It’s easy to spot a case of appendicitis ... except when it isn’t

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Before illness became complicated, with multiple drug resistant staphylococci and cerebral vasculitis, there were diseases and conditions that were familiar to everyone. Appendicitis, though hard to spell, is one of the commonest surgical diagnoses: it is easy to understand what is wrong, and to know what to do about it. It traditionally follows a straightforward script. Patient: “I have a terrible pain in my stomach!”; Doctor: “We’re going to have to operate!” – anaesthetic – rummaging – and the patient comes round to be presented with something pink floating in a jam jar (see also tonsillitis).

Appendicitis often does evolve along such predictable lines. The typical pain of appendicitis behaves in a very characteristic manner.

It starts in the middle of the abdomen, although it is hard for the patient to say exactly where the pain is worst. Most of our deep organs, including our intestines, are not innervated in a way that allows us to interpret their signals so precisely – I can’t identify a problem emanating from the “tail of my pancreas” or “the middle of my liver”.

Within a few hours, the pain moves, or “localises”, to the lower right-hand side of the abdomen. This tells you that the condition is progressing. The appendix is a little projection, like a small cocktail sausage, arising from the beginning of your colon. At first just the sausage itself becomes inflamed; then the inflammation spreads, irritating the adjacent abdominal lining (the peritoneum). The nerve supply to the peritoneum sends signals that we find much easier to interpret: the pain is now worst in one particular spot, McBurney’s point. McBurney, an American surgeon, mapped the location of the appendix in the 1880s, having found “the seat of greatest pain, determined by the pressure of one finger”.

To find McBurney’s point: run your hands down your sides until you reach your hip bones, then edge along the top of them until you meet a bony knobble on each side: these are your anterior superior iliac spines, or ASIS. Imagine a line that runs from your umbilicus to your ASIS on the right; two-thirds the way along this line is the site of your appendix.

When appendicitis develops in such a typical fashion, history and examination are all you need for diagnosis. There is the characteristic pain, which is sometimes followed by vomiting. The patient may have a low-grade fever. They will almost always have lost their appetite. Simple tests can help if there is doubt: blood tests will probably show raised white cells or other markers of inflammation; a urine dipstick may show blood, if the ureter (which lies nearby) has been irritated.

But sometimes appendicitis departs from the script. Bodies vary anatomically, and the appendix can sit low down in the pelvis, or behind the colon, or – in the very rare case of situs inversus, where everything in the body is back-to-front – on the left, rather than the right. The elderly seem to experience pain differently, and children may not be able to tell you what they’re feeling. Women have ovaries, and a uterus, that can simulate the same pain; they usually need an ultrasound to help with diagnosis.

If you get appendicitis, you need it fixed. If the infection spreads or the appendix bursts it can lead to peritonitis, which can kill you. You need to go to theatre, as Winston Churchill did just before the 1922 general election, when he found himself “without an office, without a seat, without a party and without an appendix”. Even if your appendix looks fine, the surgeons will probably remove it, to avoid any ambiguity next time you get a stomach ache.

Sophie Harrison is a hospital doctor in South Yorkshire

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