Introduction

Appendicitis is a painful swelling of the appendix. The appendix is a small, thin pouch about 5-10cm (2-4 inches) long. It's connected to the large intestine, where stools (faeces) are formed.

Nobody knows exactly why we have an appendix, but removing it isn't harmful.

Appendicitis typically starts with a pain in the middle of your abdomen (tummy) that may come and go.

Within hours, the pain travels to the lower right-hand side, where the appendix lies, and becomes constant and severe.

Pressing on this area, coughing or walking, may all make the pain worse. You may lose your appetite, feel sick and occasionally experience diarrhoea.

Read more information about the symptoms of appendicitis.

When to get medical help

See your GP or contact your local out-of-hours service if you're having abdominal pain that's gradually getting worse. If this is not possible you can call NHS Direct Wales on 0845 46 47.

Call 999 for an ambulance if you get a pain that suddenly gets much worse and spreads across your abdomen. These are signs that your appendix may have burst, which can lead to potentially life-threatening complications.

How appendicitis is treated

In most cases of appendicitis, the appendix will have to be surgically removed as soon as possible.

Removal of the appendix, known as an appendectomy or appendicectomy, is one of the most common operations in the UK, and its success rate is excellent.

The operation is most commonly performed as keyhole surgery (laparoscopy), which involves making several small cuts in your abdomen, through which special surgical instruments are inserted.

Open surgery, where a larger, single cut is made in the abdomen, is usually carried out if the appendix has burst or access is more difficult.

Most people make a full recovery from an appendectomy in a couple of weeks, although strenuous activities may need to be avoided for up to six weeks after open surgery.

Read more information about treating appendicitis.

What causes appendicitis?

It's not exactly clear what the causes of appendicitis are. Most cases are thought to occur when something blocks the entrance of the appendix.

For example, a blockage may be formed by a small piece of faeces or a swollen lymph node within the wall of the bowel, often after an upper respiratory tract infection.

This obstruction leads to the development of inflammation and swelling. The pressure caused by the swelling can then lead to the appendix bursting.

As the causes aren't fully understood, there's no guaranteed way of preventing apendicitis.

Who's affected?

Appendicitis is a common condition. It's estimated around 1 in every 13 people develop it at some point in their life.

Appendicitis can develop at any age, but it's most common in young people aged from 10 to 20 years old.

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Symptoms

Appendicitis typically starts with a pain in the middle of your abdomen (tummy) that may come and go.

Within hours the pain travels to the lower right-hand side, where the appendix is usually located, and becomes constant and severe.

Pressing on the appendix area, coughing or walking, may all make the pain worse.

If you have appendicitis, you may also have other symptoms, including:

  • feeling sick (nausea)
  • being sick
  • loss of appetite
  • a high temperature (fever) and a flushed face
  • diarrhoea

When to get medical help

If you're experiencing abdominal pain that's gradually getting worse, contact your GP or local out-of-hours service immediately. If these options aren't available, call NHS Direct Wales on 0845 4647 for advice.

Appendicitis can easily be confused with something else, such as

In young women, these symptoms can sometimes have a gynaecological cause, such as an ectopic pregnancy or menstrual pain.

However, any condition that causes constant stomach pain requires urgent medical attention.

You should call 999 for an ambulance if you get a pain that suddenly becomes worse and spreads across your abdomen. These are signs that your appendix may have burst.

If the appendix bursts, it can cause peritonitis, a potentially serious infection of the inner lining of the abdomen.

Read more information about the complications of appendicitis.

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Diagnosis

Appendicitis can be tricky to diagnose unless you have the typical symptoms, which are only present in about half of all cases.

Also, some people's appendixes may be located in a slightly different part of their body, such as:

  • the pelvis
  • behind the large intestine
  • around the small bowel
  • near the right lower part of the liver

Some people develop pain similar to appendicitis, but it's caused by something else, such as:

A GP will ask about your symptoms, examine your abdomen, and see if the pain gets worse when pressure is applied to the appendix area (your lower right-hand side).

If your symptoms are typical of appendicitis, this is normally enough for your GP to make a confident diagnosis. In this case, you'll immediately be referred to hospital for treatment.

Further tests

If your symptoms are not typical, further tests may be required in hospital to confirm the diagnosis and rule out other conditions.

Further tests may involve:

It can sometimes take time to get test results. Your surgeon may recommend a laparoscopy to inspect your appendix and pelvic organs if the diagnosis is still uncertain.

You'll usually be advised to have your appendix removed if appendicitis is suspected, rather than run the risk of it bursting. This means some people will have their appendix removed even though it's eventually found to be normal.

In some cases where a diagnosis is not certain, a doctor may recommend waiting up to 24 hours to see if your symptoms improve, stay the same, or get worse.

If your doctor suspects that your appendix has burst, you will be sent to hospital immediately for treatment.

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Treatment

If you have appendicitis, your appendix usually needs to be removed as soon as possible. The operation is usually known as an appendectomy or appendicectomy.

Surgery is usually also recommended if there's a chance you have appendicitis but it's not been possible to make a clear diagnosis.

This is because it's considered safer to remove the appendix than run the risk of the appendix bursting.

In humans, the appendix does not perform any important function and having it removed does not cause any long-term problems.

The procedure

Appendectomies are carried out under general anaesthetic, using either a 'keyhole' or 'open' technique.

Keyhole surgery

Keyhole surgery (laparoscopy) is usually the preferred method of removing the appendix because the recovery tends to be quicker than with open surgery.

