Appendicitis: Scope of Homeopathic Management

Abstract: This article illustrates the clinical aspects of appendicitis and the role of homeopathy in managing such cases. The common homeopathic remedies indicated for appendicitis have been described. A few cases from author’s practice that have been managed with homeopathy have been enlisted.
Introduction
Vermiform appendix is a rudimentary finger like projection from the caecum of the large intestine. Any infection or obstruction of the lumen of the appendix, or even the lymphatic obstruction, can lead to appendicitis. Appendicitis cases present in acute, sub-acute or in chronic form in our day to day practice.
Once, appendix was considered as a rudimentary structure; any acute pain in the right side of abdomen is not an ‘indication’ for appendectomy. There are many cases in which appendix is removed needlessly⁽¹⁾ or when abdomen was operated for some other purpose. However, as per many surgeons, appendectomy is indicated for patients with a history of persistent abdominal pain, fever, and clinical signs of  localized or diffuse peritonitis, especially if leukocytosis is present.(2)
It has been proved that appendix is a reservoir for the intestinal flora, which can supply the same to the colon after an infection or any other crisis. The appendix is also thought to have immune function based on its association with substantial lymphatic tissue, although the specific nature of that putative function is unknown.⁽³⁾ This is very essential for the digestion process.
Clinical features
Acute appendicitis presents with a pain that is initially felt in the umbilical region and later shifts towards the right lower abdomen called Mcburney’s point. Usually, vomiting and fever follow the pain in classical acute appendicitis (Pain →Vomiting→ Fever). But nowadays the clinical presentation may be with vague symptoms that often leads to diagnostic dilemma.
Taking the case from Homeopathic Perspective
The following are some points specially to be noted while case taking from a homeopathic perspective.

1. Time of onset of pain.
2. Mode of onset.
3. Duration of pain.
4. Exact location of pain.
5. Radiation and extension of pain.
6. Nature and type of pain.
7. Posture in which pain is felt.
8. Periodicity of pain.
9. Factors causing or modifying the pain.
10. Feeding habits in children.
11. Associated complaints like fever, vomiting, diarrhea etc.
12. Type of vomitus and stool. Presence of blood.
13. Relationship of pain with meals, defecation, vomiting etc.
14. Bowel movements
15. Urinary symptoms like burning micturition, increased frequency, retention etc.
16. History of previous episodes of pain.
17. History of injury, medications, surgeries, accidental swallowing of any foreign materials or toxins etc.
18. Details of previous illnesses.
19. Personal history
20. Menstrual and obstetric history in females.
21. Family history.

Clinical examination of the patient
The clinical examination has to be performed in all cases of acute abdomen with suspected appendicitis, which provides significant diagnostic clues. The patient is examined while lying relaxed in a supine position. . Certain vital clues may be missed when palpation is done while the patient is sitting as the tense abdominal muscles may mask the findings. Apart from the diagnostic point of view, clinical examination often gives some clues for the remedial diagnosis. In the repertory, there are several rubrics that can be selected only after clinical examination. For example, Kent’s Repertory there are rubrics like:

• Abdomen- Peristalsis increased
• Abdomen – Aneurism
• Abdomen – Bubo
• Abdomen – Dropsy – ascites
• Abdomen – Erysipelas
• Abdomen – hardness – Mesenteric glands
• Abdomen – Hernia
• Rectum- Hemorrhoids/Fissures/Fistula
• Respiration- Wheezing
• Generalities – Cyanosis, Muscular atrophy, Pulse.

Inspection often gives many clues; even the facial expression of the patient is significant. While palpating the patient, the more painful part should be examined at the end to make the patient cooperative. The painful part is examined to know the type of tenderness and consistency of abdominal wall. Presence of any lump is also noted. On pressing the left illiac fossa, pain can be elicited in the right iliac fossa and this sign is very important for a clinical diagnosis. In acute appendicitis, the abdominal wall becomes very sensitive even to gentle palpation. Rebound tenderness is observed while suddenly releasing pressure while doing deep palpation. If there is peritonitis, rebound tenderness becomes more marked, along with hardening of the abdominal muscles on palpation. Hyperesthesia in the Sherren’s triangle is prominent in gangrenous appendicitis, and if this sign disappears it indicates bursting of gangrenous appendix. Hence, when the patient says ‘I am feeling much better now’, we must be very cautious.
Among the vital signs, frequent monitoring of pulse is the most important point to be noted. Grade of fever may not always indicate the change in clinical status of the patient as body temperature may become normal even in case of perforation. Hence, the clinical findings must always be correlated with investigation reports and logical thinking.
Clinical Signs

