Chronic right lower quadrant abdominal pain: laparoscopic approach.

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 unremarkable group? By using the advantages of laparoscopic technique, the authors are looking for the diagnosis and management guidline of this condition.

MATERIAL AND METHOD: 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) Appendectomy by laparoscopic technique. 2) No appendectomy and post-operative anti-parasitic drugs. 3) No appendectomy 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 Fisher's 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 diference (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.