Appendicitis

Definition

Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch attached to the cecum, the beginning of the large intestine. The appendix has no known function in the body, but it can become diseased. Appendicitis is a medical emergency, and if it is left untreated the appendix may rupture and cause a potentially fatal infection.

Description

Appendicitis is the most common abdominal emergency found in children and young adults. One person in 15 develops appendicitis in his or her lifetime. The incidence is highest among males aged 10-14, and among females aged 15-19. More males than females develop appendicitis between puberty and age 25. It is rare in the elderly and in children under the age of two.

The hallmark symptom of appendicitis is increasingly severe abdominal pain. Since many different conditions can cause abdominal pain, an accurate diagnosis of appendicitis can be difficult. A timely diagnosis is important, however, because a delay can result in perforation, or rupture, of the appendix. When this happens, the infected contents of the appendix spill into the abdomen, potentially causing a serious infection of the abdomen called peritonitis.

Other conditions can have similar symptoms, especially in women. These include pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, tubal pregnancies, and endometriosis. Various forms of stomach upset and bowel inflammation may also mimic appendicitis.

The treatment for acute (sudden, severe) appendicitis is an appendectomy, surgery to remove the appendix. Because of the potential for a life-threatening ruptured appendix, persons suspected of having appendicitis are often taken to surgery before the diagnosis is certain.

Causes and symptoms

The causes of appendicitis are not well understood, but it is believed to occur as a result of one or more of these factors: an obstruction within the appendix, the development of an ulceration (an abnormal change in tissue accompanied by the death of cells) within the appendix, and the invasion of bacteria.

Under these conditions, bacteria may multiply within the appendix. The appendix may become swollen and filled with pus (a fluid formed in infected tissue, consisting of while blood cells and cellular debris), and may eventually rupture. Signs of rupture include the presence of symptoms for more than 24 hours, a fever, a high white blood cell count, and a fast heart rate. Very rarely, the inflammation and symptoms of appendicitis may disappear but recur again later.

The distinguishing symptom of appendicitis is pain beginning around or above the navel. The pain, which may be severe or only achy and uncomfortable, eventually moves into the right lower corner of the abdomen. There, it becomes more steady and more severe, and often increases with movement, coughing, and so forth. The abdomen often becomes rigid and tender to the touch. Increasing rigidity and tenderness indicates an increased likelihood of perforation and peritonitis.

Loss of appetite is very common. Nausea and vomiting may occur in about half of the cases and occasionally there may be constipation or diarrhea. The temperature may be normal or slightly elevated. The presence of a fever may indicate that the appendix has ruptured.

Diagnosis

A careful examination is the best way to diagnose appendicitis. It is often difficult even for experienced physicians to distinguish the symptoms of appendicitis from those of other abdominal disorders. Therefore, very specific questioning and a thorough physical examination are crucial. The physician should ask questions, such as where the pain is centered, whether the pain has shifted, and where the pain began. The physician should press on the abdomen to judge the location of the pain and the degree of tenderness.

The typical sequence of symptoms is present in about 50% of cases. In the other half of cases, less typical patterns may be seen, especially in pregnant women, older patients, and infants. In pregnant women, appendicitis is easily masked by the frequent occurrence of mild abdominal pain and nausea from other causes. Elderly patients may feel less pain and tenderness than most patients, thereby delaying diagnosis and treatment, and leading to rupture in 30% of cases. Infants and young children often have diarrhea, vomiting, and fever in addition to pain.

While laboratory tests cannot establish the diagnosis, an increased white cell count may point to appendicitis. Urinalysis may help to rule out a urinary tract infection that can mimic appendicitis.

KEY TERMS

Appendectomy (or appendicectomy)— Surgical removal of the appendix.

Appendix— The worm-shaped pouch attached to the cecum, the beginning of the large intestine.

Laparotomy— Surgical incision into the loin, between the ribs and the pelvis, which offers surgeons a view inside the abdominal cavity.

Peritonitis— Inflammation of the peritoneum, membranes lining the abdominal pelvic wall.

Patients whose symptoms and physical examination are compatible with a diagnosis of appendicitis are usually taken immediately to surgery, where a laparotomy (surgical exploration of the abdomen) is done to confirm the diagnosis. In cases with a questionable diagnosis, other tests, such as a computed tomography scan (CT) may be performed to avoid unnecessary surgery. An ultrasound examination of the abdomen may help to identify an inflamed appendix or other condition that would explain the symptoms. Abdominal x-rays are not of much value except when the appendix has ruptured.

Often, the diagnosis is not certain until an operation is done. To avoid a ruptured appendix, surgery may be recommended without delay if the symptoms point clearly to appendicitis. If the symptoms are not clear, surgery may be postponed until they progress enough to confirm a diagnosis.

