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Chronic pain from the appendix

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    “Appendixes never grumble, they either shout or remain silent.” That was the teaching I was brought up with and have taught to others, and it is probably regarded as almost axiomatic by many readers of this journal. Nevertheless attempts have been made from time to time to implicate the appendix as the source of chronic or recurrent abdominal pain. Now a surgeon in Cincinnati, Ohio has reported his extensive experience (Journal of Pediatric Surgery1999;334:950–4).  Over 12 years (1985–97) he operated on 52 patients with chronic right lower quadrant abdominal pain. Fifty of them were followed up for at least a year. All were judged before operation to have had “appendiceal colic” for at least a year, the interval between attacks being very variable. Appendiceal colic was diagnosed when, during an attack, the patient suffered abdominal colic and had tenderness at McBurney’s point. There was usually severe pain making the patient curl up and writhe, and often retching or vomiting with facial pallor or flushing and a clammy skin or sweating. Food or drink characteristically exacerbated the pain and this was often used as a provocative test in the surgeon’s consulting room.  The 50 patients (37 female) followed up were aged 5–20 years. Almost half of them (23) had attended the emergency department or been admitted to hospital because of previous episodes. Preoperative investigations such as abdominal ultrasound or gastrointestinal contrast studies proved unhelpful and were eventually abandoned as a routine. None of the removed appendixes showed acute or chronic appendicitis histologically. Seven were entirely normal and the most common findings in the rest were fibrosis (15), faecolith (13), and kinking (15). Forty nine patients were cured of their pain on follow up and the one remaining developed ureteric colic.  This experienced surgeon insists that appendiceal colic is a specific condition which can be diagnosed clinically and cured by appendicectomy.