Appendicitis
Introduction
Appendicitis is a swelling (inflammation) of the appendix. The appendix is a small pouch that is connected to your colon and is located in the lower right side of your abdomen (stomach).
The reason we have an appendix is unclear. The biologist Charles Darwin thought that the appendix may be a by-product of evolution; something that early humans needed to help digest plants. However, recent research has suggested that the appendix may provide a home to 'friendly bacteria' that aid digestion and help fight infection.
What is appendicitis?
It is thought that the commonest causes of appendicitis are infection and obstruction. However, in many cases, there is no obvious cause.
Obstructions can sometimes occur when a hard piece of stool (faeces) gets trapped in the appendix. Both infection and obstruction cause the appendix to become filled with bacteria that produce pus. The pus causes the appendix to swell and, if left untreated, the appendix can burst (perforate).
Appendicitis is a common condition. In the UK, 7% of people will experience appendicitis at some point in the life. The condition is more common in men than in women, and normally occurs in those between 10-30 years of age.
Appendicitis is a medical emergency
Appendicitis is regarded as a medical emergency because a ruptured appendix can lead to potentially serious, or even fatal, complications, such as blood poisoning (sepsis).
However, as a result of advances in diagnostic and surgical techniques, deaths from appendicitis are very rare. Appendicitis can be treated by surgically removing the appendix (appendectomy).
Appendectomies are one of the most commonly performed emergency surgical procedures and their success rate is excellent. Living without an appendix will cause you no related problems.
Although there is no guaranteed way to prevent appendicitis, studies have shown that it is less common among people who eat a high-fibre diet.
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Symptoms
The symptoms of appendicitis normally begin with a pain in your abdomen (stomach). The pain normally develops quickly and then gets more severe over the course of several hours.
The location of the pain can vary, particularly in the early stages of the condition, but it tends to 'settle' in the lower right hand side of your abdomen.
Applying pressure to the area will usually make the pain worse, as will coughing and walking.
If you have appendicitis, you may also experience other symptoms including:
- nausea,
- vomiting,
- loss of appetite,
- constipation,
- high temperature, or
- diarrhoea.
When to seek urgent medical advice
A constant pain in your abdomen that is getting progressively worse can be caused by many conditions other than appendicitis, such an infection of your urinary tract. All conditions that cause constant abdominal pain require urgent medical attention.
If you are experiencing abdominal pain that is getting progressively worse, you should contact your GP immediately. If that is not possible, contact your local out-of-hours service, or call NHS Direct Wales on 0845 46 47.
When to seek emergency medical help
If you are experiencing abdominal pain that suddenly gets much worse, spreads across your abdomen, and your temperature rises to, or above 38°C (101.0°F), it is likely that your appendix has burst. Call 99
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Causes
The precise cause of appendicitis is not entirely clear. However, the two most likely causes are thought to be:
- infection - possibly a stomach infection that has travelled to the site of the appendix, and
- obstruction - for example, a hard piece of stool (faeces) that gets trapped in your appendix, and the bacteria in the stool then infects the appendix.
Once bacteria gets into your appendix, they rapidly multiply causing the appendix to swell and become filled with pus.
If appendicitis is left untreated, your appendix will burst and the bacteria that is released may then go on to infect other parts of your body, such as the lining of your abdomen (peritonitis), or the blood (sepsis).
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Diagnosis
Appendicitis can be a challenging condition to diagnose correctly. There are many other conditions that can cause similar symptoms, such as urinary tract infections (UTIs), and gastroenteritis (an infection of the stomach.)
Also, almost half of people with appendicitis do not have the typical symptoms, and some people have their appendix located in different parts of their body. For example, some people can have their appendix located in their pelvis, behind their colon, or behind their liver.
Your GP will ask about your symptoms, examine your abdomen, and see if the pain gets worse when pressure is applied to the location of your appendix.
If your symptoms are typical of appendicitis, it is normally enough for your GP to confidently diagnose the condition. However, if you symptoms are not typical, further tests may be required to try to confirm the diagnosis and rule out other conditions. Further tests that you may have are listed below.
- Blood tests - which can help indicate the presence of infection.
- Urine tests - to help rule out conditions such as a bladder or kidney infections.
- An MRI scan - which uses a strong magnetic field and radio waves to build up a picture of the inside of your body.
- A CT scan - which uses a series of X-ray images to build up a '3-D' image of the inside of your body.
The latest generation of MRI and CT scanners have proven very reliable in detecting appendicitis. However, access to this advanced technology may be limited in your local area and you may have to wait several days to obtain a scan.
It may be felt that waiting for a scan to confirm the diagnosis is too dangerous and that there is a risk that your appendix might burst in the intervening time. If this is the case, your doctor may decide to remove your appendix as a precautionary measure.
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Treatment
If your appendicitis is very mild, it may be possible to treat the inflammation with antibiotics. However, in the majority of cases, the appendix will have to be surgically removed in a procedure known as an appendectomy.
Laparoscopy
In the past, when performing an appendectomy, the surgeon was required to make a large incision in the abdomen to remove the appendix. However, now a technique involving laparoscopic surgery (keyhole surgery) is preferred.
In this technique, the surgeon will make a number of small incisions in your abdomen, through which the surgeon will insert a small tube that contains a light and a tiny video camera (a laparoscope).
This allows the surgeon to see the inside your abdomen in great detail without having to make a large incision. The appendix can then be removed through the incisions.
The advantage of a laparoscopic appendectomy is that it leaves minimal scarring and the recovery time is a lot quicker than a traditional appendectomy. Most people undergoing a laparoscopic appendectomy will be able to leave hospital a few days after the operation, although it may be 1-2 weeks before you fully recover.
Traditional appendectomy
There are some circumstances when a laparoscopic appendectomy is not recommended, and a traditional appendectomy, requiring a large incision, will be required. These include:
- cases where the appendix has burst,
- people who have tumours in their digestive system,
- women who are in the first trimester of the pregnancy, and
- people who have had repeated previous abdominal surgery.
A traditional appendectomy will leave a larger scar and it may be a week before you are well enough to leave hospital.
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Complications
Peritonitis
If your appendix bursts, it releases the infection into your abdomen which can lead to a condition called peritonitis. This is when the inner lining of your abdomen that coats the organs (the peritoneum) becomes inflamed. This lining is very sensitive to infection.
Peritonitis causes your normal bowel movements to stop and your bowel to become blocked. This causes severe pain, fever, and shock. If it is not treated immediately, it can cause long-term problems and may even be fatal.
Treatment for peritonitis usually involves taking antibiotics and being given fluids intravenously (through a vein) via a drip. Sometimes, surgery is necessary to repair any internal tearing to the infected area and to drain the peritoneal cavity.
Abscess
An abscess (collection of pus) in the abdomen is another possible complication of appendicitis. This may be located between the bladder and rectum in men and between the uterus (womb) and rectum in women.
Abscesses can be treated using antibiotics. However, in some cases, it may be necessary to surgically drain the pus from the abscess by placing a tube into your abdomen.
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Prevention
High-fibre diet
Studies have shown that the incidence of appendicitis is a lot lower in countries where a high-fibre diet is common.
It is not known exactly why this is, but one possible reason is that fibre makes our stools (faeces) softer, reducing the chances of them getting stuck in the appendix.
Foods high in fibres include wholegrain cereals, bread, rice, and pasta. Root vegetables such, as carrots, and fruit, are good sources of fibre.
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