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DESCRIPTION
Appendicitis is a condition characterized by inflammation of the appendix, a lymphoid organ that opens into the first part of the large intestine. For many years, the appendix was believed to be a vestigial organ that served no function, but that is no longer the belief. In the fetus, the appendix contains endocrine cells that manufacture hormones and other important body chemicals.
In young adults, the appendix is believed to play a part in the functioning of the immune system. It is involved in the maturation of B lymphocytes (a type of white blood cell) and assists in producing an antibody called immunoglobulin A.
The appendix is a narrow tubular pouch attached to the intestines. When the appendix is blocked, it becomes inflamed and results in the condition known as appendicitis. If the blockage continues, the inflamed tissue becomes infected with bacteria and begins to die from a lack of blood supply, which finally results in the appendix bursting (perforated appendix).
Appendicitis is a common condition that affects 7 percent of the population, according to the American Academy of Family Physicians. Persons of any age may be affected, with the highest incidence occurring during the second and third decades of life. Rare cases of neonatal and prenatal appendicitis have been reported. Increased vigilance in recognizing and treating potential cases of appendicitis is required for the very young and old who have a higher rate of complications.
Appendicitis is a medical emergency. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide.
CAUSES
There is no clear cause of appendicitis.
- Appendicitis is thought to be primarily caused by improper diet. Obstruction has multiple causes. Fecal material (fecaliths - calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix) is thought to be one possible obstructing object.
- Most cases involve a blockage of the large intestine resulting from a fiber-deficient diet. The blockage stops the natural flow of fluids, which facilitates the growth of harmful bacteria from the intestinal tract, resulting in inflammation of the appendix.
- Bacteria, viruses (including lymphoid hyperplasia - related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), foreign bodies, fungi, and parasites can be responsible agents of an infection that leads to swelling of the tissues of the appendix wall, including Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species, Schistosoma species, pinworms, and Strongyloides stercoralis.
- Also, swelling of the tissue from inflammatory bowel diseases such as Crohn's disease, gastrointeritis, primary or metastatic cancer and carcinoid syndrome may cause appendicitis. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.
Appendicitis is rare in children under the age of two. The incidence peaks between the ages of 15 and 24. The risk of developing appendicitis increases after a recent illness, especially a gastrointestinal infection or roundworm infestation.
Appendicitis can be either acute or chronic. It appears that appendicitis is not hereditary or transmittable from person to person, so you should not worry if your mother, father, or sibling has had it.
PATHOGENESIS OF APPENDICITIS
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen. Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death.
Among the causative agents, such as foreign bodies (shotgun pellet, intrauterine device, tongue stud, activated charcoal), trauma, intestinal worms, and lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. The prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing countries, and an appendiceal fecalith is commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum.
Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis. This is in accordance with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces transit time.
FREQUENT SIGNS & SYMPTOMS
GENERAL SIGNS & SYMPTOMS
Appendicitis typically begins with a vague to severe abdominal pain located in the middle of the abdomen often near the navel or "belly button" (umbilicus). The pain usually gets gradually worse over a period of six to 12 hours. The pain slowly moves (migrates) to the right lower abdomen (toward the right hip above your pelvic bone) over the next 24 hours. Taking deep breaths, coughing, sneezing or other sudden movements, moving or being touched (pressed) in this area worsens the pain.
In the classic description, abdominal pain is frequently accompanied with nausea, vomiting, lack of appetite, and fever (usually less than 102°F). The pain becomes persistent and well-localized. All of these symptoms, however, occur in fewer than half of people who develop appendicitis. More commonly, people with appendicitis have any combination of these symptoms.
Symptoms of appendicitis may take 4-48 hours to develop. During this time, someone developing appendicitis may have varying degrees of loss of appetite, vomiting, and abdominal pain. Some may have constipation, diarrhea, abdominal swelling, (in late stages) or there may be no change in bowel habits. Other signs include elevated white blood cell count, inability to pass gas, painful urination, and blood in the urine.
Early symptoms are often hard to separate from other conditions including gastroenteritis (an inflammation of the stomach and intestines). Many people admitted to the hospital for suspected appendicitis leave the hospital with a diagnosis of gastroenteritis; true appendicitis is often mis-diagnosed as gastroenteritis initially.
