Appendicitis

Definition

Appendicitis is an inflammation of the appendix, which is the small, finger-shaped pouch attached to the beginning of the large intestine on the lower-right side of the abdomen. Appendicitis is a medical emergency, and if left untreated, the appendix may rupture and cause a potentially fatal infection.

Description

In children, appendicitis is the most common abdominal medical emergency and most common pediatric emergency surgical procedure. Although the appendix has no known function, it can become inflamed and diseased. This condition, called appendicitis, can rapidly evolve into a life-threatening or fatal infection of the abdominal cavity (peritonitis) if not treated immediately. Appendicitis usually involves emergency consultation with a physician and evaluation in a hospital emergency department.

Demographics

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 to 14, and among females aged 15 to 19. More males than females develop appendicitis between puberty and age 25. It is rare in infants and children under the age of two. In the United States, appendicitis occurs in four out of 1,000 children.

Causes and symptoms

Appendicitis is usually caused by a blockage of the inside of the appendix, which is called the lumen. Most often, the lumen is blocked by fecal material. Lymphoid tissue, which is present in mucosal lining of the appendix and intestines to help fight bacterial and viral infections, can swell and lead to obstruction of the appendix. This condition, called lymphoid hyperplasia, may also be associated with a variety of inflammatory and infectious diseases, such as Crohn's disease, gastroenteritis , respiratory infections, mononucleosis, and measles . Appendicitis can also be caused by foreign bodies (e.g., intrauterine device or something swallowed), traumatic abdominal injury, or tumors. In addition, genetics may play a role in appendicitis; some children may inherit genes that make them more susceptible to blockage of the appendiceal lumen. Having cystic fibrosis also increases a child's risk for appendicitis.

Blockage of the appendix then causes inflammation, increased pressure, and restricted blood flow, leading to abdominal pain and tenderness in the right lower quadrant of the abdomen. If the appendix is not removed, bacteria and inflammation within the appendix rapidly expand, the wall of the appendix stretches, and perforation can occur. Once the appendix is perforated, bacteria-filled fluid is released into the abdominal cavity and peritonitis then develops. Perforation is more common in younger children. Perforation can occur as soon as 48 to 72 hours after symptoms first begin and can become life-threatening.

Classic symptoms of appendicitis include the following:

• abdominal pain, first around the navel then moving to the lower right quadrant of the abdomen
• nausea
• vomiting
• loss of appetite
• diarrhea, constipation , and/or inability to pass gas
• fever beginning after other symptoms
• abdominal swelling and tenderness

Other possible symptoms are pain on urination, inability to urinate, or frequent urge to urinate if the swollen appendix is near the urinary tract and bladder. When perforation occurs, abdominal pain becomes more intense and involves the whole abdominal area, and fever may be very high.

Symptoms of appendicitis vary, and not every child will have all the symptoms. In children younger than age two years, the most common symptoms are vomiting and a bloated or swollen abdomen. Toddlers with appendicitis may have difficulty eating and may seem very tired. Children may have constipation, but may also have small stools that contain mucus. Although infants and children younger than two years may also have abdominal pain and other symptoms, they are too young to effectively communicate their symptoms to adults, who may then miss the symptoms of appendicitis.

When to call the doctor

Appendicitis is a medical emergency. A doctor should be called immediately if appendicitis is suspected so that children can receive prompt medical treatment before perforation occurs. Parents who suspect that their child has appendicitis should not give the child any pain medication because it may interfere with the results of a doctor's physical examination for appendicitis. In addition, parents should not give their child anything to eat or drink in case surgery is required immediately.

Symptoms in combination that require a doctor's immediate attention include significant abdominal pain, fever, diarrhea, nausea and vomiting , swollen or bloated abdomen, and loss of appetite. If abdominal pain begins before nausea and vomiting, rather than after, appendicitis rather than intestinal infection is more likely.

Diagnosis

Appendicitis is diagnosed by physical examination, laboratory tests, and imaging tests. During a physical examination, the doctor palpates the abdomen to find tender and painful spots. A physical examination can also include a rectal examination, examination of the genitals in boys, and a gynecologic examination in girls, because other conditions, such as testicular torsion and ectopic pregnancy may have symptoms similar to appendicitis. Laboratory tests involve an analysis of white blood cell count to determine whether infection is present, urinalysis to rule out urinary tract or kidney infection, and other tests, such as pregnancy and liver function tests, to rule out other causes of abdominal pain. Imaging tests can include abdominal x rays, ultrasound, and computed tomography (CT).

