Are Your Sure Its Appendix Doc?

 Acute Appendicitis is perhaps one of the commonest surgical conditions that present to any busy Emergency Dept. that open a 24-Hr services anywhere in the world.

Most patients are easily suspected from the history of the pain and the typical physical findings. Doctors then will perform some tests to support this suspected diagnosis in order to embark on definitive treatment namely Appendectomy(removal of appendix).

Quite often patients will pose a really good question to the Surgeons;..Doc, are you sure its Appendix? After operating on so many similar cases before, the most likely answer from the surgeons would be "most probably its appendix". That means you are not so sure?

This typical surgeon-patient conversation is so typical when a diagnosis of Appendicitis is made and the consent for Appendectomy is required.

The surgeon's little doubt is not without reason. The clinical pattern of many other possible conditions may mimic Acute Appendicitis especially in female patients. The many pelvic organs like the right ovary, right fallopian tube, right side of the uterus may give rise to many disease states that may present much like Appendicitis. Any experienced surgeon would have come across unsuspected normal pregnancy and the ectopic ones after ultrasonography of patients with a suspected diagnosis of Appendicitis. Very seldom ultrasound will make a positive diagnosis especially in early appendicitis when the appendicular swelling is minimal.

In fact, thats exactly the main purpose of ultrasound in patients with suspected appendicitis, that is to rule out other diagnoses. In philosophical terms, applying the falsifications principle of Karl Popper in sustaining a theory is to falsify the theory. If the theory stands up to the falsification test, then the theory survives. Many surgeons apply this philosophical of science principle without even realising it. Many patients find difficult to grasp that the test(namely the ultrasound) is done for a negative purpose.

This philosophical mismatch between the surgeon and the patient explains the scepticism of both in managing Appendicitis.

Despite these doubts on both parties, consent from patients are usually obtained and the final diganosis of Appendicitis turn out to be correct at operation.

Based in this empirical and historical experience, many surgeons would remove the patient's doubt by quoting the previous similar successful cases.

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Why Patients With Haemorrhoids Bleed in Their Stools

The above picture shows a view of the lower rectum at colonoscopy. It is obvious the prominent dilated veins in the wall of the rectum. These veins are bigger than usual and appears greenish-blue in colour. Dilated vascular systems always carry more blood flow than otherwise.

Patients with haemorrhoids that present with rectal bleeding always have these dilated veins in the lower rectal walls. These dilated blood vessels may rupture especially during bowel motion due to sudden increase in pressure within the blood vessels. Bleeding tend to be self-limiting due to minute rupture and the vessels will get clotted by itself quite easily.

Why these dilated blood vessels occur in the first place in patients that suffer common haemorrhoids is not well understood. It may be related to the stagnation of blood flow due to persistent intraabdominal pressure preventing normal blood flow out off the rectal wall area. These may explain the frequent occurence of common haemorrhoids in patients that always constipate and in pregnant ladies.

One unique medical condition that give rise to the dilated veins above is the varicose veins of the recto-anal region due to the new blood vessels connections between the systemic blood vessels of the anal region with the portal blood vessels of the lower rectum. This condition usually occur in patients with chronic liver disease and cirrhosis. Varicose veins in the recto-anal region is less common than the varicose veins(varices) in the oesophago-gastric region which presents with vomiting of blood.

The Pandemic Endoscopist

During this Coronavirus Pandemic, we the Gastrointestinal Endoscopist were advised to strictly select our patients indicated for endoscopy. For mild symptoms we will treat the patients symptoms first with a clinically presumed diagnosis without confirming by endoscopy. Only patients who do not respond to the initial medications or patients with severe symptoms suggesting the possibility of serious diagnosis like Ulcer or Cancer, only then immediate endoscopy is indicated.

Some patients will have to be done without knowing their Coronavirus status. For these patients, we will gear up with our protective shield and garments as shown in the above pictures.

All the endoscoped patients will be tested for coronavirus status at some stage of their hospitalisation. So far I have been lucky. None of my endoscoped patients turn out to be positive for coronavirus infection.