Children and the elderly often have fewer symptoms, which makes their diagnosis less obvious and the incidence of complications more frequent. Appendicitis is seldom found in older people. Since the symptoms are usually milder in this age group, however, there is a greater danger for rupture, with resulting peritonitis or the formation of abscesses. In addition, the symptoms can be difficult to diagnose because they are similar to those of bladder infections, kidney stones, and inflammations of the colon, stomach, and small bowel (and in women, pelvic infections or ovarian cysts). Older adults in particular should be very aware of the symptoms of appendicitis.
ACUTE APPENDICITIS
Acute appendicitis is the most common reason for abdominal surgery. Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis. Without prompt treatment, the likelihood increases that the inflamed appendix will burst, contaminating the abdominal cavity with fecal matter and causing peritonitis.
Symptoms of acute appendicitis can be classified into two types, typical and atypical.
- Typical Acute Appendicitis: The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing (spatial) property of visceral nerves from the mid-gut, followed by the involvement of somatic nerves (parietal peritoneum) as the inflammation progresses. The pain is usually associated with loss of appetite and fever, although the latter is not a necessary symptom. Nausea or vomiting may occur, and also the feeling of drowsiness and the feeling of general bad health. With the typical type, diagnosis is easier to make, surgery occurs earlier and findings are often less severe.
- Atypical Acute Appendicitis: Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course. If an inflamed appendix lies in contact with the bladder, there is frequency of urination. With post-ileal appendix, marked retching may occur. Tenesmus or "downward urge" (the feeling that a bowel movement will relieve discomfort) is also experienced in some cases.
CHRONIC APPENDICITIS
Unlike acute appendicitis, chronic appendicitis symptoms can vary from patient to patient - so much so that "There are no typical findings or routine diagnostic modalities to diagnose chronic relapsing appendicitis. It is a diagnosis of exclusion.
COMMON SIGNS OF APPENDICITIS
COMMON SYMPTOMS* FREQUENCY (%)
(74-78%, depending on the study)
(61-92%, depending on the study)
(Vague periumbilical pain to anorexia/nausea/unsustained vomiting to migration of pain to right lower quadrant to low-grade fever.)
Right lower quadrant pain on palpation (the single most important sign).
Low-grade fever (100.4°F [or 38°C]) - absence of fever or high fever can occur.
Peritoneal signs.
Localized tenderness to percussion.
Guarding.
Other Confirmatory Peritoneal Signs
(Absence of these signs does not exclude appendicitis.)
Psoas Sign: Pain on extension of right thigh (retroperitoneal retrocecal appendix).
Obturator Sign: Pain on internal rotation of right thigh (pelvic appendix).
Rovsing's Sign: Pain in right lower quadrant with palpation of left lower quadrant.
Dunphy's Sign: Increased pain with coughing.
Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix).
Patient maintains hip flexion with knees drawn up for comfort.
APPENDICITIS COMPLICATIONS
The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15 percent. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.
A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine.
A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.
TREATMENT
PATIENT HISTORY & PHYSICAL EXAMINATION
PATIENT HISTORY
Abdominal pain is the most common symptom of appendicitis. In multiple studies, 3-5 specific characteristics of the abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis (see tables under Signs & Symptoms). A thorough review of the history of the abdominal pain and of the patient's recent genitourinary, gynecologic and pulmonary history should be obtained.
Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients. Duration of symptoms exceeding 24 to 36 hours is uncommon in non-perforated appendicitis.
MORBIDITY & MORTALITY RATES
The overall mortality rate of 0.2-0.8 percent is attributable to complications of the disease rather than to surgical intervention. Mortality rate rises above 20 percent in patients older than 70 years, primarily because of diagnostic and therapeutic delay. Perforation rate is higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated with a sharp increase in morbidity and mortality rates.
Sex: The incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes.
Age: Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been reported. The emergency department clinician must maintain a high index of suspicion in all age groups.
DIAGNOSTIC SIGNSAPPENDIX PAIN: These include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.
ROVSING'S SIGN: Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen.
PSOAS SIGN: Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief.
OBTURATOR SIGN: If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain in the hypogastrium.
PHYSICAL EXAMINATION
A careful, systematic examination of the abdomen is essential. While right lower quadrant tenderness to palpation is the most important physical examination finding, other signs may help confirm the diagnosis. The abdominal examination should begin with inspection followed by auscultation, gentle palpation (beginning at a site distant from the pain) and, finally, abdominal percussion. The rebound tenderness that is associated with peritoneal irritation has been shown to be more accurately identified by percussion of the abdomen than by palpation with quick release.
