Appendicitis is the inflammation of the appendix and a very common surgical condition. In the following article, we’ll review this disease.
Appendicitis is one of the most common surgical emergencies. Also, it is one of the more common causes of the belly or abdominal pain. The frequency of appendicitis has declined since the 1940s. Still, nowadays, 1 out of 1000 people is diagnosed with appendicitis every year, affecting seven percent of the US population.
In the US only, approximately more than 300.000 appendix removal surgeries (appendectomies) take place every year. Appendicitis is slightly more common in developed countries than in developing ones.
Here you will find the answers to frequently asked questions like appendicitis symptoms, diagnosis, and treatment. All of this, with simple words from a doctor, so you fully comprehend this disease. So, keep reading for all you need to know about appendicitis.
What is the appendix?
The appendix is an extension of the cecum, the first part of your large intestine. It has the shape of a worm, so doctors call it a vermiform appendix. The average appendix is usually 8-10 cm in length.
The appendix doesn’t have a fixed position in your body. In fact, it can have up to five different locations. In 65% of patients, the appendix is right behind the cecum (retrocecal). On the other side, the appendix can point towards your pelvis, into the iliac fossa in 30% of cases. The other locations include pre or post ileal (in front or behind the ileum) and subcecal (under the cecum).
This latter variation in the appendix’s location can be the reason for differences in clinical findings of appendicitis.
The appendix has on its inside a mucosal layer. There is swelling in the inner lining in appendicitis; then, it spreads to the rest of the appendix. The function of the appendix remains unknown. Some doctors say it can have a role in your immune system. Other doctors say it is a home for good bacteria, releasing them when the digestive system needs them. Finally, some simply say it has no function at all, and it is just a remnant from our evolutive ancestors. The point is that the appendix doesn’t have a vital role in your body; you can live without it.
What is appendicitis?
Appendicitis is a condition in which the inner lining of the vermiform appendix swells. This inflammation can then affect other parts of the appendix. It is a surgical illness, which means its treatment requires surgery. Still, recent research proclaims that sometimes antibiotic treatment could spare people from surgery.
Even after all this time, appendicitis remains a medical emergency. It is also one of the most common causes of acute abdominal pain. However, appendicitis presentation can be very different from patient to patient. This can result in a challenge to establish the diagnosis, and therefore, delays the treatment. Without treatment, appendicitis can result in severe complications that we’ll mention later on.
Anyone can suffer from appendicitis. However, men have a higher chance of developing appendicitis than women. Also, the probability of having this condition starts rising from birth and peaks in the teen years. In kids, the peak is between 6-10 years of age, while in young adults, the peak is around 22 years old. As we grow older, the probability of developing appendicitis gradually lowers.
What are the common causes of appendicitis?
The main reason appendicitis occurs is the obstruction of the appendiceal lumen. The most common causes for this obstruction include:
- Lymphoid hyperplasia: The appendix has lymphoid tissue. This kind of tissue responds to infections and other conditions. Hyperplasia is the increase in the number of cells of certain tissue. When these cells multiply, they can take up all of the appendiceal lumen, causing an obstruction. This happens with conditions like inflammatory bowel disease.
- Infections: Because they cause lymphoid hyperplasia too. Appendicitis is associated with bacteria such as Yersinia species and parasites like Schistosomes species and Strongyloides stercoralis. This is more common in children and young adults.
- Fecal stasis: Stasis is a period of inactivity. Fecal stasis means that your feces don’t move through your colon as much as they should. This can cause intestinal obstruction and obstruction of the appendix.
- Fecaliths: These are basically stony masses made of feces. When a fecalith gets in the lumen of the appendix, it can cause an obstruction and result in appendicitis. Both fecal stasis and fecaliths are common causes in older adults.
- Tumors: A tumor that blocks the lumen of the appendix can result in appendicitis too. However, this is somewhat rare.
What are the symptoms of appendicitis?
The clinical presentation of appendicitis can be very inconsistent. This means that, even if most of its symptoms are common in most cases, variations in symptoms are very usual. This can make the diagnosis harder for doctors.
The typical presentation of appendicitis starts with loss of appetite (anorexia) and pain around your belly button. Then, it follows nausea and pain in the lower right quadrant of your abdomen (refer to the photo below). Vomiting is present in around 50% of patients. In appendicitis, vomiting is usually present after the onset of abdominal pain. If you experience vomiting before the abdominal pain, this can be a sign of bowel obstruction rather than appendicitis.
As you can see, appendicitis symptoms are not very specific. This is why there can be delays in getting medical attention and establishing a diagnosis.
The most common symptom of appendicitis is abdominal or belly pain. The most important characteristic of appendicitis pain is migration. Typically, the abdominal pain will start in your upper center abdomen or around your navel. Then, the pain migrates to the right lower quadrant (RLQ). This is one of the most discriminating features of appendicitis, helping doctors identify the condition quicker.
Patients will likely change positions to ease the pain, like lying down and flexing their hips. Later, the pain worsens, and nausea, vomiting, and anorexia can appear.
For 80% of patients, the duration of the symptoms is less than 48 hours. However, symptoms can last longer, especially in older patients and patients who suffer perforation. Almost 2% of patients report a 2-week duration of pain.
What are the early warning signs of appendicitis?
In the early stages of appendicitis, the most common warning sign is abdominal pain. At first, the pain will start gradually around the belly button or epigastrium (upper center quadrant of the abdomen). This pain is usually dull and can last for a couple of hours.
Then, if the pain intensifies and migrates to your LRQ, it can be a sign of appendicitis. After it intensifies, the pain can feel more like cramps or stabbing and can get worse when you move.
