Appendicitis is
an emergency medical condition where the appendix becomes inflamed
(red, swollen and painful). Appendicitis is a quite common medical
condition. On average, about 6% of the population (that is about 1 in 16
people) will develop appendicitis sometime during their
lifetime.
Some of the
common symptoms of appendicitis include abdominal (tummy)
pain, nausea and vomiting (feeling and being physically sick), which start as
mild and gradually get worse within a few hours. The abdominal pain usually
starts around the umbilicus (belly-button), and then localises (moves) to the
right iliac fossa (the right lower part of the tummy), where
the appendix normally lies.
However, it must
be mentioned, that some people have less typical symptoms.
An operation (known as appendicectomy or appendectomy)
to remove the inflamed appendix is usually performed before
the appendix perforates (bursts). A perforated appendix is
a serious health problem, as it can result
in peritonitis (inflammation and infection inside the tummy which is
usually sterile), and if left untreated can even be life threatening.
Schematic diagram
showing a normal and an inflammed appendix
What do we mean by
appendicitis?
Appendicitis is
inflammation of the appendix. The inflamed appendix becomes
infected with bacteria (germs) from the bowel (intestine). The
inflamed appendix gradually swells and fills up with pus. Eventually,
if not treated, the swollen and inflammed appendix may perforate
(burst). This can be a quite serious emergency medical condition, because the contents
of the bowel (intestine) can then spill into the abdominal cavity (inside of
the tummy).
This may result to
a serious infection of the peritoneum (lining/ membrane) that lines the abdomen
(known as peritonitis), and/or an abscess (a collection of
infected fluid – pus) inside the abdomen. Therefore,
if appendicitis is suspected,
early diagnosis and treatment is best, before the
inflamed appendix bursts, causing peritonitis.
An excised appendix
Who gets
appendicitis?
Appendicitis is
very common and may affect anyone of any age. Teenagers and young adults are
the people most commonly affected by appendicitis. Around 5-7% of all people
get appendicitis at some point in their life. Appendicitis is the cause of the
most common abdominal surgical emergency admission into hospital. Appendicitis
is slightly more common in males (men and boys) than in females (women and
girls). It is much more common in western countries (e.g USA/ UK/
Germany/France), and this is believed to be partly due to the western diet,
that is quite often low in dietary fibre.
What causes
appendicitis?
The reason why
the appendix becomes inflamed in the first place is not known in the
majority of patients. In some cases, it is believed to be due to a blockage
which occurs somewhere along a short appendix. This may be due to some
hard faeces (motions/ stools) which get stuck, (known as faecoliths - literal
meaning: stones of faeces). Bacteria can then thrive in this condition, and
cause inflammation behind the blockage in the dead end of the appendix.
Schematic diagrmam
showing how a faecolith can enter the lumen of the appendix and cause appendicitis
What are the
symptoms of appendicitis?
Pain in the abdomen (tummy pain) is the
main and most common symptom of appendicitis. Typically, the pain
starts in the middle of the abdomen, around the umbilicus (bellybutton). The
pain usually develops fairly quickly, over an hour or so, and it gradually gets
worse. Over the next few hours, the pain then moves to the lower right-hand
side of the abdomen, known as the right iliac fossa (RIF). This is the place of
the abdomen, where the appendix usually lies.
Typically the pain gets worse and worse over the next few hours/ few of days. The pain may become very severe. The pain tends to be sharper if the patient coughs, walks or makes any sudden movements. The pain may ease a bit by bending the knees up towards the chest wall. The lower abdomen is usually tender (painful), especially in the right iliac fossa (lower right-hand side).
Other symptoms that may occur during acute appendicitis, include the following:
Typically the pain gets worse and worse over the next few hours/ few of days. The pain may become very severe. The pain tends to be sharper if the patient coughs, walks or makes any sudden movements. The pain may ease a bit by bending the knees up towards the chest wall. The lower abdomen is usually tender (painful), especially in the right iliac fossa (lower right-hand side).