As previously noted, the location of the appendix varies. When the appendix is hidden from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may not be present. Pain and tenderness can occur in a location other than the right lower quadrant. A retrocecal appendix in a retroperitoneal location may cause flank pain. In this case, stretching the iliopsoas muscle can elicit pain. The psoas sign is elicited in this manner: the patient lies on the left side while the examiner extends the patient's right thigh (see below).
In contrast, a patient with a pelvic appendix may show no abdominal signs, but the rectal examination may elicit tenderness in the cul-de-sac. In addition, an obturator sign (pain on passive internal rotation of the flexed right thigh) may be present in a patient with a pelvic appendix3 (see below).
Patients with many other disorders present with symptoms similar to those of appendicitis. Examples include the following:
- Pelvic inflammatory disease (PID) or tubo-ovarian abscess.
- Endometriosis.
- Ovarian cyst or torsion.
- Ureterolithiasis and renal colic.
- Degenerating uterine leiomyomata.
- Diverticulitis.
- Crohns disease.
- Colonic carcinoma.
- Rectus sheath hematoma.
- Cholecystitis.
- Bacterial enteritis.
- Mesenteric adenitis.
- Omental torsion.
These disorders will need to be ruled out as a cause of presenting symptoms either through examination, lab work, or imaging tests.
DIAGNOSTIC TESTS
Diagnosis is based on patient history (classic symptoms) and physical examination of the patient's abdomen. If the patient's history and the physical examination do not clarify the diagnosis, laboratory and radiologic evaluations may be helpful. A clear diagnosis of appendicitis obviates the need for further testing and should prompt immediate surgical referral.Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly. (Am Fam Physician 1999;60:2027-34.)
Appendicitis is the most common acute surgical condition of the abdomen. Approximately 7 percent of the population will have appendicitis in their lifetime, with the peak incidence occurring between the ages of 10 and 30 years.
Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate in non-perforated appendicitis is less than 1 percent, but it may be as high as 5 percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.
LAB WORK
WBC Count: Although no blood test can confirm appendicitis, a blood sample is sent for laboratory analysis to check the white blood cell count (neutrophils), which is typically elevated in an individual with appendicitis. However, normal levels can be present with appendicitis, and elevated levels can be seen with other conditions. The white blood cell (WBC) count is elevated (greater than 10,000 per mm3 [100 3 109 per L]) in 80 percent of all cases of acute appendicitis. Unfortunately, the WBC is elevated in up to 70 percent of patients with other causes of right lower quadrant pain. Thus, an elevated WBC has a low predictive value. Serial WBC measurements (over 4 to 8 hours) in suspected cases may increase the specificity, as the WBC count often increases in acute appendicitis (except in cases of perforation, in which it may initially fall). In addition, 95 percent of patients have neutrophilia and, in the elderly, an elevated band count greater than 6 percent has been shown to have a high predictive value for appendicitis. In general, however, the WBC count and differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low specificities.
C-Reactive Protein Level: A more recently suggested laboratory evaluation is determination of the C-reactive protein level. An elevated C-reactive protein level (greater than 0.8 mg per dL) is common in appendicitis, but studies disagree on its sensitivity and specificity. An elevated C-reactive protein level in combination with an elevated WBC count and neutrophilia are highly sensitive (97 to 100 percent). Therefore, if all three of these findings are absent, the chance of appendicitis is low.
Urine Test: A urine test may be performed to exclude urinary tract infection (or pregnancy) as the cause of the symptoms. In patients with appendicitis, a urinalysis may demonstrate changes such as mild pyuria, proteinuria and hematuria, but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose appendicitis.
A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated.
IMAGING TESTS
Imaging tests are used when the diagnosis is not readily apparent. Most medical centers now use a CT scan of the abdomen and pelvis to help evaluate abdominal pain suspected of being caused by appendicitis. Ultrasound scanning is currently commonly used in small children to test for appendicitis. Atypical histories often require imaging with ultrasound and/or CT scanning.
The options for radiologic evaluation of patients with suspected appendicitis have expanded in recent years, enhancing and sometimes replacing previously used radiologic studies. Plain radiographs, while often revealing abnormalities in acute appendicitis, lack specificity and are more helpful in diagnosing other causes of abdominal pain. Likewise, barium enema is now used infrequently because of the advances in abdominal imaging.
Ultrasound Imaging: Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children. In some cases (15 percent approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis and other diseases with very similar symptoms such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.
