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 it 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 this
problem, but it occurs most often between the ages of 10 and
30.
The appendix is a small, tube-like
structure attached to the first part of the large intestine,
also called the colon. It is located in the lower
right portion of the abdomen, near where the small intestine
attaches to the large intestine.
- Causes
- Symptoms
- Diagnosis
- Treatment
- Complications
- Points to Remember
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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.