Other symptoms that may occur during acute appendicitis, include the following:
- Nausea and vomiting (feeling
and being sick)
- Being
off food (loss of appetite)
- Fever/
swinging pyrexia
- Feeling
generally unwell/ run down
- Change
in bowel habit (constipation or diarrhoea)
- Frequent micturition (passing urine lots of time). This is believed to be due to the inflammation of the appendix irritating the nearby right ureter (the tube between the right kidney and the urinary bladder that carries urine).
If
the appendix perforates (bursts) then severe pain can spread to all
of the abdomen and the patient may develop peritonitis, and become very
ill. In some cases, the symptoms of appendicitis are not typical. For
example, in some cases the pain may develop more slowly and run a more fiery
course. The pain may also start in the lower right-hand side of the abdomen.
Moreover, the pain may not become severe until
the appendix perforates (bursts). The site of the pain may not be
typical if the appendix lies in an unusual place, such as in the
pelvis or close to the liver.
An inflammed
appendix with associated fat stranding that normally occurs during this
condition.
How is
appendicitis diagnosed?
A doctor (usually
a general surgeon) can diagnose appendicitis quite easily if the patient has
the typical symptoms. However, not every patient has
typical symptoms. Sometimes it is very difficult for physicians to be
absolutely sure that it is appendicitis, which is causing the
patient's symptoms.
Some patients may develop pain in the right iliac fossa which is similar to appendicitis, but this pain is caused by other health problems, such as a ruptured ovarian cyst, mesenteric adenitis, pelvic inflammatory disease (PID), or a urine infection (urinary tract infection – UTI). Some people have surgery only to find that the appendix is normal and not inflamed.
There is not any easy and absolutely sensitive test (investigation) to confirm or exclude the presence of appendicitis. A general surgeon often has to make a judgement whether to operate or not. It depends on whether the symptoms and also the clinical findings when a patient is examined (known as the signs), are suggestive that appendicitis is the most likely diagnosis, or it cannot be safely excluded.
Some patients may develop pain in the right iliac fossa which is similar to appendicitis, but this pain is caused by other health problems, such as a ruptured ovarian cyst, mesenteric adenitis, pelvic inflammatory disease (PID), or a urine infection (urinary tract infection – UTI). Some people have surgery only to find that the appendix is normal and not inflamed.
There is not any easy and absolutely sensitive test (investigation) to confirm or exclude the presence of appendicitis. A general surgeon often has to make a judgement whether to operate or not. It depends on whether the symptoms and also the clinical findings when a patient is examined (known as the signs), are suggestive that appendicitis is the most likely diagnosis, or it cannot be safely excluded.
Occasionally, a surgeon advises the patient to wait and see for a few hours while being observed and monitored in hospital. This allows some time to determine if the symptoms progress to a more definite diagnosis, or even if they get better or even go away. Sometimes investigations (tests) are used if there is doubt about the diagnosis.
This can include
an ultrasound scan or a limited CT scan, which can help to provide more
information and clarify the cause of the symptoms in some patients.
Blood tests are also performed when a patient attends the
hospital. However, performing scans takes time and may get in the way of
doing prompt surgery, which is often the main priority.
What is the
treatment for appendicitis?
A patient with
suspected appendicitis will be admitted into hospital. He/she will have to
remain nil by mouth (nothing to eat or drink) for at least six hours, and will
be rehydrated with intravenous fluids (IV normal saline/ 5% dextrose/ Dextrose
Saline/ Hartman's solution or similar), while undergoing medical assessment and
investigations.
Antibiotics may
also be started if the diagnosis of appendicitis is made. The doctor
(surgeon) will inform the patient of the diagnosis, offer them
either open or laparoscopic (keyhole) surgery, and ask
them to sign the consent form, after explaining the logistics, indications and
possible complications of the procedure.
