Understanding and Treating Appendicitis

Podcast Transcript

Scott Steele:  Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Hi everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery at Cleveland Clinic in beautiful Cleveland, Ohio. We're very pleased today to have Dr. Diya Alaedeen who is the Section Chief of Surgery at Fairview Hospital in Cleveland Clinic and Assistant Professor of Surgery here at Cleveland Clinic Lerner College Of Medicine. Diya, welcome to Butts & Guts.

Diya Alaedeen: Thank you Dr. Steele. Glad to be here.

Scott Steele:  So we always like to start out with everybody. Just give us a little bit of background. How did it come to the point that you're at the Cleveland Clinic? Where are you from? Where'd you train?

Diya Alaedeen:  So I'm originally Palestinian. I grew up in in Palestine. I came to the United States when I was 17 years old. Went to college, medical school in Indiana, Indiana University. And then I trained at university hospitals for general surgery. And then I decided to go take my talents to Miami Beach and trained in surgical endoscopy. And when I was in Miami I thought I'd never come back and see Cleveland, but came back seven times that year because my in-laws live in town and we decided to be close to them as my wife was pregnant with twins. And I ended up at the Cleveland Clinic at Fairview Hospital for the past 10 years.

Scott Steele:  Well, we're very excited to have you here and today we're going to talk about something that I'm excited to talk about and it's something that a lot of the listeners out there may think they know a lot about, and that's appendicitis. But we're going to get into the details behind this. So give us the high level, the 50,000 foot view first. What is appendicitis? And tell the audience a little bit about what's the appendix?

Diya Alaedeen: So the appendix is an organ that comes right off the base of the cecum of the beginning of the colon, if you're following the bowel, coming from the stomach all the way to the colon. And we don't really understand what the function of the appendix is. Some people think that it is a safe house for good bacteria, so that the appendix continues to harbor that good bacteria. So when you have diarrhea, that's the appendix, will actually release that good bacteria back into the GI tract. But it looks like an earthworm and a lot of people don't understand its function and when it gets infected or inflamed, the best surgical therapy is to remove it so it doesn't fester with infection. Or worse yet, what people worry about is it bursting and causing intra-abdominal sepsis, infection, which can continue to worsen in the patient. And very rare situations back in the past, not anymore, it can lead to death if you have perforated appendicitis that goes unrecognized. But we really don't understand the function of the organ and it's safe to remove it.

Scott Steele:  Yeah, I think it's interesting. So for the listeners out there, appendicitis actually occurs in most people between the ages of 15 and 30. A little bit more common in males than females and the appendectomy, which we'll get into a little bit more, is actually one of the most common reasons that kids have abdominal surgery. About four out of every thousand children under the age of 14 have this procedure. So lots of different reasons to have belly pain. And walk me through a little bit about what are the common symptoms of appendicitis and how do we differentiate kind of the symptoms of appendicitis from that of routine abdominal pain that you might have?

Diya Alaedeen:  So we always joke because we always say the patients don't read the book when they come in. They never present with the classical symptoms. But the textbook present the classical symptoms of appendicitis, the patient starts with feeling anorexia. They feel like have no appetite, loss of appetite, little bit of nausea. The pain starts around the belly button. It starts to migrate in the right lower quadrant, and the pain starts to increase in intensity. It's not a colicky pain, it's a constant pain. It can be accompanied by fever. And then the patients have really severe pain in the right lower quadrant, that they start feeling a rebound tenderness. That means the car ride will start hurting them. The car ride to the emergency room and its focal tenderness where the appendix is in the right lower quadrant.

The nausea and vomiting can come later as the patient starts to worsen. The night sweats and the fevers can continue to happen. But as I mentioned, not everybody reads the textbook. People just come in with pain for a week, not feeling well, malaise. And when we do the work up in the emergency room, we find that they have appendicitis.

Scott Steele:  Diya, that's a lot to take in, and I've got to tell you that just obviously having treated this myself. But if I was just a listener out there, I'd be like, wow, how do they situate that all out to say, is this something that I'm worried about? Should I go to the emergency department to be evaluated for this? Or how do you situate out the routine type bowel problems that may just go away on their own from that, which is more concerning to get to the point where it won't burst?

Diya Alaedeen:  Great question. So if the pain does not resolve on its own and the pain continues to increase in intensity and the patient is having anorexia, is not resolving, we can start thinking this is a GI issue. Some people can have kidney stones that have pain that increase in intensity. The difference is kidney stones, there's colicky pain, it comes and goes. It comes in cramps. The patient is often hungry. It doesn't affiliate with their GI symptoms, so they're able to eat. They're able to keep their food down. They might have some nausea from the pain, but it's different than appendicitis pain. The patients don't want to see food, they don't want to approach food and the pain increasing its intensity, doesn't go away. It's not a pain that comes and goes.

Scott Steele:  So it's pretty scary to go to the emergency department. So walk me through, if I'm a patient and I'm about to go to the ER for the first time, what type of things can they expect to experience for a fear of appendicitis? Not necessarily, they may have it. Walk us through that process.