1. Rovsing’s sign: Pain in appendix while palpating the left iliac fossa upwards along the colon.
2. Psoas sign: Passive or active flexion of the right hip joint causes pain due to irritation of peritoneum overlying the iliopsoas muscle.
3. Obturator sign: Flexion and internal rotation of the right hip causes pain due to spasm of obturator internus muscle.
4. Dunphy’s sign: Pain already present at the site of appendix increases while coughing.
5. Kosher’s sign: Shift of pain from epigastrium to right iliac fossa.
6. Sitkovskiy’s sign: Increased pain in the right iliac region as patient lies on the left side.

Alvarado score⁽⁵⁾ is a useful tool for diagnosing appendicitis. A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute appendicitis. The logical thinking of the doctor is always important.
Clinical Variants and Presentations
Here are some varieties of appendicitis that often lead to diagnostic dilemma:

1. Rumbling appendicitis: A correctly diagnosed non-acute form of appendicitis.
2. Pseudoappendicitis: This condition mimics appendicitis, which is usually caused by Yersinia enterocolitica infection.
3. Pelvic Appendicitis: In some individuals the appendix is directed towards the pelvis hence the classical signs of appendicitis may not be present in pelvic appendicitis. But presence of bloody stools with mucus due to irritation of rectum gives some hint. Usually the pain is aggravated by urination. Per rectal examination can elicit tenderness in almost all cases due to rectal irritation. Sonography and CT scan help in diagnosis.
4. Retrocaecal Appendicitis: Here also the classical signs of appendicitis are not seen causing a diagnostic dilemma. Symptoms like diarrhea and colicky abdominal pains with painful urge for stool may be present. Sonography is diagnostic.
5. Appendicular lump: Here, as a protective mechanism, the mesentery and omentum coil around the appendix and prevent the spread of infection. Normally, when the appendicular lump is formed, it should not be operated immediately, and they do surgery later after the recoiling take place.
6. Appendicitis with Peritonitis: When an inflamed appendix ruptures, it can lead to peritonitis. This is characterised by diminution of pain followed by the symptoms of peritonitis. Initially when the appendix ruptures, it leads to local peritonitis, and later on when the infection spreads, it becomes generalised. Initially, the pain is felt in the affected region and when it becomes generalised, it is felt all over the abdomen. The abdominal wall becomes hard and tender with absence of respiratory movements. The pain gets aggravated by slightest touch, motion, coughing and sneezing. There is rebound tenderness with muscular rigidity in the affected area. This stage is followed by an interval wherein no pain is felt and the patient feels better (also the doctor!). Again the pain appears with grave signs like high fever, collapse, sunken eyes and general distension of the abdomen. This is a dangerous situation and may threaten life if not managed properly. In general peritonitis mortality is about 50%. Routine blood examination, x-ray, serum amylase estimation are useful for diagnosis.

Lab Investigations

1. Complete blood count: Blood report may be normal in some cases; however, leucocytosis is a significant finding.
2. C-reactive protein (CRP) may be increased, valid when associated with clinical features. It worsens when there is abscess formation.
3. Urine Routine Examination: Helps to rule out renal calculi (Inflamed appendix can also irritate urinary bladder)
4. 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.
5. 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. Even after requesting the ultrasonologist to mention the status of appendix, many of them do not describe the same. 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. The benefit of ultrasonography is that the other conditions like calculi, ectopic gestation etc. are ruled out
6. 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.
7. 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.

Differential Diagnosis of Appendicitis

1. Renal colic at the level of appendix
2. Cholecytitis
3. Intestinal obstruction
4. Rupture of ectopic pregnancy
5. Right sided oophoritis or salpingitis
6. Torsion of testes.

