Most students learn each topic as it is laid out in the textbooks. However,
in real life a patient does not present saying ‘I have acute appendicitis’,
and neither does he always present with the classical textbook description.
Instead, most patients tend to present with a variety of vague symptoms
and signs that do not point to any specific diagnosis. The acute abdomen
is the best topic for highlighting this fact, because a patient who presents
with epigastric pain and vomiting could be having pancreatitis, cholecys-
titis, a perforated peptic ulcer or just gastritis, and it may not be possible
to differentiate on the history alone. The examination and simple investi-
gations add further clues to help make a diagnosis, but still it may not be
possible to make an absolute diagnosis initially and management may
consist of simple treatment such as resuscitation, analgesia and a period
of observation whilst further investigations are performed. In other cases,
although a specific diagnosis is not made, exploratory laparotomy may be
needed (i.e. in cases of generalised peritonitis).
As a student, making the wrong diagnosis is not that important,
because there will always be a doctor available to correct you. As a doctor,
however, you need to ask yourself ‘What if I am wrong?’ with each deci-
sion made. Performing an appendicectomy on a patient with mesentericadenitis is
unlikely to be life-threatening; on the other hand, if you make a
diagnosis of acute appendicitis in a female with right-sided pain without
first performing a pregnancy test, then the surgeon may be left with an
appendicectomy incision to deal with an ectopic pregnancy. For example,
let us say a 14-year-old girl presents with right iliac fossa pain and nausea.
The possible causes of this are appendicitis, mesenteric adenitis, a UTI, an
ectopic pregnancy or any other gynaecological problem, or even just wind.
You should, therefore, ask not only the pertinent questions that point to a specific
diagnosis but also the questions that will rule out the other diagnoses. Thus, note the
menstrual history and the history of the pain; for example, the pain of appendicitis
usually starts centrally and moves to the right side after a few hours, whereas a torsion
of an ovarian cyst gives a sudden onset of right iliac fossa pain. A UTI usually has
associated urinary symptoms (frequency, dysuria and urgency).
Next, you derive further clues from the examination, looking for
localised right iliac fossa tenderness or peritonism. Further clues are again
derived from the simple investigations. A pregnancy test and urine dipstix
and urgent microscopy must be performed to rule out an infection. A sim-
ple blood test such as a white cell count may help (although it is not that
specific), and plain X-rays may give further clues (although not that help-
ful in this case, they would be if renal stones or bowel obstruction were on
the differential).
At this point you may have narrowed the differential down to appendicitis,
mesenteric adenitis or a gynaecological problem, but you still may not be exactly
sure which it is. It is safe then to admit the patient, start IV fluids and carefully
observe her with repeated examinations. If the pain and tenderness appear to settle,
no further treatment may be necessary.
However, if they persist, then it may be necessary to investigate the
patient further. An ultrasound can be helpful, as it can visualise the
ovaries and look for any free fluid. It may even show up an enlarged
appendix. In this situation an ultrasound is very sensitive although not
that specific, and even if it shows no abormality it does not rule out
appendicitis. Another option is to perform a diagnostic laparoscopy
where the organs are visualised directly via a laparascope. If the appen-
dix is inflamed it could be removed laparascopically (if the surgeon has
enough experience) or conversion to an open procedure can take
place. In a male with the same history, symptoms and signs there is
not much else it can be apart from appendicitis and mesenteric adenitis,
and if the pain did not settle after a period of observation many surgeons
would agree that an appendicectomy was indicated without any further
investigation.
ليست هناك تعليقات:
إرسال تعليق