Appendicitis, An Old Nemesis
Calgary seems to be having some incredibly “bad luck” with mortalities related to acute appendicitis. If our mortality rate is elevated (and I say IF), one wonders about our morbidity rate. Is it possible that in today’s’ world of new technologies, incredible surgical skills, and powerful antibiotics, we as physicians, have lost our diagnostic skills and respect for that old, but still quite formidable disease, appendicitis. Before the use of abdominal ultrasound, CT scans of the abdomen and other helpful diagnostic modalities, several golden rules existed (at least as taught to me during my training and subsequently):
1) The surgeon is appropriately cautious if he/she removes an occasional “normal” appendix to prevent the morbidity/mortality that can occur from missing, or delaying intervention, in a patient with the presumptive diagnosis of acute appendicitis.
2) The white blood count can not be used to either include or exclude an acute appendicitis.
3) The physician should, if appendicitis is a possibility, refrain from using antibiotics since they may give both the patient and the physician a false sense of security.
4) As a general rule, a patient is “safe” in the first 24 hours from the onset of symptoms, BUT, thereafter there is an increase in morbidity and mortality as time elapses before surgery.
Four years ago at an educational conference on emergency medicine, statistics revealed that the two conditions most commonly resulting in legal action were appendicitis and ectopic pregnancy. That statistic is likely still true today. It is well recognized that the diagnosis of appendicitis is extremely difficult in the very young (under two years of age) and the very old, but Calgary’s mortalities have occurred in the usual age group for appendicitis. The Calgary Herald reports that the Calgary Health Authority has pledged several changes to its approach to appendicitis, including enhanced communication with patients and families who are involved with “serious adverse events” in Calgary hospitals. I certainly hope the changes are substantive, and constitute more than a public relations exercise.
1) The surgeon is appropriately cautious if he/she removes an occasional “normal” appendix to prevent the morbidity/mortality that can occur from missing, or delaying intervention, in a patient with the presumptive diagnosis of acute appendicitis.
2) The white blood count can not be used to either include or exclude an acute appendicitis.
3) The physician should, if appendicitis is a possibility, refrain from using antibiotics since they may give both the patient and the physician a false sense of security.
4) As a general rule, a patient is “safe” in the first 24 hours from the onset of symptoms, BUT, thereafter there is an increase in morbidity and mortality as time elapses before surgery.
Four years ago at an educational conference on emergency medicine, statistics revealed that the two conditions most commonly resulting in legal action were appendicitis and ectopic pregnancy. That statistic is likely still true today. It is well recognized that the diagnosis of appendicitis is extremely difficult in the very young (under two years of age) and the very old, but Calgary’s mortalities have occurred in the usual age group for appendicitis. The Calgary Herald reports that the Calgary Health Authority has pledged several changes to its approach to appendicitis, including enhanced communication with patients and families who are involved with “serious adverse events” in Calgary hospitals. I certainly hope the changes are substantive, and constitute more than a public relations exercise.
posted by Al | 7:43 PM
7 Comments:
I am very pleased to have stumbled upon this blog. Thank you for your medical and political insights. As an American and a recently-accepted medical student I am nervous for the state of our future healthcare environment. You experience and insight is quite valuable to me. I will be checking in often.
my grandmother had appendicitis but they didn't find it because she was 77 and they figured if somethings going to be wrong with her its probably something really complicated and horrible. So they figured it was a bladder infection (since she had ignored high blood sugars she DID get a lot of bladder infections) and put her on antibiotics. WHen the pain came back they opened her up and found a huge mass of scar tissue where her appendix used to be becuase the thing had burst but contained itself likely due to the antibiotics. She ended up having to get her uterus removed and parts of her intestines.
Anyhow, she's lucky she didn't die when it burst. That and 7 years later they finally diagnose diabetes.
As mentioned, Rosie, the very old and very young are at the greatest risk of the missed diagnoses of appendicitis. The very young have no omentum to speak of and therefore do not wall off the infection well, and of course cannot explain how they feel. The elderly can have various infections that can be confused with apendicitis, the commonest is diverticulitis, which often does require antibiotic treatment (frankly, a bladder infection does not make people SICK, although in the elderly it may throw them off their usual good spirits, and general well being, a kidney infection invariably makes them SICK). Diverticular disease occurs in people over 40 years of age and usually begins with pain in the left lower abdomen and a change in bowel habit over the course of two or three days. Appendicitis usually presents with a decrease in appetite (a missed meal) and pain in the right lower abdomen over a period of 12 to 24 hours.
Thank you Scotty. Good luck with your studies.
My then 10 year old (now 14) daughter had the classic signs of acute appendicitis. Afer calling health Line I was told to take her to ACH which i did. I was late at night and there was no ultra sound technician on duty. The X ray did not show her appendix as it was hidden behind her intestine. Her white cell count was 50% above normal so the pieces fit. Her acute symtoms abated and as they did not want to call in an ultra sound technician we were told to return in 2 days barring any further symtoms.
Upon our return the ultra sound showed an appendix of sufficient size to be removed immediately. We lucked out when a very astute surgeon was called for a second opinion. He diagnosed chronic appendicitis. During surgery he also discovered a previously undiagnosed Meckels Diverticulum whose symtoms had come and gone for several years.
I agree that appendicitis is alive and kicking and I find the deaths due to undiagnosed appencitis to be absolutely inexcusable in our health care system. There seems to be an overabundance of caution in treating this.
Al,
You have mentioned in golden rule #3 that doctors must refrain from giving antibiotics if appendicitis is a possibility, because antibiotics lead to false sense of security.
What kind of false sense of security?
1) Does the pain/fever reduce as a (direct or indirect) result of using antibiotics?
OR
2) Do the patient and doctor begin to believe that the antibiotic will begin to cure soon and hence avoid surgery?
OR
3) Some other reason?
You got it---both one and two.
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