CT Scan: In places where it is readily available, CT scan has become the diagnostic test of choice, especially in adults whose diagnosis is not obvious on history and physical. (The use of CT in pregnant women and children is significantly limited, however, by concerns regarding radiation exposure.) A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95 percent and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in diameter on cross section), and appendiceal wall enhancement (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen.
Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20 percent in the pre-CT era to only 3 percent according to data from the Massachusetts General Hospital.
According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94 percent, specificity of 95 percent, a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81 percent, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27).
MMP Levels: Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture among patients with acute appendicitis according to a cohort study. MMP-1 was higher in gangrenous (p less than 0.05) and perforated appendicitis (p less than 0.01) compared with controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with controls (p less than 0.001).
A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score.
ALVARADO SCORE
Symptoms Signs Laboratory Total Score
A score below 5 is strongly against a diagnosis of appendicitis, while a score of 7 or more is strongly predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan further reduces the rate of negative appendicectomy.
SURGICAL TREATMENT OF APPENDICITIS
Appendicitis may be diagnosed in your health care provider's office or at the hospital.
The best treatment for appendicitis requires surgery to remove the appendix (the operation is called an appendectomy or an appendicectomy) before the appendix opens or ruptures. An appendectomy is always done in a hospital under general anesthetic.
The standard for medical management of non-perforated appendicitis remains appendectomy. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. Currently, the national rate of negative appendectomies is approximately 20 percent. Some studies have investigated non-operative management with parenteral antibiotic treatment, but 40 percent of these patients eventually required appendectomy.
PRE-SURGICAL PREPARATION
Before the appendectomy, your health care provider will order several tests. These include a physical exam, blood and urine tests, and X-rays or other imaging techniques to diagnose appendicitis and rule out any other causes for the abdominal pain. You will also be given an intravenous (I.V.) for antibiotics and pain medication before the surgery. An anesthesiologist will monitor the general anesthetic during the surgery. You will also undergo all the usual preparations for a surgical operation.
Do not eat for 8 hours before the procedure. You may continue to drink clear liquids until 2 hours before the procedure unless recommended otherwise by your health care provider. If your health care provider has recommended different times, follow the timing recommended by your practitioner.
Tell your health care provider or prescriber about all prescription, over-the-counter (non-prescription), nutritional supplements, and herbal medications that you are taking. Also tell them about any medication allergies and medical conditions that you may have.
Ask your health care provider or pharmacist whether you need to stop taking any of your medications before the procedure.
Warning & Precautions: Constipation commonly accompanies appendicitis. Taking a laxative increases the chance that the inflamed appendix will rupture. Never take a laxative if there is abdominal pain, vomiting, or other symptoms suggesting the possibility of appendicitis.
OPEN ABDOMINAL SURGICAL PROCEDURE
While awaiting surgery, the patient will be given IV fluids (intravenous drip) to keep hydrated. The patient will not be allowed to eat or drink (Nil-By-Mouth) because doing so may cause complications with the anesthesia during surgery.
Antibiotics are given intravenously such as cefuroxime and metronidazole. These may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anesthesia is usually used. Otherwise, spinal anaesthesia may be used.
Before the operation the patient will be sedated with a tranquillizer and then given a general anesthetic. The surgeon cleans the skin over the site of the appendix with an antiseptic solution. In a traditional appendectomy, your surgeon will make an incision through the skin 2 to 3 inches long in the lower part of your abdomen, where the appendix is located. The incision will open underlying layers of fat and the muscle, to expose the appendix.
After locating the appendix, your surgeon will first make sure there are no other problems visible that could be causing the pain.
The blood vessels leading to the appendix are tied off with sutures (stitches) and the inflamed organ is snipped off at its base. Your surgeon will then remove the appendix from the colon. The base is buried in the wall of the intestine using a purse-string suture to seal the hole in the colon. The surgeon then repairs each tissue layer until reaching the incisional opening in your abdomen, which is closed with more stitches. A drain may be left in the wound temporarily to remove any pus and other fluids which collect.
If the surgeon sees any infection, he or she will first drain the pus using rubber tubes. In some cases, the infection must be drained and given time to heal before the appendix can be removed. The surgeon then does a second surgery to remove the appendix.
The operation is more complicated if the appendix ruptures and abscesses have formed. These must be drained, so tubes may be left in the surgical wound to allow the continued removal of pus and fluids after the incision is closed. Doses of antibiotics are given to resolve the peritonitis.
