Acute appendicitis and homeopathy

Dr Priya

ABSTRACT
From the early days onwards, the timeliness of diagnosis was considered to be critical to reducing mortality rates related to appendicitis. This condition demands immediate attention and treatment. Approximately 90% cases are admitted to general surgical units urgently. It may be caused by an infection, inflammation, vascular occlusion or obstruction. Homoeopathic medicines can manage successfully this condition without surgery. Homoeopathic medicines prevent the recurrence of appendicitis.

KEYWORDS – Appendicitis, homoeopathy

INTRODUCTION
The abdomen is a large cavity in the body, encloses in the abdominal cavity and it is situated between thorax (chest) and pelvis. Appendix is the organ which is present in the abdomen. The word appendicitis derived from Latin word appendix and itis, and it means inflammation of the appendix. In 1540s appendix is describe as an elongated outgrowth of an internal organ .In the year of 1759, Appendicitis was first described  by Metiever, and it was termed perityphlitis, typhlitis, paratyphlitis, or extra-peritoneal abscess of the right iliac fossa. From the early 20th century onwards, appendicitis occur due to the secretion of fluids causes obstruction in the appendix. The cause of acute appendicitis is unknown. The causes of abdominal pain are acute appendicitis, acute cholecystitis, acute pancreatitis, bowel obstruction, perforated peptic ulcer, etc. Acute appendicitis is a most common cause of abdominal pain worldwide. Acute appendicitis is a common cause of abdominal pain in paediatrics and adult age groups.

EPIDEMIOLOGY
Appendicitis is one of the commonest acute conditions manifesting as pain abdomen in the Emergency room. The life time rate for appendicectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendicectomy in their lifetime. Both sexes are affected, with a slight male to female predominance about 3:1.

PATHOGENESIS
Appendicitis begins due to obstruction of the lumen due to various causes as mentioned above. This leads to a closed loop obstruction. As there is continued mucosal secretion from the obstructed part, this leads to increased and rapid distension of the appendix. The distension stimulates the visceral afferent nerve fibres, and is responsible for the vague/diffuse pain in the periumbilical region. It become more distended  due to rapid multiplication of bacteria. This causes reflex nausea and vomiting. Due to the distension, there is capillary and venous occlusion, and due to involvement of the serosa and parietal peritoneum, pain migrates to right iliac fossa. On further arterial occlusion, there is increased bacterial invasion, which leads to peritonitis and manifests as fever, tachycardia and leucocytosis. The greater omentum attempts to limit the peritonitis by localizing the spread of peritoneal infection, and hence is known as the abdominal policeman.

SIMPLE APPENDICITIS	COMPLICATED APPENDICITIS
Inflamed appendix, in the absence of gangrene, perforation, or abscess around the appendix	Perforated or gangrenous appendicitis or the presence of peri-appendicular abscess

TYPES OF ACUTE APPENDICITIS

NON-OBSTRUCTIVE ACUTE APPENDICITIS – The process of inflammation usually begins in the mucosa, sometimes in the lymphatic follicles. Once infection reaches the submucosa, it progresses rapidly. The organ turns red, inflamed and haemorrhage into the mucous membrane. If left untreated, the tip may become gangrenous, because at this part the artery is intramural and is more prone to occlusion by inflammation or thrombosis. But in non-obstructive appendicitis per se, progress is slower, allowing time for the omentum to form a protective barrier and localize the peritonitis. In most of the cases, infection does not even cross the mucosal layer (i.e. catarrhal inflammation). Inflammed appendix terminates in any of the following ways – Ulceration, Suppuration, Fibrosis, Gangrene or Resolution.

OBSTRUCTIVE APPENDICITIS – it progresses very fast. There is pain is colicky in nature. It is important to remember the fact that the consequence of an appendicitis in an obstructive pathology depend on the following four factors –

1.The contents in the lumen

2. Degree of obstruction
3. Continued secretion by the mucosa
4. Inelastic character of the serosa

Anatomical considerations in the presentation of acute appendicitis

The vermiform appendix is a tubular structure attached to the base of the caecum at the confluence of the taeniae coli. It is approximately 8-10 cm long in adults and represents the underdeveloped distal end of the large caecum seen in other animals. In humans it is regarded as a vestigial organ, and acute inflammation of this structure is called acute appendicitis

Retrocaecal/retrocolic (75%)—Right loin pain is often present, with tenderness on examination. Muscular rigidity and tenderness to deep palpation are often absent because of protection from the overlying caecum. The psoas muscle may be irritated in this position, leading to hip flexion and exacerbation of the pain on hip extension (psoas stretch sign)

