Appendicitis and TEOTWAWKI, by Cynthia J. Koelker, MD

Thursday, Mar 14, 2013

When considering the question of appendicitis at TEOTWAWKI the most important questions are these:
1.     What is the cause?
2.     How can it be recognized?
3.     Who is most at risk?
4.     Is it always fatal?
5.     Can it be treated non-surgically?
6.     Should it be removed before TEOTWAWKI?
Appendicitis is caused by a blockage of the appendix, which varies according to age.  In children and young adults this is usually due to infection.  In the elderly it is usually due to hardened feces.  In developing countries appendicitis may be caused by parasites.  In people with an inflamed bowel it can be due to swollen lymphoid tissue, which can also occur with stomach flu, viral respiratory infections, measles, or mononucleosis.
Once the blockage has occurred, the appendix swells due to continued production and trapping of secretions, causing the appendix to enlarge like a water balloon until it bursts, spewing the contents into the abdomen (peritoneal cavity), leading to sepsis (overwhelming infection), and death.  The inflammation also draws white blood cells to the area, which produces pus and additional pressure.
Also, once the pressure within the appendix rises too high, this acts like a tourniquet, cutting off the circulation to the appendix.  This injures the lining of the appendix, which allows infection to invade the wall of the appendix, and may lead to gangrene of the appendix and/or perforation (a hole in, or bursting of, the appendix). 

What symptoms does this lead to?  As S.M.G. describes, the classic history is one of loss of appetite associated with pain around the navel, followed by nausea and right lower abdominal pain.  Unfortunately, no single symptom or test is completely accurate in diagnosing appendicitis.  Only 50% of patients have vomiting.  Because the location of the appendix varies, the location of the pain may vary.  Even with modern medicine, 20% of cases of appendicitis are misdiagnosed as something else.  Though surgeons hope to be 100% accurate, even now up to 40% of patients who undergo emergency appendectomy are found to have a normal appendix.  When someone claims that they have cured appendicitis at the painful and nauseous state by administering a purgative, I question the accuracy of the diagnosis.

The classic signs described above occur only half the time in true appendicitis (diagnosed with surgery and pathological examination of the appendix).  Nausea and loss of appetite occur most but not all the time, and at the same rate that occur with other causes of abdominal pain. Vomiting that follows onset of pain is more typical of appendicitis than vomiting that precedes abdominal pain.  Diarrhea or constipation may occur with appendicitis, and the diagnosis of either as a cause for abdominal pain does not rule out appendicitis.

Abdominal pain is the most consistent symptom of appendicitis.  The migration of the pain from one location to another increases the likelihood of a correct diagnosis of appendicitis.  Fever is not usually present early on.  Appendicitis can be confused with bladder infection, kidney stones, endometriosis, ovarian cysts, diverticulitis, gallbladder disease, intestinal virus or other infection, or duodenal ulcers.   
If this is the case now, what will it be at TEOTWAWKI?  Will diagnostic accuracy improve in a scenario without blood testing or internal imaging (CAT scans, MRI, ultrasounds).  Not likely.   No doubt cases of appendicitis will not be diagnosed as such, possibly leading to fatality.  Other causes of abdominal pain will be mistaken as appendicitis, sometimes leading to treatments being mistaken as cures.

Since a person can live a completely normal life without an appendix, should it then be removed to prevent a life-threatening emergency at TEOTWAWKI?  The current incidence of appendicitis in the U.S. is about 1 per 1,000 people per year, with a 7% lifetime risk.  (This is less than the incidence of breast cancer.  Should women have prophylactic mastectomies before TEOTWAWKI as well?  Just a thought.)  No doctor is likely to perform such a surgery unless you have a documented genetic predisposition to appendicitis (and insurance is not likely to pay either). 
The incidence of appendicitis is less in undeveloped countries where the intake of dietary fiber is much higher, and is actually decreasing in developed countries where dietary intake of fiber has increased.  Dietary fiber draws water into the stool, making feces softer and less likely to form fecaliths (stone-like feces) which may obstruct the bowel or appendix.

The best answer for prevention of appendicitis is a high fiber diet, high enough to keep the stools on the softer side.  A bowel movement that has the consistency of a soft banana is about right.      

Without treatment is appendicitis always fatal?  The standard answer is “yes,” though the truth is “not always.”  If an obstruction is relieved, the inflammation may resolve without treatment.  I have seen a few cases of recurrent appendicitis which were not recognized as such until the appendix was eventually removed.  At times the body will wall off the infection resulting in a local abscess which prevents bacteria from entering the blood stream.    
Can antibiotics help?  An interesting study by Eriksson (BR J Surg. 1995; 82(2):166-9) compared antibiotic therapy alone to surgery.  Their conclusion was that IV antibiotic treatment (followed by oral antibiotics) was as effective for acute appendicitis as was surgery, though 7 of 20 patients who took antibiotic therapy alone had recurrent symptoms within a year (and underwent subsequent appendectomy).

Can appendicitis be treated with oral antibiotics alone?  While I have never tried this, if surgery were not an option, I would treat acute appendicitis much as I have treated acute diverticulitis, a fairly common illness in the middle-aged and elderly.  For diverticulitis I commonly prescribe either ciprofloxacin plus metronidazole, or Levaquin plus metronidazole.  Other possibilities might be amoxicillin-clavulanate plus metronidazole or trimethoprim-sulfamethoxazole plus metronidazole.  It generally takes two antibiotics used in combination to kill intestinal bacteria (aerobic and anaerobic bacteria).   
If you believe you or your loved one is suffering from appendicitis, go to the nearest emergency room.  However, at TEOTWAWKI, if no surgeon is available, administering the above antibiotics may be life-saving.  It will not cure everyone, and the likelihood of recurrence is high.  Still, it is a much better answer than doing nothing at all, and gives the patient at least a fighting chance of survival. 

About the Author: Dr. Cynthia J. Koelker is SurvivalBlog's Medical Editor. Her web site is: www.ArmageddonMedicine.net 


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