Wednesday 14 December 2016

Similar experience, on the other side of the globe!

I was contacted in early September by a father in New Zealand who had found this blog and whose daughter was experiencing very similar symptoms and treatment (or lack thereof) by the medical profession.

"Our 13 year old daughter has had LRQ pain for 4 months now and basically off school for most of that time.  The pain started centrally near her navel and migrated to the LRQ.  She has frequent headaches and it hurts to walk, jump etc...  Her pain fluctuates between 3 & 8 and some days she is able to attend school.  She has had all tests including an MRI and all negative for acute appendicitis.

I have long believed she has chronic appendicitis and just read your blog.  The hospital have not completely ruled this out, but are wanting to 'treat' her for FAP which basically involves pretending nothing is wrong and waiting for her to magically get better.

Just wondering if you have any more relevant information or if any more came of your complaint?".

We talked about how the doctors treat teenage/pre-teen girls as though they have no ability to recognize their own symptoms (presumably too 'overwhelmed' with hormones to be able to judge their own pain). And that in the end, as parents, we do need to trust in their self-awareness and help them navigate through a medical system that has no faith in them.

Fast forward to yesterday:

"...finally had her appendix removed 10 days ago and the pain she has had for 8 months is now gone!  
 It will take her a little while to fully recover from the surgery but she is already back at school."

He has also shared some other reference on treatment of chronic RLQ pain in children:

"There are so many cases like this that it needs to be officially recognised as a condition.  There are 3 reports which show an 8 - 9 out of 10 chance of an appendectomy resolving long term LRQ pain in children.
 
 
Medical professionals who choose to ignore those statistics are quite simply negligent and liable for malpractice if they do not allow patients the 'option' of an appendectomy.  
 
We haven't had a biopsy report back yet and my guess is the appendix will appear normal in every known way.  My brother had acute appendicitis and his appendix appeared fine after it was removed.  I believe this is the case in about 15-20% of appendectomies.  On that basis an MRI cannot be considered conclusive in diagnosing appendicitis."
 Information that may help others out there experiencing the same situation.

Tuesday 9 April 2013

A small victory......

We had the follow up visit with the surgeon, Dr. Mitchell, today - just to check and make sure she healed properly - which she did.

He thanked me for my 'package' - I copied him on the original complaint which was a fairly large document. AND he told me that he and Dr. Steed have been requested to present their research into chronic appendicitis to a group of physicians at Alberta Children's Hospital. This was one of the things I requested in the complaint.

I'm still waiting for the official response from Alberta Health but it sounds like maybe we made a bit of a dent in their rigid stance against chronic appendicitis.


Monday 4 February 2013

A bureaucratic boondoggle.....

We filed a written complaint on January 15, 2013 requesting that Alberta Health Services review the Children's Hospitals treatment of our daughter and approach to chronic appendicitis. We were immediately assigned a representative with AHS Patient Relations who advised it would take some time. At this point, we were impressed with the Patient Relations system.

Then last Friday, Feb. 1, we received a call from our representative who relayed their response verbally. It was from Alberta Children's Hospital (ACH) Head of Surgery - the surgery department was central to our complaint against ACH.

It was the same circular argument - that our daughter didn't have anything wrong with her appendix because the tests were negative, although the tests cannot 100% eliminate the appendix as the problem, at which point we would request appendectomy, to which they would say no - her appendix isn't the problem. The rep even said 'surgery is only a last resort' to which I replied 'we were at the last resort and were still denied the option of surgery'. She said we should meet with the Head of Surgery at ACH for 'closure'. We aren't looking for closure - we got closure when she got better after her appendix was removed. We are looking for appendectomy to be offered as a 'diagnosis of exclusion' and that appendectomy be provided as treatment in these cases, if parents/guardian's are fully cognizant of and willing to accept the risks.

We then said we'd prefer to wait for written response to which she replied 'why would you want a written response?'. We consider it inappropriate and unprofessional that the response would come from the party we are complaining about and that it not be written and that we would be expected to meet with ACH without an outside, 3rd party present.

We have sent a letter back to AHS Patient Relations requesting a written response and that the case be reviewed by a medical professional outside of ACH. This seems obvious to us but appears to be very difficult for AHS to grasp.