Case Management
Successful management of appendicitis is a skilful job. Managing chronic and sub-acute cases are relatively easier, whereas a case of acute appendicitis must be managed with utmost care, especially the cases with possibility of septic appendicitis and rupture. The progress of the case must be monitored properly. If doubtful, a second opinion must be taken or the case be referred to a surgeon.
‘Initially, due to lack of confidence and inexperience, I used to refer acute appendicitis cases for emergency surgery. But after achieving several cures with homeopathy, now I very rarely refer such cases, but when the patient and attendants prefer surgery, or when septic appendicitis is suspected in patents of low vitality I have to refer the case for a surgical management. I can say with confidence that homeopathy can manage most of the acute appendicitis cases, by which the so-called rudimentary organ can be preserved for the rest of the life.’
Some practical hints
From the author’s experience, the following points help in management of appendicitis cases along with the homeopathic treatment.

• Once acute appendicitis is suspected, the patient should be nil orally. Since we prefer managing the case without intravenous fluids, liquids can be given gradually. For the sake of hydration and supply of electrolytes, coconut water or gruel water can be given in small quantities frequently since gulping a large quantity may induce further vomiting.
• Patient must take bed rest.
• Once the acute state is improved, gruel can be given, also some juices.
• It is better to admit the patient for proper rest and care. If no facility is available, the patient can be managed as an out-patient case, but there must be good communication to timely review the status of the patient with respect to the general condition, nature of pain, pulse, temperature, respiratory rate, leucocyte count, bowel movement and urine output. Nature of tongue is also important.
• Having no facility to admit the case is definitely a limitation in case management. In fact, it is the main reason we are forced to refer such cases. So, arranging such facilities can definitely yield better results.

Homeopathic Therapeutics
The following homeopathic medicines are often indicated in acute episodes of appendicitis.
Iris tenax

• This is the specific remedy for appendicitis.
• Pain in the ileocaecal region
• I have good results in cases with absence of strong indications for other medicines.

Belladonna

• Abdomen distended, hot and tender.
• Throbbing pain with very sensitiveness to external impressions like touch.
• Pain comes and goes suddenly, < by jar.
• Pain as if clutched by a hand or griped by nails.
• Pain causes delirium.
• Convulsions at every attack of pain.
• Intense cramping pain with red face.
• Pain in uncovered parts.
• Spasm of stomach with uncontrollable vomiting.
• Nausea ameliorated by passing flatus.

Colocynthis

• Cutting pain in the abdomen after anger.
• Violent colic in paroxysms.
• Bruised pain in the intestine.
• Pain in abdomen as if squeezed between two stones.
• Agonizing pain in the abdomen causing the patient to bend double.
• Pains ameliorated by pressure, rolling on floor, coffee.
• Distortion of face and eyes with pain.
• Wants to support the abdomen by pressing.

Pyrogenium

• Complaints of septic origin.
• Cutting pain in abdomen with bloating.
• Tenesmus of both bladder and rectum.
• Parts lay on feels sore and bruised.
• Coffee ground offensive vomiting with obstructed bowels.
• Constipation with complete inertia.
• Horribly offensive stools.
• Pulse out of proportion to temperature.

Hepar sulphur

• Splinter like pains with hyper sensitiveness.
• Fainting from pains.
• Abdomen greatly distended and tender.
• Burning and heaviness in stomach after meals.
• Pains aggravated by lying on painful side.
• Stitching in liver region when moving and turning.
• Distention of abdomen compels the patient to loosen the clothing.

Bryonia alba

• Ailments from cold drinks during hot weather.
• Slow onset of complaints.
• Gastritis, peritonitis
• Stitching type of pain.
• Abdominal pain aggravated by coughing, motion, deep inspiration etc.
• Holds the abdomen to prevent least motion
• Lies still, knees up to relax abdominal muscles.
• Pain ameliorated by pressure, absolute rest and lying on painful side.
• Nausea and vomiting after eating.
• Dry tongue with intense thirst.

Apis mellifica

• Stinging and burning pains with soreness.
• Pains with screaming.
• Peritonitis with burning pains.
• Great sensitiveness of abdomen.
• Pain in abdomen aggravated by sneezing.

