Appendicitis – All you need to know about it
Last updated date: 30-Dec-2021
13 mins read
The appendix is a small tube of tissue that extends from the large intestine and is located on the right side of your body. Appendicitis implies the inflammation of the appendix. Appendicitis is a medical emergency and almost always requires surgical removal of the appendix as soon as possible to delay further complications. People live a normal life without their appendix. In the United States, 1 in 20 people will develop appendicitis at some point in their lives. Although it can occur at any age, appendicitis is rare in children younger than 2 years old. It is most commonly found in people between the ages of 10 and 30.
Appendicitis occurs when the appendix becomes blocked, most commonly by stool, foreign objects or cancer. Blockage can also be caused by infection, as the appendix can swell due to an infection in the body.
Pathophysiology of appendicitis
It is reported that appendicitis is caused by obstruction of the lumen of the appendix caused by various reasons. Regardless of the cause, it is believed that the obstruction will cause the pressure in the lumen to increase. This increase is related to the continuous secretion of fluid and mucus by the mucous membrane and the stagnation of this substance. At the same time, the intestinal bacteria in the appendix multiply, leading to formation of pus, which leads to an increase in intraluminal pressure.
If the obstruction of the appendix persists, the intraluminal pressure will eventually rise above the venous pressure of the appendix, causing the obstruction of the venous outflow tract. As a result, ischemia of the appendix wall begins, leading to loss of epithelial integrity and allowing bacteria to invade the appendix wall. Within a few hours, due to arteriovenous thrombosis of the appendix, this local condition may worsen, leading to perforation of the appendix and gangrene. As this process continues, abscesses or peritonitis may develop around the appendix.
Typical symptoms of appendicitis include:
- Pain in the right lower abdomen or pain near the belly button moving downward. This is usually the first sign of appendicitis.
- Nausea and vomiting shortly after the onset of abdominal pain.
- Abdominal swelling.
- A fever.
- Inability to pass gas.
- Loss of appetite.
Other less common symptoms of appendicitis include:
- Dull or severe pain in the upper or lower abdomen, or anywhere on the back or buttocks
- Pain or difficulty urinating
- Vomiting before the onset of stomach pain
- Severe abdominal cramps
- Constipation or diarrhea
If you have any of these symptoms, seek medical attention immediately. Prompt diagnosis and treatment are extremely important to help avoid complications. If you think you might have appendicitis, try not to eat, drink or use any kind of pain relief, antiacids or laxatives.
Symptoms in Infants and Children
Children and infants may not feel pain in a particular area. There may be tenderness or pain throughout the body. Children and babies may have less bowel movements. If diarrhea occurs, it may be a sign of an illness. Although infants and children may not experience precise pain like older patients, research shows that abdominal pain remains the most common symptom of appendicitis in this age group.
Symptoms in older adults and during pregnancy
Older people and pregnant women may also have different symptoms. Stomach pain can be less severe and less specific. Possible symptoms include nausea, vomiting, and fever. During pregnancy, pain may move up to the right upper quadrant after the first trimester. There may also be some back pain. If you have abdominal pain, it may be due to another condition.
Although rare, appendicitis can also occur during pregnancy. Symptoms of appendicitis during pregnancy are similar to those of non-pregnant people. However, the appendix is higher in the abdomen during pregnancy because the growing baby changes the position of the intestines. Therefore, the severe pain associated with an inflamed appendix may feel higher on the right side of the abdomen.
A ruptured appendix is dangerous for both mother and baby. Traditional appendectomy (surgical removal of the appendix) is also more challenging during pregnancy. However, according to a 2016 study, a minimally invasive procedure called laparoscopic appendectomy appears to be a safe procedure during pregnancy with a low risk of complications.
What are the symptoms of a ruptured appendix?
The risk of appendicitis is that if left untreated, your appendix can rupture. From the moment you first notice any symptoms, it may take 36 to 72 hours for your appendix to rupture. In some cases, this time frame may be shorter. This is why it is so important to take these early symptoms seriously. There are signs that your appendix may rupture for several hours. Because when the appendix ruptures, the pressure and the source of pain in the appendix are relieved, and you may feel better at first. However, once your appendix ruptures, the bacteria in the appendix will overflow into your abdominal cavity, causing inflammation and infection. This is called peritonitis. Peritonitis is a serious disease that requires immediate medical attention.
Symptoms of peritonitis may include:
- Pain and tenderness throughout the abdomen.
- Pain that worsens with exercise or touch.
- Nausea and vomiting.
- Abdominal distension.
- Diarrhea or constipation.
- Need to rest.
- Fever and chills.
These symptoms may last until treatment begins and may get worse over time.
How appendicitis is diagnosed?
The diagnosis of appendicitis can be complicated, as the symptoms are usually unclear or similar to other diseases, including gallbladder problems, bladder or urinary tract infections, Crohn's disease, gastritis, kidney stones, intestinal infections, and ovarian problems.
The doctor will most likely:
- check your abdomen for inflammation;
- do a urine test to rule out infection;
- perform a rectal exam;
- test your blood to see if your body is trying to fight an infection;
- do a CT scan or ultrasound.
