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MagazineApril 2009 (Vol. 20 Issue 1)Appendicitus

Q) I'm 35 years old, and have had a recurring stomach pain, with nausea and bloating

Q) I'm 35 years old, and have had a recurring stomach pain, with nausea and bloating. I worry that it's my appendix. If so, what are my options?-Mrs F.B., Barnes

A) Although having an appen-dix removed is a common and seemingly simple opera-tion, actually diagnosing appendicitis can be difficult. Although it's usually located low down on the right-hand side of the abdomen, it can wander about a bit. It may even be on the left side-a configuration known as situs inversus (Latin for 'inverted position'), where the body's internal organs are in a mirror-image arrange-ment. (However, situs inversus is relatively rare, affecting fewer than one person in every 10,000.) Neverthe-less, it's not surprising that the average GP may find it difficult to diagnose appendicitis with certainty.

The appendix is a tiny tail of tissue attached to a pouch on the end of the intestines. It's generally thought to be a useless organ, a shrunken vestige of a distant grass-eating ancestor, for which we now have no use. But the appendix is actually full of immunity-boosting lymphoid tissue (Gut, 1985; 26: 672-9), which suggests that it may contribute to health-although doc-tors claim that removing it has no detectable ill effects.

Appendicitis tends to strike between the ages of 10 and 40, after which the organ tends naturally to shrink and become less troublesome. Men are more likely to suffer from the condi-tion than women, and it is far more common in Europe, America and Australia than in Asia or Africa. However, people who migrate to the developed world become more suscep-tible to appendicitis, which suggests that there may be something in the Western diet or lifestyle that predis-poses to it.

However, appendicitis rates are, in fact, currently falling, from a peak at around 50 years ago. Theories to explain the decline range from changes in diet to the use of antibiotics.

The underlying cause of the infection is believed to be a sudden obstruction in the appendix or an infection, leading to a localized inflam-matory response, although sometimes the inflammation can occur spontane-ously for reasons unknown.

The typical symptoms of appendic-itis are an initial pain in the centre of the stomach, together with a loss of appetite, nausea and mild fever. The pain may gradually move towards the site of the appendix.

However, these are not hard-and-fast symptoms, and may easily be mistaken for signs of many other conditions: for example, in cases of diverticulitis, an inflammation of the colon, the pain is usually focused on the left side of the abdomen-but it can also be on the right, and thus very close to the appendix itself. Other symptomatically similar conditions are pelvic inflam-matory disease of the fallopian tubes and ovaries, a perforated duodenal ulcer, gallbladder disease and inflam-matory liver disease.

All of this may help to explain why, in an average of one out of eight appendectomies, surgeons find them-selves confronted with a perfectly healthy appendix. More disturbing, a recent survey has shown that this rate of unnecessary surgery hasn't changed in years, despite the advent of new diagnostic imaging techniques such as ultrasound, laparoscopy and magnetic resonance imaging (MRI) (JAMA, 2001; 286: 1748-53).

Some doctors are becoming increasingly concerned at the number of needless operations being carried out, mainly because an appendectomy, although simple, turns out not to be risk-free. Serious infections and abdominal abscesses are not uncom-mon following such surgery (Cochrane Database Syst Rev, 2005; 3: CD001439).

But perhaps the most important downside of misdiagnosis is that other conditions are not picked up. The disease that is most often confused with appendicitis is irritable bowel syndrome (IBS). This is because some of the symptoms of IBS, such as cramping pain in the lower abdomen, and diarrhoea or constipation, can mimic those of an inflamed appendix.

IBS is another 'idiopathic' condition that doctors don't understand; in the past, it was frequently dismissed as all in the head. The medical profession finally accepts that IBS is a genuine condition. In two-thirds of cases, it's caused by a food intolerance (Scand J Gastroenterol, 1995; 30: 535-41).

The subject has been bedevilled by the lack of objective tests of food intolerance, so the only way to diag-nose the culprit foods is to embarkon a near-starvation diet, and then introduce foods one by one, and see what happens. Taking probiotics is a useful second-best option (J Clin Gastro-enterol, 2004; 38 [6 Suppl]: S104-6).

Coeliac disease is another gastro-intestinal condition that is frequently mistaken for appendicitis. In one survey, over 70 per cent of coeliac sufferers elected to undergo an appendectomy before they were correctly diagnosed (Dig Dis Sci, 2001;

46: 2206-8).

Finally, bear in mind that appen-dicitis is not necessarily an end-stage condition. Doctors have only recently woken up to the fact that it can often resolve by itself, just like any other infection and, in cases where there's any doubt about the diagnosis, it's reasonably safe to simply watch and wait, rather than throw yourself head-long under the scalpel (World J Surg, 2007; 31: 86-92).

It also appears that the risk of a burst appendix has been exaggerated. According to a recent US study, it occurs in, at most, one in 20 cases(J Am Coll Surg, 2006; 202: 401-6).

Graded compression sonography and computed tomography can confirm a diagnosis if handled by an experienced operator. If the picture is not a definitive case of appendicitis that could rupture, again, you could try a 'wait-and-see' approach, and use alternative remedies-at least initially.

Homeopathic remedies to try are Belladonna, Bryonia and Iris Tenax.

Traditional Chinese medicine can also offer a handful of detoxifying and fever-reducing herbs, as well as acu-puncture. In fact, in one survey of over 600 cases, acupuncture cured a grumbling appendix in more than half of them (Chin Med J [Engl], 1977; 3: 266-9).

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