During the surgery, if the surgeon finds that the appendix is not swollen or infected, the surgeon will inspect the surrounding organs. The surgeon will likely remove the appendix anyway to prevent any future complications.
LAPAROSCOPIC SURGERY
If a laparoscope is used, the surgeon is able to make smaller incisions in the skin and to dissect the appendix inside the body before removing it.
The surgical operation is commonly done laparoscopically (laparotomy), an approach usually through a limited right lower quadrant via three small incisions using a camera in the abdominal cavity to visualize the area of interest in the abdomen). Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes). However, in some cases it may be necessary to do an open abdominal procedure to take the appendix out.
While laparoscopic intervention has the advantages of decreased post-operative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time. Open appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.
If the laparoscopic findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly. In March 2008, an American woman had her appendix removed via her vagina, in a medical first.
LAPAROSCOPIC & OPEN PROCEDURE COMPARISONS
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio 0.45; CI 0.35 to 0.58), but the incidence of intra-abdominal abscesses was increased (odds ratio 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups.
There is debate whether emergent appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study no significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. These findings may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. Findings at the time of surgery suggest that perforation occurs at the onset of symptoms in atypical cases.
DURATION OF SURGERY & POST-SURGICAL HOSPITAL STAY
Surgery may last from 15 to 30 minutes in typical appendicitis in thin patients to several hours in complicated cases. Hospital lengths of stay usually range from overnight to a matter of days (rarely weeks in complicated cases.)
An appendicectomy is a standard, safe operation that is usually followed by a rapid recovery. It makes about half an hour. However, complications may sometimes set in from the accidental release of tiny amount of infected matter into the peritoneum during the operation. For this reason, antibiotics are usually prescribed routinely in order to prevent or treat any infection of this nature.
POST-PROCEDURE EXPECTATIONS
Following an appendectomy, you will spend time in a surgical recovery room, likely followed by a day or two in hospital. You will likely feel some discomfort or pain around the stitches. Your doctor may prescribe a painkiller for this pain.
To reduce the risk of infection, you will be given follow-up instructions and shown how to care for the stitches following your release from hospital. If your appendix was infected or had burst, you may require a slightly longer stay in hospital and you may need to take antibiotics.
Arrange for someone to drive you home from the hospital.
RISKS & PRECAUTIONS
Because you only have one appendix and it cannot grow back after being removed, you can only have an appendectomy once.
The most common risk associated with an appendectomy is an infection around the stitches following surgery. The infection may be mild, causing redness and tenderness, or severe, requiring antibiotics and further surgery. There is also the risk of infection in the area where the appendix was, requiring further treatment. Bleeding is another risk of any surgery.
An appendectomy will leave a scar on the abdomen, though laparoscopic surgery may leave less scarring because the openings are smaller.
Certain risks are common to all surgery and every time an anesthetic is used. These include side effects of the anesthetic, breathing problems, infection, and bleeding.
COMPLICATIONS
The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients.
Appendiceal rupture accounts for a majority of the complications of appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care, age extremes (young and old) and hidden location of appendix. A brief period of in-hospital observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve diagnostic accuracy.
Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient's symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm3 (200 to 300 3 109 per L) with a prominent left shift.
A periappendiceal abscess may be treated immediately by surgery or by non-operative management. Non-operative management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.
SPECIAL CONSIDERATIONS
The technique of appendiceal computed tomography is more accurate than ultrasonography in confirming the diagnosis of appendicitis.
While appendicitis is uncommon in young children, it poses special difficulties in this age group. Young children are unable to relate a history, often have abdominal pain from other causes and may have more nonspecific signs and symptoms. These factors contribute to a perforation rate as high as 50 percent in this group.
In pregnancy, the location of the appendix begins to shift significantly by the fourth to fifth months of gestation. Common symptoms of pregnancy may mimic appendicitis, and the leukocytosis of pregnancy renders the WBC count less useful. While the maternal mortality rate is low, the overall fetal mortality rate is 2 to 8.5 percent, rising to as high as 35 percent in perforation with generalized peritonitis. As in non-pregnant patients, appendectomy is the standard for treatment.
Elderly patients have the highest mortality rates. The usual signs and symptoms of appendicitis may be diminished, atypical or absent in the elderly, which leads to a higher rate of perforation. More frequent perforation combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a mortality rate of up to 5 percent or more.