- Rovsing sign: the person is lying down, usually on the exam table. The clinician will slowly and gently press down on the lower left side of the patient's abdomen, then gradually release the pressure. If the individual feels sudden pain in the lower right quadrant of the abdomen, it is a positive Rovsing sign. A positive Rovsing sign is the result of acute appendicitis, characterized by inflammation, infection, or inflammation of the appendix. The pressure of the test is believed to create high stress on the abdomen near the appendix. This manual pressure, along with the buildup of intestinal gas in the colon and resistance from the ileocecal valve (which connects the large and small intestines), causes pain in the right lower quadrant. Or, the pain may be the result of the inflamed appendix rubbing against the right iliac fossa (the surface of the hip bone), which is the result of the movement of the small intestine to the right. Finally, pain caused by Rovsing's sign may be due to manual pressure on the peritoneum, which creates friction over the inflamed appendix.
- Obturator sign. The obturator sign is a clinical sign of acute appendicitis, defined as the discomfort that the subject/patient feels when the hip joint moves slowly inward when the right knee is bent. Represents the inflamed appendix in contact with the internal obturator muscle.
- Rebound tenderness, also called Blumberg's sign, is something your doctor can check when diagnosing peritonitis. To check rebound sensitivity, the doctor will put pressure on an area of your abdomen with your hands. They quickly retracted their hands and asked you if you felt pain when the skin and tissue they pressed bounced back into place. If you feel pain or discomfort, you have rebound sensitivity. If you don't feel anything, your doctor can help rule out peritonitis as the cause of your symptoms.
How is appendicitis diagnosed in children?
Your child's healthcare provider will perform a physical exam and they will ask about your child's symptoms and medical history. Your child's healthcare provider may order blood and urine tests to check for an infection in the body. Imaging tests for the diagnosis of appendicitis in children may include:
- X-rays of the abdomen.
- Abdominal ultrasound (that uses high-frequency sound waves to show pictures of your child's organs).
- A computed tomography (CT) scan that shows a cross section of your child's body. It combines X-ray and computer technology.
Recommendations and treatment for appendicitis
Appendicitis is almost always considered a medical emergency. An appendectomy (the surgery that requires the removal of the appendix), is the standard treatment for almost all cases of appendicitis. In general, if your doctor suspects that you have appendicitis, they can remove it quickly to avoid rupture. If you have an abscess, you may have two types of surgery: one to remove pus and fluid from the abscess, and the other to remove the appendix. But some research shows that treating acute appendicitis with antibiotics can help you avoid surgery.
What happens during an appendectomy?
Before the appendix is removed, you will most likely have to take antibiotics to fight the infection. You will receive general anesthesia, which means you will be asleep during the procedure. The doctor removes your appendix through a 4-inch incision or using a device called a laparoscope (a thin tool that allows them to see the inside of your abdomen and to insert surgical tools that help remove your appendix). This procedure is called laparoscopy. If you also have peritonitis (a dangerous complication of appendicitis), the surgeon will also clean your abdomen and drain the pus.
You can get up and move within 12 hours after the operation. You should be able to return to your normal life in 2 to 3 weeks. If you have a laparoscopy, your recovery will be faster.
After an appendectomy, get in touch with your doctor if you have the following conditions:
- Increased abdominal pain;
- Dizziness / feeling faint;
- Blood in vomit or urine;
- Increased pain and redness in the area of the incision or incisions;
- Pus in the incision;
How is appendicitis in children treated?
Sometimes appendicitis in children can be treated with antibiotics alone, but in most cases, appendicitis is treated by removing the appendix. The appendectomy on the child, just like in the case of an adult, can be done in two ways:
- Laparoscopy: The surgeon makes several small incisions in your child's right lower abdomen. Next, your surgeon will place the camera through one of the incisions. Then they will use a small tool to remove your child's appendix through the incision. This type of appendectomy has a shorter recovery time and a lower infection rate.
- Laparotomy: The surgeon makes a larger incision in the lower right part of your child's abdomen. This type of appendectomy is generally used for more complicated cases of appendicitis. It has a longer recovery time.
Before the operation, your child will be treated with antibiotics. The operation takes about an hour to complete.
What happens after the operation?
How long your child stays in the hospital depends mainly on the severity of the appendicitis. For acute appendicitis, most patients will stay overnight after surgery and go home. Some people can go home the same day. For advanced cases of appendicitis (perforating appendicitis), if the appendix ruptures or bursts, they will need to be hospitalized for approximately five days to receive more intravenous (IV) antibiotics. This will help treat more serious infections and prevent their recurrence.
Your child will receive pain medicine and antibiotics through a vein during the hospital stay. If your child can eat and drink normally, has no fever or discharge from the incision, and has normal bowel function, he can be discharged.
What complications can occur after an appendicitis surgery?
Complications sometimes occur after appendectomy. These complications are more common in more severe cases of ruptured appendicitis and may include:
- Infection: Infections can be treated with antibiotics. Sometimes it may be necessary to open the wound to clear the infection.