Friday 18 January 2013

The circular argument regarding chronic appendicitis....

I wanted to share the information that my family and I gathered from Sept-Dec 2012 during our daughter's suffering of chronic appendicitis.

During this crazy period of countless visits to many doctors, we discovered that there is a debate in the medical community about the existence of chronic appendicitis. Our experience is that chronic appendicitis does exist. There are at least two conditions that create chronic pain in the RLQ, neurogenic appendicopathy and appendiceal torsion that will not show up on any of the typical tests that are done for appendicitis. Ultrasounds and CT Scans are NOT able to completely rule out appendicitis, despite the fact that I was repeatedly told this by the staff at ACH. The ONLY way to completely rule out appendicitis is to remove it.

It is possible that appendectomy would not have fixed the problem however, we were willing to accept the 20-30% chance that she didn't have appendicitis in order to rule out appendicitis once and for all, but we were not given that option by anyone at Alberta Children's Hospital.


We also discovered that many doctors are unable to make a decision without 'paper' confirmation from a large array of tests. We believe that it is critical that the people who know the patient (family, GP, friends) be listened to and if you are in that position it is important to advocate for the patient. This is incredibly difficult in the face of often arrogant doctors, but it is worthwhile in the end.

Here is a copy of the letter of complaint we sent to Alberta Health Services over the treatment of our ten year old daughter for intense right lower quadrant (RLQ) pain for 3 months in the fall of 2012.


The following excerpts from our complaint explain further and I have also attached back up medical citations that my father kindly found.

Excerpt:


We are filing this complaint both as parents and taxpayers. The complaint is that no one at ACH believed our daughter, us (her parents), our GP, or Radiologist that has studied chronic appendicitis that she had appendicitis for almost 3 months. 
We were told repeatedly by ACH that chronic appendicitis does not exist. As a result of this, our daughter lingered in intense pain for this entire time.  Not considering the option of treating her symptoms with an appendectomy resulted in thousands of dollars of unnecessary tests and prescriptions of unnecessary drugs. Our complaint boils down to the fact that the only way to completely rule out appendicitis in patients with these symptoms is to remove it. The solution is that patients or their guardians be given this as an option.
The physical, emotional and financial toll of this ordeal was huge. Our daughter missed almost 3 months of school; her mother is self-employed and missed almost 3 months of work in order to home school our daughter, while acting as nurse as well. Her sleep patterns remain disrupted, she has lost all muscle tone and she has lost her natural self-confidence. Our family struggled to maintain a semblance of normalcy, our other child suffered the worry and stress that permeated our household. One parent slept with her every night during this time because she would wake in intense pain. We were afraid that her appendix may rupture, which is then a medical emergency.
We have attached the journal (Schedule A) that we kept through the ordeal which gives the chronology and treatment during that time. The short synopsis is that she had a night of vomiting on Sept. 21 and this was followed by constant, intense, pain in her RLQ. Over the ensuing weeks we took her to Emergency at Alberta Children’s Hospital 6 times. They issued and treated her for numerous ‘diagnoses of exclusion’ including mesenteric adenitis, irritable bowel syndrome, FAB (Functional Abdominal Pain), and despite the fact that her pain never moved from RLQ or changed in intensity, appendicitis was ruled out due to negative blood tests, ultrasounds and CT scan. Two ACH surgical residents refused to removed her appendix, while at the same time were unwilling to give us assurance that it wasn’t appendicitis. At no time was she seen by a fully licensed surgeon at ACH. From the outset, we were treated with suspicion instead of compassion by staff at ACH ER. At no point were neurogenic appendicopathy or appendiceal torsion raised as possible diagnoses, despite the fact that these fit her symptoms and test results far better than any of the diagnosis’ of exclusion offered by ACH.
In our dealings with ACH the following issues arose and were never satisfactorily addressed:
Why would the appendix be immune to chronic conditions when the rest of the organs are not?
Why do test results cause ACH Physicians to ignore the patient’s physical symptoms? On the third surgical consult the surgical resident didn’t even examine her abdomen.
How is a colonoscopy/endoscopy under general anesthetic less invasive than a laproscopic appendectomy?
Why, in an otherwise healthy child with no history of mental problems, would the ACH Physicians default to psychosomatic or neuropathic pain when her symptoms were so clearly physical?
Since the only way to completely rule out appendicitis is to perform an appendectomy and in the face of such clear physical symptoms, why was this not the first diagnosis of exclusion? Why were we told that ultrasounds, CT scan and colonoscopy could rule out appendicitis when they are clearly not able to do so?
Why are they willing to leave a 10 year old (or anyone) at risk of her appendix going acute and bursting when this possibility can be eliminated with a 30 min day surgery?
Why is the use of ‘off label’ drugs condoned and even promoted when they don’t even know how/why/if these drugs work and the drugs really weren’t indicated? Why, when these drugs didn’t work for Quinn was an appendectomy not considered?

