DIAGNOSIS OF ACUTE
APPENDICITIS IN THE TROPICS
LIEUT. COL. CARL P. SCHLICKE AND CAPT.
SAMUEL B. HARPER
Medical Corps, Army of the United States
HE onset of a number of diseases indigenous to the tropics is associated with abdomina1 signs and symptoms necessitating carefuI exchision of acute appendicitis. For the surgeon whose judgment and experience as weII as training are the product of a temperate cIimate the diagnosis of acute appendicitis under these circumstances presents a rea1 chahenge. In a recent articIe Ravdin and WoIfr brought attention to the simuItaneous occurrence of appendicitis and maIaria as we11 as the diffrcuIty encountered in interpreting abdomina1 signs and symptoms in patients with maIaria and receiving antimaIaria1 medication. Howe2 has admirabIy discussed the probIem in regard to amebiasis in his paper on the surgical aspect of intestina1 amebiasis. During the past two years on the surgica1 service of a hospita1 operating in New Guinea and Luzon, P.I., we have encountered simiIar diagnostic difficuIties in other tropica diseases as weI1. WhiIe not excIusiveIy confined to the tropics amebiasis is highIy endemic in the PhiIippines. In the majority of cases encountered the possibiIity of appendicitis is not suggested aIthough in cases with cramping abdomina1 pain, sIight nausea and Iower abdomina1 tenderness without diarrhea appendicitis must be excIuded.
quentIy deveIoped a Iow grade hepatitis which proIonged convalescence for severa weeks.
RecentIy a white maIe soIdier was admitted compIaining of nausea and Iower right quadrant abdomina1 pain of twelve hours’ duration. He had previousIy been in good health with no gastrointestinal compIaints except for an attack two weeks previousIy of what he referred to as the “G.I.‘s,” an army term excIusiveIy, which proved to be a bout of otherwise asymptomatic diarrhea which subsided compIeteIy in twentyfour hours. On examination significant findings were confined to marked Iower right quadrant tenderness, rebound tenderness and muscIe spasm. On recta1 examination tenderness high
The expIanation for the symptoms simuIating appendicitis is not hard to find. In amebiasis the coIon and occasionaIIy the termina1 ileum is invaded by the trophozoites of endomoeba histoIytica. In some cases the cecum or, as noted above, even the appendix may be the site of the initia1 invoIvement. The primary Iesion is a submucosa1 abscess which may go on to mucosa1 uIceration, thickening of the bowel waI1 and inffammation of the serosa.3 In acute amebic typhihtis diarrhea may be
on the right side of the peIvis was noted. A tota Ieukocyte count of 16,500 with 82 per cent granuIocytes and 18 per cent Iymphocytes contributed to the provisiona diagnosis of acute appendicitis. When the appendix was exposed and found to be norma in appearance the cecum was examined. The onIy Iesion found
was a granuIar appearing, hemorrhagic, acutely inffamed area 235 cm. in diameter and sharply circumscribed on the IateraI serosa1 surface of the cecum. The appendix was not removed and
postoperativeIy active therapy for amebiasis was started. It was not until severa weeks foIIowing operation that the diagnosis of amebiasis couId be confirmed by the finding of endomoeba histoIytica in the stool. Operation, in this instance, apparentIy did not alter the course of the disease. Another case presented a simiIar syndrome of nausea, vomiting, and abdomina1 pain of sudden onset. Right Iower abdomina1 tenderness, muscIe spasm, tenderness on recta1 examination and Ieukocytosis were found. The patient had had no history of diarrhea or other recent gastrointestina1 symptoms. At operation a characteristic acute inff ammatory process involving distance
the appendix and the cecum for a of about 3 cm. from the base of the
appendix was found. In this instance the appendix was removed because perforation appeared IikeIy. AIthough active therapy for amebiasis was administered the patient subse-
absent and the syndrome produced by such a IocaIized Iesion may be differentiated with diffIcuIty from appendicitis due to other causes. FortunateIy, in most cases diarrhea or more generalized findings are present. Trophozoites or amebic cysts may be found in the stoo1 and when the rectum or sigmoid is invoIved characteristic proctoscopic findings are present. “Dengue is an acute infectious disease caused by a fiIterabIe virus and transmitted to man by species of aedes mosquitoes.“4 Dengue and a Iarge group of dengue-Iike fevers are endemic in the tropica isIands of the Pacific. GeneraIIy, the diagnosis is easiIy made from the acute onset of the characteristic post-orbita pain, genera1 maIaise, joint pains and fever followed shortIy by a morbiIIiform rash. Leukopenia is an outstanding finding and is heIpfu1 in making a diagnosis. OccasionaIIy miId or atypica1 cases of dengue are encountered in which the onset and subsequent course of the disease Iacks many of the diagnostic features. MiId abdomina1 soreness and tenderness associated with sIight nausea frequentIy accompany the disease. SeveraI patients with dengue in which abdomina1 soreness was the outstanding initia1 feature have been admitted to the surgica1 service. From these patients a history of onset severa hours previousIy of sIight genera1 malaise, nausea, occasiona vomiting and pain in the Iower abdomen was obtained. In two instances tenderness and voluntary spasm in the right Iower quadrant of the abdomen was of sufficient prominence to direct attention to the possibiIity of subacute appendicitis. In one instance rightsided tenderness on recta1 examination was noted. In the absence of other signs the low initia1 Ieukocyte count with a reIative Iymphocytosis Ied us to defer operation. The onset severa hours Iater of fever, generaIized aching, severe headache and a few days Iater of a characteristic rash confirmed the diagnosis of dengue. AIthough IittIe is known of the pathoIogy of uncompIicated dengue, a few petechia1 hemorrhages in the gastrointestina1 tract