- Abscess: Sometimes an abscess can be treated with antibiotics. Larger abscesses may require drainage.
- Small bowel obstruction: Partial or complete obstruction of the small intestine may occur. Surgery may be required.
How soon will my child feel better after treatment?
Most children recover quickly after surgery. No diet or lifestyle changes are required. Children undergoing laparoscopic surgery should limit their physical activity during the first three to five days of recovery. Children who have had open surgery (laparotomy) should rest for 10 to 14 days before engaging in physical activity.
After the surgical procedure, slight swelling around your child's incision site is normal. However, if your child has any of the following symptoms, please call your child's healthcare provider:
- Has a fever.
- Is in a lot of pain
- Has excessive swelling, redness, or exudation of the incision.
Complications of appendicitis
If left untreated, the inflamed appendix will burst, spilling bacteria and waste into the abdominal cavity, which is the central part of your body and is responsible for housing your liver, stomach and intestines. This can lead to peritonitis, which is severe inflammation of the inner wall of the abdominal cavity (peritoneum). Unless it is quickly treated with antibiotics by a doctor, it can be fatal.
When should you go to the Emergency Room?
If your abdominal pain worsens, contact your doctor or local emergency room.
Appendicitis could easily be confused with other things, such as:
- Irritable bowel syndrome (IBS);
- Infection of the bladder or urinary tract;
- Crohn's disease;
- Pelvic infection;
- Stomach lesions;
- Ulcerative colitis;
- Abdominal injury.
In women, symptoms similar to appendicitis sometimes have gynecological causes, such as ectopic pregnancy, menstrual pain, or pelvic inflammatory disease (PID). But any condition that causes persistent abdominal pain requires urgent medical attention. If your pain suddenly worsens and spreads to your abdomen, or if your pain temporarily improves before it worsens again, call an ambulance.
If your pain is temporarily relieved but then worsens, your appendix may have ruptured. A ruptured appendix can cause peritonitis, which is a serious infection of the lining of the abdomen called the peritoneum.
Appendicitis vs Gas
Severe abdominal pain is usually caused by the accumulation of gas. But it can also be a symptom of appendicitis. It is important to know the difference between the two, because an inflamed appendix can be a life-threatening medical emergency. Gas-induced pain however is usually short-lived and generally does not require treatment. Pain can be caused by swallowing air while eating or drinking. Since bacteria in your gut breaks down food and release gas in the process, gas will also build up in your digestive tract. The most obvious symptom of appendicitis is sudden, severe pain that begins on the right side of the lower abdomen. It can also start near your navel and then work it way down to your right side. The pain may feel like cramps at first, but when you cough, sneeze, or move, the pain may get worse. Pain usually does not go away until the inflamed appendix is surgically removed.
What are the symptoms of gas pain?
Gas pain is like a knot in the stomach. You may even have the sensation of gas flowing in your intestines. Gas pain, unlike appendicitis can be felt anywhere in the abdomen. You may even feel chest pain. Other symptoms include:
- Abdominal pressure;
- Bloating (significant enlargement of the abdomen).
Most flatulence pain is caused by diet, so some dietary changes can help prevent or limit this type of pain. It can be helpful to record all the foods you eat and drink and to record when you feel flatulence. This can help you determine the connection between food or drink and your symptoms. Common causes of gas pain include:
- Dairy products;
- Carbonated beverages;
- High-fiber foods;
- High-fat foods.
To help relieve flatulence, you may want to try the following home remedies:
- Peppermint tea;
- Chamomile tea;
- Over-the-counter medications, such as simethicone (GasX, Mylanta), can help collect bubbles and make them pass more easily. If you are lactose intolerant and experience pain and other symptoms after consuming dairy products, lactase supplements may help.
Walking and other physical activities can also help you release trapped gas. If your gas pain persists, be sure to see a doctor to find out the cause. Gas pain often lasts for a few minutes to a few hours and usually disappears without treatment.
If you think your pain is gas-induced pain, but the duration exceeds 24 hours, please see a doctor as soon as possible. Pain may be a sign of a more serious condition.
Special cases in children, pregnant women and elderly
Although appendicitis is rare in young children, it presents special difficulties in this age group. Young children cannot tell stories, often have abdominal pain from other causes, and may have more non-specific signs and symptoms. These factors lead to an appendix perforation rate of up to 50% in this group.
During pregnancy, the position of the appendix begins to change significantly between the fourth and fifth months of pregnancy. Common pregnancy symptoms can mimic appendicitis, and the white blood cells are usually at a lower number in pregnancy. Although the maternal mortality rate is low, the overall fetal mortality rate is between 2% to 8.5%, and perforation with systemic peritonitis is as high as 35%. As with non-pregnant patients, appendectomy is the standard treatment.
Elderly patients have the highest mortality rate. The common signs and symptoms of appendicitis may be reduced, atypical, or absent in the elderly, leading to a higher rate of perforation. More frequent perforations combined with a higher incidence of other medical problems result in mortality rates as high as 5% or even higher.
Although appendicitis is very likely to happen during one’s lifetime, it can be a threat if left untreated. If you think you might have appendicitis, call your doctor.