HEALTH writers often warn readers about high rates of unnecessary surgery and caution them to beware of surgeons who are too quick to operate. But there is at least one circumstance in which surgery that turns out to be unneeded may be more than justified.
When preoperative tests strongly suggest that an inflamed appendix is the cause of a patient's symptoms, the surgeon who operates without further delay does so in hope of preventing a far more serious complication: rupture of a germ-laden appendix, resulting in a potentially life-threatening infection of the entire abdominal cavity.
Sometimes the surgeon is wrong. Some studies suggest that the appendix is perfectly normal in up to 30 percent of operative cases, although the usual number is less than 10 percent. Mistakes can be made even with the most sophisticated diagnostic tools. But as often as an appendix is removed unnecessarily, the diagnosis is missed until the problem has become far more serious.
And a mistake resulting in surgery for a healthy appendix may even be preferable to inaction because of delayed diagnosis. That was certainly the experience of Marilyn Murray of Chatham, N.J., who arrived at her local hospital emergency room at 6 A.M. one day with abdominal pain so severe she found it difficult to talk. She had some classic signs of an infection: a slightly elevated level of white blood cells and a low-grade fever. But it took 30 hours before doctors decided that Ms. Murray probably had an infected appendix and needed an emergency appendectomy.
By that time, she said, she began to think she might die and told the doctor, ''You have to do something, I am going downhill fast.'' After the surgery, she had to be given three antibiotics intravenously to counter the abdominal infection caused by her perforated appendix. Her recovery was greatly prolonged. An avid exerciser, she estimates that it will take three months before she is able to return fully to her usual activities of cycling and brisk walking.
An Appendix in Trouble
The appendix is, as its name implies, an appendage, a thin, worm-like pouch averaging three and a half inches in length and half an inch in diameter. It extends into the abdomen from the uppermost section of the large bowel, but has no known digestive role in people, although in some animals the appendix aids in processing plant materials that humans cannot digest. And while the appendix contains lymph tissue, suggesting that it was at some point in evolution a part of the immune system, it plays no known role in immune defenses.
Thus, for all intents and purposes, the appendix is a useless appendage that serves only to cause trouble in about 4 of every 1,000 children under 14 and in 1 in 15 adults. The peak age for appendicitis is from 15 to 30. Acute appendicitis is the most common reason for performing abdominal surgery in children and adults. Each year, more than 250,000 Americans undergo an appendectomies.
Appendicitis results when a piece of food or hardened feces blocks the opening of the appendix and prevents it from draining into the bowel. Some experts believe that the rise in appendicitis early in this century resulted from a decline in dietary fiber and consequent increase in constipation. The blocked appendix becomes filled with pus and bacteria, and the resulting infection causes abdominal pain that often starts in the upper-middle abdomen before subsiding and then moving to the lower right side, where the appendix lies.
As the pain of appendicitis, which is made worse by movement, intensifies, other symptoms often develop: loss of appetite, nausea and vomiting, constipation and fever. And when a doctor examines a patient with appendicitis, the lower right abdomen is often tender to the touch.
The problem with diagnosis is that many other abdominal conditions can cause similar symptoms, including bowel diseases like diverticulitis and Crohn's disease, a ruptured ovarian cyst, an infection of a fallopian tube or a ruptured ectopic pregnancy. In Ms. Murray's case, doctors thought at first that she was having gallbladder trouble and they were planning to do gastrointestinal tests before deciding to operate. In the month before her episode of severe pain, she had experienced periodic abdominal symptoms suggestive of gallstones.
Further complicating the diagnosis is the fact that a large minority of patients with appendicitis do not experience the classic symptoms. When the diagnosis is unclear, the doctor may order imaging tests to try to determine the cause of the patient's symptoms. Sometimes the surgeon has no choice but to perform a laparotomy, an internal examination with a scope that is inserted into the abdomen through a tiny incision.
What To Do
Let's start with what not to do. Do not take a laxative when you have abdominal pain or other symptoms suggestive of appendicitis. It could cause an infected appendix to rupture. And do not ignore abdominal cramps and tenderness that you cannot readily explain. This is especially important in children, who may be unable to describe the nature of their pain. When a child has more than a routine bellyache, and especially if the child vomits, has fever or lies with knees bent and is unwilling to straighten them, call the doctor without delay.
Doctors, including pediatricians, often miss a diagnosis of appendicitis in a child the first time around. The wise parent will ask the doctor what checks he or she made to rule out that possibility. This question may prompt the doctor to look more closely and perhaps do further tests before sending the child back home and risking a ruptured appendix. If the doctor is unsure of the diagnosis, overnight hospitalization for close observation may be the wisest course.
Treatment of appendicitis is always surgical, although if there is widespread abdominal infection, surgery may have to be delayed until antibiotics bring the infection under control. In uncomplicated cases, recovery is rapid. Patients return home within a few days and gradually resume normal activities within a few weeks.
Since the decline in complications and deaths from appendicitis that accompanied the advent of antibiotics, there has been little or no further change, largely because of missed or delayed diagnoses. Future improvements are up to both patients and doctors, who must remain alert to the possibility of appendicitis when suggestive symptoms occur.