Appendicitis

[George K]

What a transformation this condition has undergone.

Back in the dark ages, if someone presented to the ER with symptoms consistent with appendicitis, it was deemed a true surgical emergency. "Emergency" enough to call in the team at no-o'clock in the morning, "emergency" enough to cause a surgeon to disrupt a surgical schedule to get his "emergency" squeezed in.

I worked with a surgeon (let's call him "Steve") who did a colorectal fellowship in Cambridge. When he was on call, and was consulted for a possible appendicitis, he was told, "No problem, Dr. Steve, we will get to your appendicectomy first thing in the morning."

He was appalled that he might have to wait 5-6 hours.

And then, the CT scan came in. Here's what made me think of this:

https://www.upi.com/Health_News/2021/11/16/lose-dose-CT-diagnose-appendicitis-study/1061637014801/

The CT changed everything. No longer did a surgeon have to come to the ER to examine a patient with suspected appendicitis. He would be called by the ER staff after the blood work was done, the CT scan was done, and then, he'd schedule the case.

And then, the science came in...

Guess what? It's no longer a critical "emergency." It can wait for hours to get done.

How times have changed.

[Horace]

I wrote here about massive stomach pains which landed me in the ER one night. I suggested it was my appendix but they didn't really think so. The pain subsided while still in the ER and they sent me home with a 4k bill. (out of pocket, after insurance.)

Eventually I was diagnosed with chronic appendicitis, the sort that flares up from time to time but which isn't actually a burst appendix. I had it removed with a scheduled surgery rather than an emergency one. But it was interesting that the ER, even with the hint I gave them, could not diagnose it.

[brenda]

@horace said in Appendicitis:

I wrote here about massive stomach pains which landed me in the ER one night. I suggested it was my appendix but they didn't really think so. The pain subsided while still in the ER and they sent me home with a 4k bill. (out of pocket, after insurance.)

Eventually I was diagnosed with chronic appendicitis, the sort that flares up from time to time but which isn't actually a burst appendix. I had it removed with a scheduled surgery rather than an emergency one. But it was interesting that the ER, even with the hint I gave them, could not diagnose it.

I'll see your appendicitis and raise the bid with a gall bladder that needs removal!

Really. Two ER visits, with numerous tests between, and the diagnosis was still only a guess that it might be gallbladder problems. Without any other options, they did surgery to remove the gallbladder after the second ER visit.
AHHHHHHHHHH!!!!!! RELIEF!!!!!!!!!!!!!!11

Medical science is still a long way from absolute.

[Horace]

@brenda said in Appendicitis:

@horace said in Appendicitis:

I wrote here about massive stomach pains which landed me in the ER one night. I suggested it was my appendix but they didn't really think so. The pain subsided while still in the ER and they sent me home with a 4k bill. (out of pocket, after insurance.)

Eventually I was diagnosed with chronic appendicitis, the sort that flares up from time to time but which isn't actually a burst appendix. I had it removed with a scheduled surgery rather than an emergency one. But it was interesting that the ER, even with the hint I gave them, could not diagnose it.

I'll see your appendicitis and raise the bid with a gall bladder that needs removal!

Really. Two ER visits, with numerous tests between, and the diagnosis was still only a guess that it might be gallbladder problems. Without any other options, they did surgery to remove the gallbladder after the second ER visit.
AHHHHHHHHHH!!!!!! RELIEF!!!!!!!!!!!!!!11

Medical science is still a long way from absolute.

It's striking how differently you'll get treated by different doctors. For my broken thumb tendon, the first doctor screwed everything up so bad, my second doctor could hardly believe it. The first one didn't even have the equipment necessary in her office to diagnose anything, which probably ended up costing me my normal tendon and any semblance of normal movement. Then there's my ruptured quad tendon that wasn't diagnosed in the ER either... again with my own hint that that is what it is. At least they recommended I make an appointment with an orthopedist for that one. Who diagnosed it in 3 seconds with a single finger pressed to my kneecap.

[bachophile]

@brenda said in Appendicitis:

Medical science art is still a long way from absolute.

FIFY

as for urgency, we've known a long time that the main delay in appendices which lead to perforation is the wait at home before coming to the ER. The ones that sit on abdominal pain 3-4 days at home before finally coming in. The wait between a night arrival to the ER and a next morning surgery is practically meaningless.