Augmentin
(Co-amoxiclav) is one of the antibiotics most commonly used to treat
appendicitis
An operation (appendicectomy or appendectomy)
to remove the inflamed appendix is performed as soon as possible once
the diagnosis has been made. It is much better to remove an
inflamed appendix before it perforates (bursts). The
inflamed appendix is found and divided (cut) off the caecum (the
first part of the large bowel). The hole left in the caecum is stitched up, in
order to stop any contents from the gut leaking out into the abdomen.
Antibiotics are
administered just before the operation in order to minimise the risk of an
infection developing at the site of the operation. If there is evidence of peritonitis,antibiotics may
be continued by the doctor after the operation for a few days
(usually 5-7 days). Washout of the inside of the abdomen with normal saline,
can also be performed by the surgeon, at the time of the operation.
Removal of the appendix is one of the most commonly performed emergency general surgical operations. In the majority of cases, the operation is performed before theappendix perforates (bursts). This is usually a straightforward and successful operation requiring only a short period of recovery (usually the patient goes home the following day). However, sometimes surgery may be more difficult, and the patient may take longer to recover if the appendix has perforated (burst) and the patient developed peritonitis.
Removal of the appendix is one of the most commonly performed emergency general surgical operations. In the majority of cases, the operation is performed before theappendix perforates (bursts). This is usually a straightforward and successful operation requiring only a short period of recovery (usually the patient goes home the following day). However, sometimes surgery may be more difficult, and the patient may take longer to recover if the appendix has perforated (burst) and the patient developed peritonitis.
Surgery is usually done by
a keyhole operation (laparoscopic appendicectomy), as the
post-operative recovery is faster, compared to having an open operation.
The keyhole operation is performed through three very small incisions
(cuts), the largest of which is only about 10-15mm in size.
Usually, there are
no long-term complications after the operation. As with
any operation, there is a small risk of complications from
the operation itself and from the general anaesthetic. However, if a
patient with acute appendicitis does not have an emergency operation, an
inflamed appendix is likely to perforate and cause a serious infection in the
abdomen (peritonitis), which can be even life-threatening.
Causes of appendicitis
Despite much research into the area, Itis still not entirely clear what causes appendicitis. The appendix is connected to the caecum (first part of the large intestine (bowel)), where faeces are formed. It's located in the right iliac fossa (RIF) - the lower right-hand side of the abdomen (tummy). Some cases of appendicitis are thought to be caused by a small piece of hard faeces getting trapped in the appendix and causing a blockage. Bacteria in the appendix then start to multiply, causing it to fill up with pus and swell.
Despite much research into the area, Itis still not entirely clear what causes appendicitis. The appendix is connected to the caecum (first part of the large intestine (bowel)), where faeces are formed. It's located in the right iliac fossa (RIF) - the lower right-hand side of the abdomen (tummy). Some cases of appendicitis are thought to be caused by a small piece of hard faeces getting trapped in the appendix and causing a blockage. Bacteria in the appendix then start to multiply, causing it to fill up with pus and swell.
Other potential sources of a blockage of the lumen of the appendix resulting in appendicitis, include types of inflammatory bowel disease, such as Crohn's disease and ulcerative colitis. It's also thought that appendicitis may be caused by a stomach infection that has travelled to the appendix.
If the inflammed and swollen appendix is not removed through surgery, it will eventually perforate (burst) and the released faeces, infected fluid and pus may cause peritonitis, and/or infect other parts of your body (e.g. cause septicaemia).
Schematic diagram showing Peritonitis
These are all extremely dangerous conditions, requiring urgent medical attention and treatement, which may include care in a High Dependency Unit (HDU), or even in Intensive Care Unit (ITU).
Symptoms
Appendicitis typically starts with
a pain in the middle of your abdomen (tummy) that may come and
go. Within hours the pain travels to the lower right-hand side, where
the appendix is located, and becomes constant and
severe. Pressing on the appendix area, coughing or walking, may
all make the pain worse.
