Appendicitis is many diseases: recent posts on one best method of diagnosing appendicitis ignore something basic, which applies to surgical conditions generally. Here are some varieties of appendicitis which I hope others will recognise. [Level 5 or 6 evidence, i.e. anecdotage in my dotage, where dotage = failing older memory].
- – Classical abdo pain ->RIF, nausea, constipation, mild fever etc.
- – Variations if retrocaecal – masked tenderness, diarrhoea if retro-ileal, like left ureteric colic if inflamed tip of long appendix tickling left ureter [very rare – a case I missed over a weekend].
- – Young man who walks in, looks OK, mild features, gangrenous appx.
- – Appx abscess, mild features, presenting with established abscess
- – Violent pain plus other features, lily-white appendix. You protest to pathologist, and he obligingly finds “early appendicitis”.
- – Incidental appy, done in former years, pathologist reports “inflamed”.
- – Gangrenous appendix, history of milder similar attacks.
- – Normal appendix, history of mildere similar attacks.
This isn’t to try and excuse sloppy thinking or “open slather” but to ask for less dogmatism along the lines of one monolithic condition / one monolithic answer.
You can raise the same arguments about gall-stones, gastric ulcer, etc etc.
With breast cancer the spectrum runs from young woman with aggressive disseminated disease to old lady with Alzheimer’s and fibrotic little cancer which won’t do anything much, or which may surprise you by ulcerating if she survives two years.
But it’s more than one spectrum. It’s several different spectra, or several different axes, which may be quite independent of each other, or “orthogonal” to use part of the jargon of thinking in terms of systems and complexity.
Anyone medical can diagnose and treat the easy case of appendicitis. The difficult case will fool most of us at different times. What we need is some extra rules. One that I am learning is the Time Axis, which includes progress or response to treatment. In practical terms this means reviewing the possible appx case in 4-6 hours, or that evening or the next morning. When to review depends on the personal mental data base you build up over 2 years, 10 years, 30 years and learning of the data base built by others.
Somewhere in a cupboard I’ve got a slim book bought in a sale at a medical bookshop about 30 years ago called “The Seven Varieties of Appendicitis”. I remember one of the varieties proposed was Chronic Dyspepsia. Before others have an apoplectic fit, it’s not something I remember seeing, and I certainly acknowledge the bulldust factor in this area of discussion.