Up to 20 percent of surgeries for appendicitis reveal a non-inflamed appendix (negative appendectomy). The difficulty in making a definite diagnosis of this medical problem and the risk of missing the acutely inflamed appendix (and the patient becoming very ill due to perforation) makes a certain rate of misdiagnosis inevitable. Women in particular have a high rate of negative appendectomy as ovarian and uterine problems make the diagnosis more difficult. CT scanning prior to surgery has been shown to decrease this percentage to closer to 7-8 percent in women.
SURGICAL FOLLOW-UP
After an uncomplicated appendectomy, the patient may gradually resume a normal diet with a restriction in physical activity for at least two to four weeks. The health care provider will check the incision the following week to look for possible wound infection.
PROGNOSIS (OUTLOOK AFTER SURGERY)
The abdominal pain caused by the appendicitis should ease immediately following surgery, however, you will likely experience some pain or tenderness around the stitches as a result of the surgery itself.
Recovery from appendicitis and the surgery is usually complete and, if there are no complications, you will likely be able to return to your normal activities within two to three weeks. This recovery time can be even shorter if you had laparoscopic surgery.
Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old) the recovery takes three weeks.
With uncomplicated appendicitis, most appendicitis patients recover easily with surgical treatment with no long-term problems. Prompt diagnosis of appendicitis ensures timely treatment and prevents serious complications. However, complications can occur if treatment is delayed or if peritonitis occurs. If the appendix ruptures, there is a greater than 10 times risk of complications, including death. This increase in risk generally is found in the very young, elderly, and those with weakened immune systems, including people with diabetes. Whether a perforated appendix is a significant risk for infertility has not been well established. Some experts recommend that this be considered in young women who might be at risk.
The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e. outside of a proper hospital), when a timely medical evaluation was impossible.
Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy.
PREVENTION
There is no way of predicting when appendicitis will occur. It cannot be prevented. However, eating a proper diet with plenty of fiber can help to properly move fecal matter through the colon, reducing a chance of fecal obstruction problems.
If you have intestinal disorders, have them diagnosed and treated properly.
MoonDragon's Health Disorders: Crohn's Disease
APPENDICITIS SELF-CARE AT HOME
There is no home care for appendicitis. If the condition is suspected, contact a health care provider or go to an emergency department. Avoid eating or drinking as this may complicate or delay surgery. If the person is thirsty, he/she may rinse their mouth with water. Do not take (or give your child) laxatives, antibiotics, or pain medications because these may cause delay in diagnosis that increases the risk of rupture of the appendix or mask the symptoms, which makes diagnosis more difficult.
HOLISTIC RECOMMENDATIONS & CONSIDERATIONS
The nutrients and herbs recommended in this section are intended to support recovery AFTER surgery, if appropriate, has been performed. These recommendations are NOT meant to replace conventional medical treatment for appendicitis.
CONSIDERATIONS
There are two schools of thought on treating appendicitis. Most medical experts recommend removal of the appendix. Another group recommends attempting to save it as a lymphoid organ. In addition, it may be useful if reconstructive surgery on the bladder becomes necessary. If you should develop bladder cancer at a later time and the bladder must be removed, the appendix can be fashioned into a sphincter muscle and joined to a section of intestine that will serve as a new bladder. If the appendicitis is about to burst, it must be removed at once. However, this is a valuable organ, and some practitioners believe it should not be removed unless your health care provider deems it absolutely necessary because he or she believes it will burst. In any case, you should not allow a health care practitioner to remove your appendix during an operation for some other condition ("as long as we are in there...").
DIETARY & LIFESTYLE RECOMMENDATIONS
To lessen the risk of appendicitis, you should eat a diet high in soluble fiber, avoid refined and fried foods, and limit your intake of cooked animal proteins to one serving a day.
If you suspect appendicitis, do NOT take a laxative and do NOT use a heating pad, as these can provoke rupturing of the appendix. Also, avoid pain relievers as they can lead to misdiagnosis. Avoid eating and drinking. See your health care provider or emergency department immediately.
HERBAL RECOMMENDATIONS
Alfalfa, Agrimony, Buckthorn, and Slippery Elm teas are soothing.
Herbal Remedies: Alfa Max, Alfalfa Extract, Nature's Way, 525 mg, 100 Caps
Herbal Remedies: Alfalfa, NOW Foods, 650 mg, 500 Tabs.
Herbal Remedies: Alfalfa Tincture, 100% Organic, 2 fl. oz.
