Appendicitis is an inflammation of the appendix. The appendix is a small pouch in a finger-like shape that is connected to your large intestine, in the lower right part of the abdomen. In humans, the appendix has no known physiological role. Inflammation of the appendix can occur when the opening of the appendix is obstructed, a situation that leads to infection. It is the most common indication for emergency abdominal surgery.
Although appendicitis can affect any person at any age, the peak incidence is between 10 and 30 years of age. In the United States, appendicitis affects approximately 7% of the population and is 1.4 times more frequent in men than in women. The incidence is also higher among the white population.
Appendicitis is not a contagious disease, and individuals suffering from it do not constitute a risk to others. Although there isn't an effective method to prevent appendicitis, the condition is less frequent in people who have diets rich in fiber-containing foods, such as fruits and vegetables.
Appendicitis is a medical emergency that requires the immediate removal of the swollen appendix. The overall mortality rate is low (0.2-0.8%), and death is most often caused by complications of the disease rather than from surgery. In older patients (70 years or higher), the mortality rate increases considerably because of late diagnosis (leading to higher rates of perforation) and less resistance to infections (due to the overall health status).
The cause of appendicitis isn't always clear, however, it can occur in different ways such as:
- Obstruction of the appendix – a foreign object, food, a stool, enlargement of local lymph nodes or, in rare cases, a tumor blocks the opening of the appendix.
- Infection – such as a gastrointestinal viral infection or from other types of inflammation.
If not treated immediately, bacteria can quickly multiply causing severe inflammation and a buildup of pus which can lead to the rupture (perforation) of the appendix. After perforation, the infection will spread to the abdominal cavity causing peritonitis – a severe and potentially life-threatening condition.
Pain is the most common symptom of appendicitis and its location varies among individuals, depending on the age and exact position of the appendix. People suffering from this condition might feel like they are having stomach cramps or severe indigestion.
Symptoms of appendicitis include:
- Abdominal pain – due to contractions of the appendix or distention of its lumen. It is normally located around the navel (belly button). It is initially described as mild or cramping, but eventually becomes steady and sharp. With spreading of the infection and inflammation, it becomes more localized and moves from the right lower abdomen to a more specific position: the McBurney's point.
- Abdominal rebound tenderness – this is the most important and reliable symptom and occurs after releasing pressure applied to the lower right abdomen.
- Nausea and vomiting
- Loss of appetite
- Constipation or diarrhea
- Inability to pass gas.
Symptoms of appendicitis are commonly indistinguishable or particularly related to other diseases such as gallbladder problems, urinary tract infection, Crohn's disease, gastritis, intestinal infection, and ovary problems.
In pregnant women, a right lower abdominal pain and tenderness dominate in the first trimester, but a right upper side or right flank abdominal pain might be reported if appendicitis develops at later stages of pregnancy.
Diagnosing appendicitis might be difficult because the symptoms may change quickly and unpredictably. This condition is typically difficult to diagnose in young children, the elderly or pregnant women.
Tests and procedures used to diagnose appendicitis include:
- Abdominal exam - to detect inflammation.
- Blood test - to check for elevated white blood cell count that indicates the presence of infection. Blood tests are inexpensive, quick, and widely available, however, the findings are non-specific.
- Urine test - to rule out that an urinary tract infection or a kidney stone are not causing the pain.
- Imaging exams, such as ultrasound, X-ray or computed tomography (CT) scan – to assess enlargement of the appendix.
- Diagnostic laparoscopy - if the diagnosis is inconclusive and the patient is at high risk for complications from a suspected appendicitis (for example, peritonitis), a surgeon may perform an exploratory laparoscopy.
CT scan is the imaging tool of choice as it is more precise than ultrasound and X-ray in the diagnosis of appendicitis in both adults and adolescents. However, ultrasound can be particularly useful to detect appendicitis in children.
There is no conclusive clinical evidence showing that the digital rectal examination provides useful information for diagnosis of appendicitis, nonetheless, successful malpractice claims often invoke failure to perform this exam.
During a physical exam, your doctor might look for the following signs:
- Guarding - Happens when a patient tenses the abdominal muscles during examination. Can be voluntary, occurring upon contact of the doctor's hand with the abdomen, or involuntarily, occurring before contact.
- Rebound tenderness - Is tested by applying pressure to the abdomen and then releasing it. If pain is experienced upon release of the pressure, then the test is positive.
- Rovsing's sign - Right lower abdominal pain upon releasing pressure exerted on the left lower side.
- Obturator sign - Right lower abdominal pain with rotation of the flexed right hip.
- Psoas sign or Obraztsova's sign - Right lower abdominal pain upon extension of the right hip or when the right hip is flexed against resistance.
- Dunphy's sign - Voluntary cough provokes a sharp pain in the right lower abdomen.
- Blumberg sign - Sudden release of pressure after deep palpation over the appendix causes a severe pain.
- Bartomier-Michelson's sign - Palpitation of the right iliac region produces more intense pain response when patient is lying on the left side compared to when patient is lying down and facing up.
- Sitkovskiy (Rosenstein)'s sign - Increasing pain when the patient lies on the left side.
These signs are present only in a small fraction of patients with appendicitis. Their absence should not be used to rule out inflamed appendix.