In 2004, a new imaging technique that uses nuclear medicine imaging and an injection of an imaging agent called NeutroSpec was introduced for the diagnosis of appendicitis. This technique provides images of infected areas and may help physicians decide which children are candidates for surgery to remove the appendix. Up to 20 percent of appendectomies are performed on infants and children with a normal appendix.

Abdominal pain is a common complaint in children, and making a timely diagnosis of appendicitis before perforation is often difficult. Up to 30 percent of children with appendicitis are misdiagnosed, even by experienced physicians. In infants, diagnosis is often not possible and not made until after perforation. Appendicitis is most often misdiagnosed as gastroenteritis or respiratory infection.

Treatment

Appendicitis is treated by immediate surgery to remove the appendix, called an appendectomy. Appendectomy is the most common emergency surgery performed by pediatric surgeons. In an open appendectomy, the appendix is removed through a standard abdominal incision. In laparoscopic appendectomy, surgeons insert a small scope through tiny abdominal incisions to remove the appendix. A laparoscopic appendectomy results in less postoperative pain and fewer surgical incision infections. However, the procedure is longer and requires specialized surgical experience in operating on pediatric patients. In female teen patients, laparascopy has the added benefit of being able to diagnose and treat gynecologic conditions and ectopic pregnancy during the appendectomy if the appendix is found to be normal.

Preoperative antibiotics are given to children with suspected appendicitis and stopped after surgery if there is no perforation. Antibiotic treatment kills bacteria, and stronger and longer courses of antibiotics are required if peritonitis occurs.

If the appendix is removed before perforation occurs, the hospital stay is usually two to three days. A child with a perforated appendix and peritonitis must remain in the hospital up to a week.

Prognosis

Appendicitis is usually treated successfully by appendectomy, and unless there are complications, children should recover without further problems. The mortality rate in cases without complications is less than 0.1 percent. Perforated and ruptured appendix, as well as peritonitis, occur at higher rates among children. When the appendix has ruptured or a severe infection has developed, the likelihood for developing complications is higher, and recovery is longer. Peritonitis is a life-threatening condition, and death occurs in about 1 percent of cases.

Prevention

In general, appendicitis cannot be prevented. The incidence of appendicitis is lower in cultures where people eat more daily dietary fiber, which is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions within the appendix.

Parental concerns

Because the appendix is more likely to perforate in children than adults, parents should not hesitate to call the doctor if their child develops symptoms that may indicate appendicitis. Parents should feel free to ask their doctor and other medical staff questions about any medical tests or treatments their child receives.

KEY TERMS

Appendectomy —Surgical removal of the appendix.

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

Computed tomography (CT) —An imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures; also called computed axial tomography.

Ectopic pregnancy —A pregnancy that develops outside of the mother's uterus, such as in the fallopian tube. Ectopic pregnancies often cause severe pain in the lower abdomen and are potentially life-threatening because of the massive blood loss that may occur as the developing embryo/fetus ruptures and damages the tissues in which it has implanted.

Laparoscopy —A surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube (laparoscope) is inserted. This allows the doctor to examine abdominal and pelvic organs. Other small incisions can be mad to insert instruments to perform procedures. Laparoscopy is done to diagnose conditions or to perform certain types of surgeries.

Peritonitis —Inflammation of the peritoneum. It is most often due to bacterial infection, but can also be caused by a chemical irritant (such as spillage of acid from the stomach or bile from the gall bladder).

Testicular torsion —A condition involving the twisting of the spermatic cord inside the testicle that shuts off its blood supply and can seriously damage the testicle.

Ultrasonography —A medical test in which sound waves are directed against internal structures in the body. As sound waves bounce off the internal structure, they create an image on a video screen. Ultrasonography is often used to diagnose fetal abnormalities, gallstones, heart defects, and tumors. Also called ultrasound imaging.

Resources

BOOKS

Majumdar, P. C. Appendicitis. New Delhi, India: B. Jain, 2003.

Tilden, J. H. Appendicitis: The Etiology, Hygienic, and Dietetic Treatment. Pahrump, NV: Library of New Atlantis, 2003.

Harvard Medical School. Medical Tests: A Practical Guide to Common Tests. Boston, MA: Harvard Health Publications, 2004.

PERIODICALS

Kosloske, A. M., et al. "The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on Pediatric Surgical Evaluation." Pediatrics 113 (January 2004): 29–34.

McCullough, M. "Targeting Appendicitis: A New Tool Offers Wider Promise." Philadelphia Inquirer (July 7, 2004).

Zitsman, J. L. "Current Concepts in Minimal Access Surgery for Children." Pediatrics 111 (June 2003): 1239–52.

ORGANIZATIONS

American College of Emergency Physicians. Web site: <www.acep.org>.

American College of Radiology. Web site: <www.acr.org>.