Subcaecal and pelvic (20%)—Suprapubic pain and urinary frequency may predominate. Diarrhoea may be present as a result of irritation of the rectum. Abdominal tenderness may be lacking, but rectal or vaginal tenderness may be present on the right. Microscopic haematuria and leucocytes may be present on urine analysis

Pre-ileal and post-ileal (5%)—Signs and symptoms may be lacking. Vomiting may be more prominent, and diarrhoea may result from irritation of the distal ileum

CLINICAL FEATURE

1. Pain in abdomen – patient complains of violent colic which comes and disappears suddenly, it is diffuse and dull in type, situated in the umbilical or lower epigastric region.
2. Anorexia
3. Nausea and Vomiting – children and teenagers have a vomit but absent in adult.
4. Loss of appetite

SIGNS –

GENERAL CONDITION:

FEVER – Temperature rises to 99 to 100 F.

Pulse rate is slightly elevated.

Patient could be toxic, dehydrated based on the severity of the disease. ·

Mc BURNEY’S SIGN: It is described as the point of maximum tenderness. It lies at the junction between the medial 2/3rd and the lateral 1/3rd along the imaginary line that joins the umbilicus and the right anterior superior iliac spine.

BLUMBERG SIGN: Commonly known as Rebound tenderness. A hand is placed on the right iliac fossa and progressively pressed with each movement of expiration. It is then released suddenly. If the sign is positive, the patient will wince or cry with pain. This indicates inflammation of the parietal peritoneum.

ROVSING’s SIGN – On palpation, pressure is exerted in the left lower quadrant , pain is felt in right lower quadrant.

PSOAS SIGN – It is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscle..

OBTURATOR TEST- Right lower quadrant pain with flexion and internal rotation of the right hip) sign depends on the location of the appendix in relation to these muscles and the degree of appendiceal inflammation.

POINTING TEST: Patient is asked to point the site of maximum pain on coughing, using one finger. If it corresponds with the site of maximum tenderness, it proves the site of inflammation.

DUNPHY’s SIGN – Increased pain in the right lower quadrant with coughing. •

DIFFERENTIAL DIAGNOSIS

• Surgical – Intestinal obstruction, Intussusception, Acute cholecystitis, Perforated peptic ulcer, Meckel’s diverticulitis, Colonic/appendicular diverticulitis, Pancreatitis
• Urological – Right ureteric colic, Right pyelonephritis, Urinary tract infection
• Gynaecological – Ectopic pregnancy, Ruptured ovarian follicle, Torsion ovarian cyst, pelvic inflammatory disease
• Medical – Gastroenteritis, Pneumonia, Diabetic ketoacidosis, Porphyria.

LABORATORY TESTS ·

Complete blood count – Leucocyte count >10,000/mm³ , Left shift of neutrophils with normal total white blood cell count ·

C-reactive protein- elevated ·

Urine analysis– to determine presence of genitourinary tract inflammation

X-ray: Obstructive appendicitis due to fecolith is easily diagnosed by plain abdominal x-ray. It also helps to diagnose perforation (gas shadow under diaphragm). Barium enema x-ray may demonstrate non filling of appendix.

Ultrasonography: Many times it is seen in practice, even in acute appendicitis cases with clear clinical features, the ultrasonography report does not show changes in the appendix. This is because, on many occasions, it cannot be diagnosed by ultrasound, mainly due to the gas shadow and excess fatty tissue. Hence clinical correlation has great value in diagnosis. Free fluid collection in right iliac fossa can be easily diagnosed by ultrasonography. False negative results seen in appendicitis of the appendiceal tip, gangrenous, perforated appendix, retrocaecal appendicitis, gas-filled appendix.  False positive results may be seen in resolving appendicitis, inflammatory bowel disease and dilated fallopian tube

CT scan: It gives better details than ultrasonography, especially in adults as fat in peritoneum makes the appendix more visible on CT. So, obviously CT gives fewer clues in children and thin subjects.

Exploratory laparotomy: In case of an acute abdomen, when the disease diagnosis is not established by all modes of investigations, and general conditions and pain become worse, then exploratory laparotomy may be done after taking a second opinion.

MANAGEMENT AND TREATMENT FOR ACUTE APPENDICITIS

BELLADONA -Useful in early inflammatory stage, much before suppuration has set in, that is, when there is generalized pain in the abdomen. It hasten the suppuration causing the inflamed appendix to burst, resulting in peritonitis. There is inability to slightest touch even of bed cover. The patient feels better by lying on back with knees drawn up. There is throbbing headache, vomiting and fever without perspiration.

