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CASE NOTES
Tuesday 27 January 2009, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION

RADIO SCIENCE UNIT


CASE NOTES Programme no. 5 - Appendix



RADIO 4

TX DATE: TUESDAY 27TH JANUARY 2009 2100-2130
PRESENTER: MARK PORTER

CONTRIBUTORS: BILL PARKER
ROS PORTER
HUGH BARR
ANTHONY LANDER
KATE CHITTY
PAUL ZIPRIN

PRODUCER: PAULA MCGRATH





NOT CHECKED AS BROADCAST

PORTER
Hello. Today's programme is all about the appendix and what happens when it becomes inflamed. It is an unusual structure, at the root of one of the most common surgical emergencies.

CLIP
The first day that she had the tummy ache I hadn't even thought about it, it was only when she had a fever and that she hadn't had any diarrhoea that I thought something - you know this isn't normal, which is - that was when we spoke to the doctor.

PORTER
We'll be hearing more later from that mother whose daughter is now member of a sizeable minority - between 5 and 10 percent of the population - who need to have their appendix surgically removed. And time isn't on their side. If the diagnosis is delayed the inflamed appendix can burst and infect the abdominal cavity - a potentially lethal complication known as peritonitis.

But what's the upside - why do we have an appendix and what does it do? Conventional wisdom has it that the appendix serves no useful role - that it's an evolutionary remnant with no specific function. But that belief is being turned on its head by new research suggesting that the appendix could have an important immune function, and that it helps the billions of friendly bacteria that live in our bowels.

PARKER
These good bacteria that are sort of protected from an infection in the appendix could then sort of be used to reboot the gut bacteria which are so vital to human life.

PORTER
But before we find out more about what it does, I want to take a closer look at the problems it causes.

The classic symptoms of appendicitis - vague abdominal discomfort that moves within 12 hours or so to a sharper pain in right lower side - is drilled into medical students. But diagnosis is not always as straightforward as the text books suggest - as I discovered to my cost in 1992. Professor Hugh Barr from Gloucester Royal Hospital was the surgeon who removed my appendix after I treated myself at home for what I thought was gastroenteritis. My wife Ros picks up the story.

ROS PORTER
Well he literally came home from surgery saying he had stomach cramps and we really didn't think much about that. And then the following day he said I've got a really upset stomach - you know stomach - I hope I haven't had picked up one of the bugs that are going round. And then the following day he got a pain in his right side and it was really bad so of course being a doctor he started to prescribe his own drugs and of course it sort of got better then. But actually then I noticed that he'd shrunk by about - well it seemed about three inches because he was sort of bent forward. So I thought that was a bit strange. And then that night he was like a furnace and then he was hallucinating, he was fighting bats in the bedroom and everything. So the following morning I got up and decided that's it, so I got my GP in, she came in and gave him a thorough check up and the next thing I knew we were flying into the hospital.

BARR
Well by the time I saw Mark the diagnosis was very apparent, often in the early stages it's quite difficult. So Mark had taken the sensible measures, sort of reflected on it and fortunately Ros had taken over control when it was clear that he was perhaps not functioning as he should. But when you arrived you clearly were quite poorly. There was a mass in the right iliac fossa, he had high fevers and you were having little sceptic episodes. So the diagnosis was made very easy for me and we advised immediate surgery through a wound. So we got the anaesthetist to see you and a little bit of resuscitation and antibiotics, in fact, just to make sure you were in tip top condition. Took you to the theatre, I opened up the tummy and you had a walled off abscess, related to your appendix, which had perforated locally.

ROS PORTER
I was waiting on the ward and I thought it was only going to be a very short op, I was beginning to wonder whether he was actually amputating a leg instead of appendicitis. And the next thing I saw was Hugh walking down the corridor and he stuck his head in the room, he said: "God, that was awful, the stench was appalling." And I thought oh my god what's happened to him. But apparently it was all fine but it was just pretty smelly and nasty.

BARR
Your body actually was mounting a very good response, it was walling it off because before surgeons were about people survived appendicitis and you'd have survived - it had walled off and dealt with it. And what we did was took out the remains of the appendix and drained the pus, the wound had to be extended a little bit just to make sure we could get everything out and controlled everything and you made an excellent recovery.

PORTER
And I'm still carrying the signature on my stomach. It doesn't look like a normal appendix scar, though Hugh, and that's presumably because you had to extend it a little bit.