If you have appendicitis, you may
also have other symptoms, including:
- nausea
(feeling sick)
- vomiting
(being sick)
- loss
of appetite
- constipation
- a
fever of 38ºC (100.4ºF) or more
- diarrhoea
Fever can be a significant symptom of
appendicitis, requiring urgent medical attention
If you're experiencing abdominal
pain that's gradually getting worse, contact your doctor or local out-of-hours
health service immediately. If these options are not available, you should
visit your nearest Accident and Emergency (A&E) department.
Appendicitis can easily be
confused with something else, such as bladder or urine infections, Crohn's
disease, gastritis, intestinal infection and ovary problems. However, all
conditions that cause constant stomach pain require urgent medical
attention. You should call 999 for an ambulance if you get a pain
that suddenly becomes worse and spreads across your abdomen. These are
signs that your appendix may have burst.
If the appendix bursts, it will release
bacteria, which can cause serious infections, such as swelling of the inner
lining of the abdomen (peritonitis) and blood poisoning.
Signs
It is important to remember that the position of
the appendix is variable. Of 100 patients undergoing 3-dimensional
(3-D) multidetector computed tomography (MDCT) scanning, the base of
the appendix was located at the McBurney point in only 4% of
patients; in 36%, the base was within 3 cm of the point; in 28%, it was 3-5 cm
from that point; and, in 36% of patients, the base of the appendix was more
than 5 cm from the McBurney point.
The most specific physical findings in appendicitis are
rebound tenderness, pain on percussion, rigidity, and guarding. Although RLQ
tenderness is present in 96% of patients, this is a non-specific finding.
Rarely, left lower quadrant (LLQ) tenderness has been the major manifestation
in patients with situs inversus or in patients with a lengthy appendix that
extends into the LLQ. Tenderness on palpation in the RLQ over the McBurney
point is the most important sign in these patients.
Abdominal pain due to appendicitis usually starts in the umbilical
region, and then moves to the right iliac fossa (RIF).
A careful physical examination, not limited to the abdomen, must be
performed in any patient with suspected appendicitis. Gastrointestinal
(GI), genitourinary, and pulmonary systems must be studied. Male infants and
children occasionally present with an inflamed hemiscrotum due to migration of
an inflamed appendix or pus through a patent processus vaginalis.
This is often initially misdiagnosed as acute testicular torsion. In addition,
perform a rectal examination in any patient with an unclear clinical picture,
and perform a pelvic examination in all women with abdominal pain.
According to the American College of Emergency Physicians (ACEP) 2010
clinical policy update, clinical signs and symptoms should
be used to stratify patient risk and to choose next steps for testing and
management.
In a minority of patients with acute appendicitis, some
other signs may be noted. However, their absence never should be used
to rule out appendiceal inflammation.
The Rovsing sign (RLQ pain with palpation of the LLQ)
suggests peritoneal irritation in the RLQ precipitated by palpation at a remote
location.
The Rovsing sign
The Rovsing sign
The Obturator sign (RLQ pain with internal and external
rotation of the flexed right hip) suggests that the
inflamed appendix is located deep in the right hemipelvis.
The Obturator sign
The Psoas sign (RLQ pain with extension of the right
hip or with flexion of the right hip against resistance) suggests that an
inflamed appendix is located along the course of the right psoas
muscle.
The Psoas sign
The Dunphy sign (sharp pain in the RLQ elicited by a
voluntary cough) may be helpful in making the clinical diagnosis of
localized peritonitis. Similarly, RLQ pain in response to percussion of a
remote quadrant of the abdomen, or to firm percussion of the patient's heel,
suggests peritoneal inflammation.
The Markle sign, pain elicited in a certain area of the
abdomen when the standing patient drops from standing on toes to the heels with
a jarring landing, was studied in 190 patients
undergoing appendectomy and found to have a sensitivity of 74%.
Rectal examination
There is no evidence
in the medical literature that the digital rectal examination (DRE) provides
useful information in the evaluation of patients with
suspected appendicitis; however, failure to perform a rectal examination
is frequently cited in successful malpractice claims. In 2008, Sedlak et
al studied 577 patients who underwent DRE as part of an evaluation for
suspected appendicitis and found no value as a means of
distinguishing patients with and without appendicitis.
