Appendicitis: Causes, Symptoms and Treatment

An appendix also called a “Vermiform appendix”, is a vestibule small finger-like pouch that is attached to the end of the caecum (part of the large intestine).  The average length of the appendix is about 8-10cm. Although, the exact function of the appendix is unclear. From the studies, it is believed that the appendix acts as a storehouse for good bacteria which helps in “rebooting” the digestive system, post diarrheal illness. Appendicitis is a condition where we notice inflammation of the appendix, which will result in causing severe pain in the right lower abdomen, fever, nausea, and vomiting. Appendicitis is an emergency condition, which has to be treated immediately.

Causes of appendicitis

The causes of appendicitis are listed below:

• In most cases, the cause is idiopathic (the cause is not known).
• Blockage in the opening where the appendix is connected to the intestine
• Trauma
• Inflammatory bowel diseases
• Intestinal worms infection
• Tumors (extra growth inside the appendix)
• Enlarged lymphoid follicles 

Risk factors for appendicitis

The risk factors for appendicitis are listed below:

• Age- appendicitis is seen most common in teens and people in their 20’s. However, it can affect any age group.
• Gender- the incidence is higher in men compared to women
• Hereditary- Patients with a family history of appendicitis, are at higher risk of having appendicitis.
• Children diagnosed with cystic fibrosis, have an increased risk of getting appendicitis

Symptoms of appendicitis

The most common signs and symptoms associated with appendicitis are listed below:

• Severe pain in the abdomen, often worsen with time
• Sudden onset of pain, which usually begins in the umbilical area (naval) and later shifts to the right lower abdomen.
• Nausea and vomiting
• Fever
• Loss of appetite
•  Abdominal bloating
• Constipation or diarrhea
• Increase in severity of pain with cough, or any other sudden movements 

Physical examination findings for appendicitis

The physical examination findings for appendicitis include:

• Tenderness
• Rebound tenderness
• Accessory signs which are present in appendicitis include:

a) Rovsing sign: During this test, palpation in the left lower quadrant of the abdomen, pain exerts on the right lower quadrant.

b) Obturator sign: During this test, the right lower quadrant pain is noticed with internal and external rotation of the flexed right hip.

c) Psoas sign: During this test, extension or flexion of the right hip against resistance will result in causing pain in the right lower quadrant.

d) Markle sign

e) Dunphy sign: During this test, sharp pain in the right lower quadrant is increased by a voluntary cough

Diagnosis of appendicitis

Whenever the patient experiences any of the above-mentioned symptoms, the patient should consult the doctor immediately. The doctor in order to confirm the condition, advises the patient to undergo a couple of tests. They are listed below:

• Physical examination- During the physical examination, the doctor will palpate (touch) the abdomen to look for any kind of tenderness (pain) present.
• Records family history of the patient- to know if any of the patient’s family members were diagnosed with appendicitis.
• Blood tests- They include a complete blood count (an increase in the number of white blood cells, indicates signs of infection), and a CRP (C-reactive protein) test.
• Urine routine tests
• Investigational scans- They include ultrasonography of the abdomen, CT scan, or MRI scan of the abdomen.

Treatment for appendicitis

The treatment of appendicitis is usually done on an emergency basis. Once the condition is confirmed through the laboratory and investigational scans, and based on the overall condition of the patient, the doctor will plan for treatment. The treatment options include:

• Conservative management- the patient initially will be treated through conservative management, which includes antibiotics, painkillers, iv fluids, etc.
• Surgery- Surgery is the treatment of choice for treating appendicitis. Due to advancements in technology, appendicitis can be operated through

a) open (traditional) appendicectomy- During this procedure, the surgeon makes an incision (cut) in the right lower quadrant of the abdomen, exposes the inflamed appendix, and takes it out. Closes the abdominal layers with sutures (stitches). A drainage tube might be placed in case of a burst appendix or pus noticed in the appendix.

b) Laparoscopic appendicectomy- This procedure is also called a minimally invasive surgery or a keyhole surgery. During this procedure, three to four small incisions are made in the abdomen, and a small tube along with a camera is placed inside the abdomen. The appendix is identified and taken out.  

Post-operative care

Post-surgery, the patient is advised to stay around 2-3 days in the hospital. The patient might experience pain associated with discomfort in the operated area for 5-6 days. In order to minimize the pain and avoid post-operative infection, the doctor will prescribe antibiotics, painkillers, antacids, etc. The patient is advised to have regular follow up with the doctor for further management and care. The patient can get back to their work after 1-2 weeks post-surgery.

Complications of appendicitis

The complications associated with appendicitis are listed below:

• Bleeding
• Infection- sepsis
• Ruptured appendix- peritonitis
• Collection of pus in the abdomen
• Scarring
• Hernia

Outcome of appendicitis

The prognosis of appendicitis in most patients is good. The patients recover completely after the procedure. The patients can get back to their usual routine life within 2-3 weeks after the procedure.

 Prevention of appendicitis

Since the exact cause of appendicitis is unknown, appendicitis cannot be prevented completely. However, there are a few measures that can lower the risk of causing appendicitis. Some of the measures are listed below:

• Eating a high-fiber diet
• Adding a lot of fruits, green leaves, and vegetables to the diet
• Maintain a healthy lifestyle
• Consult the doctor immediately, in case you notice any abnormal signs and symptoms 

Morbidity and mortality associated with appendicitis

Early diagnosis and treatment will result in an overall good prognosis for the patients. However, delay in diagnosis and treatment can result in causing some serious complications which include, rupture of the appendix, and sepsis, in a few cases if left untreated can cause death. The overall mortality rate associated with appendicitis is about 0.2-0.8%, and the mortality in children is seen at about 0.1% to 1%, in patients older than 70 years of age, the mortality rate rises to more than 20%, due to delay in diagnosis and treatment.

References

1. https://www.webmd.com/digestive-disorders/picture-of-the-appendix#:~:text=Normally%2C%20the%20appendix%20sits%20in,remnant%20from%20our%20evolutionary%20past.
2. https://www.healthline.com/health/appendicitis#causes
3. https://www.hopkinsmedicine.org/health/conditions-and-diseases/appendicitis
4. https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543#:~:text=Appendicitis%20is%20an%20inflammation%20of,the%20navel%20and%20then%20moves.
5. https://www.nhs.uk/conditions/appendicitis/treatment/
6. https://www.healthline.com/health/appendicitis#prevention
7. https://emedicine.medscape.com/article/773895-overview
8. https://emedicine.medscape.com/article/773895-overview#a7