BARR
Oh no, no it's not normal, often these days we do a lot of them down the laparoscope, you would never have been suitable for the laparoscope. And there is a surgical aphorism that big mistakes are made through small incisions. And the crucial to getting the patient better is to get all the sepsis, all the infection out, well drained, clean it out very well, wash out the cavity, make sure that all the pus and the dead and necrotic tissue is removed and then the patient almost invariably make an excellent recovery with proper post-operative care. The scar, you're quite right, is perhaps - perhaps you'd better not appear in a mankini or whatever the modern young man uses but perhaps a more full bathing suit when you're on the Riviera Mark, is that alright?

PORTER
And I've never looked back since, or worn a mankini for that matter.

Professor Hugh Barr talking to me earlier. And I am also pleased to report that that was the only case of appendicitis I have ever knowingly missed. So far anyway…

Time now for a bit of anatomy. The appendix looks like a pink earthworm, and is typically five to six centimetres long. It hangs down from the lower part of the caecum - the section of the gut where the small intestine meets the colon, just above the right groin.

It's a blind ending cul-de-sac that's just about wide enough to push a matchstick down. And it's this narrowness that's thought to be one of the reasons that the appendix is so prone to becoming inflamed - it's easily blocked.

And as it becomes inflamed, the thin walls swell and their blood supply becomes restricted. If left for too long, the whole structure starts to rot allowing the contents to of the bowel to seep out into the sterile abdominal cavity leading to peritonitis - a dangerous infection.

Appendicitis can strike at any age, but most cases are in young adults or children. Anthony Lander is Consultant Paediatric Surgeon at Birmingham Children's Hospital.

LANDER
Plenty of the children with early acute appendicitis may present in much the same way as an adult, in that they go off their feeds, they may vomit once or twice, they have some sort of abdominal pain usually in the centre of their abdomen and later on that abdominal pain settles on the right hand side of their abdomen - just the classic presentation. And often we see that in children if you take a very careful history. And the older child's often able to give a very good history, they even get great things where you say where did the pain first start, you'll often get the answer in the kitchen.

PORTER
Rather than the tummy yeah. And what about age group, I mean what sort of age are these children?

LANDER
The vast majority are in children over five years of age and the older you are the more likely you are to have appendicitis. But we do see plenty of children under five who have appendicitis, although it's less common. And in the younger child it is often more difficult to make the diagnosis, the presentation is more likely to have been confused with other problems that the child might have, such as having a temperature and belly ache from other reasons. And so in those children the biggest problem can be either a delay in diagnosis or that the condition's actually somewhat fundamentally different than it is in the older child and they're at risk of the complications of appendicitis in a greater way because they can deteriorate more rapidly, they can become iller in various ways and this causes problems.

PORTER
What sort of diagnostic pitfalls are there, I mean what are the sort of things that are likely to get mistaken for appendicitis in the young child?

LANDER
Because there are so many other things that can give abdominal pain the classic confusing ones are what we call gastroenteritis, so somebody with diarrhoea and vomiting may have tummy pain and have had vomiting, so there's potential confusion there and they can have a low grade temperature. It's a pitfall because a child with gastroenteritis might be sent home from hospital, might not be reviewed and the key to making the diagnosis in appendicitis is repeated clinical examination by somebody who's skilled in managing children with abdominal pain. And that confusion with, for example, gastroenteritis will be avoided if the child is admitted, given appropriate intravenous fluids and watched regularly and followed up closely with repeated clinical examination. The pitfall - if the appendicitis becomes complex in that you've got say a collection of pus sitting behind the bladder or in the region of part of the lower bowel, that can itself generate diarrhoea. So not uncommonly we have a child presenting with diarrhoea, abdominal pains and vomiting and it is attributed to gastroenteritis when in fact they've had a complex appendicitis.

PORTER
But as a GP I mean we see a lot of children with gastroenteritis, we don't actually see a lot of children with quite severe abdominal pain and is that the factor that pulls it out, is that the factor that's differentiated?

LANDER
The symptom of pain may not always be that marked, especially if the appendix is hidden behind the caecum, part of the colon, so if the appendix is well hidden their symptom of pain might be relatively mild. But the key to distinguishing them is the clinical examination - if they've got tenderness in the region of the right lower part of the abdomen then they're much more likely to have appendicitis then they are to have gastroenteritis. The problem is that you can't always make that decision the first time you see the patient and as a general practitioner that can be very difficult because the doctor in hospital has the benefit of being able to review the patient every few hours. And I remember one child where eventually the diagnosis was made, after I'd examined him a fair number of times, and the mother was very impressed about my attention to the care of the child that I'd seen him so often but she was disappointed with the general practitioner who'd seen the child at clinic, he'd then come and visited her at home and seen the child, he'd seen him again that evening, seen him again the next day and she thought he couldn't make the diagnosis. But the GP had done the right thing by constantly reviewing the patient until he was feeling that the child was not getting better and therefore needed expert help. But it's very difficult in general practice for many GPs to continually review patients.

