Appendicitis

Appendicitis is a medical emergency that can occur at any age but is more common among people of 10-30 years of age. It is a painful swelling or inflammation of the appendix, a small, tubular or finger-like pouch that extends from the large intestine. The opening of the appendix is small, and food or faecal matter can accumulate in it, sometimes creating a blockage. This blockage can develop a bacterial infection. If the appendix bursts at this stage, it will spread the bacterial infection in the abdominal cavity which can be life-threatening if not treated in time. When the appendix gets inflamed, you may experience intermittent pain (that comes and goes) in your abdomen. The pain gradually becomes severe and constant. It fixes over the lower right side where the appendix is located. Walking, coughing, or pressing the abdomen can worsen the pain. Fever, loss of appetite and diarrhoea are also occasionally associated with appendicitis.

Appendicitis is categorised into three types:

• Acute appendicitis
  Acute appendicitis develops in a short period of time. It is the most commonly seen type of appendicitis and is easily diagnosed. Immediate removal of the appendix is the treatment of choice.
• Recurrent appendicitis
  Recurrent appendicitis is uncommon. It occurs repeatedly with mild symptoms and resolves on its own.
• Chronic appendicitis
  Chronic appendicitis develops slowly as compared to acute and recurrent appendicitis. It has fewer symptoms and is difficult to diagnose. The treatment of chronic appendicitis is focussed on reducing the inflammation, which is mostly sufficient in relieving the symptoms. However, it may require surgery for a permanent cure. Chronic appendicitis accounts for 1% to 2% of all cases of appendicitis.

Pain in the lower right side of the abdomen is typical of appendicitis. However, you may also experience other symptoms associated with it, such as:

• Diarrhoea or constipation.
• Low-grade fever.
• Nausea and vomiting.
• Loss of appetite.
• Abdominal swelling.
• Bloating or an inability to pass gas.
• Pain around the navel progressing to the lower right side of the abdomen.

Symptoms of appendicitis may worsen on walking, pressing the lower abdomen or coughing.

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Causes

There are many causes that may lead to appendicitis. However, most of the time, the underlying cause remains unclear. A few conditions that may result in appendicitis include: 

• Inflammatory bowel disease.
• Abdominal injury.
• Infection of the digestive tract.
• Inflammation in the wall of the appendix.
• Clogging of the appendix with stool or parasites.
• Blockage of the opening of the appendix.

Risk factors

Certain factors that increase the risk of developing appendicitis in adults include:

• Diabetes.
• Steroid use.
• Chronic pulmonary (lung) disease.

Appendicitis is the most common medical emergency among children. The common risk factors for children include:

• A family history of appendicitis, especially in male children.
• A genetic disorder called cystic fibrosis increases the risk of appendicitis in a male child.

There is no way to prevent appendicitis. However, the chances of developing appendicitis are lesser in people who consume a fibre-rich diet and plenty of fluids.

Your doctor will suspect appendicitis based on your symptoms, medical history, and the physical examination.

To confirm the diagnosis of appendicitis, ultrasound, CT scan, MRI or X-ray of the abdomen might be advised. These tests help detect:

• The exact cause and location of abdominal pain.
• Other sources of abdominal pain.
• The area of inflammation.
• A burst appendix.
• A blockage in the appendix opening.

Blood test results showing a high white blood cell count can help confirm an infection.

Urine tests are also performed to rule out kidney stones or urinary tract infection that might be causing the abdominal pain.

Once appendicitis is confirmed, a surgery is the treatment of choice. Immediate surgery reduces the chances of a perforation of the appendix. The surgical term for removing the appendix is called appendectomy or appendicectomy.

Surgical treatment

Depending upon each case of appendicitis, the options available, and individual choice, any of the following methods may be employed to perform appendectomy:

• Laparoscopic surgery
  This is the most preferred method since it is followed a shorter recovery period. In this surgery, special instruments and a flexible tube with an attached camera are used to locate and remove the appendix through small incisions made in the abdomen.
• Laparotomy
  In this surgery, the doctor makes only one incision to remove the appendix. A cut is made in the lower right area of the abdomen. This procedure is also preferred in the presence of peritonitis- an infection of the inner lining of the abdominal cavity.
• Open surgery
  An open surgery is performed instead of laparoscopy when:
  • The person with appendicitis has previously had abdominal surgeries.
  • The appendix develops a lump called the appendix mass.
  • The appendix bursts.
• Antibiotic therapy
  According to some studies that compared the respective outcomes of surgeries and antibiotic treatments to treat appendix, 70% of the appendix cases may resolve with antibiotics without needing a surgery.
  Antibiotics are usually given to people who are too weak to undergo a surgery. IV (Intravenous) antibiotics preferably cephalosporins are administered before an appendectomy. If the appendix bursts open (perforated appendicitis), the pus is drained immediately and antibiotics are administered till the patient's white blood cell count and temperature normalise.

Lifestyle management

Following tips can help you recover once you are sent home after the treatment:

• Do not take any antibiotics unless your doctor prescribes them.
• Keep a record of your temperature every 2 hours if you still have a fever. Bring it along in your next visit to the doctor.
• Do not use painkillers. Taking medication for pain can make it hard to recognise if the appendicitis is getting better or worse.
• Do not drink or eat if you are going for another health exam the next day.
• Do not use laxatives or enemas; they could increase the risk of a ruptured appendix.
• Take ample rest and enough sleep. It helps in recovering from an appendectomy faster.
• Avoid straining your abdominal muscles and do not lift heavy things.
• Include more fibre in your diet as it will help in preventing constipation and help ease bowel movement.
• Take plenty of fluids every day.

Contact your doctor immediately if there is:

• Blood in your urine or while vomiting.
• Prolonged difficulty in emptying the bowel.
• Constant vomiting.
• Dizziness.
•  An increase in the intensity of pain in your abdomen

Prognosis

If immediate surgery is performed to remove the appendix, most people are discharged within a day. For a complicated surgery that involves treating peritonitis, it may take about a week to be discharged. Chances of death from appendicitis are very low with an early medical intervention. Older people take a longer time to recover. More than 50% of people who do not have access to surgery or medications may lose their lives due to complications. The prognosis of a ruptured appendix is very poor.

In most cases, people can get back to their normal activities within a couple of weeks. However, after an open surgery, strenuous activities might need to be avoided for 4 to 6 weeks. One may experience constipation for a while, which can be resolved by eating a fibre-rich diet, staying hydrated, and taking codeine painkillers. People may experience pain in the tip of the shoulder after undergoing a laparoscopic surgery due to the gas that gets pumped in the abdomen during the surgery.

Complications

Following complications are possible after an appendix operation:

• Obstruction of the small bowel
  People who undergo an operation for appendicitis have a 3% to 5% risk of having a small bowel obstruction (blockage in the small intestine).
• Infection of the wound
  An infection of the surgical wound happens in about 3% of cases. The wound may either need a reopening or treatment with antibiotics may be needed depending upon its condition.
• Peritonitis
  Bursting of the appendix can lead to spreading of the bacteria to other body parts. If the infection spreads to the peritoneum, a thin layer of tissue lining the abdomen, it is called peritonitis. Following are the signs indicating that your appendix may have burst:
  • Fever
  • Rapid heartbeat
  • Abdominal swelling
  • Feeling sick
  • Constant abdominal pain

Long-term problems or even death may occur if peritonitis is not treated immediately. Antibiotics and appendectomy are usually used for the treatment of peritonitis.

• Abscesses
  Sometimes, pus collects around a burst appendix known as an abscess. Antibiotics are given to treat the abscess or the pus is drained out surgically.