Diya Alaedeen:  So I get, often calls from family or friends and saying I'm having abdominal pain. It is in the right lower quadrant, is this appendicitis? How can I find out? And in fact, my brother in law had that just a few weeks ago. So when you go to emergency room, you're going to see the triage nurse who's going to take your chief complaint and evaluate you and get your vital signs. And if you have a fever, you're going to be expedited to get into their emergency room to be seen by a physician, you're going to have an IV placed. Most of patients are dehydrated because they're having vomiting and nausea. An IV placed to start the IV fluids and eventually you might need IV antibiotics to get started. The workup in the United States is basically most of the patients will have been evaluated by the emergency room physician or physician assistant.

And if they have clinical signs and symptoms of appendicitis, which what we mentioned, the right lower quadrant pain, the fever, the nausea. Most patients will eventually, if they're a candidate, they proceed to the CT scan. Unfortunately in the United States we over-utilize the CT scan than other countries. Sometimes the diagnosis can be very easily made just with clinical signs and symptoms. But the CT scan has very high sensitivity and specificity. That means it's sensitive to the disease and specific to the disease. And when the CT scan finds signs and symptoms of appendicitis, usually the surgical consultation is sought and that's when we get involved and see the patient. Usually in our practice we try to get the patient in the operating room within the first 12 hours. It is a misnomer. They think that if they don't get to the operating room, that appendix is going to burst, it's actually less than 10% of appendicitis burst and it doesn't have really to do with the severity of illness or waiting for a long time.

We now know from different studies that the appendix burst in different people based on the bacteria that is in the appendix for that person. So it's not really a matter of waiting a long time. We've had patients that have come to see us months after they've had pain that they sat on. We call it chronic appendicitis. So not everybody with a diagnosis of appendicitis will have a burst appendix if they wait longer. As I mentioned, we get them into the operating room. Usually the operation is done laparoscopically and usually the hospitals stay after the procedure is less than 12 hours. If the appendix is not perforated, there's no abscess. It's a common appendectomy. We tend to discharge them shortly after the appendix is removed. They take one or two doses of antibiotics and usually the patient have a quick relief and they go back to work pretty quickly.

Scott Steele:  Let's dive in the details of the appendix operation a little bit. So you mentioned laparoscopy versus open. Can you comment on each of those and again, what is involved in the actual operation itself?

Diya Alaedeen:  So traditionally before the advent of laparoscopy, which is the early 2000s or late 1990s, the open operation was a small incision in the right lower quadrant at what, classically surgically known as McBurney's point. It's a muscle splitting operation. We don't cut the muscle, we split the muscle to get into the abdomen, reach the appendix and then ligate the appendix from its root at the base of the cecum and remove the appendix that way. With laparoscopy, we could do that through very small incisions, the biggest incision's about an inch at the belly button. The other incisions are about quarter of an inch and we use probably three incisions. It's done with small incisions so that we can remove the appendix that way and patients recover much faster.

In open surgery, which is still done in most of the world, especially the second world and third world countries, the incidents of complications from removing the appendix in the open technique are very small. And it's usually about 6% infection rate at the incision site. That translates to less than 3% the use of laparoscopy. So laparoscopy, if you think about it, 3%, 6%, is small numbers, but we're getting 50% reduction of infection at the incision by doing it laparoscopically. The laparoscope involves the patient has to go under general anesthesia. In open surgery, we can do it under local. We would be hard pressed to do it under local because we don't want the patient to participate in the operation.

But it can be done in the open and laparoscopic cannot be done under local because the patient's abdomen get insufflated with carbon dioxide and the abdomen is insufflated like a big box. And those patients are not able to maintain deep breathing if it's done without general anesthesia. So the patients are usually paralyzed under general anesthesia for laparoscopy. So in patients who cannot undergo laparoscopy, open appendectomy is an option. Also in pregnant women in late trimester, third trimester, sometimes it's difficult to maneuver the laparoscope in an abdomen that's gravid with a big uterus, we opt to do these open appendectomies.

Scott Steele:  So you mentioned a couple of terms that I want to get a little bit more information about. One of them is to be perforated and develop an abscess. So what is an abscess, and how might that change the treatment option for somebody with appendicitis?

Diya Alaedeen:  So if the patient presents and they already have developed an infection outside the appendix and they have now an abscess close to the cecum or the base of the cecum where the appendix lies. Those patients, a lot of times they have a focal infection that contains pus. In those patients, there might be a chronic inflammation. That means an inflammation that made the entire area inflamed and difficult to dissect through to remove the appendix. Those patients we routinely, we treat with draining the abscess and with IV antibiotics and we wait until the abscess is healed and the antibiotics has taken effect. The patient's better. We do something called interval appendectomy where we remove the appendix at a later date. The reason is if you try to operate early, while the appendix is very inflamed and there's an abscess and there's a lot of inflammation in the area, the patient may suffer from a consequence of removing too much. Like removing the base of the cecum or removing the ilium or we might have to remove the right colon and not be able to put them together.