PORTER
Are there any test that we could use in primary care - I mean things like blood tests and things that we can take now obviously that might be helpful in differentiating an acute appendicitis, or is it just looking at the abdomen and watching ...

LANDER
It is, it is a clinical examination. There is a thing called a white blood cell test where you can count the number of white cells and that's raised in infection but if you've got a child with a raised white count, which could be raised for lots of reasons, and the abdomen is perfectly alright or settles they're not going to end up having an appendisectomy. Likewise you can have a child who's got a normal white count or other measures of inflammation and yet they've got appendicitis. So the key is essentially repeated clinical examination.

PORTER
And in terms of danger to the child, if an appendix is missed and they develop peritonitis, how dangerous a condition is that?

LANDER
It's not as dangerous as it used to be. Peritonitis for our grandparents and the generation before them, the word peritonitis was associated with death, it was as bad as hearing that you'd got cancer if you had peritonitis. That's not been the case since antibiotics have been around and with special antibiotics for anaerobic bacteria the world's a much safer place if you've got appendicitis. But nonetheless there still are deaths in this country every year in children and in adults who've had complications of appendicitis and delay in diagnosis contributes to some of those deaths, it's still a serious condition.

PORTER
And is time of the essence, once you see these children do you need to get them to theatre quickly?

LANDER
It is a very urgent condition to manage but the condition has to be managed. Once the diagnosis has been made or in managing the sick child in the way up to a diagnosis they're usually managed with intravenous fluid to resuscitate them. And then once a diagnosis has been made antibiotics are started and then theatre is planned but there's no need to be rushing in the middle of the night to take a child to theatre for appendicitis in most cases, very rarely something needs to be done in the middle of the night but mostly this can be a planned procedure, either the next morning or in the afternoon after they've presented. So they need an operation within a few hours but it doesn't have to be done in the next hour or two.

PORTER
And the operation offered is what - using laparoscopy - keyhole techniques?

LANDER
There's a complete - there's a spread. Some children have a laparoscopic or keyhole approach to managing their appendicitis once the diagnosis has been made. And some children have an open operation. This sometimes depends on child based factors, other times it depends in the country on what facilities are available and what level of training there is. As time progresses more and more children will be having appendicitis and other abdominal conditions managed in a keyhole fashion, that will be the way of the future.

PORTER
And is that the sort of technique that you're using in your unit?

LANDER
I'm not but I'm starting to do it but many of my colleagues do do laparoscopic appendesectomies and 20% of our appendesectomies in children are currently done laparoscopically. We find that the more complicated the child with problems related to appendicitis the less easy that can be sometimes to manage it by a keyhole approach.

PORTER
And if all goes smoothly how quickly would you expect them to be home?

LANDER
In a child with early acute appendicitis diagnosed they can be going home on the second post-operative day. But we know that there's a spread of the length of time that children stay in hospitals and this can be up as long as three weeks and this can be in children who've had major complex problems associated with their appendicitis. But our average stay in our hospital is about four days. And in other hospitals it can be as short as two days. But in hospitals where they're sent home very early there's often a readmission rate.

PORTER
Anthony Lander from Birmingham Children's Hospital. Sophia Chitty was just five when she developed appendicitis a couple of years ago - and she was a long way from home - as her mother Kate explains.

CHITTY
We were on holiday in Egypt; sailing and kids in the clubs and a bit of sunshine, gorgeous sunshine. We were due to fly home on the Sunday, on the Thursday morning Sophia woke up and was sick and we just thought oh tummy bug, she's eaten something dodgy in Egypt. During this time she hadn't had any diarrhoea, so I was beginning to think this is a bit odd, it's not a typical D and V.

So we then called the hotel doctor and he came and had a look at her and said he wasn't quite sure, he said he'd come back a bit later. So during that day - it was actually - it was getting worse that day, she was complaining of a lot of pain but not in one particular area, just sort of all over her stomach. Anyway he came back about four o'clock that afternoon and had another look at her, prodded her a little bit and said I think we need to take her to hospital. And I was thinking help, what's wrong with her. And he mentioned that it might be appendicitis.