WEB SITES

"Appendicitis." Available online at <http://kidshealth.org/parent/infections/stomach/appendicitis.html> (accessed October 24, 2004).

"Appendicitis." National Digestive Diseases Information Clearinghouse. Available online at <http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/> (accessed October 24, 2004).

Trevino, M. "CT for Appendicitis Diagnosis in Children Gains Popularity." Available online at <www.dimag.com/dinews/2003050901.shtml> (accessed October 24, 2004).

Tucker, J. "Pediatrics: Appendicitis." Emedicine. Available online at <www.emedicine.com/emerg/topic361.htm> (accessed October 24, 2004).

Jennifer E. Sisk, M.A.

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 one of the most common abdominal emergencies found in the United States. More males than females develop appendicitis. 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. Other conditions can have symptoms similar to appendicitis, 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.

A timely diagnosis of appendicitis is important, 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. Very rarely, the inflammation and symptoms of appendicitis may disappear but recur again later. If appendicitis is suspected, the following activities should be avoid, as they may cause the appendix to rupture:

• consuming food or drink
• taking pain medication, laxatives, or antacids
• the use of a heating pad on the affected area

Causes & symptoms

The causes of appendicitis are not totally understood, but are believed to occur as a result of blockage of the appendix. This blockage may be due to fecal matter, a foreign body in the large intestine, cancerous tumors, a parasite infestation, or swelling from an infection.

The distinguishing symptom of appendicitis is the migration of pain to the lower right corner of the abdomen. The abdomen often becomes rigid and tender to the touch. The patient may bend the knees in reaction to the pain. Increased rigidity and tenderness indicate an increased likelihood of perforation and peritonitis. Loss of appetite is very common, accompanied by a low–grade fever , and occasionally there is constipation or diarrhea , as well as nausea . Unfortunately, these signs and symptoms may vary widely. Atypical symptoms are particularly present in pregnant women, the elderly, and young children.

If bacteria multiply unchecked within the appendix, it will become swollen and filled with pus, and may eventually rupture. This produces an inflammation of the lining of the abdominal wall, or peritonitis, which is a medical emergency. Signs of rupture include the presence of symptoms for more than 24 hours, a high fever, a distended abdomen, a high white blood cell count, and an increased heart rate.

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. The physician will ask questions regarding the nature and history of the pain, as well doing an abdominal exam to feel for inflammation, tenderness, and rigidity. Bowel sounds will be decreased or absent. A blood test will be given, because an increased white cell count may help confirm a diagnosis of appendicitis. Urinalysis may help to rule out a urinary tract infection that can mimic appendicitis. In cases with a questionable diagnosis, other tests, such as a computed tomography scan (CT) or ultrasound may be performed to help with diagnosis without resorting to surgery. Abdominal x rays, however, are not of much value except when the appendix has ruptured.

Patients whose symptoms and physical examination are compatible with a diagnosis of appendicitis are usually hospitalized and a surgical exploration of the abdomen, called a laparotomy, is done immediately to confirm the diagnosis. A normal appendix is discovered in about 10–20% of patients who undergo laparotomy. 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. If the symptoms are not clear, surgery may be postponed until they progress enough to confirm a diagnosis. Sometimes the surgeon will remove a normal appendix as a safeguard against appendicitis in the future.

Treatment

Appendicitis must be treated by a surgeon in a hospital setting. However, acupressure can be helpful for recuperation. One dose of homeopathic phosphorus 30c can be taken before surgery to help reduce nausea, light-headedness, and disorientation due to anesthesia. Phosphorus 6c can be also taken two to three times in the hours following surgery. Other appropriate remedies may include Aconite napellus 30c, Arnica montana 30c, Gelsemium 6c, and Staphysagria 30c.

Allopathic treatment

The treatment for sudden, severe appendicitis is surgery to remove the appendix, called an appendectomy. An appendectomy may be done by opening the abdomen in the standard operating technique, or through laparoscopy, in which a small incision is made through the navel. Recovery may be faster with a laparoscopy than with an ordinary appendectomy. An appendectomy should be performed within 48 hours of the first appearance of symptoms, to avoid a rupture of the appendix and peritonitis. Antibiotics are given before surgery in case peritonitis has already taken hold. If peritonitis is discovered, the abdomen must also be irrigated and drained of pus, and then treated with multiple antibiotics for 7-14 days.

Expected results

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 leafy green vegetables may help prevent appendicitis.

Resources

BOOKS

The Editors of Time–Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. Virginia: Time–Life, Inc., 1996.

Lininger, D.C., Skye, editor–in–chief, et al. The Natural Pharmacy. California: Prima Health, 1998.