When appendicitis is strongly suspected in a woman of child-bearing age, a diagnostic laparoscopy (an examination of the interior of the abdomen) is sometimes recommended before the appendectomy in order to be sure that a gynecological problem, such as a ruptured ovarian cyst, is not causing the pain. In this procedure, a lighted viewing tube is inserted into the abdomen through a small incision around the navel.

A normal appendix is discovered in about 10-20% of patients who undergo laparotomy, because of suspected appendicitis. Sometimes the surgeon will remove a normal appendix as a safeguard against appendicitis in the future. During the surgery, another specific cause for the pain and symptoms of appendicitis is found for about 30% of these patients.

Treatment

The treatment of appendicitis is an immediate appendectomy. This may be done by opening the abdomen in the standard open appendectomy technique, or through laparoscopy. In laparoscopy, a smaller incision is made through the navel. Both methods can successfully accomplish the removal of the appendix. It is not certain that laparoscopy holds any advantage over open appendectomy. When the appendix has ruptured, patients undergoing a laparoscopic appendectomy may have to be switched to the open appendectomy procedure for the successful management of the rupture. If a ruptured appendix is left untreated, the condition is fatal.

Prognosis

Appendicitis is usually treated successfully by appendectomy. Unless there are complications, the patient should recover without further problems. The mortality rate in cases without complications is less than 0.1%. When an appendix has ruptured, or a severe infection has developed, the likelihood is higher for complications, with slower recovery, or death from disease. There are higher rates of perforation and mortality among children and the elderly.

Prevention

Appendicitis is probably not preventable, although there is some indication that a diet high in green vegetables and tomatoes may help prevent appendicitis.

Resources

PERIODICALS

Van Der Meer, Antonia. "Do You Know the Warning Signs of Appendicitis?" Parents Magazine (April 1997): 49.

APPENDICITIS

DEFINITION

Appendicitis (pronounced uh-pen-di-SIE-tis) is the inflammation of the appendix, a worm-shaped pouch near the beginning of the large intestine. The appendix has no known function in the body, but it can become diseased. Appendicitis is a medical emergency. If the condition is left untreated, the appendix may rupture and cause a potentially fatal infection.

DESCRIPTION

Appendicitis is the most common abdominal emergency among children and young adults. One person in fifteen develops appendicitis in his or her lifetime. The frequency of appendicitis is highest among males between the ages of ten and fourteen and among females between the ages of fifteen and nineteen. The disease is rare among the elderly and in children under the age of two.

The main symptom of appendicitis is increasingly severe pain in the abdomen. Many different conditions can cause abdominal pain, so an accurate diagnosis of appendicitis can be difficult. A prompt diagnosis is important, however. A delay can result in perforation (rupture) of the appendix. When this happens, the infected contents of the appendix spill into the abdomen. A serious infection known as peritonitis (pronounced per-i-tuh-NIE-tiss) may result.

Other conditions produce symptoms similar to those of appendicitis, especially among women. An example is endometriosis (pronounced en-do-mee-tree-O-suhs), an infection of the lining of the uterus, or pelvic inflammatory disease, an infection of the pelvis. Some forms of stomach upset and bowel inflammation may also imitate appendicitis.

The treatment for acute (sudden, severe) appendicitis is an appendectomy, a surgical procedure to remove the appendix. Since a ruptured appendix can be life-threatening, people suspected of having appendicitis may be taken to surgery before the diagnosis is certain.

CAUSES

The causes of appendicitis are not well understood. A number of factors are thought to be responsible for the disease. One is an obstruction (blocking) within the appendix. Another is the development of an ulceration (a sore) within the appendix. A third factor is a bacterial infection.

Appendicitis: Words to Know

Appendectomy:

Surgical removal of the appendix.

Appendix:

The worm-shaped pouch near the beginning of the large intestine.

Computed tomography (CT) scan:

A procedure by which X rays are directed at a patient's body from various angles and the set of photographs thus obtained assembled by a computer program.

Computerized axial tomography (CAT) scan:

Another name for a computed tomography (CT) scan.

Laparoscopy:

A procedure in which a tube with a small light and viewing device is inserted through a small incision near the navel, allowing a surgeon to look directly into the patient's abdomen.

Laparotomy:

A surgical procedure that allows a surgeon to view the inside of the abdominal cavity.

Peritonitis:

Inflammation of the membranes that line the abdominal wall.

Under any one of these conditions, disease-causing bacteria may begin to multiply within the appendix. The appendix becomes swollen and filled with pus. Pus is a fluid formed in infected tissue consisting of white blood cells and dead cells. When this happens, the appendix may rupture.

SYMPTOMS

An indication that the appendix is ready to rupture is the presence of certain symptoms that last more than twenty-four hours. These symptoms include a fever, an abnormally high white blood count, and a rapid heart rate.