Echinacea angustifolia

• Conditions of septic origin
• Special affinity on vermiform appendix
• Useful remedy in acute appendicitis
• Its tincture can be given as a supporting drug to prevent septic appendicitis

(Boericke gives a warning that it can rupture the neglected appendicitis with pus formation. But, till date I have not seen any rupture after giving this medicine)
Arnica montana

• Pain in abdomen after heavy exertion.
• Pressure as from a stone in stomach.
• Sore lame bruised feeling all over the body.
• Sharp thrusts through the abdomen.
• Feels as if stomach was pressing against the spine.
• During pain there is fear of touch or approach of anyone.
• Bad odour from the mouth with coated tongue.

A Few Case Examples
The following are some of the cured cases of acute appendicitis from author’s practice. Except a few, most of these cases were diagnosed clinically as the ultrasonography reports were non-conclusive about the appendix. The medicines were given on the basis of symptoms presented during each visit. Since all these cases were treated as out-patient cases, they were asked to report their condition twice daily, or as per the requirement. Most of the appendicitis cases are advised to visit daily or on alternate days. Clinical evaluation is a must even if the patient says everything normal.
Case 1: Master AB, M/9.
First visit: Presented with colicky pain in the abdomen relieved by pressure and forward bending. Given Colocynthis 30 in water every two hourly.
Second visit: Constipation with urge to pass stool, along with vomiting after eating. Given Nux vomica 200 in water.
Third visit: In general, the patient was feeling better. Sulphur 200, one dose was given. I often use Sulphur 200 to complete the cure.
Case 2: SJ, M/15.
First visit: Symptoms of appendicitis with frequent urge to pass stool. Given Nux vomica 30.
Second visit: There was constipation with colicky pain; Plumbum 200 given.
Third follow-up: Patient was feeling better, hence placebo continued.
Case 3: SM, F/12.
First visit: Symptoms of appendicitis associated with constant nausea, clean tongue. Given Ipecac 30 in water doses.
Second visit: There was high fever with signs of sepsis. Given Pyrogen 200 a few doses.
Third visit: Completely cured. Given placebo.
Case 4: AK, M/12
First visit: High fever with clinical features of appendicitis, redness of face. Given Belladonna 30.
Second visit: Fever and other symptoms were not present, except the pain in the right illiac fossa. Given Iris tenax 30, four doses daily.
Third visit: Pain was better, but abdomen was sensitive along with chills. Given Hepar sulphur 200 four doses daily.
Forth visit: Free from signs and symptoms. Given placebo.
Case 5: RM, F/18
First visit: Colicky pain with amelioration by bending forward. Given Colocynthis 30.
Second visit: Sensitive abdomen with chills. Given Hepar sulphur 200.
Third visit: Completely cured.
Case 6: Master AF, M/6
First visit: Clinical features of appendicitis with pain in the right iliac fossa. Given Iris tenax 30.
Second visit: Free from symptoms with general well-being. Given placebo.
Case 7: Mrs JS, F/46
First visit: Appendicitis with aggravation by slightest motion. Given Bryonia alba 1M in water doses.
Second visit: No signs and symptoms with general wellbeing. Given Placebo.
Case 8: Mr LM, M/25 (online case)
First prescription: Diagnosed case of appendicitis admitted in a hospital, scheduled for surgery. Based on the clinical features, Iris tenax 30 was given along with Echinaea Q in water.
Second prescription: Patient was feeling better, and surgery was cancelled against medical advice. Continued Echinaea Q.
Third follow-up: Completely cured, continued placebo for 15 days.
Case 9: Mrs SN, F/43
First visit: Signs and symptoms of appendicitis with pains aggravated by motion. Given Bryonia alba 200, also Echinacea Q.
Second visit: Clear improvement observed, given Sulphur 200 a few doses.
Third follow-up: Completely cured.
Case 10: Master IN, M/8
First visit: Acute appendicitis with high fever and redness of face. Given Belladonna 200 along with Echinacea Q in water.
Second visit: General improvement, continued Echinacea Q
Third visit: Completely cured.
Discussion
We are living in an era wherein normal organs of the body are surgically removed for the prevention of cancer in the future. However, the tendency for cancer cannot be removed by surgery. If one organ is absent, the disease may manifest at the other organs that have more affinity for that disease. Surgical intervention is indeed a life-saving treatment modality in certain cases; however, all the cases do not need surgery. The old dictum is very relevant here – The good surgeon is the one who knows when not to operate the patient.
Bibliography

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