With the help of our GP and a radiologist, we found a surgeon who has studied chronic appendicitis, diagnosed our daughter with it and removed her appendix on Dec. 19 at Peter Lougheed Hospital.  She has been pain free since her recovery from the surgery. Although the pathology results were negative, the therapeutic result of the appendectomy obviously indicates that there is something missing in AHS testing for appendicitis. I have attached a list of medical citations (Schedule B) for two diagnoses that were never mentioned and/or tested for, appendiceal torsion and neurogenic appendicopathy.
Through our discussions with friends, neighbors and acquaintances we have met 4 other Albertans (3 adults and 1 child) with this same story - months of pain (in one case 3 years) followed by either acute or ruptured appendix. They are willing to be contacted if you are interested.  
In our rough estimate (Schedule C attached), her ‘treatment’ cost over $25,000 when a rule out appendectomy would have cost about 20% of this or $5000. As tax payers we find this to be wasteful and unnecessary.
ACH appears to have an unhealthy monopoly on pediatric care in Calgary that has resulted in an ivory tower mentality that disregards the actual patient, their physical symptoms, their GP and any other, outside medical professionals. The GP’s role should be considered crucial when dealing with patients and in our experience, this is not the case.

Medical citations - neurogenic appendicopathy and appendiceal torsion



Medical Citations Concerning Appendiceal Torsion and Neurogenic Appendicopathy
 January  2013

Appendiceal Torsion

Google search of this phrase resulted in 285,000 hits of which the following 11 were selected as representative of cases in which the appendix removed showed signs of contortion. Many of these hits referred to the torsion of other abdominal organs and not the appendix.

Item 1
Title:                        Torsion of the Vermiform Appendix: a Case Report.
Author:                        Bestman, T. et al - (Dept. of Surgery, Middelares Hospital, Antwerp, Belgium)
Source:                        Acta Chir. Belg.. -  Vol. 106
Date:                        2006

Item 2
Title:                        Torsion of the Vermiform Appendix: A case report.
Authors:                        Wani, I et al - (Dept. of Surgery, SMHS Hospital, Srinagar, India)
Source:                        Internet Journal of Medical Update - Vol. 4, Issue 2
Date:                        July 2009

Item 3
Title:                        Torsion of the Appendix.
Author:                        Carter, A - (Surgeon, St. Mary's Hospital, London, England)
Source:                        Postgraduate Medical Journal - Vol. 35
Date:                        December 1959

Item 4
Title:                        Secondary Torsion of the Vermiform Appendix with Mucinous Cystadenoma.
Author:                        Kitagawa, M  - (Dept. of Surgery, Kyoto Hospital, Japan)
Source                        Case Reports in Gastroenterology - Vol.1 Issue 1
Date:                        June 2007

Item 5
Title:                        Laparoscopic Management of a Torted Appendix.
Authors:                        Rajendram, N et al -
Source:                        Annals of the Royal College of Surgeons of England, Vol. 88, Issue  6
Date:                        October 2006

Item 6
Title:                        Primary torsion of vermiform appendix mimicking acute appendicitis.
Authors:                        Marsden, E et al - (Dept. of Surgery, Horton Hospital, Oxford, England)
Source:                        BMJ Case Reports 2011
Date:                        October 2011

Item 7
Title:                        Torsion of vermiform appendix: value of ultrasonographic findings.
Authors:                        Uroz-Tristan, J et al - (Dept. of Pediatric Surgery, Las Palmas Hospital, Grand Carary, Spain)
Source:                        European Journal of Pediatric Surgery, - Vol. 8, Issue 6
Date:                        December 1998

