The Elusive Appendicitis

It transpires that appendicitis in Africa is actually quite unusual. As a surgeon working in a District General Hospital (DGH) in the UK, we would expect to have several (perhaps 3-5) confirmed cases per week. It is certainly considered one of the most common surgical emergencies in the West. The population we serve in Muheza is comparable to that of a DGH back home, but I was yet to see a single confirmed case in my nearly 5 months here. Until today.

It would not be unreasonable to wonder if we were just missing them for one reason or another, but I now understand that this paucity of such pathology is entirely consistent with others experience. Furthermore, I had reluctantly taken on about 6 cases of ‘suspected’ appendicitis during my time here (whilst my scepticism was valid, to have a look was really the only ‘safe’ option), performing exploratory laparotomy. All had normal appendixes (although the local surgeons commented on how long the structures were).

And then today I was taken to see a 16 year old lad who was unwell. He had been admitted for a couple of days already, but for whatever reason, I had not been asked to see him until now. It did not take me long to establish that he was peritonitic (this means the findings of abdominal examination were very concerning). Whilst the signs were by no mean typical of appendicitis (his tenderness was in the ‘wrong’ place), he clearly warranted surgery. I probably ought to say that these decisions are entirely based on clinical judgement here, there are no other tests easily available. I had asked for an FBC (full blood count) as the machine is now fixed, but it was not forthcoming. I also probably ought to say that it would be easy to dismiss such symptoms and signs (perhaps why I had not been asked to review him sooner). The population here is incredibly stoical, and to complain of or show pain is quite a statement. But you cannot hide true involuntary guarding (this is when the abdominal muscles contract involuntarily to protect the abdomen from pain) and I was quite clear that he needed an operation. I was suspicious of what we might find, although there was some scepticism of this provisional diagnosis locally. I asked him to be prepared for theatre.

Unfortunately, it transpired that he had just eaten some porridge. Hmmm. Despite this being an emergency, I felt it was probably safer to wait the recommended 4-6hrs before putting him to sleep. He was on antibiotics and not systemically septic. Given all our anaesthetic challenges, I thought it would be prudent to minimise any additional risk.

Today, we had again been visited by the Surgeon Nun from Korogwe. Rather flatteringly, now that she knows I am here, is keen to capitalise on every possible opportunity to work with me.  We started the day’s operating list as planned. A 2-year 8-month old with a large inguinal hernia and a lady with an incisional hernia (lower midline from previous caesarean section) which we repaired with the ‘mosquito net’ mesh.  Both were quite challenging, but both operations went very well I am pleased to say. Sister was keen to stay for the emergency case too.

The young man arrived at theatre reception and I was asked to review him again by the local team – did I still want to operate? His signs were apparently quite changeable, which did not fit with my initial impression earlier. I approached him and in the better light of this atrium, could see even more clearly that he was not well (there is a certain subtle, almost waxy, look to the acutely unwell).  I laid a hand on his tummy and was left in no doubt. “Yes, he needs surgery”. For the first time since being here, I was also in the privileged position of having a second opinion to hand. Whilst I was clear as to the required decision, with my Surgeon Nun colleague standing next to me, such an opinion was invited and forthcoming. Thankfully, she was in complete agreement. I suspect this also reinforced some very useful learning for the local team.

Given that the diagnosis was not certain (and theoretically could have been any number of things), I elected for a midline incision (this way of opening the abdomen leaves all options open), rather than the classical appendix incision in the right lower tummy. It was a good decision as there was a lot of mischief inside. He did have appendicitis, which had perforated, and there was evidence of infection throughout his abdomen. We removed his appendix, with a gaping hole in the distal third. We broke up lots of adhesions and interloop abscesses; this is when pus collects between other loops of bowel – the body’s natural reaction is to wall this off and try to destroy the bugs. Then we thoroughly washed out his abdomen with warmed saline (salty water) adhering to the old adage ‘the solution to pollution is dilution’ learned early on in my surgical career (this holds true for the human body, if not the environment). Things went very well. The local team, the visiting team and the British team (that’s me) were all equally delighted with the case. I at least felt it would have been almost rude to come all the way to Tanzania, operate as a General Surgeon for five months and not take out an abnormal appendix. But I have also certainly learned that it is comparatively rare here.

For the evening, a rather impromptu invitation to visit the Convent in Korogwe was reiterated (it was mentioned briefly in passing last week). A moments hesitation soon gave way to a sense of adventure, even if it was a ‘school night’. How could we refuse. I quickly established that my wife and children were up for it too. I managed to secure the Hospice car and we made the 75-minute journey arriving in the dusk. It was so very worth it. We visited their health centre first (another interesting piece of the healthcare puzzle for me) and were then treated to the most delicious African meal. Hospitality here really is exceptional. Another delightful and memorable Tanzanian experience.