Yamada, Tadataka, ed. et al. Textbook of Gastroenterology. Philadelphia: J.B. Lippincott, 1995.

PERIODICALS

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

Wagner J.M., et al. "Does This Patient Have Appendicitis?" JAMA: The Journal of the American Medical Association 276 (1996).

Patience Paradox

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 and inflamed. Appendicitis is a medical emergency. If it is left untreated, the appendix may rupture and cause a potentially fatal infection.

Description

Appendicitis is the most common abdominal emergency 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 females aged 15-19. More males than females develop appendicitis between puberty and age 25. It is rare among the elderly and in children under the age of two.

The hallmark symptom of appendicitis is increasingly severe abdominal pain. The pain of appendicitis begins in the center of the abdomen and becomes concentrated in the lower right quadrant of the abdomen. 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, 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 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 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 or coughing. 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. A 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 people, and infants. In pregnant women, appendicitis is easily masked by the frequent occurrence of mild abdominal pain and nausea from other causes. Elderly people may feel less pain and tenderness than most individuals, 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.

Persons 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 (CT) scan 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 an appendix has ruptured.

Often, the diagnosis is not certain until an operation is completed. 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 is sometimes recommended 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 for 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 for appendicitis is an immediate appendectomy, which is done by opening the abdomen in the standard open appendectomy technique, or through laparoscopy. In laparoscopy, a smaller incision is made beside the navel. Both methods can successfully accomplish the removal of an appendix. It is not certain that laparoscopy holds any advantage over open appendectomy. When an appendix has ruptured, patients undergoing a laparoscopic appendectomy may have to be switched to the open appendectomy procedure for 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, people usually 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 for complications is higher, with slower recovery, or death from disease. There are higher rates of perforation and mortality among children and elderly persons.

Health care team roles

A physician, physician assistant, or nurse practitioner usually makes an initial diagnosis of appendicitis based on history, physical findings, and laboratory results. A laboratory technician may provide a test that confirms a diagnosis. A surgeon removes an appendix. Nurses assist by collecting data from the patient and family, monitoring vital signs and status of pain, and providing patient education about the diagnosis, surgery, and recovery.

Prevention

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

KEY TERMS

Appendectomy— Surgical removal of the appendix.

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

Laparotomy— A surgical incision into the abdomen, made between the ribs and the pelvis, that offers surgeons a view inside the abdominal cavity.

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

Ulceration— An abnormal change in tissue accompanied by the death of cells.

Resources

BOOKS

Carter, David C. "The Acute Abdomen." In Diseases of the Gastrointestinal Tract and Liver, edited by David J.C. Shearman et al. New York: Churchill Livingstone, 1997.

Hartman, Gary E. "Acute Appendicitis." In Nelson Textbook of Pediatrics, 16th ed., edited by Richard E. Behrman et al. Philadelphia: Saunders, 2000, 1178-81.

Krahenbuhl, L. Acute Appendicitis: Standard Treatment and the Role of Laparoscopic Surgery. Basel, Switzerland: Karger Publishing, 1998.

Silen, William. "Acute Appendicitis." In Harrison's Principles of Internal Medicine, 14th ed., edited by Anthony S. Fauci et al. New York: McGraw-Hill, 1998, 1658-59.

PERIODICALS

Bachoo, P., A. A. Mahomed, G. K. Ninan, and G. G. Youngson. "Acute Appendicitis: The Continuing Role for Active Observation." Pediatric Surgery International 17 no. 2-3 (2001): 125-28.

Gronroos, J. M., and P. Gronroos. "Diagnosis of Acute Appendicitis." Radiology 219 no. 1 (2001): 297-98.

Jones, P. F. "Computed Tomography in Suspected Acute Appendicitis." Surgery 129 no. 4 (2001): 514-15.

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

ORGANIZATIONS

American College of Gastroenterology. 4900 B South 31st Street, Arlington VA 22206. (703) 820-7400. (703) 931-4520. 〈http://www.acg.gi.org〉.

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611. (312) 202-5000. (312) 202-5001. 〈http://www.facs.org〉. [email protected].

OTHER

American Academy of Family Physicians. 〈http://www.aafp.org/afp/991101ap/2027.html〉.

Dr. Koop.com. 〈http://www.drkoop.com/conditions/ency/article/000256.htm〉.

Harvard University and Brigham Hospital. 〈http://www.brighamrad.harvard.edu/Cases/bwh/hcache/112/full.html〉.

National Digestive Diseases Information Clearinghouse. 〈http://www.niddk.nih.gov/health/digest/summary/append/〉.

National Library of Medicine. 〈http://www.nlm.nih.gov/medlineplus/appendicitis.html〉.

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).