Appendicitis (patient information)

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 * Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[mailto:msbeih@perfuse.org]; Assistant Editor-In-Chief: Meagan E. Doherty.

Overview
Appendicitis is a painful swelling and infection of the appendix. The appendix is a small, tube-like organ attached to the first part of the large intestine, also called the colon. It is located in the lower right area of the abdomen. It has no known function. A blockage inside of the appendix causes appendicitis. The blockage leads to increased pressure, problems with blood flow and inflammation. If the blockage is not treated, the appendix can break open and leak infection into the body. Appendicitis is a medical emergency. Treatment almost always involves removing the appendix. Anyone can get appendicitis. It happens most often to people between the ages of 10 and 30.

What are the symptoms of Appendicitis?
Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain.

The abdominal pain usually:
 * Occurs suddenly, often causing a person to wake up at night
 * Occurs before other symptoms
 * Begins near the belly button and then moves lower and to the right
 * Is new and unlike any pain felt before
 * Gets worse in a matter of hours
 * Gets worse when moving around, taking deep breaths, coughing, or sneezing

Other symptoms of Appendicitis may include:
 * Loss of appetite
 * Nausea
 * Vomiting
 * Constipation or diarrhea
 * Inability to pass gas
 * Low-grade fever that follows other symptoms
 * The feeling that passing stool will relieve discomfort

Symptoms vary and can mimic other sources of abdominal pain, including:
 * Intestinal obstruction
 * Inflammatory bowel disease
 * Pelvic inflammatory disease and other gynecological disorders
 * Intestinal adhesions
 * Constipation

What causes Appendicitis?
Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include:

An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomen—a potentially dangerous condition called peritonitis.
 * Feces, parasites, or growths that clog the appendiceal lumen.
 * Enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body
 * Inflammatory bowel disease, including Crohn's disease and ulcerative colitis
 * Trauma to the abdomen.

Who is at highest risk?
Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other cause.

Diagnosis
A doctor or other health care provider can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical examination. If a person shows classic symptoms, a doctor may suggest surgery right away to remove the appendix before it bursts. Doctors may use laboratory and imaging tests to confirm appendicitis if a person does not have classic symptoms. Tests may also help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or the mentally impaired.

Medical history
The doctor will ask specific questions about symptoms and health history. Answers to these questions will help rule out other conditions. The doctor will want to know when the pain began and its exact location and severity. Knowing when other symptoms appeared relative to the pain is also helpful. The doctor will ask questions about other medical conditions, previous illnesses and surgeries, and use of medications, alcohol, or illegal drugs.

Physical examination
Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by touching or applying pressure to specific areas of the abdomen. Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis. The doctor may also examine the rectum, which can be tender from appendicitis.

Laboratory tests
Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests may also show dehydration or fluid and electrolyte imbalances. Urinalysis is used to rule out a urinary tract infection. Doctors may also order a pregnancy test for women.

Imaging tests
Computerized tomography (CT) scans, which create cross-sectional images of the body, can help diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.

When to seek urgent medical care?
Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a doctor or go to the emergency room right away. Swift diagnosis and treatment reduce the chances the appendix will burst and improve recovery time.

Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the likelihood the appendix will burst.

Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.

Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery.

Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.

Nonsurgical treatment
Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.

Recovery
With adequate care, most people recover from appendicitis and do not need to make changes to diet, exercise, or lifestyle. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity during this time allows tissues to heal.

Diseases with similar symptoms
According to age group:

In children:

 * Gastroenteritis
 * Mesenteric adenitis
 * Meckel's diverticulum
 * Intussusception
 * Henoch-Schõnlein purpura
 * Lobar pneumonia

In adults:

 * Regional enteritis
 * Renal colic
 * Perforated peptic ulcer
 * Testicular torsion
 * Pancreatitis
 * Rectus sheath hematoma
 * Pelvic inflammatory disease
 * Ectopic pregnancy
 * Endometriosis
 * Torsion/rupture of ovarian cyst
 * Ruptured Graafian follicle

In the elderly:

 * Diverticulitis
 * Intestinal obstruction
 * Colonic carcinoma
 * Mesenteric infarction
 * Leaking aortic aneurysm.

Where to find medical care for Appendicitis?
Directions to hospitals treating appendicitis

Prevention of Appendicitis
There is no clinically proven method to prevent appendicitis.

What to expect (Outlook/Prognosis)?
Most appendicitis patients recover easily with treatment, but complications can occur if treatment is delayed or if peritonitis occurs.

Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old) the recovery takes three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e. outside of a proper hospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated.

Possible complications

 * Abnormal connections between abdominal organs or between these organs and the skin surface (fistula).
 * Abscess
 * Infection of the surgical wound.
 * Peritonitis