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Abdominal pain not to be ignored

A common surgical problem that tends to be a surgical emergency

Lower-right abdominal pains, at times, begin around the belly button area, then move to the lower-right abdomen, followed by a bout of nausea and vomiting, that may or not have associated fever and chills and pain so severe at times, that it can awake you from your sleep. If you do experience any of these symptoms, oncologist Dr. Don Major said they are not to be ignored – and to seek medical help.

According to the oncologist, the pains could be acute appendicitis, a common surgical problem that tends to be a surgical emergency requiring urgent care.

If symptoms are ignored, the appendix can rupture with more serious complications, and even death, according to Major. Therefore, he said, the symptoms should not be ignored and passed off as “gas”.

The oncologist said individuals with uncomplicated acute appendicitis can be treated with a course of antibiotics, however, he said there is a risk of failure and recurrence of acute appendicitis with antibiotic-only treatment. Surgery is relatively low risk and most individuals go on to lead a normal life following surgery.

“Abdominal [belly] pains are a common complaint for individuals reporting to the emergency room. Up to a third of individuals that present to hospital with acute appendicitis will have a ruptured appendix which requires emergent surgery,” said Major. “It’s a common disease process that we see and most people do not know the symptoms and what to expect. Also, they have no idea that it can be deadly if they wait too long to be seen.”

Major said it’s a disease process that he deals with on an almost daily basis.

“Abdominal pains can be due to a myriad of different pathologies which can involve almost every organ in the abdominal cavity and even some organs outside of the abdominal cavity. An acute abdomen is a surgical emergency and it is the sudden onset of severe abdominal pains requiring urgent surgery. The most common cause for an acute abdomen is acute appendicitis. Acute appendicitis is inflammation of the appendix which is a vestigial organ located in the right lower abdomen.”

At birth, the function of the appendix is to assist in the maturation of the white blood cells. As people age, the function is lost.

“At present, there is no real function for the appendix,” said Major.

The doctor said acute appendicitis most commonly occurs in people between the ages of 10 and 20 years old and has a lifetime risk of 8.6 percent and 6.7 percent for males and females, respectively. But that the peak incidence is between 15 and 19 years of age.

“Acute appendicitis is not limited to this age group and can occur in the pediatric as well as elderly population – however, less commonly.”

He said approximately one in 15 individuals in the United States will develop acute appendicitis in their lifetime, with nearly a third of these individuals presenting with a ruptured appendix.

To get a diagnosis, the doctor said a detailed history and examination of the patient will be done. And that on examination, the patient may experience tenderness in the lower-right abdomen. When they cough or laugh, he said, the patient may experience pain.

“At times, when examining the left side of the abdomen, the individual may also experience pain on the right side. When these features are present, these warrant blood investigations and a possible radiological investigation such as a CT scan or ultrasound. In cases where there is a question to what the diagnosis is or there is clinical uncertainty, imaging modalities can be used in the form of an ultrasound or CT scan.

Major said that, commonly, the diagnosis of acute appendicitis is based on history and physical examination.

He said the ultrasound tends to be the first image used to make the diagnosis as there is no radiation involved and can be used in pregnant women. However, it is user-dependent and can at times be inconclusive. In these cases, a CT scan is ordered, which is more sensitive in picking up acute appendicitis. Usually, there is evidence of inflammation of the appendix and surrounding tissues with or without fluid around the area. When the appendix perforates or ruptures, these patients tend to be quite ill and may require intensive care admission.

The doctor said the blood investigations tend to show signs of infection, upon an elevation in the white blood cells, which are the cells that fight off infection.

“Sometimes, it may also show evidence of abnormalities in the kidney function testing as the individual may be dehydrated.”

Appendicitis can be characterized as complicated versus uncomplicated and the treatment is based on the type. Uncomplicated appendicitis is when the appendix is only inflamed. When it becomes complicated, he said, there is evidence of perforation or abscess formation.

“Previously, the diagnosis of acute appendicitis meant that the individual needed surgery in the form of a laparoscopic appendectomy. Recently, there has been a described role for antibiotics alone in the treatment of uncomplicated appendicitis. However, up to a third of the patients treated with antibiotics only and no surgery will have a recurrent episode of acute appendicitis within 90 days, usually requiring surgery. Also, up to 40 percent of patients will have a recurrent attack in one year requiring surgery. Due to these statistics, most surgeons would still recommend removal of the appendix once inflamed.”

Appendix removal is usually via laparoscopy, according to Major. The patient is put to sleep in the operating room and the surgeon makes small incisions on the skin. Through the tiny incisions, he said, instruments are placed that are used to inflate the abdomen with gas to allow for adequate working space. He said the instruments are then used to remove the appendix and also to have a look around in the abdomen for any other pathology.

He added that there are some risks involved with a laparoscopic appendectomy, specifically anesthetic and surgical risks.

“Anesthetic risks involve allergic reactions to the anesthesia, a sore throat and post-operative nausea and vomiting. Surgical risks involve bleeding, infections and damage to surrounding structures.”

He said it is rare to convert to an open operation. And that the complications are all less than five percent.

“Post-operatively, most patients are allowed to go home the very next day. When the appendix is complicated by perforation or an abscess, individuals may have to stay longer.”

Once discharged, patients usually get two to three weeks off from work. During the healing period, he said, patients are advised to not lift anything heavy for a period of six weeks to minimize the possibility of developing a hernia. After one month, Major said most people have returned back to leading a normal life with no concerns.

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Shavaughn Moss

Shavaughn Moss joined The Nassau Guardian as a sports reporter in 1989. She was later promoted to sports editor. Shavaughn covered every major athletic championship from the CARIFTA to Central American and Caribbean Championships through to World Championships and Olympics. Shavaughn was appointed as the Lifestyles Editor a few years later.

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