Appendicitis – An Introduction
Not many are actually aware of the fact that what appendicitis in reality is. It is basically the inflammation of the vermiform appendix which is a 3.5 inch long tissue extending from the large intestine. It is a pouch like tissue mass in the shape of a finger projecting out from the lower right side of the abdomen. When it gets inflamed it is filled with pus. Though the appendix has no apparent known usage in the human body but its swelling can be life threatening if left untreated. It can burst emitting poisonous fluids which can lead to peritonitis, a swelling of abdominal cavity lining and can be fatal as well.
Pathophysiology Of Appendicitis
The series of consequences which leads to the enlargement of appendicitis from a normal vermiform appendix is termed as pathophysiology of appendicitis. A blockage of appendiceal lumen enhances the pressure within it. Such increased pressure in turn leads to secretion of mucus from the mucosa which ultimately begins to stagnate. The condition is worsened further by the bacterium found in gut and this transforms into the formation of pus after the recruitment of white blood cells to fight the bacterial invasion. The deadly combination of dead tissues, white blood cells and bacteria causes pus formation. A comprehensive pathophysiology takes about 24 to 72 hours, further delay can be fatal.
The primary cause of appendicitis is the obstruction of the appendix lumen. The major agents which cause this blockage can be intestinal worms, foreign bodies, food waste, fecal stone or hardened piece of stool, gastrointestinal viral infection, trauma and appendicoliths (calcified deposits). The foreign bodies include Yersinia species, cytomegalovirus, histoplasma species, actinomycosis, pinworms, strongyloides stercoralis. Lesser intake of fiber in the diet can lead to low number of bowel movements per week; this in turn can reduce the transit time ultimately creating a right sided fecal reservoir. It is also important to know that what causes appendicitis apart from the aforesaid reasons. Though family history is not a cause of it but cancer in the rectum and colon can lead to acute appendicitis.
Upon obstruction of the lumen, it subsequently gets filled with pus and swells. The swelling leads to increased pressure in appendix walls resulting in blood clot in the small vessels. Due to this restricted blood flow the appendix suffers from local anemia or becomes ischemic. The sequence of occurrence all the aforesaid mentioned activities is very rapid and ultimately leads to the rupture of the appendix which causes death.
It is quite difficult to distinguish the symptoms of appendicitis with that of other ailments of the GI track like gastroenteritis. It is quite often seen that people are admitted to hospitals with acute pain and severe condition but are released on the grounds of gastric or stomach flue. Appendicitis is often misdiagnosed. However, the most common and early appendicitis symptoms are as follows;
- Acute pain starting from the naval area which gradually shifts to the lower right side of the abdomen called the McBurney’s point. This is the foremost indication.
- With passing hours the pain becomes more and more excruciating. It often gets aggravated due to body movements of walking or while standing and sitting. Even coughing can lead to enhancement of pain.
- Vomiting and nausea soon are followed after the commencement of the abdominal pain.
- Swelling of the abdomen with occurrence of tenderness upon application of pressure on the right side of the abdomen.
- Loss of appetite.
- Mild fever ranging from 99 ºF to 102 ºF.
If left unchecked, then the acute appendicitis symptoms are as follows;
- Difficulty in passing gas.
- Cramps and sharp pains in upper as well as lower abdomen in the left side.
- Constipation or diarrhea.
- Pain during urination.
Appendicitis Symptoms In Adults
Interestingly the location of pain in your abdomen differs with age and sex depending on the position of the appendix. Apart from the aforesaid symptoms, the other appendicitis symptoms in adults involve blood in urine. This is due to the irritation of the bladder which is caused if the appendix rests on its wall. This condition is extremely rare though.
Appendicitis Symptoms In Women
Appendicitis symptoms in women who are pregnant are different from those who are not and are not the classic ones. The location of pain may not be at the usual site of McBurney’s point. Mostly women who are in the third semester of the gestation period are at the highest risk. However, appendicitis in women within 10 to 30 years of age is most common.
Appendicitis Symptoms In Children
Appendicitis symptoms in children under the age of 5 are less common as compared to older kids. They tend to become unusually sleepy and have difficulty in consuming food. They also suffer from constipation as well as small amounts of mucus in their stool. Fever is also present and the appendix may rupture with 72 hours of its onset.
First Signs Of Appendicitis
The first signs of appendicitis include pain in abdomen, usually starting from the middle which eventually gets shifted to the lower right side of the abdomen. This is often accompanied with nausea and constipation. The pain is aggravated with sudden body movements or jerks as suffered from coughing and sneezing. There will be potential decrease in hunger and the presence of low grade fever. However, the signs of appendicitis in people with diabetes, HIV infection, who has undergone an organ transplant, chemotherapy, immunosuppressant and who are overweight do not show the classic set of indications. They might just suffer from a general condition of being unwell. Other appendicitis signs include Rovsing’s, Psoas, Obturator, Blumberg, Kosher, Sitkovskiy, Bartomier-Michelson’s and Aure-Rozanova’s signs.
The location of appendix is not same in everybody, it different in each person. Most commonly it is found to be at or around the McBurney’s point. The point is located at the lower right side of the abdomen, almost two thirds of the distance betwixt the navel and upper part of pelvic bone. The location of the appendix tip can be retrocecal, or in the pelvis to being extraperitoneal. It is rare though but it can be found to be in the lower left side of the abdomen in people with situs inversus.
