The Facts

A sudden inflammation or swelling of the appendix is called appendicitis. The appendix is a tube-like structure that branches off where the large intestine (colon) begins. It's pencil-thin and normally about 10 cm (4 inches) in length.

For many years, scientists were unsure of the function of the appendix in the body. Now we know it helps make immunoglobulins – substances that are part of the immune system. Immunoglobulins are made in many parts of the body, thus removing the appendix does not seem to result in problems with the immune system.

Appendicitis is rarely fatal these days, due to the use of antibiotics and safe surgery. The condition affects 1 in 20 people and strikes men more than women. The incidence of appendicitis decreases with age and hardly ever affects young children or older adults. It occurs most commonly in people between 10 and 30 years of age.

Causes

Inflammation of the appendix is usually the result of blockage causing an infection. The appendix is open at one end where it connects to the large intestine. Appendicitis may occur when the appendix is blocked by hardened masses of feces or a foreign body in the intestine. This blockage can cause inflammation of the appendix directly and can encourage bacterial infection.

Blockage may also occur if lymph nodes in the appendix swell. Less common causes of blockage are vegetable and fruit seeds, stomach worms, and thickened barium from prior X-rays.

In seniors, appendicitis is occasionally caused by a tumour (cancer) of the colon.

Symptoms and Complications

Early symptoms of acute appendicitis may include:

• constipation, diarrhea, or gas
• dull pain beginning around the navel, turning to sharp pain in the lower right portion of the abdomen – this takes place over about 2 hours
• migrating pain (pain that shifts)
• loss of appetite
• low fever (37°C to 39°C)
• nausea and vomiting
• tenderness when pressure is applied in the lower right abdomen; a good indicator of appendicitis is rebound tenderness (this means it hurts less when the fingers press over the tender area than it does when the pressure is suddenly released)

These are the classic symptoms common in adolescents and young adults. In younger children, pain is less localized and there may be no tender points. In older adults, there is generally less pain.

Symptoms of more advanced appendicitis include:

• abdominal swelling and rigidity
• pain on the right side of the abdomen when pressed on the left side

These are both signs that inflammation has spread to the abdominal cavity or peritoneum. Left untreated, appendicitis will proceed from mild to severe symptoms. When the infection has reached this stage, it's called peritonitis, which is life-threatening, and a doctor should be seen immediately.

During the first 24 hours after first symptoms develop, about 90% of people develop inflammation. In some patients, inflammation is accompanied by necrosis ("tissue death") of the appendix, which places them at an increased risk for perforation of the appendix.

The great danger in appendicitis is rupture or perforation of the appendix. All the inflammatory agents and bacteria in the appendix spill out into the abdominal cavity, causing severe peritonitis. Sometimes there's mild peritonitis even before the appendix ruptures.

Occasionally, a mass of scar tissue forms an abscess around the appendix. In some ways, this reduces risk, since it insulates the abdomen from the dangerous pus inside. It tends to complicate surgery, however, often requiring two operations.

Making the Diagnosis

If you think you have appendicitis, see a doctor immediately. Avoid laxatives because they can cause your appendix to burst.

Appendicitis is usually a clinical diagnosis and needs to be determined by a doctor. The doctor will perform a number of tests that may also provide information on the extent and location of inflammation. After a physical examination, a blood test may be done to check for infection. A doctor might also take a urine sample to rule out a urinary tract infection, because symptoms can be similar to those of appendicitis.

Sometimes an ultrasound will be performed to help with the diagnosis. An abdominal CT scan is occasionally needed for people when other tests do not give clear results.

Other diseases that can be confused with appendicitis include colitis, Crohn's disease, gastritis, gastroenteritis, tubal pregnancy, and ovary problems.

Treatment and Prevention

Surgery is the only treatment for acute appendicitis. The appendix is often removed (appendectomy) within hours of diagnosis. Appendectomy is a fairly simple operation even if the appendix is already ruptured. Antibiotics will be given before surgery and may be continued after the operation in case bacteria enter the abdomen during the procedure.

Some surgeons are now doing a less invasive form of appendectomy called laparoscopic appendectomy where the appendix is removed through a small tube, leaving a very tiny scar.

Depending on the type of procedure, some people can get out of bed the same day. In most cases, the incision will heal within a few days to a week.