PLUMBUM METALLICUM -Useful for violent colic for which patient assumes the strangest postures for relief. Given when pain radiates to all parts of the body.  Violent colic, with constrictive pain, esp. in umbilical region, with violent contraction of abdomen (navel and anus are violently drawn in), < by slightest touch, and sometimes increased at night to the highest degree .Large, hard swelling in ileo-caecal region, very sensitive to contact or least motion; sneezing or coughing.

BRYONIA ALBA- There is tenderness in abdominal wall. Useful for burning pains, worse pressure, coughing and breathing. The slightest movement causes great pain. Patient is better from lying on the painful side, pressure, rest and cold things. Helpful for pressure in the stomach after eating as if , of a stone. Epigastrium is sensitive.

MAGNESIUM PHOSPHORICUM –Useful for spasmodic cramping of stomach, nipping, griping and pinching with belching that does not relieve. Also useful for flatulent colic that forces the patient to bend, better by warmth and rubbing.

IRIS TENAX – Iris tenax is indicated in acute appendicitis. There is fearful pain in the ileo-caecal region with great tenderness to pressure and deadly sensation at the pit of the stomach associated with dryness of mouth

MERCURIUS CORROSIVUS – -Pain about umbilicus, > by bending double Pain in abdomen, sharp cutting, coming and going suddenly. Pain in left iliac fossa. Bloating sensation in the abdomen which is very painful. Temperature raised a degree, with flushed face and fullness of head, accelerated full pulse. Sweat chiefly on upper part of body. Desire for cold water.

ECHINACEA ANGUSTIFOLIA –It acts on vermiform appendix, Echinacea should be considered in septic conditions of appendicitis. Patient complains of chilliness with feeling of nausea.

DIETARY AND LIFESTYLE MANAGEMENT

Food items to be taken

• Do moderate exercise in daily routine
• Oats or wheat gram over breakfast cereals
• Whole wheat flour instead of all-purpose flour
• Brown rice instead of white rice
• Fresh fruits for dessert

Food Items To Limit in Appendicitis

• Do not Consumption of high-fat food. High-fat food contains meat, cooked egg, cheese, whole mik, chocolate, ice cream, fried foods and preparations having high butter and oil
• Food with high sugar content like sweets, candy, cake, muffins, sweeteners, ice cream, etc.
• Canned foods and juices
• Avoid Aerated drinks, Beverages, Alcohol, Pepper and spices
• Beans and cruciferous vegetables that form gas
• Bakery items that contain cereal and white flour

CONCLUSION
 In present day Homoeopathy is the great system of the alternative system of  medicine. Homeopathy is based on law of similars, homeopathic remedies are chosen not only on the basis of disease symptoms but also a individual miasm. A constitutional homeopathic medicine will be given in appropriate dosage helpful in cases of appendicitis and prevent surgery.

REFERENCES

1. Larner AJ ,The aetiology of appendicitis. Br J Hosp Med 1988;39: 540–2.
2. Addiss DG, Shaffer N et al. “The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1996;132:910- 925.
3. Luckmann R, Davis P. The epidemiology of acute appendicitis in California: racial, gender, and seasonal variation. Epidemiology. 1991;2(5):323-30.
4. Acute appendicitis. Humes DJ, Simpson J. 2006;333:530–534.
5. Krzyzak M , Mulrooney S M, Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and treatment; 2020 Jun; 12(6): e8562.
6. Kumar V, Cotran RS, Robbins SL, Appendix In: Robbin’s Basic Pathology, W.B Saunders, London, 1992: p. 520. 31.
7. Masek T, Poulová M, Schwarz J, Bavor P. [Ultrasonography as an auxiliary method in diagnosis of acute appendicitis]. RozhlChir. 2003;82(6):320-3.
8. Boericke W. New Manual of Homoeopathic Materia Medica with Repertory. 3rd Revised and Augumented Ed. New Delhi: B Jain Publishers; 2010.
9. petroianu A ,Diagnosis of acute appendicitis, International Journal of Surgery Volume 10, Issue 3, 2012, Pages 115-119).
10. Clarke J H. A Dictionary of practical Materia medica Vol 2. New Delhi: B. Jain publishers (P) Ltd.

Dr Priya
PG ScholarmPractice of Medicine
Bakson Homoeopathic Medical College & Hospital, Greater Noida, Gautam Buddha Nagar, Uttar Pradesh.