Acute Appendicitis

The inflammatory condition of the appendix is termed appendicitis; it is usually due to infections.

  • Acute pain in the abdomen, fever, and nausea, are the usual symptoms.
  • Often a blockage inside the appendix causes it to become inflamed as well as infected.
  • Imaging tests, either an ultrasound scan, or a CT scan, may help confirm the diagnosis.
  • The infection may be treated with antibiotics, but surgical removal of the entire appendix is the ideal solution for appendicitis.

Appendix is not considered an essential organ as it does not perform any vital function, though a role in the immune system is suspected. The finger-like appendix is attached to the large intestine near the junction of the small and the large intestines. This organ does not have any identifiable digestive function.

Appendicitis Pain can be explained as Acute pain in the abdomen, occurring suddenly without any apparent reason. Strangulated hernias are the other usual cause for sudden abdominal pain. These two conditions are the main reason for emergency abdominal surgeries. The surgical removal of the appendix is termed appendectomy. The incidence of acute appendicitis is more frequent in teenagers and young adults, but it can occur at any age. More than 5% of the general population may eventually have this condition and may have to undergo appendectomy.

The exact reason behind the development of appendicitis is still not clear. An obstruction developing inside the organ is believed to be the trigger for appendicitis. A foreign body or a small piece of hard stool may cause obstruction in the appendix. Rarely, worms may cause blockage. This may lead to inflammation as well as severe infection. The inflamed appendix may rupture anytime spilling its contents and the infective material in to the abdominal cavity. It may result in peritonitis, which is the inflammation and infection of the lining of the abdomen. Peritonitis is a potentially fatal condition which requires immediate medical intervention. Abdominal abscesses filled with pus may develop on the walls of the abdomen or in other organs in the abdominal cavity. Female reproductive organs such as fallopian tubes and ovaries may pick up the infection. Infertility may be caused if the fallopian tubes get blocked due to infection. When the infected appendix ruptures, the bacteria causing the infection are released into the blood stream also, which may precipitate a massive infection of the blood called sepsis. Uncontrolled sepsis can lead to death due to septic shock as the vital organs shut down.

Symptoms Of Appendicitis

The typical symptoms of appendicitis usually begin with pain felt around the naval or in the upper part of the abdomen followed by nausea and vomiting. Eventually, the nausea wears off and the pain relocates to the lower abdomen, particularly the right side. During the physical examination, the doctor may check the lower right area of the abdomen for any tenderness by applying gentle pressure. When the area is pressed, pain and tenderness may be felt by the patient, but when the pressure is suddenly released, the patient may flinch due to a sharp increase in pain called rebound tenderness, which is typical of appendicitis.   The patient’s response, especially on releasing the pressure, helps the doctor to diagnose appendicitis. Low grade fever, usually around 100° to 101° F or 37.7° to 38.3° C is a common symptom. Pain due to appendicitis may increase with coughing or with movement.

However, less than 50% of appendicitis cases display the typical symptoms. Older people, and those who are pregnant, may not feel severe pain when they have appendicitis. Tenderness in the area also may be markedly reduced. In children and infants, the pain may not be localized; they usually feel it in the whole of the abdominal area rather than in the lower right part.

The rupture of the appendix may cause severe pain and high temperature. As the infection spreads, symptoms of shock may appear.

Diagnosis

The symptoms displayed by the patient and a physical examination of the abdomen help in diagnosing appendicitis. During the physical examination, the doctor especially looks for tenderness in the area above the appendix and for rebound tenderness. If the symptoms suggest an advanced state of the disease, emergency surgery is done without waiting for other diagnostic tests. When the symptoms are not typical, and the diagnosis is inconclusive, doctors may prefer to do one of the imaging tests. Both ultrasound scan and CT scan are useful in confirming the diagnosis. However, for children, ultrasound scans are preferred to avoid exposure to radiation from a CT scan. A minimally invasive procedure called laparoscopy also may be used to detect appendicitis. A blood test may be conducted, and if it the WBC count is elevated, it may indicate an infection.

Prognosis and Treatment

If appendicitis is detected early and treated promptly, it is not a fatal condition. Appendectomy is considered a comparatively simple surgery and the patient need not be hospitalized for more than two or three days. The patient may achieve complete recovery in a short period of time, though the recovery period may be extended for older people. If timely medical intervention and antibiotic treatment are not available, appendicitis has a 50% fatality rate. This situation usually occurs when the symptoms are too mild or when they are not taken seriously, or when there is no access to a hospital with surgical facility.

A ruptured appendix is a more complicated and potentially fatal condition. It almost always used to result in death in earlier days, but with emergency surgery and efficient antibiotic treatment, the prognosis is much better now. But complications usually develop due to secondary infections and the recovery period may be greatly extended.

Surgical removal of the appendix is always the best treatment option. When the doctor feels a rupture is likely, exploratory surgery is done immediately and the appendix is removed. There may be a small risk of error in judgment as in 15% of cases the appendix is found to be normal during the exploratory surgery. However, considering the higher risk of complications from the sudden rupture of the appendix, it may not be advisable postpone the surgery till the diagnostic test results arrive. Even if the appendix is found to be normal during the exploratory surgery, it is still removed any way, to avoid a second surgery in the future.

The rupture of the appendix is a life threatening condition. An appendix inflamed due to an infection may suddenly rupture, even on the same day the symptoms appeared. When appendicitis is diagnosed, antibiotic drugs are administered intravenously and appendectomy is done as soon as possible.

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Yasser Elnahas

MD, PHD, Professor Of CardioVascular Surgery
Dr. Yasser Elnahas, Is an associate Professor of Cardiovascular Surgery. Dr. Elnahas was trained as a fellow At Texas Heart Institute And Mayo Clinic Foundation.Dr. Elnahas is dedicated to educating the general public about different disease conditions and simplifying the medical knowledge in an easy to understand terminology.

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