Chronic Right Lower Quadrant Abdominal Pain: Laparoscopic Approachã
Wuttichai Thanapongsathron, MD, FRCST*, Burapa Kanjanabut, MD, FRCST**, Tamnoon Vaniyapong, MD, FRCST*, Santapol Thaworncharoen, MD***
Affiliation : ã Presented at the 23rd Annual Meeting of the Royal College of Surgeons of Thailand, Royal Cliff Hotel, Pattaya, Thailand. July 8-11, 1998 * Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Maha Chakri Sirinthorn Medical Center, Nakhon-Nayok ** Department of Surgery, Vajira Hospital *** Borai Hospital, Trat
Background/
Objective : From December 1997 to April 1998, 122 appendectomies were done in Cambodian
refugees at Borai Hospital, Thailand. 44% of the pathological reports were acute appendicitis, 20% were
eosinophilic appendicitis and 36% were unremarkable appendix. What is the etiology of unremarkable
appendix in right lower quadrant (RLQ) abdominal pain? How to decrease appendectomy in the unremark-
able group? By using the advantages of laparoscopic technique, the authors are looking for the diagnosis
and management guidline of this condition.
Materials and Methods : The inclusion criteria was all patients who presented with chronic RLQ abdominal
pain (persisted > 5 days of the symptom) with informed consent. They underwent laparoscopy with a video
record of the whole abdomen especially the appendix. The treatment depends on gross diagnostic findings:-
appendiceal disease → appendectomy, other diseases → follow the standard treatment, unremarkable
findings and normal appendix → peritoneal lavage and randomized into 3 studied subgroups. 1) Appendec-
tomy by laparoscopic technique. 2) No appendectomy and post-operative anti-parasitic drugs. 3) No appen-
dectomy and post-operative placebo.
Results : Laparoscopy was performed in 30 Cambodians (male:female = 2: 28). The average age was 27.5
(18-43) years. Average duration of RLQ abdominal pain was 11.5 (6-19) days. Average white blood cell
(WBC) count was 8,772 cell/mm3. Average neutrophils and eosinophils were 50% and 10% respectively.
Laparoscopic findings included chronic appendicitis (1 case), chronic pelvic inflammatory disease (1 case),
ruptured graffian follicle (1 case) and normal appendix (27 cases). The normal appendix group was randomized
into 3 subgroups; appendectomy subgroup (9 cases), anti-parasite subgroup (10 cases) and placebo subgroup
(8 cases). Analysed peritoneal lavage in the normal appendix group were unremarkable 16 cases and
eosinophilic inflammation 11 cases. Pathological reports of the appendectomy subgroup were unremarkable
appendix 8 cases and eosinophilic appendicitis 1 case. The visual analogue score of RLQ abdominal pain
was analyzed by Fisherís exact test on the 7th post-operative day. The curative treatment (pain score = 0) by
appendectomy or an anti-parasitic drug regimen compared with a placebo had no statistical difference (p > 0.05).
Conclusion : Laparoscopic study showed that 90% of the patients had normal appendix that was not a surgical
disease, although the clinical presentations mimicked appendicitis. The etiology was still unknown but
parasitic cause was mostly suspected. However, further epidemiological and clinical studies should be done.
Keywords : Chronic, Right lower quadrant, Abdominal pain, Laparoscopy