Scoring systems are available to guide evaluation of the likelihood of appendicitis based on the result of clinical and laboratory tests. The most commonly used is the Alvarado system. According to this method, pain in the right-inferior abdominal region and increased white blood cell count are the factors with higher score (2 points). The other diagnosis elements (anorexia; nausea and/or vomiting; rebound tenderness; fever and neutrophilia) have a score of 1. A total score above 5 indicates acute appendicitis.
All patients with suspected or confirmed appendicitis should be hospitalized. Surgical removal of the appendix is the indicated treatment for most situations and should be performed as soon as possible. Other treatments may be necessary depending on the status of the disease and condition of the patient.
Before the Surgery: The patient is kept from eating and drinking in preparation for the surgery and is hydrated by the use of an intravenous drip. Antibiotics are administered intravenously to minimize bacterial growth. This will reduce spread of the infection in the abdomen, improves wound healing and prevents complications after surgery.
Appendectomy: Is an open, conventional and uncomplicated procedure, in which the surgeon removes the appendix through an incision in the right lower abdomen. Normally, the recovery period is slow. General anesthesia is applied in order to keep the muscles totally relaxed and to keep the patient unconscious. Most uncomplicated appendectomies today are done via laparoscopy.
Laparoscopic Appendectomy: This surgical option allows a faster recovery period and heals with minimal scarring. The surgeon makes three to four incisions in the abdomen. A laparoscope is inserted into one of the incisions. The laparoscope is attached to a monitor outside the patient's body and it is intended to assist the surgeon in inspecting the infected area in the abdomen. Two incisions are made for the specific removal of the appendix using surgical instruments. Laparoscopic surgery isn't suitable for everybody. If the appendix is perforated and infection has spread to other areas of the abdominal cavity, an open appendectomy is required. This will allow the surgeon to clean the abdominal cavity.
Note: There are no side effects from the absence of the appendix. It is not well understood if the appendix serves a purpose or not, but apparently, the body can function normally without it.
After the Surgery: In order to prevent complications immediately following the surgery, the patient's vital signs should be closely monitored in an intensive-care unit. If necessary, medication for pain relief could be administrated. When the patient is totally awake, he/she is moved to a hospital room to recover. Within 12 hours after the surgery the patient can stand up and move around. The day after the surgery, the diet will consist of liquids and then progress to a regular diet as soon as the intestines resume normal functioning. Patients are normally required to walk over short distances several times per day. This will reduce the likelihood of any blood clot formation and will aid in recovery. Normally, the patient can start regular activities within 2 to 3 weeks following the surgery, and full recovery is expected within 4 to 6 weeks.
During this recovery time the patient can take steps to help healing after surgery:
- Support the abdomen when coughing - use a pillow and place it over the abdomen and apply enough pressure before coughing to avoid the incision from opening.
- Avoid strenuous activities - for laparoscopic appendectomy, limit activity for at least three to five days after the surgery. For an open appendectomy, limit activity for at least 10 to 14 days after surgery. Consult your doctor about when you can go back to your normal activity pattern.
- Enough sleep and rest.
- Call a doctor if pain medications aren't helping - pain causes stress on the body and slows the healing process.
Medication is given to eradicate infection, manage pain and prevent further complications. Antibiotics used for pre and/or post-appendectomy treatment are:
- Piperacillin and tazobactam sodium
- Ampicillin and sulbactam
Antibiotic administration decreases the rate of postoperative wound infection. When needed, analgesics can be used to relieve abdominal pain. Opioids, such as morphine sulfate, are normally given in the post-operative setting.
Appendicitis is a medical emergency and should be treated immediately using conventional methods known to be effective, i.e. surgical removal of the appendix. Alternative and complementary medicine treatments can be useful during recovery from surgery to manage pain and improve overall health status.
Several non-strenuous activities may help you to distract you from the pain. Vitamins and antioxidants help to fight infection and improve overall health status.
A diet rich in fruits and vegetables was associated with lower rates of appendicitis, but a direct link between nutrition and prevention of this condition has not been conclusively established.
When the appendix is removed before it ruptures, the patient will recover easily and fast after the surgery. However, if the appendix ruptures before surgery, the patient's recovery is delayed and is more prone to develop an abscess or other complications. Generally, the prognosis is very good.
Complications of appendicitis and/or appendectomy that may occur include:
- Wound infection (after surgery)
- Wound opening or bursting (after surgery)
- Bowel obstruction
- Abdominal and/or pelvic abscess
- Stump appendicitis - inflammation of a remnant of the appendix after incomplete appendectomy (rare)
- Peritonitis (following perforation of the appendix)
- Death (rare)
Occurrence of appendicitis is difficult to predict and prevent. Keeping a good health status, through diet and physical exercise, helps to fight infection and to recover from surgery.
This medical emergency is less frequent in people that follow a diet rich in fruits and vegetables.
Living with appendicitis is very painful. If you are experiencing symptoms of appendicitis, consult a doctor as fast as possible. Delaying treatment will increase the risk of severe complications. If administered soon, after onset of symptoms, treatment for appendicitis has excellent outcomes, however, if the disease is not treated it can lead to a life-threatening condition.
An increasing number of modern imaging procedures, including magnetic resonance imaging, are being developed, tested and applied in the preoperative setting for the evaluation of appendicitis. Investigators are also trying to improve diagnosis through research into new and more specific markers of the disease.