And luckily our friends could look after our two year old son and Phil and I were able to go in the taxi with this doctor, who came with us, to a private hospital in Hurghada, which was about 45 minutes from the hotel, on a nice bumpy road with poor Sophia not very happy. And when we got there she had an ultrasound and an x-ray which was really painful for her, especially the x-ray. And they then said straightaway that it was a burst appendix. She was in a lot of pain by this point and not really taking much in. She was five at the time. And so I had mad phone calls back to England trying to get people to talk to their friends who are GPs or whatever to confirm that her symptoms were probably what they were saying - that it was a burst appendix.

And then at about seven o'clock on the Saturday night she was operated on and Phil and I were sitting outside praying like mad for an hour and a half as they sorted her out.

They said it had gone really well, she was left with a little tube coming out of her, which was to drain everything coming out. And yeah we were in - she was then kept in for about four nights. So one of us stayed at the hospital with her and the other one went back to look after our son William back at the hotel. And at the time I was six months pregnant as well, so yeah not the best holiday experience.

After a week we were allowed to fly home and yep she didn't have any problems afterwards and back here I got her checked out and they said that they were really impressed with the scar and with their operation and that it had gone well.

It's two years on now so yes, she's seven, but yeah she definitely remembers it and she's quite proud of her scar.

PORTER
Kate Chitty talking about her daughter Sophia.

There are two approaches to removing the appendix. The time honoured open operation through a small scar above the right groin, or the newer laparoscopic procedure. This keyhole approach uses a camera inserted into the abdomen - normally through the tummy button - and separate instruments pushed through other tiny cuts. Not only does it mean smaller external scars and quicker recovery, but the laparoscope also gives the surgeon the chance to look around and confirm that the appendix is causing the symptoms. It's not always to blame - in around one in five appendectomies it's subsequently found to be normal, though more specialised pre-op tests like CT and ultrasound scans have helped reduce the likelihood of misdiagnosis.

Paul Ziprin is a consultant surgeon at St Mary's Hospital in Paddington.

ZIPRIN
I think keyhole surgery or a laparoscopic approach is more and more common, I think it's particular valuable in the female where again the diagnosis is still uncertain because you can get a very good view of the inside of the abdomen and again exclude gynaecological causes or other causes of their pain. And then if the diagnosis is confirmed at keyhole surgery then the operation can proceed with keyhole surgery. Perhaps in a young male, who's thin, then a standard open operation is still performed.

PORTER
What do you actually see as the surgeon, whether you go in laparoscopically or whether you open the patient up, what does the appendix look like?

ZIPRIN
It depends on the severity of the inflammation and infection of the appendix. It may be just swollen, red, maybe a bit of fluid around the appendix or in the pelvis of the patient. Or it can be very inflamed and gangrenous, it may even be perforated, where a hole has developed in the appendix and then there's usually associated pus throughout the abdomen. And that's the most severe form.

PORTER
Because presumably when you get that perforation - the so-called burst appendix - that the lay person would talk about I mean you're getting the contents of the bowel are leaking out into the area around, what happens then?


ZIPRIN
Sometimes a piece of faeces may have spilt out into the abdominal cavity but it's not common, normally you just have a lot of pus and you just then have to make sure you wash out the cavity of the abdomen thoroughly to make sure you get rid of all the infection as much as possible.

PORTER
It's a very common surgical problem, in your years as - particularly as you're coming up through the ranks because the junior surgeons tend to be the ones who are doing the appendices quite often - what sort of diagnostic pitfalls have you come across?

ZIPRIN
I think the two areas in adult surgery would be the older person presenting with pain in the lower part of their stomach, in particular patients may have - we call diverticulitis, where there's inflammation most commonly of the left side of the large bowel but that can present with lower abdominal pain and pain on the right side and I have seen patients who've had - passed when I was a trainee that were for appendicitis and found to have diverticulitis. Another patient that we sometimes have difficulty in diagnosing appendicitis are ladies who are pregnant because they may have problems with urinary tract infection, on examination the pregnancy itself may hide the appendix so they may not have as much tenderness when we examine the abdomen so the signs aren't often there. And the appendix can again be difficult to visualise even with ultrasound. We have used some MRI scan more recently which has helped in the diagnosis of a couple of ladies I remember who had appendicitis during pregnancy.
The downside of missing an acute appendix, obviously in pregnancy, is it could threaten an abortion and if we explore ladies unnecessarily and put them through an operation then it could again threaten the pregnancy. One lady, I remember, developed appendicitis three or four weeks after delivering her first child and again it was difficult to diagnose whether this was a complication of the caesarean section that she had or whether this was a new problem and actually she had a very nasty perforated appendix and we had to do a dare I say an old fashioned exploration of the abdomen through a big midline incision and found a gangrenous perforated appendix.

