Appendicitis

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What is Appendicitis?

Appendicitis is an inflammation that develops from the inside of the vermiform appendix. The appendix is a small finger-like tube that projects from a pouch-like structure called the caecum, near the junction of the large and the small intestine, and usually found on the right side of the abdomen.

Is Appendicitis a Medical emergency?

Appendicitis is a medical emergency and requires immediate medical and surgical intervention.

Types

Appendicitis could be of the following types:

  • Acute Appendicitis: A sudden development of inflammation of the appendix
  • Spontaneously resolving Appendicitis: This is seen when disease resolves on its own when the obstruction is relieved such as sometimes seen in fecolith or impacted feces
  • Recurrent Appendicitis: This is when there is more than one episode of disease that resolved spontaneously and confirmed as due to inflammation after an appendectomy
  • Chronic Appendicitis: This is when the individual has symptoms of pain for a period of over 3 weeks with a confirmed diagnosis of Appendicitis, and the pain subsides completely after an appendectomy, and the pathological examination of the removed appendix confirms inflammatory changes.

Causes

Appendicitis is caused when there is an obstruction inside which causes excess production and collection of secretions and mucus, multiplication of the intestinal bacteria within the appendix, inflammatory reaction, increase in pressure, obstruction of blood flow and resulting tissue death, and eventually the formation of gangrene and perforation or rupture of the appendix wall.

The various causes that can lead to an obstruction include:

  • Inflammatory bowel disease
  • Foreign bodies
  • Worms
  • Impacted feces
  • Calcified fecal deposits or fecoliths

Signs & symptoms

The symptoms and signs of Appendicitis may include:

  • Pain that begins suddenly in the lower right side of the abdomen
  • Pain that begins suddenly and moves to the lower right side (usually not seen in children or infants)
  • Abdominal pain that becomes worse on coughing, walking, or sudden movements
  • Pain that increases when deep pressure is applied to the abdomen and suddenly released (rebound tenderness)
  • Stiffness of the abdominal muscles that worsens on touch (rigidity and guarding); (this may be absent if the inflamed appendix is in the pelvis)
  • Nausea and vomiting
  • Loss of appetite
  • Fever is usually of a low grade in the beginning and increases as the condition progresses
  • Abdominal bloating, flatulence
  • Constipation or diarrhea

Investigations

The following investigations may be done to establish a diagnosis are:

  • Blood tests: Such as CBP and ESR, to detect the presence of infection or inflammation
  • Urine tests: To rule out pregnancy, ectopic pregnancy, kidney infections, or stones
  • Imaging tests:
    • Abdominal ultrasound: Preferably doppler ultrasonography
    • CT scan
    • MRI: Preferred over CT in pregnant women and children 

Diagnosis

A diagnosis of Appendicitis is established based on medical history, clinical evaluation, and results of the investigations. An Alvarado score of 7 or more is predictive of acute Appendicitis and is arrived at by adding the scores of the symptoms and signs such as nausea & vomiting, fever, tenderness, pain, etc., that are present.

Course & Stages

The stages of Appendicitis are as follows:

  • Early-stage Appendicitis: This is the first stage where the obstruction of the hollow part of the appendix causes swelling of the inner lining, increased secretion of mucus and fluids, and multiplication of bacteria. The pain is usually around the umbilicus at this stage and may last for a few hours.
  • Suppurative Appendicitis: In this stage, the increased pressure on the walls of the appendix causes the blood flow to the appendix to be reduced, along with the stretching and thinning of the appendix wall, and the spread of the bacteria into the wall. At this point, the enlarged appendix is touching the peritoneum, and this causes a shift of the pain from the navel to right lower side of the abdomen, and the pain now is more severe and constant.
  • Gangrenous Appendicitis: There is the formation of blood clots in the veins and arteries and the subsequent formation of gangrene in the wall of the appendix.
  • Perforated Appendicitis: The continued tissue death in the wall of the appendix leads to a rupture, and the spilling of the contents of the appendix into the abdomen and causing peritonitis.
  • Phlegmonous Appendicitis or Abscess formation: The ruptured appendix can be sealed off by the adjacent intestines or the peritoneal covering layer of the intestines (omentum), leading to the formation of a localized abscess.

Treatment options

The mainstay of management in Appendicitis is surgery.

Medical management

The role of medical management in Appendicitis is limited and may include:

  • Antibiotics: Are given before surgery as well as for the treatment of infections if present. There is a high possibility of recurrence if treated with antibiotics alone and the condition will eventually require surgical intervention.
  • Analgesics: To provide relief from pain

Interventional including surgery and indications for surgery

Surgical intervention is advisable within 48 hours of the onset of symptoms, as intervention beyond this time is associated with a greater risk of complications. In cases where the appendix has already burst, it may be advisable depending on the condition of the individual, to either perform emergency surgery or treat with IV antibiotics, and drainage of the abscess, and performing a surgery (interval appendectomy) 4 - 8 weeks later. Surgical intervention includes a procedure called appendectomy or appendicectomy or appendicectomy. The surgery may be:

  • Appendectomy via open surgery: The abdomen is opened under general anesthesia to remove the appendix
  • Laparoscopic appendectomy: This minimally invasive procedure is suitable and preferred in the following cases:
    • Uncomplicated Appendicitis
    • Elderly patients
    • Pediatric patients
    • Pregnant women
    • Obese patients

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

It cannot be prevented. Some measures that can be taken during recovery from surgery for the treatment of Appendicitis include:

  • Getting ample rest
  • Avoiding strenuous activity and lifting heavyweights
  • Supporting the abdomen when coughing

Complications

The complications due to Appendicitis may include:

  • Rupture of the inflamed appendix: This can lead to the spreading of the bacteria within the abdomen and subsequently to serious infections
  • Formation of an abscess
  • Stump Appendicitis (rare): Inflammation of the small part (stump) of the appendix that remains after appendectomy
  • Complications of surgery:
    • Wound infection
    • Bleeding
    • Bowel obstruction

Prognosis

The prognosis for Appendicitis is generally good for cases that are diagnosed and managed immediately. The recovery from disease and surgery depends on the age, the general condition of the individual, the presence of complications, etc. The usual recovery time is about 2 weeks in adults and about 3 weeks in children.

When to contact the doctor or hospital? / How to identify the emergency or complications?

Appendicitis is a medical emergency and it is advisable to seek immediate medical attention as soon as the symptoms are noticed.

Indications for hospitalization if required

Hospitalization will be required for Appendicitis mainly for the surgical management of the condition.

Suggested clinical specialist/ Departments to consult for this condition

Appendicitis will be attended to by the Emergency Department, Gastroenterologists, and Laparoscopic Surgeons.

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