Picture 1 : Appendix Location
Note : Mcburney’s point – Line drawn between Umbilicus and Upper part of pelvic bone and the point is 2/3 rd distance from the Umbilicus and 1/3 rd distance from the pelvic bone ( upper part )
Picture 2 : Mcburney’s point ( Anatomical view)
Image source : hakeem-sy.com
Picture 3 : Appendicitis
Image source : thehealthage.com
Appendicitis pain usually begins in the epigastria and it moves down to right ileal fossa. The pain will start after several hors of inflammation and usually increases over a time frame of 6-12 hours a day. Most people find it difficult to explain the pain, which is felt like something they never had before. If one feels moderate belly pain for 4 hours continuously or a severe belly pain then he/she must contact a medic soon. The pain might be felt in the lower back area as well. Elderly, infants and pregnant women might not feel the appendicitis pain in the lower right side. This can lead to misdiagnosis and can prove fatal if untreated for long.
Due to the fact that symptoms of appendicitis are similar to those seen in gastroenteritis, inflammation in kidneys and genital organs; so, any person admitted to hospital with abdominal pain is not operated upon immediately. Acute appendicitis is treated with surgical intervention only, so the medic will conduct tests and diagnosis in order to confirm the same. Once the presence of appendicitis is confirmed Appendectomy is conducted either in endoscopic or traditional way. However, people might suffer from “confined appendicitis”, in which the inflammation is localized to an area and is mild in nature. This can be cured with antibiotics but at a later stage the appendix may or may not be surgically removed. Sometimes an abscess can be formed due to the rupture of the appendicitis. This can be present for several weeks. If the abscess is small then it can be effectively treated with antibiotics and can be subsequently drained. Further after the drainage of the abscess, the appendix can be removed by what is called “interval appendectomy” to minimize the chances of second attack.
Typically as soon as the appendicitis is suspected, without prolonged diagnosis the doctor will go for a surgical removal of the appendix. If it is not done promptly, then a chance of the rupturing of the appendix is enhanced. Surgical removal of an inflamed appendix is termed as appendectomy. Earlier laparotomy was performed in which the appendix is removed via a single incision made on the lower right side of the abdomen. This procedure focuses on the point of maximum inflammation which is the McBurbey’s point. The single incision made measures 2-3 inches long. Upon opening of the incision the appendix is identified and is cut from the surrounding tissues and is removed. After the removal; the incision is closed with surgical staples and is usually covered with sterile bandages to prevent any infection. The entire procedure of an open laparotomy can be completed within an hour.
Later the laparoscopic approach was taken in which three to four incisions are made and a camera or surgical tool called the laparoscope is used to view the area affected via one of the incision. Rest of the incisions made is specifically used to remove the appendix. The incisions typically measure 0.25 to 0.5 inches long. Any problem including rupture and abscesses if found, is taken care by open laparotomy. The entire process can take up to two hours for completion.
Surgery for appendicitis can be open and laparoscopic as mentioned earlier. The latter methodology is considered to be advantageous as compared to the former one. Here are some of them;
- Infection of the wound or the surgical incision is less likely to develop.
- Pain after a day of the laparoscopic surgery is supposed to be lower as compared to open procedure.
- Stay in the hospital after the laparoscopy is reduced by 1.1 day.
- One can return to normal daily activities of work and sport earlier as compared to open laparotomy.
After appendicitis surgery also, issues can crop up if proper care is not taken. One of the most common appendicitis surgery complications is the infection of the wound or the surgical incision which was made during the surgery. When the inflammation of the appendix is severe, then the surgeon does not stitch back the incision considering the fact that the wound is already infected. The closure is delayed for some days and antibiotic therapy is provided in the meantime for the infection to subside. Once the wound is no longer prone to any sort of infection then it is stitched back. If any infections occur, it will be either a mild one with tenderness and redness over the incision, while if the infection becomes severe, antibiotics followed by a surgical treatment is necessary.
Other appendicitis complications after surgery is the formation of an abscess filled with pus at the site of the appendix. However, it can be drained surgically. Basically if the appendix has not ruptured then the complication rate is only about 3% as compared to a 59% when it bursts. Bleeding, hernia of the incision and pneumonia can also be other complications.
Appendicitis recovery after surgery usually takes 4 to 6 weeks. During this time there is no particular restriction in diet but lesser physical activity aids the healing process.
Appendicitis recovery time differs from person to person. Some recover in no time at all while some will require several weeks for healing completely. In case of uncomplicated surgery the patient can be released from the hospital within 1-3 days. If the surgery was performed over a ruptured appendix then the stay might extend up to a week and the healing in this case is slower as well. As mentioned earlier the healing time can take up to 4-6 weeks and can prolong up to 8 weeks if the appendectomy was performed on a ruptured appendix.
Appendicitis recovery in children usually takes up to 3 weeks with limited physical activity. Children recover excellently and do not generally require any lifestyle changes. However, to aid in the healing process the appendicitis recovery diet must comprise of soft liquid and solid diet low in fibrous content. The low fiber diet is easily broken down in the GI tract.
Most remotely one might feel redness and tenderness in the incision as the appendicitis recovery pain with pus formation as well. In such a case the surgeon must be contacted immediately.
by on in Digestive System