Herbal Remedies: Alfalfa Leaf Root (Medicago Sativa) Powder, Kosher, 4 oz. Bulk
Herbal Remedies: Alfalfa Leaves, Nature's Way, 405 mg, 100 Caps
Herbal Remedies: Alfalfa Powder, Whole Food Supplement
Herbal Remedies: Agrimony Bach Flower Remedies Tincture, Bach Flower Essences, Agrimony Eupatoria, 20 ml
Herbal Remedies: Chlorofresh Liquid Chlorophyll, Nature's Way, 16 fl. oz.
Herbal Remedies: Chlorofresh, Chlorophyll Supplement, Nature's Way, 50 mg, 90 Softgels
Herbal Remedies: Chlorophyll With Alfalfa Powder, NOW Foods, 100 mg, 90 Caps
Herbal Remedies: Slippery Elm Bark Powder (Ulmus Rubra), 4 oz. Bulk
Herbal Remedies: Slippery Elm Bark, Nature's Way, 370 mg, 100 Caps
Aloe Vera juice, cold-pressed from the whole leaf, can help to reduce intestinal problems and is good for general colon health.
Herbal Remedies: Aloe Vera Gel, NOW Foods, 32 oz.
Herbal Remedies: Aloe Vera Gel, NOW Foods, 1 Gallon
Herbal Remedies: Aloe Vera Concentrate, NOW Foods, 100% Organic, 4 oz.
Echinacea relieves discomfort and enhances the immune system. Caution: Do not take Echinacea if you have an autoimmune disorder.
Herbal Remedies: Echinacea Immune Support Tea, Yogi Tea, Certified Organic, 16 Tea Bags
Herbal Remedies: Echinacea Tincture For Children, Orange Flavor, Alcohol Free, 100% Organic, 1 fl. oz.
Herbal Remedies: Echinacea Tincture, Nature's Way, Alcohol Free, 1 fl. oz.
Herbal Remedies: Echinacea Root Complex, Nature's Way, 180 Caps
Herbal Remedies: 5 Echinacea Supplement, Vegetarian, Herbal Remedies USA, 1,000 mg, 60 Liquid VCaps
Herbal Remedies: Echinacea Extract, Standardized, Nature's Way, 340 mg, 60 Caps
Herbal Remedies: Echinacea Herb, Nature's Way, 400 mg, 180 Caps
Herbal Remedies: Echinacea & Olive Leaf Extract, Standardized, Nature's Way, 60 Caps
NUTRITIONAL SUPPLEMENTS
Unless otherwise specified, the following recommended doses are for adults over the age of 18. For a child between 12 and 17 years, reduce the dose to 3/4 the recommended dose. For a child between 6 and 12 years old, use 1/2 the recommended dose, and for a child under 6, use 1/4 the recommended dose. These supplements are for support after appendectomy surgery.
APPENDICITIS SUPPLEMENTS & PRODUCTS
Supplements and products for appendicitis, an inflammation of the appendix, a lymphoid organ that opens into the large intestine.
Alfa Max, Alfalfa Extract, Nature's Way, 525 mg, 100 Caps
Nature's Way Alfa-Max Alfalfa Extract capsules is a 10x extract of fresh green Alfalfa leaves.AloeMaxLax (Aloe Laxative), All Natural Remedy For Constipation, Nature's Way, 445 mg, 100 VCaps
AloeMaxLax, aloe laxative natural remedy for constipation, from Nature's Way is specially formulated for those with tough constipation.Beta Carotene, Natural Dunaliella Salina, 100% Natural, Nature's Way, 25,000 IU, 100 Softgels
Nature's Way Beta Carotene is 100% all natural from Dunaliella salina.Chlorofresh Liquid Chlorophyll, Mint, Nature's Way, 16 fl. oz.
Chlorofresh is a special liquid chlorophyll complex, derived from premium alfalfa leaves.Colon & Liver Cleanser, 16 fl. oz.
CAC liquid is a colon and liver cleanser and detoxifier as well as a blood cleanser that serves to regulate the bowel movements so that the stool is so soft it breaks up into a cloud.Colon & Liver Cleanser, Truman's CAC Tea, Loose Leaf, 1/2 lb.
Use of this cleansing tea has many additional benefits: improves overall digestion; strengthens the immunity; helps to prevent cancer; makes the skin more emollient and flexible: clears the eyes; and provides an overall tonic effect on the body.Colon Health, The Key To A Vibrant Life, By Dr. Norman W. Walker
Presents a complete program for rejuvenating the entire body and for reviving ailing health through colon cleansing and nourishment.Detoxify Formula Bowel & Liver Cleanser Tincture, 100% Organic, 2 fl. oz.