Item 8
Title:                        Cecal eplploica appendix torsion in a female child mimicking acute appendicitis: a case report
Authors:                        Christianakis, E - (Pendeli Children's Hospital, Athens, Greece)
Source:                        Case Journals 2009, 2:8023
Date:                        January 2009


Item 9
Title:                        Primary acute torsion of the vermiform appendix.
Authors:                        Val-Bernal, J et al - (Pathology Dept, Cantabria University Hospital Medical Faculty, Santander, Spain)
Source:                        Pediatric Pathology & Laboratory Medicine - Vol. 16, Issue 4
Date:                        July 1996

Item 10
Title:                        Torsion of a mucocele of the vermiform appendix: a case report and review of the literature.
Authors:                        Lee, CH  et al - (Dept. of Surgery, Chonbuk University Medical School, Jeonju, S. Korea)
Source:                        Journal of Korean Surgical Society - Vol. 81 (Suppl.1)
Date:                        December 2011

Item 11
Title:                        Torsion of the Vermiform Appendix - Report of 2 cases
Authors:                        Somogyi, R et al - (Dept. of Pediatrics, University of Pecs, Hungary)
Source:                        Journal of Pediatric Surgical Specialies - Vol. 4, Issue 1
Date:                        April 2010

Neurogenic Appenicopathy

Google search of this phrase resulted in 4330 "hits" of which the following ten are indicative of information  available on this disease.

Item 1
Title:                        Neurogenic appendicopathy: Clinical presentation in a paediatric population
Authors            ::            Sesia, Sergio et al - (University of Basel, Children's Hospital, Switzerland)
Source:                        Deutsche Gesellschaft fur Chirurgie -  Proceedings of 128 th. Congress.
Date:                        May 2011

Item 2
Title:                        Neurogenic appendicopathy - A common disorder, seldom diagnosed.
Author:                        Hofler, H - (Technical University of Munich)
Source:                        Langenbecks Archiv fur Chirurgie - Vol. 351, Issue 3
Date:                        1980

Item 3
Title:                        Neurogenic appendicopathy - A clinical disease entity?
Author:                        Franke, C et al -  (Dept. Of Surgery, H.H. University, Dusseldorf)
Source:                        International Journal of Colorectal Disease - Vol. 17, Issue 3
Date:                        May 2002

Item 4
Title:                        Multi detector CT findings of neurogenic appendicopathy
Authors:            Tatakawa, H et al - (Dept. of Radiology, Kyoto Hospital, Japan)
Source:                        European Journal of Radiology Extra - Vol. 77, Issue 2
Date:                        February 2011

Item 5
Title:                        Evaluation of Neurogenic Appendicopathy in negative appendectomy in pediatric patients.
Authors:            Melnikov, I et al (Serbia)
Source:                        Health Med, Vol. 6, Issue 2
Date                        June 2012


Item 6
Title:                        Neurogenic Appendicopathy
Author:                        Doberauer, W - (Surgeon,  Geriatric Hospital, Vienna, Austria)
Source:                        Journal of Gerontology, Vol. 12, Issue 4
Date:                        1957

Item 7
Title:                        Neurogenic Inflammation in Chronic Pain Condition
Author:                        Janicki, T - (Director, Pelvic Pain Centre, University of Cleveland, Ohio, USA)
Source:                        International Pelvic Pain Society, Vol. 11, Issue 1
Date:                        2010 ?


Item 8
Title:                        Vermiform Appendix Disease
Author:                        Pathology Associates of Lexington, West Columbia, SC.
Source:                        Publication of  Pathology Associates of Lexington.
Date:                        October 2010

Item 9
Title:                        Neurogenic appendicopathy: A frequent and almost unknown disease
Authors:            Guller, U et al - (Dept. of Surgery, University of Basel, Switzerland)
Source:                        Chirurgie, Vol. 72 Issue 6
Date                        June 2001

 Item 10
Title:                        Pathology of the appendix in children: An institutional experience and review of the literature
Author:                        Rabah, R. - ( Children's Hospital of Cleveland, Ohio, USA)
Source:                        Pediatric Radiology, Vol. 37 Issue 1
Date:                        January 2007