This operation involves making three or four small cuts (incisions) in your tummy (absomen). Special instruments are then inserted, including:

  • a tube that gas is pumped through to inflate your abdomen - this allows the surgeon to see your appendix more clearly and gives them more room to work
  • a laparoscope - a small tube containing a light source and a camera, which relays images of the inside of the abdomen to a television monitor
  • small surgical tools used to remove the appendix

Once the appendix has been removed, the incisions will usually be closed with dissolvable stitches. Regular stitches may also be used, which need to be removed at your GP surgery 7-10 days later.

Open surgery

In some circumstances, keyhole surgery isn't recommended and open surgery is performed instead. These include:

  • when the appendix has already burst and formed a lump called an appendix mass
  • when the surgeon isn't very experienced in laparoscopic removal
  • people who have previously had open abdominal surgery

In these cases, the operation involves a single larger cut  in the lower right hand side of your abdomen to remove the appendix.

When there is widespread peritonitis (infection of the inner lining of the abdomen) it is sometimes necessary to operate through a long cut along the middle of the abdomen in a procedure called a laparotomy.

As with keyhole surgery, the incision is closed using either dissolvable stitches or regular stitches that need to be removed at a later date.

Recovery

One of the main advantages of keyhole surgery is the recovery time tends to be short and most people can leave hospital a few days after the operation.

If the appendix is operated upon promptly, most patients can go home within 24 hours. With open or complicated surgery (for example, if you have peritonitis), it may take up to a week before you're well enough to go home.

For the first few days after the operation you are likely to experience some pain and bruising. This will improve over time but you can take painkillers if necessary.

If you had keyhole surgery, you may experience pain in the tip of your shoulder for about a week. This is caused by the gas that was pumped into the abdomen during the operation.

You may also experience some short-term constipation. You can help reduce this by not taking codeine painkillers, eating plenty of fibre and staying well hydrated. Your GP can prescribe medication if the problem is particularly troublesome.

Before leaving hospital, you will be advised about caring for your wound and what activities you should avoid.

In most cases, you can return to normal activities in a couple of weeks, although more strenuous activities may need to be avoided for four to six weeks after open surgery.

When to seek medical advice

While you recover, it's important to keep an eye out for signs of any problems. Contact the hospital unit where the appendectomy was performed or your GP for advice if you notice:

  • increasing pain and swelling
  • you start vomiting repeatedly
  • a high temperature (fever)
  • any discharge coming from the wound
  • the wound is hot to touch

These symptoms could be a sign of infection.

Risks

Appendectomies are one of the most commonly performed operations in the UK and serious or long-term complications are rare.

However, like all types of surgery, there are some risks. These include:

  • wound infection (although antibiotics may be given before, during or after the operation to minimise the risk of serious infections)
  • bleeding under the skin causing a firm swelling (haematoma) – this usually gets better on its own but you should see your GP if you are concerned
  • scarring – both surgical techniques will leave some scarring where the incisions were made
  • a collection of pus (abscess) – in rare cases, an infection caused by the appendix bursting can lead to an abscess after surgery
  • hernia – at the site of the open incision or any of the incisions used in the laparoscopic approach.

The use of general anaesthetic also carries some risks, such as the risk of an allergic reaction or inhaling stomach contents, leading to pneumonia. However, serious complications like this are very rare.

Alternatives to emergency surgery

In some cases, appendicitis can lead to the development of a lump on the appendix called an 'appendix mass'. This lump, consisting of appendix and fatty tissue, is an attempt by the body to deal with the problem and heal itself.

If an appendix mass is found during an examination, your doctors may decide it is not necessary to operate immediately. Instead, you will be given a course of antibiotics and an appointment will be made for an appendectomy a few weeks later, when the mass has settled.

Another possible alternative to immediate surgery is the use of antibiotics to treat appendicitis. However, studies have looked into whether antibiotics could be an alternative to surgery and as yet there is not enough clear evidence to suggest this is the case.

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Complications

If appendicitis is not treated, the appendix can burst and cause potentially life-threatening infections.

Call 999 for an ambulance if you have abdominal (tummy) pain that suddenly gets much worse and spreads across your abdomen. These are signs your appendix may have burst.

Peritonitis

If your appendix bursts, it releases bacteria into other parts of the body. This can cause a condition called peritonitis if the infection spreads to the peritoneum, the thin layer of tissure that lines the inside of the abdomen.

Symptoms of peritonitis can include:

  • severe continuous abdominal pain
  • feeling sick or being sick
  • a high temperature (fever)
  • a rapid heartbeat
  • shortness of breath with rapid breathing
  • swelling of the abdomen

If peritonitis is not treated immediately it can cause long-term problems and may even be fatal. Treatment for peritonitis usually involves antibiotics and the surgical removal of the appendix (appendectomy).

Abscesses

Sometimes an abscess forms around a burst appendix. This is a painful collection of pus that occurs as a result of the body’s attempt to fight an infection.

It can also occur as a complication of surgery to remove the appendix in about 1 in 500 cases.

Abscesses can sometimes be treated using antibiotics, but in the vast majority of cases the pus needs to be drained from the abscess.

This can be carried out under ultrasound or computerised tomography (CT) guidance using local anaesthetic and a needle inserted through the skin followed by placement of a drain.

If an abscess is found during surgery, the area is carefully washed out and a course antibiotics is given.

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Selected links

NHS Direct Wales links

Gastroenteritis

Abscess

Laparoscopy

Peritonitis

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 22/04/2016 11:34:57