and enIargement of the interna Iymph nodes are mentioned by Stitt” as having been noted by other authors. Such findings couId account for the signs noted in the cases mentioned. AncyIostomiasis is widespread in the PhiIippines where it is usuaIIy due to infection by the heIrninth necator americanus. Considering the pathogenesis of the infection it can be expected that penetration of the mucosa of the smaI1 intestine by the worms wiI1 produce gastrointestinal disturbances. In patients encountered among the native popuIation a recrudescence of hookworm infestation with abdomina1 pain and tenderness associated with nausea and vomiting has at times been confusing. The frequent necessity of obtaining a history through a Iay interpreter coupIed with a firm conviction on the part of the patient that he has appendicitis further compIicates making a diagnosis. In spite of the fact that the duodenum and jejunumfi are the site of the heaviest infection a number of instances have been encountered showing Iower right-sided abdominal pain and tenderness with associated nausea. In such cases with a normal white count and reIative eosinophiIia operation has been deferred. The subsequent benign course of the disease and the finding of a hookworm ova in the stool have justified conservative therapy. The Iarge nematodes, including ascuris lumbricoides, oxyuris vermiculuris and tricburis trichuriu, are frequentIy found in the Iumen of appendices removed in the tropics. In some cases acute appendicitis occurs as the direct resuIt of their presence in the appendix. We have had two cases of acute suppurative appendicitis, one secondary to obstruction of Iumen by a Iarge ascaris worm, and the other due to the presence of a Iarge number of oxyuris vermicularis. The mere presence of these worms in the bowe1 may give rise to il1 defined abdominal symptoms which may be confused with appendicitis, but rather easiIy differentiated by examination of the stool for ova or However, worms. when the appendix
American Journal of Surgery
becomes obstructed or inflamed by these worms the resuIting syndrome is not to be differentiated from appendicitis secondary to other causes. In the tropics the constant presence of baciIIary dysentery and multipIe types of gastroenteritis is a cause of considerabIe concern to the conscientious medica offscer. OccasionaIIy the onset of diarrhea may direct attention away from the possibiIity of appendicitis onIy to have the persistence of symptoms and signs in the region of the appendix Iead to operation. More often than not it wiI1 be found that the enteritis in the adjacent smaI1 bowe1 was responsibIe for the symptoms. However, a very acuteIy inflamed appendix was recentIy removed from a patient with an acute baciIIary dystentery (ShigeIIa paradysenteriae). Another patient was admitted with vomiting and diarrhea which had come on foIIowing a drinking bout. He ran a high fever, and passed fifteen to twenty bIood-tinged stooIs daiIy. There was moderate Ieukocytosis. Treatment with suIfadiazine brought about IittIe improvement in what was thought to be severe enterocoIitis. Proctoscopic examination reveaIed onIy diffuse mucosa1 reddening. StooI examinations were not remarkabIe except for the presence of bIood and pus. Ten days Iater a Iarge Ieft Iower quadrant abscess was drained which subsequentIy was demonstrated to have been due to a ruptured appendix. It is stated that the picture of subacute appendicitis occasionaIIy deveIops in cases of schistosomiasis japonica.7 In the earIy stages of the disease when the mature worms reach the intestina1 tract and the femaIes deposit eggs in the vesseIs of the
intestina1 waI1, abdomina1 pain may be experienced. However, a history of exposure, the occurrence of fever, chiIIs, urticaria, cough, generaIized aching, Ieukocytosis with eosinophiIia and the presence of ova in the stooIs shouId Iead to the correct diagnosis. Schistosomiasis is not endemic on Luzon and we have had no direct experience with the disease in its acute phase. SUMMARY
The presence of a number of tropica1 diseases new to the temperate cIimate surgeon stimuIates interest in the differentia1 diagnosis of appendicitis which too often is somewhat perfunctoriIy made. However, the principIes of surgica1 judgment are no different in the tropics than any other pIace. The surgeon must famiIiarize himseIf with and aIso be prepared to recognize tropica disease which may simuIate appendicitis. REFERENCES I. RAVDIN, I. S. and NORTH, JOHN P. The occurrence of acute appendicitis Ann. Surg., 122: 432-43>1 1945. 2. HOWE, PHILIP. The surgical aspect amebiasis. Surg., Gynec. ti Obst.,
simultaneous and malaria. of intestinal 81: 387-404,
1945. War Department TechnicaI Bulletin 3, Amebiasis. (TB Med 1591, PP. 1-8, May, 1945. 4. Dengue. Bull. U.S. Army M. Dept., 4: 300-301, . 1945. 5. STRONG, RICHARD P. Stitt’s Prevention and Treatment of Tropical Diseases. 6th ed., vol. 2, pp. 872-1742. PhiIadeIphia, 1941. The Blakiston Co. 6. Memoranda on Medical Diseases in Tropical and Subtropica Areas. P. 305. London, 1942. His Majesty’s Stationery Ofice. 7. Schistosomiasis japonica. War Department Technica1 BuIIetin, (TB Med 167), pp. I-IO, June, 1945.