The characteristic symptom of appendicitis is pain that begins around or above the navel. The pain may be severe or relatively mild. It eventually moves to the lower right-hand corner of the abdomen. There, it becomes more steady and more severe. Movement or coughing makes the pain worse. The abdomen becomes rigid (hard) and tender to the touch. An increase in these symptoms indicates an increased likelihood of perforation and peritonitis.

Loss of appetite is a common symptom of appendicitis. Nausea and vomiting occur in about half of the cases, and constipation or diarrhea may also occur. Body temperature may be slightly elevated, but a fever suggests that the appendix may already have ruptured.

DIAGNOSIS

Many abdominal problems have symptoms like those of appendicitis. The task of the doctor is to rule out other problems before diagnosing appendicitis. The first step in diagnosis usually involves a series of questions about the patient's pain: where did the pain begin; has it moved, and where is the pain now? The doctor also presses on the abdomen to find out where the soreness is and how rigid the abdomen has become.

The sequence of symptoms described occurs in about half of all patients with appendicitis. In certain cases those symptoms may be harder to detect. For example, abdominal pain is common in pregnant women and can be the result of any number of factors relating to a pregnancy. Elderly people are likely to have less pain and tenderness than younger patients. The absence of these symptoms can make diagnosis more difficult. In about 30 percent of cases involving the elderly, the appendix ruptures before a diagnosis has been made. Infants and young children often have diarrhea, vomiting, and fever in addition to pain.

Laboratory tests cannot totally determine appendicitis, but do help in the diagnosis. A blood test that shows a high white blood count may be an indication of the infection. Urine tests can rule out other possible causes of abdominal pain, such as an infection of the urinary tract.

People who are diagnosed with appendicitis are usually taken directly to surgery. The doctor then performs a laparotomy (pronounced lap-uh-ROT-uh-mee), an operation on the abdomen. The laparotomy usually confirms a diagnosis of appendicitis.

In some cases, additional tests may still be necessary. For example, an ultrasound test may help identify appendicitis or other conditions that may have the same symptoms. A computed tomography (CT) scan may also be performed to avoid surgery. A CT scan is a procedure by which X rays are directed at a patient's body from various angles and the set of photographs thus obtained assembled by a computer program. This procedure is sometimes called a computerized axial tomography (CAT) scan.

Often, a diagnosis of appendicitis is not certain until an operation is done. To avoid a ruptured appendix, surgery may be recommended without delay if the symptoms point clearly to appendicitis.

Additional procedures may be used for women of child-bearing age. Women in this age group may have problems with their reproductive organs that produce symptoms similar to those of appendicitis. In these cases, a doctor may perform a laparoscopy (pronounced lap-uh-ROS-kuh-pee). In this procedure, a small incision (cut) is made near the navel. A tube containing a light and viewing device is then inserted through the incision. This allows a surgeon to look directly into the patient's abdomen. He or she can usually determine whether the patient has appendicitis or some other condition.

A normal appendix is found in about 10 to 20 percent of all patients who have a laparotomy. Sometimes the surgeon removes a normal appendix anyway to safeguard against appendicitis in the future. In about 30 percent of these cases, surgeons find other medical problems that have caused the appendicitis-like symptoms.

TREATMENT

The treatment for appendicitis is an immediate appendectomy. This procedure can be carried out as a standard open appendectomy technique or through laparoscopy. Laparoscopy is sometimes preferred because it produces a smaller scar. It does not seem to have other advantages over an open appendectomy. In the case of a ruptured appendix, an open appendectomy must be performed. If the ruptured appendix is left untreated, the condition is fatal.

PROGNOSIS

Appendicitis is usually treated successfully with an appendectomy. Unless there are complications, patients recover without further problems. Less than 0.1 percent of patients die as a result of a standard appendectomy. In cases where the appendix has ruptured or infection has occurred, there is a higher possibility of complications and recovery occurs more slowly. Children and the elderly are more prone to such complications.

PREVENTION

Appendicitis is probably not preventable. But some authorities think the condition can be avoided with a diet rich in green vegetables and tomatoes.

FOR MORE INFORMATION

Periodicals

Van der Meer, Antonia. "Do You Know the Warning Signs of Appendicitis?" Parents Magazine (April 1997): p. 49.

Web sites

"Acute Appendicitis." HealthAnswers.com [Online] http://www.healthanswers.com/centers/body/overview.asp?id=digestive+system&filename=000256.htm# (accessed on October 16, 1999).

Appendicitis

What Is Appendicitis?

Who Gets Appendicitis?

What Happens to People with Appendicitis?

Resource

Appendicitis (ap-pen-di-SY-tis) is the inflammation of the appendix (ap-PEN-dix), which is a small organ that branches off the large intestine. The inflammation usually begins abruptly, causes a characteristic right-sided abdominal pain, and may lead to rupture or bursting of the appendix and to severe illness.

