by

Charles A. Bertrand, M.D., FACP, DIM-CD (Ret.)
Associate Clinical Professor of Medicine at New York Medical College
and at the Medical University of South Carolina

APPENDICITIS IN THE 21ST CENTURY

Well now, it's almost the next century. So what do we expect in health care? More of the same? Perhaps. But probably not. After all, the field of medicine has undergone dramatic changes in the 20th century. Consider these two.

First, we've seen a considerable decline in the frequency of appendicitis. A mere 25-50 years ago, operating room schedules would have been crowed with appendectomies. Today we see very few. This trend is the result of several factors, including improved health care and the use of antibiotics. However, every year around 250,000 people still have an attack of appendicitis.

Second, during the same period, we've experienced a marked decline in surgical mortality -- probably less than one percent at present for an appendectomy. This dramatic improvement can be attributed to many factors, including modern anesthesia, the development of antibioticsm much more sophisticated equipment, and improved surgical skills.

Despite these encouraging trends, however, appendicitis still poses a problem. The diagnosis of the condition can sometimes be very difficult. Ordinarily, this is not the case. In the typical patient, spotting appendicitis is very easy. If the patient's symptoms are fever, vomiting, an elevated white blood count, with abdominal pain that finally localizes in the lower right part of the abdomen with a tenderness to the touch, then you can identify the problem correctly.

However, sometimes patients have atypical symptoms that make the correct diagnosis extremely difficult. In such cases, delay in diagnosis can lead to a ruptured appendix or peritonitis, to name but two possible complications.

Then again, other medical conditions may stimulate acute appendicitis. For example, a severe gall bladder attack may also cause pain in the same segment of the abdomen. As a result, physicians have sometimes made serious errors in diagnosis.

Fortunately, help is on the way, and from an unexpected source -- the radiologist (x-ray doctor), who does more than just read x-rays. The radiologist is now skilled in the interpretation of MRI's, CT scans, and even radioactive techniques. The result: a high rate of accurate diagnosis in cases of appendicitis and other diseases with similar symptoms.

Patrick M. Rao, MD at al, from the radiology department of Massachusetts General Hospital recently published an article on the subject in the New England Journal of Medicine (January 15, 1998, Vol. 338, No. 3, pages 141-146). The researchers studied 100 consecutive emergency patients who were suspected of having acute appendicitis. All received CT scans of the appendix, and the researchers compared their analysis of the results with the outcomes of the cases. Of those who had a normal appendix on CT scan, 47 percent, appendicitis was ultimately ruled out either during an appendectomy or during clinical follow up. Of those with acute appendicitis the CT scan was correct in diagnosis almost always.

The authors conclusion: Interpretations using CT scans are 98 percent accurate in diagnosing appendicitis. They further concluded that since CT scans prevented unnecessary surgery in some patients, this method was more economical than surgery with hospitalization.

The authors also point out that the CT scan is safe, can be performed in approximately 15 minutes, and the results can be communicated immediately to the surgeon. Also, the amount of radiation exposure was approximately one third of the exposure of a standard abdominopelvic CT scan.

Of course, the circumstances under which the study was conducted were optimum. Three radiologists were serving the emergency rooms. They used the best possible equipment. And they were located in one of the finest hospitals in the country. In other words, this study represents the ideal in clinical research.

How well the same technique will succeed under more ordinary circumstances remains to be determined. Certainly there will be problems, and it may be years before the technique is put into practice.

The advice provided on this website is intended to be general in nature and should not be relied upon for specific treatment. If you need personal medical attention please contact your physician.

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