December 21, 2014
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Digestive Health

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Appendicitis: what is it?

The appendix is a small worm-shaped tube that projects from the large intestine near the point where it joins the small intestine, in the lower right side of your abdomen. It has no known function now, but may have played a role in our ancient ancestors who ate a much higher fibre diet. Appendicitis is an inflammation of the appendix, usually requiring surgical treatment.

Although the cause of appendicitis is not fully understood, it is thought that a blockage of some kind, inside the appendix, causes the appendix to become inflamed and infected. The blockage may be from a small hard piece of stool plugging the appendix (called a fecolith) or swelling of lymph tissue in the appendix wall (this may be the common cause in children). If the inflammation continues untreated, the appendix wall may rupture and spill bacteria-laden intestinal contents into the abdominal cavity. This, in turn, can lead to peritonitis, an inflammation of the lining of the abdominal cavity. Peritonitis is extremely painful and will make even the toughest patients eventually seek medical help. The most serious outcome of a burst appendix is the release of bacteria and bacterial products into the bloodstream, called bacteremia, which is life-threatening and must be treated immediately.

There is no way of preventing appendicitis and to date, the only recognized treatment is an appendectomy, which is the surgical removal of the appendix. Mild cases may settle with antibiotics, but recurrence is common.

Signs and symptoms

Although appendicitis is fairly common (it is one of the most common abdominal operations), it is worth keeping in mind that the vast majority of abdominal complaints are not due to appendicitis. After all, we have all experienced abdominal cramps or pain at one time or another, but most of us have never had our appendix removed.

Appendicitis can occur at any age, although it is most common in people between the ages of 10 and 30. Characteristic symptoms of appendicitis include constant and progressive abdominal pain, nausea, vomiting, a fever of approximately 37.8°C to 38.3°C, and loss of appetite. However, not everyone will have all these symptoms. Usually, pain will first be noticed in the mid abdomen in the region of the navel, with nausea and vomiting developing before or shortly afterward. After a few hours, the pain typically shifts to the right lower portion of the abdomen. When your doctor presses on this area, it will feel tender.

In infants and children the pain may be more generalized. In pregnant women and elderly people the pain may be less severe and the abdomen less tender. Consequently, appendicitis in children, pregnant women, and the elderly may be difficult to diagnose. Also, in pregnant women, the appendix may be pushed up into the upper right abdomen by the enlarged uterus, so the location of tenderness may complicate the diagnosis.

Diagnosis

The diagnosis of appendicitis is made by:

  1. carefully listening to the patient's story (taking the "history")
  2. physical examination of the patient by a physician or surgeon
  3. blood and urine tests (usually the white cell count in the blood is moderately elevated, urine will be normal or contain only a few white cells or red cells)
  4. other tests including plain X-rays, abdominal ultrasound, rarely CT scan or MRI
  5. Sometimes, particularly in women, where problems with the appendix may be difficult to distinguish from problems in the right ovary or tube, the surgeon may choose to perform a diagnostic laparoscopy of the abdomen in the operating room. A laparoscope is a small fiberoptic viewing tube that permits the surgeon to visually inspect the contents of the abdomen. If the appendix is found to be abnormal, it can often be removed through small incisions using the laparoscope to guide the procedure. If the problem is something else instead of appendicitis, appropriate management can then be undertaken.

Treatment

Acute appendicitis is a surgical emergency, and your doctor will likely suggest an operation as soon as a diagnosis of appendicitis is made. Antibiotics and intravenous fluid are generally given in preparation for surgery.

If an appendectomy is performed early on, the chance of significant complication or death is very low and you will most likely be able to leave the hospital within 2 or 3 days of surgery. If the appendix is found at surgery to have been ruptured, or if you have diabetes or other problems that might reduce your ability to fight infections, a course of antibiotics may be prescribed afterwards.

Currently, there are 2 ways of performing an appendectomy, and the method your doctor chooses will depend on your individual circumstances. The standard method involves making a 2- or 3-inch incision in the right lower portion of the abdomen through which the appendix is removed. A newer method, called a laparoscopic appendectomy is performed using a laparoscope (a fiber-optic viewing tube), which is inserted through a small incision, usually just below your navel. Additional grasping and cutting instruments are inserted through other small incisions in order to do the removal. Both methods of appendectomy are done in a hospital under general anesthetic. Recovery may be a bit faster if the procedure is performed by laparoscopy than by the more traditional "open" incision route.

 
Michael E. Pezim, MD

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