KEYWORDS

for searching the Internet and other reference sources

Inflammation

Vermiform appendix

What Is Appendicitis?

Acute* appendicitis occurs when the vermiform (VER-mi-form) appendix becomes infected with bacteria. Vermiform means shaped like a worm. The appendix is a narrow, finger-shaped tube, usually 3 to 6 inches long, that branches off the large intestine into the lower right side of the abdomen. Inflammation is the body’s response to this infection. Once the appendix becomes inflamed, it must be removed so that it does not break, or rupture, and spread the infection to the rest of the abdomen, a condition known as peritonitis*. The appendix has no known function, and its removal has no adverse effect on the body.

* acute

means rapid in onset and short-lasting. Conditions that continue for a long period of time are called “chronic.”

* peritonitis

(per-i-to-NI-tis) is inflammation of the peritoneum (per-i-to-NE-um), which is the membrane that lines the abdominal cavity.

Who Gets Appendicitis?

Each year, appendicitis affects 1 in 500 people. Anyone can develop appendicitis, but it is most common in young people between 15 and 24 years old, and it affects boys more often than girls. Appendicitis is not preventable. Surgical removal of the appendix, appendectomy (ap-pen-DEK-to-mee), is a common reason for abdominal surgery in children. People can die from appendicitis if it is left untreated, but this is rare.

What Happens to People with Appendicitis?

David’s appendicitis happened suddenly, when he awoke at 1:00 am with a terrible bellyache. He blamed it on the chips and ice cream he had eaten after dinner and tried to go back to sleep. By 7:00 am, his bellyache was worse, he was not hungry, and he felt very hot. He told his parents about the intense pain in his right side, and they took him to see the doctor immediately. A series of events followed rapidly.

March 2, 10:00 am

The doctor asked David lots of questions about the pain: Was it constant? Did the right side hurt the most? Was the pain worse when he moved, coughed, or took a deep breath? Was he nauseated? He said yes to all of them. David’s abdomen felt hard when the doctor touched it, and when the doctor pushed on the right lower part, David yelled. A nurse took David’s temperature and a blood sample.

March 2, 12:00 pm

The doctor returned and reported that David’s blood test showed more white blood cells than usual, which is one of the signs of inflammation. David’s other symptoms of fever and abdominal pain led the doctor to diagnose appendicitis and to advise David’s parents to check him into the hospital.

March 2, 8:00 pm

David had been at the hospital for several hours. The nurses kept checking on him, asking him about the pain, and pushing on his abdomen. The pain did not go away and started to get worse. David’s doctor decided that David should be taken to the operating room right away to have an appendectomy (surgical removal of the appendix). To prepare David for the surgery, the doctor explained about general anesthesia* and showed David where he would receive a small cut in the abdomen through which the surgeon would remove the diseased appendix. The doctor and nurses kept reassuring David and his parents that he would be fine as they do this kind of surgery all the time.

* general anesthesia

(an-es-THE-zha) means using drugs or inhaled gases to create a state of unconsciousness and muscle relaxation throughout the body to block pain during surgery. Local anesthesia blocks or numbs pain in one part of the body while patients remain awake.

March 2, 10:00 pm

David awoke in the hospital recovery room, groggy, tired, and a little sore. His appendix, which had not yet ruptured, had been removed at 8:00 am.

March 4, 8:00 am

David went home from the hospital, minus his appendix, but otherwise healthy. He was still aware of a slight soreness at the site of his appendectomy scar.

Within a couple of weeks, David was back to doing just about everything he had done before his appendicitis. His appendectomy surgery had been a complete success.

See also

Resource

The U.S. National Digestive Diseases Information Clearinghouse posts a fact sheet about appendicitis at its website. http://www.niddk.nih.gov/health/digest/summary/append/index.htm

appendicitis (ă-pen-di-sy-tis) n. inflammation of the vermiform appendix. acute a. the most common form of the condition, usually affecting young people. The chief symptom is abdominal pain, first central and later in the right lower abdomen, over the appendix. If not treated by surgical removal (appendicectomy) the condition usually progresses to cause an abscess or generalized peritonitis. chronic a. a formerly popular diagnosis to explain recurrent pains in the lower abdomen. It is rare, and appendicectomy will not usually cure such pains.

appendicitis Inflammation of the appendix caused by obstruction and infection. Symptoms include severe pain in the central abdomen, nausea, and vomiting. Acute appendicitis is generally treated by surgery. A ruptured appendix can cause peritonitis and even death.

ap·pen·di·ci·tis / əˌpendəˈsītis/ • n. a serious medical condition in which the appendix becomes inflamed and painful.

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