And there's been reports definitely of patients having that operation end up with an ileostomy, which is most, patient fear more than anything, end up with a bag until things heal and put them back together. So in patients with a chronic infection, it's called a phlegmon. Phlegmon is an abscess that kind of resolved but now it's all a lot of scar tissue or chronic inflammation, a lot of scar tissue. Also, those patients may benefit from having an antibiotic therapy until the phlegmon resolves and then have an interval appendectomy at a later date. So not everybody with a diagnosis of appendicitis mandate an acute going to the operating room and getting their appendix removed.

Scott Steele:  Yeah, and exactly like you said, the chances of somebody needing that larger operation. And even needing a bag at all is very, very rare of happening. So let's play a little bit of myth or reality. First one, appendicitis can be prevented.

Diya Alaedeen:  Myth.

Scott Steele:  And myth or reality? Surgery is always needed for appendicitis.

Diya Alaedeen:  Myth.

Scott Steele:  And tell us a little bit more about that.

Diya Alaedeen:  So we know this from people like you, Dr. Steele who've been in the Navy and we know that people in the Navy back in the old days when they had appendicitis and they were treated with antibiotics and did just fine. And to validate that, the Europeans just did a few studies in the past few years where they actually treated patients with non-complicated, acute appendicitis. Non complicated means there's no abscess, no phlegman, no signs of sepsis. Those patients that presented with appendicitis that was non-complicated without any signs of hemodynamic compromise, they were treated with antibiotics and did just fine. We don't tend to do that in the United States because we know from those studies that about 40% of patients still came back and had their appendix removed in one year, after they were treated with antibiotics. But of course if the patient is not a candidate for surgery, they're on blood thinners, they don't have a good heart to undergo the surgery or other contra indications to surgery, antibiotics is a good option. So surgery is not always indicated for acute appendicitis.

Scott Steele:  And for full disclosure, as a West Point grad, I have to say I was in the army, go army, beat Navy.

Diya Alaedeen:  There you go.

Scott Steele:  So last one. So appendicitis is cancer? Myth or reality.

Diya Alaedeen:  Appendicitis is not cancer.

Scott Steele:  Yeah, I think that's critically important that everybody understands out there that this is an inflammatory condition and not associated with malignancy.

Diya Alaedeen:  Correct.

Scott Steele:  So if I do undergo surgery and I'm a patient out there listening or this happens to me, what is the recovery time and kind of what does that recovery entail? Let's say they're able to do it laparoscopically. Like most of them are in the U.S.

Diya Alaedeen:  Most patients are able to leave the hospital within hours of removing their appendix if they have uncomplicated appendicitis, most patients are able to go back to work within a few days, two or three days. Some patients need longer time. Everybody's recovery is different, but no more than a week. We usually put the constraints of no heavy lifting just because we don't want the incisions to rip open and the patient get a hernia per se. But they're really not going to hurt anything on the inside.

Most patients take about 24, 48 hours to recover from their anorexia and get their appetite back. Some patients that wait longer may need longer time recovery as the body recovers from the dehydration, of the nausea and vomiting. But as I mentioned, most patients are able to return back to work and activity within a few days after a laparoscopic appendectomy.

Scott Steele:  So we'd like to end up all of our podcasts with a couple of quick hitters for our guests. So first of all, what's your favorite sport?

Diya Alaedeen:  I watch basketball. I watch the Cavaliers quite a bit.

Scott Steele:  Go Cavs. What's your favorite meal?

Diya Alaedeen: My favorite meal. So there is a traditional Middle Eastern meal, which is rice and lamb meat and cauliflower.

Scott Steele:  Sounds delicious. And what's the favorite trip or place that you've been to?

Diya Alaedeen:  Sedona in Arizona, definitely one of the favorite.

Scott Steele:  Very, very beautiful. What's the last nonmedical book that you've read?

Diya Alaedeen:  I actually was on the plane reading, How To Give A Ted Talk, which practicing giving talks, medical or nonmedical but giving like a Ted Talk.

Scott Steele:  And tell the listeners something that you like about Cleveland.

Diya Alaedeen:  Cleveland diversity is actually astonishing and is great. It's actually not labeled as much, but there's a lot of diversity in Cleveland and the multiculturalism in Cleveland is great.

Scott Steele:  So that's wonderful stuff. So final take home messages you have regarding appendicitis for our listeners.

Diya Alaedeen:  Don't be scared of it. If you do have right lower quadrant pain and it continues to progress and it gets worse and you have a fever, anorexia, fear of food, go to your nearest emergency room. If it is appendicitis, most board certified surgeons in the United States will be able to handle it, this disease process. Get you out pretty quickly. The longer you wait, the worse things can be and you don't want to wait, but it's nothing to be worried about. It is not cancer. It's an inflammatory process, and you do not need your appendix, so it can be easily removed.

Scott Steele:  So for more information on appendicitis, please visit Cleveland Clinic’s Health Library at clevelandclinic.org/health. That's clevelandclinic.org/health. H-E-A-L-T-H. And to speak with a specialist in the Digestive Disease And Surgery Institute, please call (216) 444-7000. That's (216) 444-7000.

Diya thanks for joining us on Butts & Guts.

Diya Alaedeen: Thank you Dr. Steele. Pleasure.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.