Appendicitis

Appendicitis

It Can Be the Unkindest Cut

On the lower right side of your abdomen, there's a smoldering pain that won't go away. You've thrown up twice in the past hour, your temperature is climbing, and the thought of food is revolting.

Do you have appendicitis?

Maybe. But if you're a woman, chances are that even if you don't, you could still end up losing your appendix.

A study of more than three million men and women conducted over a six-year period by the Centers for Disease Control and Prevention (CDC) in Atlanta found that women have twice as many appendectomies as men, even though they have about half the number of cases of appendicitis.

The same study showed that a mistaken diagnosis is 12 percent more likely to occur in women than in men and that women between the ages of 35 and 44 are 12 times more likely than men to have a healthy appendix removed.

What's more, the study determined that five out of every six appendixes surgically removed from women ages 35 to 39 are likely to be disease-free--meaning they didn't need to be taken out.

Why Us?

Appendicitis is an inflammation of the small appendage situated near where the small and large intestines meet. The appendix itself doesn't serve much purpose--you can live just fine without it--but once it's diseased it has the potential to reach life-threatening status.

Nobody knows what causes appendicitis. Only 110,000 women have appendicitis every year, but nearly 372,000 women have appendectomies.

"I was surprised by the statistics," says medical epidemiologist David Addiss, M.D., the investigator who led the CDC study.

Studies indicate that the most common reason women undergo more appendectomies than men is the biological makeup of the female anatomy: Doctors often have difficulty differentiating between gynecological problems and appendicitis. And sometimes a doctor will simply decide to remove a normal appendix while operating in the abdomen for other reasons.

"Women tend to get more appendectomies than men because of the confusing picture presented by gynecologic disorders," says gastroenterologist Marie Borum, M.D., assistant professor of medicine at George Washington University Medical Center in Washington, D.C.

The problem is that the symptoms of appendicitis--predominantly right-lower abdominal pain--are nearly the same as those of a dozen other conditions ranging from ectopic (outside the uterus) pregnancy to inflammatory bowel disease. "Even though I do a thorough physical and perform lab and radiologic studies," says Dr. Borum, "I still may not be certain what's causing the symptoms."

Confusing the diagnosis even further, she adds, is the fact that the appendix may not be where it should be. "Sometimes the appendix can be in an unusual position and refer pain to the right shoulder, above the stomach or even to the rectum," says Dr. Borum.

Taking Caution's Side

Aside from the complexities of diagnosis, one factor that sends doctors reaching for the scalpel is the knowledge of how dangerous appendicitis can be.

"I too have the concern that women are getting more appendectomies than men," says Dr. Borum. "But I think it's because doctors are concerned that they may miss a potentially catastrophic event like a perforated appendix."

Perforation--a hole or break in the appendix wall--can lead to peritonitis, a condition in which the appendix bursts and spreads pus throughout the abdominal cavity, she explains. The result is a massive infection that threatens every part of the body and can be fatal.

"Those appendixes are the ones that doctors are scared to miss," says Dr. Borum, even though perforations themselves are present in less than 5 percent of all appendectomies and occur mostly in children 10 to 14.

The fear of a perforation in the future may also encourage doctors to cut out a healthy appendix during surgery for other conditions.

"Doctors are just doing it because they're in there," says Dr. Borum. They figure that since the appendix has no known purpose, and since no one's really sure what triggers appendicitis to begin with, they'll get it before it causes a problem.

How to Save Your Appendix

According to some doctors, there's a medical school opinion that removing a large number of healthy appendixes is the only way to make sure you get the ones that are likely to perforate. Based on medical textbooks and studies, in fact, it's expected that somewhere between 15 and 23 percent of procedures will remove a healthy appendix.

Here's how you can make sure yours is not one of them.

Get an abdominal exam. You should have an abdominal exam and, if necessary, a pelvic exam, to rule out as many gynecological problems as possible, says Dr. Borum. If these examinations are inconclusive, lab tests, including a complete blood count, should be performed, she says.

Talk. Any time you have an abdominal operation, discuss the procedure with your physician. Since no one's really sure what purpose the appendix serves, you may or may not want to keep it. If tests show that you do have a diseased appendix, you should have it removed, says Dr. Borum.

Consider a laparoscopic examination. This diagnostic technique, used by gynecologists and adapted in recent years by surgeons, should mean that there is no longer any reason to remove a woman's appendix because of the difficulty in diagnosing appendicitis, says Gustavo G. R. Kuster, M.D., senior surgical consultant at the Scripps Clinic and Research Foundation in La Jolla, California.

"The laparoscope is like a pencil. It is long, with lenses, a light and microcameras. It is introduced through the belly button, so there's no scar. You can use it to look inside the abdomen, and you can visualize the appendix and all the organs around it--the fallopian tubes, the ovaries, the liver, the gallbladder, the stomach and the intestines."

What to Do If You've Got It

If appendicitis is the problem, the surgeon can insert two narrow tubes through quarter-inch incisions on both sides of the abdomen and use long, narrow instruments to remove the appendix.

"It's something like a video game," says Dr. Kuster. "You look into a TV monitor as you work outside the abdomen to manipulate the instruments."

The surgeon can grasp, cut, stitch and cauterize through the tubes, says Dr. Kuster. Compared with the old-fashioned way of opening up the abdomen, "there's less infection, less adhesions that can lead to bowel obstruction, less chance of infertility due to pelvic infection, less pain and scars and quicker recovery," he says. With laparoscopic surgery, you're out of the hospital the next day, if there is no severe infection. The old way, you're flat on your back for three to five days, and you shouldn't lift or exercise for another five or six weeks.