Diagnosis of appendicitis
Appendicitis can
be tricky to diagnose unless you have the
typical symptoms.However, around one in two people
with appendicitis do not have typical symptoms. Moreover,
some people's appendix may be located in a slightly different part of
their body, such as the pelvis, behind the large intestine or behind the
liver.
Some people develop
pain similar to appendicitis, but it's caused by something else, like a
bladder or urine infection, Crohn's disease or gastritis. A
doctor will ask about your symptoms, examine your abdomen and see if the
pain gets worse when pressure is applied to the appendix area (the
lower right-hand side). If your symptoms are typical
of appendicitis, this is normally enough for your physician to make a confident diagnosis.
The nine regions of
the abdomen. Abdominal pain due to appendicitis usually starts in the umbilical
region, and then moves to the right iliac fossa (RIF).
However, if
your symptoms are not typical, further tests may be required to
confirm the diagnosis and rule out other conditions.
Further tests may
include:
- a blood test to see
if your body is fighting infection
- a urine test to rule out
other conditions, such as a bladder infection
- a magnetic resonance
imaging (MRI) scan or an ultrasound scan - scans have
proven very reliable in detecting appendicitis
- a pregnancy
test for women
Ultrasound scan
showing a normal appendix
It can take several
hours or days to get test results. Therefore if appendicitis is
suspected, it is likely you will be advised to
have your appendix removed rather than run the risk
of it bursting. If your doctor suspects that
your appendix has burst, you will be sent to hospital immediately
for treatment.
Complications of appendicitis
If appendicitis is
not treated, the appendix can burst and cause potentially life-threatening
infections.
If
your appendix bursts, it releases pus to other parts of the body,
which can cause an infection in the abdomen
called peritonitis. Peritonitis is the painful swelling of the abdomen area
around the stomach and liver. The condition causes your normal bowel movements to
stop and your bowel to become blocked. This causes:
- severe abdominal pain
- a fever of 38ºC (100.4ºF) or
more
- a rapid heartbeat.
If peritonitis is
not treated immediately it can cause long-term problems and may even
be fatal.
Sometimes
an abscess forms around a burst appendix.
An abscess is a painful collection of pus that results from the
body’s attempt to fight an infection.
Drainage of an
abscess. Yellow liquid is pus.
Abscesses can
be treated using antibiotics, but in some cases the pus may need
to be drained from the abscess.
Treatment of appendicitis
If you
have appendicitis, your appendix will need to be removed
by surgery. Removal of the appendix (which doctors
might call an appendectomy) is one of the most commonly performed
operations in the UK, and its success rate is excellent.
It's not always easy
to make a clear diagnosis. But if there's an outside chance that you
have appendicitis, doctors tend to advise surgery rather than
run the risk of the appendix bursting.
A keyhole
operation (medically known as laparoscopy) is usually carried
out as the recovery is quicker compared to an open operation. Three small cuts are
made to remove the appendix. The advantage of keyhole surgery is
that scarring is minimal and the recovery time is fast.
Patients with
appendicitis can be successfully treated with laparoscopic appendicectomy.
Most people can leave
hospital a few days after the operation, although it may be one or two
weeks before you fully recover.
In some
circumstances, keyhole surgery isn't recommended. Open
surgery will be performed instead.
Appendix removed
during open appendicectomy
These include:
- cases where the appendix has burst
- people who have tumours in
their digestive system
- women who are in the first
trimester (up to week 13) of pregnancy
- people who have previously
had stomach surgery.
In these cases, the
operation will involve a single large cut to remove the appendix. Open
surgery will leave a larger scar and it may be a week before you're well
enough to leave hospital. Both keyhole and open
surgery are carried out under a general anaesthetic, which means that
you're asleep throughout the operation.
Source: NHS Choices
http://healthitis.blogspot.com
Source: NHS Choices
http://healthitis.blogspot.com