What is appendicitis?
Appendicitis is one of the causes of serious belly pain. It happens when the appendix, a part of the large
intestine, becomes infected and inflamed. Experts do not know what the appendix does in the body, but
most of the time it does not cause problems.
About 8 out of 100 people will get appendicitis sometime during their lives. It is most common in people
ages 10 to 30, but it can happen at any age.
What causes appendicitis?
It is not clear why people get appendicitis. Infection in the appendix causes appendicitis. But doctors and
scientists are not sure what causes the infection. In many cases, a small object (such as a hard piece of
stool) blocks the opening to the appendix. Then bacteria can grow in the appendix and cause an infection.
What are the symptoms?
The main symptom of appendicitis is belly pain. Many people feel the first pain near the belly button. Then
it moves to the lower right side of the belly. But the pain can be in different parts of your belly or even on
your side or back. The pain may get worse if you move, walk, or cough. You may also have a fever or feel
sick to your stomach.
Sometimes the only symptom is a general feeling of not being well and a pain that is hard to describe.
The pain in your belly may be different than any pain you have had before. It may be severe. Or it may
not seem like a very strong pain, but you may have the feeling that something is wrong. Trust your
instincts.
Because the diagnosis is not always easy to make, it is very important to see a doctor as soon as
possible if you have symptoms.
In some cases, appendicitis does not cause any symptoms except for belly pain. If you have moderate
belly pain that does not go away after 4 hours, call your doctor. If you have severe belly pain, call your
doctor right away.
How is appendicitis diagnosed?
Your doctor will ask you questions about what symptoms you have, when they started, and what was
happening before the pain began. Your doctor will press on your belly to see where the pain is. He or she
will take your temperature to see if you have a fever, which is a sign of infection. You also may have
blood tests to look for signs of infection.
Your doctor may not be sure whether you have appendicitis. You may need other tests, such as a CT
scan or an ultrasound of your belly.
Sometimes tests can't show for certain that you have appendicitis, but your doctor may strongly suspect
that you do because of your symptoms. In this case, your doctor probably will recommend you have
surgery to have your appendix taken out. Most of the time, the doctor is right and the appendix is infected.
During surgery your doctor may find that your appendix is normal and something else caused your pain.
Your doctor will go ahead and remove your appendix. You can live just fine without it, and taking it out
gets rid of any chance that it could cause problems later.
How is it treated?
The only treatment for appendicitis is surgery to remove your appendix (appendectomy). If you have
appendicitis and do not have surgery in time, your appendix can burst. A burst appendix can cause
serious problems. It’s best to remove the appendix before it bursts.
There are different types of surgery for appendicitis. Your surgeon may operate through a large cut
(incision) in your belly or use a tool called a laparoscope to remove your appendix through a few smaller
incisions. Either way, you may take antibiotics before your surgery, after your surgery, or both. There are
advantages and disadvantages to each type of surgery. Talk with your surgeon about which type is best
for you.
If your appendix does burst, you will need antibiotics. Surgery to remove a burst appendix may be more
complicated.
HISTORY
The natural history of appendicitis varies slightly in the elderly and early life, as well as
during pregnancy. Recognition of this is key to accurate diagnosis and treatment of this
common but potentially fatal medical condition.
We shall give a brief history of this disease here, and then highlight the natural history of
acute appendicitis in the very young, adult, and elderly.
Even though the word appendicitis was already in use in 1885 when the Oxford English
Dictionary was first publish, it was not until 1902 after the king of England, Edward VII had
his appendix removed that the term came to be acceptable and widely used.
Reginald Fitz in 1886 presented a paper to the American Association of Physicians where he
describes the first recorded case of appendicitis.
Later, Dr Charles Mc Burney described in details the constellation of signs and symptoms
that characterizes appendicitis, as well as map out the spot where maximum pain is felt by
patients suffering from this disease – the Mc Burney’s point, which is the junction of the
outer third of a line drawn from the navel to the anterior superior iliac crest (tip of the waist
bone).
Appendicitis is so common today, that it is the greatest cause of acute abdominal
admissions worldwide.