Use Bowel & Liver Cleanser for travel, especially when going to other countries.Easy Going & Colon Clean Herb Tea, 20 Tea Bags
Easy Going & Colon Clean Herb Tea, Colon Cleanse Tea, is made of wild rhubarb (rhei rhizoma) and cassia seed which facilitates easy bowel movements and cleanses the intestines.Echinacea Root Complex, Nature's Way, 180 Caps
Echinacea Root Complex helps promote general well-being during the cold and flu season and support the Immune System.Naturalax 2, Herbal Laxative, Nature's Way, 445 mg, 100 Caps
Naturalax 2, an herbal laxative, is also known as the lower bowel formula it is used for relief of occasional constipation. This product generally produces bowel movement in 6 to 12 hours.Pain Formula Tincture, 2 fl. oz.
Use the Pain Formula to alleviate pain naturally.Red Clover With Prickly Ash Bark, Nature's Way, 460 mg, 100 Caps
Red Clover Herb from Nature's Way is a synergistic blend of traditionally popular herbs Red Clover, Prickly Ash Bark and other synergistic herbs.Slippery Elm Bark Powder (Ulmus Rubra), 4 oz. Bulk
Slippery Elm Bark is a soothing nutritive demulcent which is perfectly suited for sensitive or inflamed mucous membrane linings in the digestive system.Smart Medicine For A Healthier Child: A Practical A-to-Z Reference To Natural & Conventional Treatments For Infants & Children
Here's a practical A-to-Z reference guide to children's health. This source offers the best perspectives of both alternative care and conventional medicine for the most common childhood disorders and their treatments.Vitamin B-100 Complex With Coenzyme B-2, Nature's Way, 631 mg, 100 Caps
A complete Vitamin B complex of 8 essential vitamins. B Vitamins are precursors of coenzymes involved in the conversion of cellular energy, manufacture of hormones and proteins, and repair and maintenance of nerve structures.Vitamin C-1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps
Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.Vitamin C-500 With Rosehips, Nature's Way, 100% Natural, 500 mg, 250 Caps
Nature's Way Vitamin C with rose hips offers a rich whole plant source of vitamin C.Vitamin E, Natural D-Alpha-Tocopherol, 400 IU, 100 Softgels
Vitamin E has potent antioxidant activity, supplies oxygen to the blood, aids in strengthening capillary walls, and plays a beneficial role in cancer and cardiovascular disease prevention, anti-aging benefits, circulation, wound-healing, immune function, nervous system function, PMS, hot flushes, diabetes, vascular disease, eye health, tissue repair, athletic performance, leg cramps, skin and hair health, and alleviating fatigue.Whole Leaf Aloe Vera Juice, 99.7% Pure, Certified Organic, Nature's Way, 1 Liter
Nature's Way Whole Leaf Aloe Vera Juice offers you the rich benefits of the most potent part of the aloe plant. Whole Leaf Aloe Vera Juice contains an abundance of advantageous components not found in most aloe gel filler products.Zinc Ionic Mineral Supplement, Fully Absorbable, 100 +/- ppm, 16 fl. oz.
WaterOz Ionic Zinc is a pure liquid Zinc supplement. Zinc moves through all the fluids in the body, it creates a defense against infection-causing bacteria and viruses trying to enter the body and stops bacterial and viral replication.Zinc Lozenges With Echinacea & Vitamin C, Nature's Way, 23 mg, 60 Lozenges
Nature's Way Zinc lozenge boosts cold season defense with zinc, widely recognized as an important nutritional support during the cold season, and echinacea pupurea, clinically shown to support the immune system, and Vitamin C, a vitally important vitamin for general health maintenance.
Herbal Remedies: Appendicitis Information
Herbal Remedies: Appendicitis Supplements & Products
NOTIFY YOUR HEALTH CARE PROVIDER IF...
Call your health care provider if there are acute symptoms of middle/lower or right/lower abdominal pain with fever and/or vomiting.
If symptoms of abdominal pain continue for more than four hours, an urgent medical evaluation should be done at the practitioner's office or the hospital's emergency department.
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HELPFUL PRODUCTS & FURTHER EDUCATION
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 4th Edition
Prescription for Herbal Healing: The A-To-Z Reference To Common Disorders
-- by Phyllis A. Balch
The Complete Guide to Natural Healing
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