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The appendix is a small, tube-like structure attached to
the first part of the large intestine, also called the colon.
The appendix is located in the lower right portion of the
abdomen. It has no known function. Removal of the appendix
appears to cause no change in digestive function.
Appendicitis is an inflammation of the appendix. Once it
starts, there is no effective medical therapy, so appendicitis
is considered a medical emergency. When treated promptly,
most patients recover without difficulty. If treatment is
delayed, the appendix can burst, causing infection and even
death. Appendicitis is the most common acute surgical emergency
of the abdomen. Anyone can get appendicitis, but it occurs
most often between the ages of 10 and 30.
Causes
The cause of appendicitis relates to blockage of the inside
of the appendix, known as the lumen. The blockage leads to
increased pressure, impaired blood flow, and inflammation.
If the blockage is not treated, gangrene and rupture (breaking
or tearing) of the appendix can result.
Most commonly, feces blocks the inside of the appendix.
Also, bacterial or viral infections in the digestive tract
can lead to swelling of lymph nodes, which squeeze the appendix
and cause obstruction. This swelling of lymph nodes is known
as lymphoid hyperplasia. Traumatic injury to the abdomen
may lead to appendicitis in a small number of people. Genetics
may be a factor in others. For example, appendicitis that
runs in families may result from a genetic variant that predisposes
a person to obstruction of the appendiceal lumen.
Symptoms
Symptoms of appendicitis may include
- pain in the abdomen, first around the belly button, then
moving to the lower right area
- loss of appetite
- nausea
- vomiting
- constipation or diarrhea
- inability to pass gas
- low fever that begins after other symptoms
- abdominal swelling
Not everyone with appendicitis has all the symptoms. The
pain intensifies and worsens when moving, taking deep breaths,
coughing, or sneezing. The area becomes very tender. People
may have a sensation called "downward urge," also known as "tenesmus," which
is the feeling that a bowel movement will relieve their discomfort.
Laxatives and pain medications should not be taken in this
situation. Anyone with these symptoms needs to see a qualified
physician immediately.
People With Special Concerns
Patients with special conditions may not have the set of
symptoms above and may simply experience a general feeling
of being unwell. Patients with these conditions include
- people who use immunosuppressive therapy such as steroids
- people who have received a transplanted organ
- people infected with the HIV virus
- people with diabetes
- people who have cancer or who are receiving chemotherapy
- obese people
Pregnant women, infants and young children, and the elderly
have particular issues.
Abdominal pain, nausea, and vomiting are more common during
pregnancy and may or may not be the signs of appendicitis.
Many women who develop appendicitis during pregnancy do not
experience the classic symptoms. Pregnant women who experience
pain on the right side of the abdomen need to contact a doctor.
Women in their third trimester are most at risk.
Infants and young children cannot communicate their pain
history to parents or doctors. Without a clear history, doctors
must rely on a physical exam and less specific symptoms,
such as vomiting and fatigue. Toddlers with appendicitis
sometimes have trouble eating and may seem unusually sleepy.
Children may have constipation, but may also have small stools
that contain mucus. Symptoms vary widely among children.
If you think your child has appendicitis, contact a doctor
immediately.
Older patients tend to have more medical problems than young
patients. The elderly often experience less fever and less
severe abdominal pain than other patients do. Many older
adults do not know that they have a serious problem until
the appendix is close to rupturing. A slight fever and abdominal
pain on one's right side are reasons to call a doctor right
away.
All patients with special concerns and their families need
to be particularly alert to a change in normal functioning
and patients should see their doctors sooner, rather than
later, when a change occurs.
Diagnosis
Medical History and Physical Examination
Asking questions to learn the history of symptoms and a
careful physical examination are key in the diagnosis of
appendicitis. The doctor will ask many questions—much
like a reporter—trying to understand the nature, timing,
location, pattern, and severity of pain and symptoms. Any
previous medical conditions and surgeries, family history,
medications, and allergies are important information to the
doctor. Use of alcohol, tobacco, and any other drugs should
also be mentioned. This information is considered confidential
and cannot be shared without the permission of the patient.
Before beginning a physical examination, a nurse or doctor
will usually measure vital signs: temperature, pulse rate,
breathing rate, and blood pressure. Usually the physical
examination proceeds from head to toe. Many conditions such
as pneumonia or heart disease can cause abdominal pain. Generalized
symptoms such as fever, rash, or swelling of the lymph nodes
may point to diseases that wouldn't require surgery.