PORTER
Paul Ziprin from St Mary's in London.

Humans are actually quite unusual - most mammals don't have an appendix - and those that do are a strange mix.

PARKER
The mole rat, porcupines tends to have an appendix and the beaver has an appendix like structure in it too and those are all rodents. The koala bear has something that tapers off, much like a rabbit does and the possum, not to be confused with the opossum, has an appendix.

PORTER
Professor Bill Parker is a research scientist at Duke University in North Carolina and a driving force behind the theory that the cul-de-sac of the appendix acts as safe haven for the some of the billions of friendly bacteria that live in the colon.

PARKER
In 1996 we stumbled across an idea that took us seven or eight years to really nail down that the immune system is supporting the growth of the bacteria that live in our guts. So of course traditionally we thought that the immune system was anti-bacterial and indeed it is, it fights off bacteria that get into our bloodstream or other vascularised organs. But when we realised and concluded eventually that the immune system is supporting the growth of bacteria it paints a picture really that this little appendix is in a perfect location, it has all this immune tissue that is helping these bacteria to grow in a relatively protected environment. What would happen then is if you had an infection in the gut, which is very, very common in developing countries because of contaminated drinking water, and everything gets flushed out, these good bacteria that are sort of protected from an infection in the appendix could then sort of be used to reboot the gut bacteria which are so vital to human life.

PORTER
So it's simple - what's happening, say you had an outbreak of gastroenteritis, the diarrhoea flushes all of your healthy bacteria out, which play an important role in digestion and absorption of your food, and you're saying that from the appendix, little tiny appendix, hanging off the caecum, it sort of reseeds that growth.

PARKER
That is correct and the idea there is that the centre - the lumen - or the inside of the appendix where it can actually hold bacterias, it's only about the size of a pencil lead, so it's going to be fairly protected, just the length of it and the very small internal diameter of it, are going to protect those bacteria from infection and that's the idea.

PORTER
Presumably that same design that makes it a good sanctuary makes it an area that can easily get blocked perhaps as well and cause problems?

PARKER
Yes that's true. However, when we look at appendicitis and the cause for appendicitis a British epidemiologist named David Barker, he's still around, did some work back in the '80s and really showed that appendicitis is a result of hygiene that we have in our developed countries, such as Great Britain and the United States, and because of that the immune system becomes over reactive, this has to do with the hygiene hypothesis, which wasn't even discovered at that time, he didn't realise that this was part of that because nobody knew what the hygiene hypothesis was, but in general the hygiene hypothesis which is now widely accepted says when you live in a very clean environment your immune system does get overly reactive and we now know that - and we've known for some time - that the appendix is an immune organ. So that would explain nicely appendicitis.

PORTER
What happens thereafter if you've then lost this sanctuary, are there any negative effects on the bacterial population within our guts as a result?

PARKER
That is an intriguing question and there's several ways to look at the answer to that question. One is, first of all, that we know that widespread outbreaks of contaminating [indistinct word], that are a result of contaminated drinking water, just don't happen in developed countries where you typically see appendicitis. In third world countries deaths from diarrhoeal associated illness are the third leading cause of deaths from disease. Whereas obviously you just don't see that at all in developing countries. So it may be that when you have a clean environment which causes can lead to appendicitis ironically enough it changes the environment in such a way so that you don't actually need the appendix. And indeed that's what we find when you take an appendix out of a patient that there's no discernable side effects from that.

PORTER
But our modern society in the developed world means that we actually can cause - it causes more problems than it solves effectively.

PARKER
I would guess that it probably solves no problems, it probably is now a vestige of social evolution, I guess you could say, that would be the idea, the model that we have is correct. And yeah it definitely causes quite a bit of problems. Fortunately we have well trained surgeons who can take that out.

PORTER
Bill Parker talking to me earlier from Duke University in the States.

If you would like anymore information on his work then you can visit our website at bbc.co.uk/radio4, where you can also listen to any part of the programme again, and find out how to download Case Notes as a weekly podcast.

For next week's programme I will be visiting one of the UK's leading cardiac hospitals to find out about a radical approach that can stop a heart attack in its tracks - assuming the patient gets to the unit in time. And the treatment - primary angioplasty - should eventually be coming to a hospital near you. Join us next week to find out why it's now even more important to seek medical help urgently if you develop suspicious chest pains.

ENDS

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