Appendicitis

Appendicitis is an inflammation of the vermiform appendix. The typical symptoms include periumbilical pain, vomiting and nausea followed by fever and right lower quadrant abdominal pain.

The disease is related to infectious processes.

Presentation

Classic presentation of acute appendicitis begins with pains, with vomiting setting in and fever coming in lastly. The appendix’s innervation enters the spinal cord at the same level as the umbilicus so the pain begins higher up the stomach area [7]. As the appendix becomes more swollen and irritates the adjoining abdominal wall, it will localise over a few hours into the right lower quadrant. The only exception is with children younger than 3 years of age. The pain is often severe and can be elicited through various signs.

The signs include localised findings in the right iliac fossa and the abdominal wall becomes very sensitive to gentle pressures and palpation.

Workup

Diagnosis is based almost entirely on the presentations and so it is often difficult as there are other conditions that can present same symptoms as appendicitis [8]. When the medical history and presentations isn’t enough to form a definitive diagnosis other approaches that can be considered include:

  • Gross and Microscopic Evaluation
  • Radionuclide Scanning
  • CBC Count
  • C-Reactive Protein
  • Liver and Pancreatic Function Tests
  • Urinary 5-HIAA
  • Urinalysis
  • Urinary Beta-HCG
  • CT Scanning
  • Abdominal Radiography
  • Ultrasonography
  • Barium Enema Study
  • MRI

However, care must be taken to ensure that too much time is not spent on the diagnostic procedure.

Treatment

When appendicitis is suspected, the patient is admitted to the hospital. Laparotomy is used to remove the inflamed appendix. The inflamed appendix is found and cut off the caecum while a stitch is used to prevent any contents in the gut from leaking out. Antibiotic medicines are often given just before the operation so as to reduce the risk of an infection developing at the site of operation [9].

Prognosis

The most common reason for emergency abdominal surgery is acute appendicitis. The appendectomy leads to a complication 4-15% of the time. This is not counting the discomfort of hospitalisation and surgery as well as associated costs [6].

Delayed diagnosis and treatment is one of the major causes of morbidity and mortality and therefore the goal of the surgeon is to ensure early and accurate diagnosis.

The overall mortality rate is 0.2-0.8% and this can be attributed to complications of the disease instead of the surgical intervention in itself. In children, the mortality rate ranges from 0.1% to 1% while in patients that are older than 70 years of age, the rates rise above 20% basically due to late diagnosis and delay in therapeutics.

Etiology

Acute appendicitis is the end result when the appendix lumen is obstructed. When this happens, the appendix becomes filled with mucus and swells [2]. This increases pressures inside the appendix walls and lumen leading to occlusion of the small vessels, stasis of lymphatic flow and thrombosis. At this stage, it is very difficult for spontaneous recovery to occur. With the thrombosis continues to spread, the appendix first becomes ischemic and after a while it becomes necrotic. The dying walls begin to leak bacteria and thus suppuration occurs (pus around and within the appendix). An appendiceal rupture or a burst appendix is the end result of the cascade. When this happens, peritonitis sets in leading to septicaemia and death in many cases.

The main causative agent for peritonitis is faecal deposits referred to as fecaliths or appendicoliths but the following have also been known to cause appendicitis: lymphadenitis, intestinal worms, trauma, foreign bodies and bezoars.

Epidemiology

Appendicitis is one of the most common surgical emergencies. It is also one of the most common causes of abdominal pain. In the United States for example, there are 250,000 cases of appendicitis reported every year. Since the 1940s however, the incidence of appendicitis has continued to decline and presently, the annual incidence is 10 cases for every 100,000 people. 7% of the US population get appendicitis meaning 1.1 cases for every 1000 people each year. There have been talks of familial predisposition as well [3].

In Africa and Asia, the incidence of acute appendicitis is lower and this may be due to dietary habit of the individuals in those geographic areas. Records show that appendicitis is lower in cultures where there is a higher intake of dietary fibre. Dietary fibre is believed to decrease the viscosity of faeces and this decreases time for bowel transit thereby discouraging the formation of fecaliths which will predispose individuals to obstructions of the appendiceal lumen.

Over the last few years, there has been a marked decrease in the frequency of appendicitis in Western Countries. This may be related to changes in the intake of dietary fibre. This has given credence to the theory that a higher incidence of appendicitis in those areas is as a result of poor intake of fibre in such countries.

In teenagers and young adults, there is a slight male preponderance of 3:2. In adults, the incidence in men is 1.4 times greater than in women. There is equality in primary appendectomy in both males and females [4].

Sex distribution
Age distribution

Pathophysiology

The obstruction of the appendiceal lumen is what causes appendicitis as seen above in the etiology. The obstruction brings about an increase in pressure within the lumen and this increase in pressure is related to the continual secretion of fluids and mucus from the mucosa as well as stagnation of the secreted material [5].

At the same time intestinal bacteria within the appendix multiplies leading to the recruitment of the white blood cells. This leads to the formation of pus while intraluminal pressure continues to increase.

When appendiceal obstruction persists, the intraluminar pressure will go beyond the pressure of the appendiceal veins leading to the outflow of the obstruction. Consequently, appendiceal wall ischemia will begin leading to a loss of epithelial integrity which will allow appendiceal wall to be invaded by bacteria.

In a few hours, the localised condition will worsen due to thrombosis of the appendicular artery and veins. This will lead to perforation and gangrene of the appendix. As the process continues, peritonitis or a periappendicular abscess may occur.

Prevention

There is no way to predict when appendicitis will occur and thus prevent it from happening but epidemiological evidence suggest the need to avoid diets that are low in fibre and high in sugar.

Also, infections and a family history increase chances of developing appendicitis [10].

Summary

Also referred to as epityphlitis, appendicitis is the inflammation of the appendix. It is a surgical emergency in many cases [1]. Due to the high level of mortality associated with a ruptured appendix and the fact that it can bring about sepsis and peritonitis, most cases of appendicitis require a removal of the inflamed appendix by laparoscopy and laparotomy.

It was first described in 1886 by Reginald Fitz and today, it is recognised as one of the most significant causes of severe and acute abdominal pain in the world today.

Patient Information

Appendicitis is a disease where your appendix gets filled with pus and inflamed. The appendix is a projection from the colon  and it is found in the lower right part of the abdomen. Although the appendix doesn't have any known benefits to the body, it can still cause a great deal of problems. 

When appendicitis sets in, the symptoms often beging around the belly button before shifting to the lower right abdomen. The pain of appendicitis increases within 18 hours of first signs, becoming severe. 

This condition can affect anyone but it is mostly seen in people aged 10-30. 

The main treatment is the surgical removal of the appendix. 

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References

  1. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. Jan 2010;55(1):71-116
  2. Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, et al. Ultrasonography/MRI Versus CT for Diagnosing Appendicitis. Pediatrics. Mar 3 2014
  3. Yeh B. Evidence-based emergency medicine/rational clinical examination abstract. Does this adult patient have appendicitis?. Ann Emerg Med. Sep 2008;52(3):301-3. 
  4. Markle GB 4th. Heel-drop jarring test for appendicitis. Arch Surg. Feb 1985;120(2):243.
  5. Thimsen DA, Tong GK, Gruenberg JC. Prospective evaluation of C-reactive protein in patients suspected to have acute appendicitis. Am Surg. Jul 1989;55(7):466-8.
  6. Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983; 197:495.
  7. Fitz, RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92:321.
  8. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910.
  9. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337.
  10. Burkitt DP. The aetiology of appendicitis. Br J Surg 1971; 58:695.

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