[bachophile]

@brenda said in Appendicitis:

Really. Two ER visits, with numerous tests between, and the diagnosis was still only a guess that it might be gallbladder problems. Without any other options, they did surgery to remove the gallbladder after the second ER visit.

ok, lets be honest, biliary colic, which is the pain from gallstones, is sometimes not an easy thing to diagnose. its easier with full blown cholecystitis, (infection of GB like appendicitis) because there its easy to see with an US.
OTOH, biliary colic is simply colicky pain without necessarily have an overt infection, and sometimes biliary stones may not be stones at all but rather sludge and gunk, which is not clearly visualized on US (nor CT for that matter)

the differential diagnosis of epigastric pain is broad, peptic ulcer, hiatal hernia, pancreatitis, (even myocardial infarction and impending disasters such as a ruptured aneurysm) and as the only real way to cure biliary colic is surgery, one tends to be cautious before operating on someone without a clear diagnosis. not fun to go into a lap chole and remove a completely healthy gall bladder (been there done that, not fun at all)

so yes, diagnosing an abdomen is an art, not a science. thats why surgery residency is five years, thats a lot of belly checking in the ER, and even then, someone with thirty years experience (ahem...) may be better qualified then some ER resident who thinks they are hot shit Dr House.

[brenda]

@bachophile said in Appendicitis:

@brenda said in Appendicitis:

Really. Two ER visits, with numerous tests between, and the diagnosis was still only a guess that it might be gallbladder problems. Without any other options, they did surgery to remove the gallbladder after the second ER visit.

ok, lets be honest, biliary colic, which is the pain from gallstones, is sometimes not an easy thing to diagnose. its easier with full blown cholecystitis, (infection of GB like appendicitis) because there its easy to see with an US.
OTOH, biliary colic is simply colicky pain without necessarily have an overt infection, and sometimes biliary stones may not be stones at all but rather sludge and gunk, which is not clearly visualized on US (nor CT for that matter)

the differential diagnosis of epigastric pain is broad, peptic ulcer, hiatal hernia, pancreatitis, (even myocardial infarction and impending disasters such as a ruptured aneurysm) and as the only real way to cure biliary colic is surgery, one tends to be cautious before operating on someone without a clear diagnosis. not fun to go into a lap chole and remove a completely healthy gall bladder (been there done that, not fun at all)

so yes, diagnosing an abdomen is an art, not a science. thats why surgery residency is five years, thats a lot of belly checking in the ER, and even then, someone with thirty years experience (ahem...) may be better qualified then some ER resident who thinks they are hot shit Dr House.

Agreed on all this. There are some things, such as a gallbladder problem, that can present in ways that make it very difficult to diagnose. Mine presented as chest pain that would radiate all the way into my lower jaw. The first time it happened, I had my very first, and so far only, ambulance ride. My local doc thought it was a heart attack. The main ER doc I saw that time was the first person to say she would bet it was gallbladder.

For all the reasons you wrote, I went through a very broad range of tests over many weeks, with no clear diagnosis. I joked that my digestive tract had been scoped from top to bottom (colonoscopy done earlier included). The pain attacks continued at various times through those weeks, too, always in the chest and jaw.

There was never a clear diagnosis, but by process of eliminating all other common causes, it became apparent that the gallbladder was the most likely problem. Yes, you are correct to call it an art, and the first ER doc's impression was spot on, though not actionable at that stage.

The only good part was that the entire thing cost me zero dollars. My earlier and separate surgery that year blew through all our deductibles for our insurance. There was such a long list of tests done before the gallbladder surgery, the bill was over $100K just for that period, on top of the expenses from earlier in the same year. I was definitely not a cheap date that year.

[brenda]

And bless those two nurses in the ER during the second time I went because I was unable to manage or withstand the pain. They could not believe how much I had gone through over two months, nearly three.

They came to talk to me when no other staff was around to tell me not to go home that night. It was obvious the pain was so out of control that I would not manage it at home. They said it could only be managed in the hospital, and that it would mean the surgery could be done sooner. It was already late evening, and a few hours later I was in the OR. I woke up to no pain thanks to those brave nurses talking to me without the permission of the docs. Love those nurses for being so willing to explain. They had their own art.

[Improviso]

@bachophile said in Appendicitis:

as for urgency, we've known a long time that the main delay in appendices which lead to perforation is the wait at home before coming to the ER. The ones that sit on abdominal pain 3-4 days at home before finally coming in.

Back in 2013, when it happened to me, guilty as charged. That's exactly what I did. Thought it might go away on its own which is why I waited.

I only relented when my wife (current one, not the other one) said she was either going to drive me to the ER or call an ambulance, my choice. Longest car ride of my life. Surgery at 1:00 in the morning. 3 days in the hospital. When I inquired about going home, I was told not until "the kids were in the pool". At the time, I didn't know what that meant. I do now.

My PCP has characterized me as "not a frequent flyer" when it comes to medical services. I loathe hospitals,

[George K]

@improviso said in Appendicitis:

"not a frequent flyer" when it comes to medical services.

I refer to Mrs. George as a "repeat offender."

[brenda]

@improviso said in Appendicitis:

My PCP has characterized me as "not a frequent flyer" when it comes to medical services. I loathe hospitals,

Same here. Not fond of hospitals, especially not as a patient.

The few times I've been in the hospital, I've not wanted any visitors other than hubby and our kid. If I'm there, it means I'm very sick or hurting or both, so stay away, people.

I did know about dropping the kids off at the pool.