Examination of the abdomen helps narrow the diagnosis. Location
of the pain and tenderness is important. Pain is a symptom
described by a patient; tenderness is the response to being
touched. Two signs, called peritoneal signs, suggest that
the lining of the abdomen is inflamed and surgery may be
needed: rebound tenderness and guarding. Rebound tenderness
is when the doctor presses on a part of the abdomen and the
patient feels more tenderness when the pressure is released
than when it is applied. Guarding refers to the tensing of
muscles in response to touch. The doctor may also move the
patient's legs to test for pain on flexion of the hip (psoas
sign), pain on internal rotation of the hip (obturator sign),
or pain on the right side when pressing on the left (Rovsing's
sign). These are valuable indicators of inflammation but
not all patients have them.
Laboratory Tests
Blood tests are used to check for signs of infection, such
as a high white blood cell count. Blood chemistries may also
show dehydration or fluid and electrolyte disorders. Urinalysis
is used to rule out a urinary tract infection. Doctors may
also order a pregnancy test for women of childbearing age
(those who have regular periods).
Imaging Tests
X rays, ultrasound, and computed tomography (CT) scans can
produce images of the abdomen. Plain x rays can show signs
of obstruction, perforation (a hole), foreign bodies, and
in rare cases, an appendicolith, which is hardened stool
in the appendix. Ultrasound may show appendiceal inflammation
and can diagnose gall bladder disease and pregnancy. By far
the most common test used, however, is the CT scan. This
test provides a series of cross-sectional images of the body
and can identify many abdominal conditions and facilitate
diagnosis when the clinical impression is in doubt. All women
of childbearing age should have a pregnancy test before undergoing
any testing with x rays.
In selected cases, particularly in women when the cause
of the symptoms may be either the appendix or an inflamed
ovary or fallopian tube, laparoscopy may be necessary. This
procedure avoids radiation, but requires general anesthesia.
A laparoscope is a thin tube with a camera attached that
is inserted into the body through a small cut, allowing doctors
to see the internal organs. Surgery can then be performed
laparoscopically if the condition present requires it.
Treatment
Surgery
Acute appendicitis is treated by surgery to remove the appendix.
The operation may be performed through a standard small incision
in the right lower part of the abdomen, or it may be performed
using a laparoscope, which requires three to four smaller
incisions. If other conditions are suspected in addition
to appendicitis, they may be identified using laparoscopy.
In some patients, laparoscopy is preferable to open surgery
because the incision is smaller, recovery time is quicker,
and less pain medication is required. The appendix is almost
always removed, even if it is found to be normal. With complete
removal, any later episodes of pain will not be attributed
to appendicitis.
Recovery from appendectomy takes a few weeks. Doctors usually
prescribe pain medication and ask patients to limit physical
activity. Recovery from laparoscopic appendectomy is generally
faster, but limiting strenuous activity may still be necessary
for 4 to 6 weeks after surgery. Most people treated for appendicitis
recover excellently and rarely need to make any changes in
their diet, exercise, or lifestyle.
Antibiotics and Other Treatments
If the diagnosis is uncertain, people may be watched and
sometimes treated with antibiotics. This approach is taken
when the doctor suspects that the patient's symptoms may
have a nonsurgical or medically treatable cause. If the cause
of the pain is infectious, symptoms resolve with intravenous
antibiotics and intravenous fluids. In general, however,
appendicitis cannot be treated with antibiotics alone and
will require surgery.
Occasionally the body is able to control an appendiceal
perforation by forming an abscess. An abscess occurs when
an infection is walled off in one part of the body. The doctor
may choose to drain the abscess and leave the drain in the
abscess cavity for several weeks. An appendectomy may be
scheduled after the abscess is drained.
Complications
The most serious complication of appendicitis is rupture.
The appendix bursts or tears if appendicitis is not diagnosed
quickly and goes untreated. Infants, young children, and
older adults are at highest risk. A ruptured appendix can
lead to peritonitis and abscess. Peritonitis is a dangerous
infection that happens when bacteria and other contents of
the torn appendix leak into the abdomen. In people with appendicitis,
an abscess usually takes the form of a swollen mass filled
with fluid and bacteria. In a few patients, complications
of appendicitis can lead to organ failure and death.
Points to Remember
- The appendix is a small, tube-like structure attached
to the first part of the colon. Appendicitis is an inflammation
of the appendix.
- Appendicitis is considered a medical emergency.
- Symptoms of appendicitis include pain in the abdomen,
loss of appetite, nausea, vomiting, constipation or diarrhea,
inability to pass gas, low-grade fever, and abdominal swelling.
Not everyone with appendicitis has all the symptoms.
- Physical examination, laboratory tests, and imaging tests
are used to diagnose appendicitis.
- Acute appendicitis is treated by surgery to remove the
appendix.
- The most serious complication of appendicitis is rupture,
which can lead to peritonitis and abscess.
To read the rest of this article and related material from
The National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), please click here: http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/index.htm
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