Appendicitis

Reviewed by Dr Robert Diggory, consultant general surgeon and Dr Paul Klenerman, consultant physician and infection specialist

What is appendicitis?

Appendicitis is an inflammation of the appendix, a small worm-like pouch attached to the large bowel. It can happen at any age but most cases are between 8 and 25 years of age. It is rarely seen in children aged under two years.

For young people, appendicitis is probably the most common cause of stomach pain requiring emergency surgery.

What causes appendicitis?

In most cases, the specific reason for the inflammation is not known but it is sometimes caused by small pieces of hardened stool (faecaliths) that get stuck in the appendix.

What are the symptoms of appendicitis?

The symptoms can be extremely variable but often take the following classic pattern. The first sign is usually a pain or discomfort in the centre of the abdomen. This pain comes and goes in waves and is often thought at first to be a simple stomach upset.

After a few hours, the pain becomes more noticeable and constant in the lower right part of the stomach. It is increased by movement or coughing. The patient often loses their appetite, feels sick, and vomits. The temperature is raised and the complexion becomes flushed. The breath may smell offensive.

How is appendicitis diagnosed?

The doctor takes a medical history from the patient and checks their temperature. Blood and urine tests are performed to look for infection.

The doctor examines the patient by pressing on the lower right part of the abdomen and sometimes by inserting a finger in the anus (back passage) in order to exclude other causes of pain. Women are often given a vaginal examination.

There is no one test that will diagnose appendicitis with certainty. Surgery is performed on the basis of the doctor's examination and results of the tests. Many diseases can cause the same symptoms as appendicitis which is why surgeons find a normal appendix in 3 out of 10 operations.

How is appendicitis treated?

Surgical removal of the appendix (appendicectomy) is the most common procedure. A 3 to 6cm horizontal incision is made in the lower part of the abdomen on the right side, through which the appendix is removed. It is performed under general anaesthesia.

In some hospitals, the appendix is routinely removed by a keyhole operation or the insertion of a three-fibre optic camera through the stomach (laparoscopy). This technique does not seem to have any advantages over ordinary surgery.

In uncomplicated cases, a two to three day hospital stay is typical. The person can go home when their temperature is normal and their bowel starts to function again. The stitches are removed 10 days after the operation by a GP. A return to ordinary daily life within four to six weeks is usual.

What can go wrong during the operation?

About one fifth of the patients who undergo surgery turn out to have a ruptured (perforated) appendix. This causes peritonitis or inflammation of the peritoneum, which is the membrane around the internal organs.

Nowadays, this condition can be treated with antibiotics which makes it less dangerous than it used to be but there is still a risk of abscess formation in the abdominal cavity which will require draining.

Adhesions from postoperative scar tissue may develop and block or obstruct the bowel. This happens in a small number of all patients who have their appendix surgically removed. The condition usually occurs within three months of the operation. A bowel obstruction may require emergency surgery.

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