CLASSICAL HISTORY OF APPENDICITIS
The classic history is that of a dull to severe right side abdominal pain that may have
commenced around the umbilicus and moved over the course of 30 minutes to 24 hours to
the right lower abdomen, called right iliac fossa.
The pain may be accompanied by fever, nausea, and vomiting.It is important to note that
the most common symptom associated with appendicitis pain is anorexia, or loss of
appetite. Vomiting after the onset of pain is also classical.
APPENDICITIS IN THE VERY YOUNG
Appendicitis has been reported within the first 28 days of life. Such new born babies
obviously can not complain of pain. They often become unwell, and
may refuse their feeds, showing non-specific signs and symptoms.
They may or may not run temperature.
A careful examination of the newborn to rule out all other cause of illness in this age group
may help to point to the appendix as the cause of trouble. Thankfully, appendicitis in
newborn is extremely rare.If diagnosed, surgical operation is still the cure.
For older children, they may be able to localize pain to the tummy, and where such child
can speak, he or she may give a reasonable history of appendicitis.
APPENDICITIS IN THE ELDERLY
History of appendicitis in the elderly is more or less like would be expected in a young adult,
but with the absence of fever on most occasions.
There may be associated diarrhoea or constipation, with loss of appetite.
APPENDICITIS IN PREGNANCY
Appendicitis and pregnancy could go together. Depending on the stage of pregnancy, the
history will be the same, but the position of the pain may be higher on the right side of the
abdomen than is normally expected.
The pathophysiology of appendicitis is the constellation of processes that
leads to the development of acute appendicitis from a normal appendix.
Understanding the pathophysiology of appendicitis helps to explain all the signs and
symptoms as well as complications seen in appendicitis.
The main thrust of events leading to the development of acute appendicitis lies in the
appendix developing a compromised blood supply due to obstruction of its lumen and
becoming very vulnerable to invasion by bacteria found in the gut normally.
Obstruction of the appendix lumen by faecolith, enlarged lymph node, worms, tumour, or
indeed foreign objects, brings about a raised intra-luminal pressure,
which causes the wall of the appendix to become distended.
Normal mucus secretions continue within the lumen of the appendix, thus causing further
build up of intra-luminal pressures. This in turn leads to the occlusion of the lymphatic
channels, then the venous return, and finally the arterial supply becomes undermined.
Reduced blood supply to the wall of the appendix means that the appendix gets little or no
nutrition and oxygen. It also means a little or no supply of white blood cells and other
natural fighters of infection found in the blood being made available to the appendix.
The wall of the appendix will thus start to break up and rot. Normal bacteria found in the
gut gets all the inducement needed to multiply and attack the decaying appendix within 36
hours from the point of luminal obstruction, worsening the process of appendicitis.
This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby
white blood cells are recruited to fight the bacterial invasion.
A combination of dead white blood cells, bacteria, and dead tissue makes up pus.
The content of the appendix (faecolith, pus and mucus secretions) are then released into
the general abdominal cavity, bringing causing peritonitis.
So, in acute appendicitis, bacterial colonisation follows only when the process have
commenced.
These events occur so rapidly, that the complete pathophysiology of appendicitis takes
about one to three days. This is why delay can be deadly!
Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix,
and later when the grossly inflamed appendix rubs on the overlying inner
wall of the abdomen (parietal peritoneum) and then with the spillage of
the content of the appendix into the general abdominal cavity
(peritonitis).
Fever is brought about by the release of toxic materials (endogenous pyrogens) following
the necrosis of appendicael wall, and later by pus formation.
Loss of appetite and nausea follows slowing and irritation of the bowel by the
inflammatory process.
The pathophysiology of appendicitis obviously correlates with the clinical picture.
Acute appendicitis pathophysiology follows the same pattern, even in children and pregnant
women.
In the elderly, the pathophysiology of appendicitis remains unaltered, but the inflammatory
response generated by the elderly is often less than that seen with young fit individuals,
accounting for the often benign presentation froth with a tendency to miss the diagnosis,
thus courting more complications.