Another early sign of appendicitis can be nausea and vomiting soon after the start of the abdominal pain. Also, appendicitis patients can have a fever, but it’s not high most of the time.
What does appendix pain feel like?
Like said earlier, abdominal pain is the most important symptom of appendicitis. In fact, it is a pain that gets patients to the ER. Typically, it is sudden and sharp pain in the right lower quadrant of your abdomen. However, it is very common that the pain starts gradually as a dull pain around your belly button. This dull pain can last for around 4 to 6 hours. After this, the pain migrates toward the LRQ, one of the most important characteristics of appendicitis pain.
Sometimes, the pain can feel like a cramp, but it will worsen over time. Also, the pain gets worse when patients cough, sneeze, or move. Since the appendix’s location may variate, some patients can experience pain in the lower back or the pelvis. This happens in patients that have the appendix behind the colon or deep within the pelvis. Another essential characteristic is that the pain won’t go away until the appendix is removed.
What are the possible complications of appendicitis?
Without proper treatment, appendicitis can lead to some life-threatening complications. Therefore it’s important to get the right diagnosis as soon as possible. Some of the most common complications of appendicitis are:
- Perforation or ruptured appendix: When the appendix gets inflamed, the blood flow towards it lowers or even stops. This is known as ischemia. If the ischemia doesn’t get solved soon, the tissue will die and get perforated. When this happens, bacteria inside the appendix spread towards the rest of the abdominal cavity. It can cause a dangerous condition: peritonitis.
- Intra-abdominal abscess: Sometimes, the infected tissue can form a mass of pus around the appendix. This is really painful and can result in peritonitis as well. Abscesses can be treated with antibiotics—however, most of them require draining of the pus to resolve.
- Peritonitis: The inside of your abdominal cavity is sterile; this means that no bacteria are living there. However, when your appendix is perforated, bacteria can get to the abdominal cavity. This causes a serious infection called peritonitis. Peritonitis can damage your internal organs and causes symptoms like high fever, rapid heartbeat, and shortness of breath. If not treated quickly, peritonitis can result in long term problems and even death. This is why, in cases of suspected acute appendicitis, medical attention is vital.
What is the difference between uncomplicated and complicated appendicitis?
The main difference between uncomplicated and complicated appendicitis is the illness stage and the findings during surgery. For example, uncomplicated appendicitis is when the inflamed appendix is almost intact. This means the appendix is not gangrenous (ischemia of tissue hasn’t taken place), and it is not perforated. It is not associated with abscesses or peritonitis.
In the early stages, all cases of appendicitis are considered uncomplicated. If left untreated, they can progress to complicated appendicitis. In complicated appendicitis cases, the appendix is gangrenous, it can leak pus, and it is ruptured. These cases are also associated with intra-abdominal abscesses (pus collections) and peritonitis (life-threatening complication).
Another term you probably heard of is chronic appendicitis. It is rare and happens in only 1% of appendicitis patients, but chronic appendicitis is actually a thing. Doctors define it as:
- A patient with at least three weeks of LRQ pain without another diagnosis.
- Total relief of symptoms after the patient gets the appendectomy.
- Microscopic finds of chronic inflammation and fibrosis in the appendix.
What is the prognosis of appendicitis?
Appendicitis is the number one reason for emergency abdominal surgery. However, if diagnosed early, appendicitis shouldn’t result in any complications.
The mortality rate (which is the number of deaths in association with a disease) of appendicitis is around 0.2-0.8%. Therefore, less than 1% of patients with this disease die. And when they die, it is the result of the complications of untreated appendicitis, not the surgical procedure by itself, although, of course, every medical procedure could have complications.
The mortality rate in children is around 0.1-1%. For patients older than 70 years old, the rate increases to 20%, mostly because of delays in the diagnosis and treatment.
In the case of perforated appendicitis, the complications and death chances are higher than in non-perforating appendicitis. Complications like perforated appendicitis occur in 1-5% of patients. Postoperative wound infections are a common complication of appendectomy, responsible for about a third of the postoperative complications (after surgery complications).
What conditions can be mistaken for appendicitis?
Sometimes the diagnosis of appendicitis is hard because it can be mistaken with many other conditions. In fact, it is more difficult to diagnose it in women. This happens because women have a different reproductive system and have more organs in the pelvis than men. The diagnostic accuracy can vary from 78 to 92% in males and 58-85% in female patients.
Some of the more common differential diagnosis are:
- In women: Pelvic inflammatory disease (PID), endometriosis, ovarian cysts or torsion, and ectopic pregnancies.
- Gastrointestinal conditions: Gastroenteritis, large bowel conditions like diverticulitis, Crohn disease, and other conditions like pancreatitis.
- Urinary tract conditions: Urinary tract infections, renal colic, and ureterolithiasis (when a kidney stone goes through the ureters that carry urine to the bladder).
How do you rule out appendicitis?
As we’ve mentioned before, the diagnosis of appendicitis can be tricky. If you suspect you have appendicitis, you should go to the emergency room. There, a doctor will ask you questions about the symptoms you have and perform a physical examination.
The doctor will palpate your abdomen, looking for tenderness and painful areas. Also, by palpating, they can feel if the abdominal wall is rigid and has signs of peritonitis. Some important clinical findings to diagnose appendicitis include the following.
- Rebound tenderness: When your doctor palpates your abdomen, they can apply deep pressure to see if it hurts. While doing this, they can ask if it hurts more with the pressure or when they release. This maneuver is known as rebound. In appendicitis, patients likely experience more pain during the rebound.
- Right lower quadrant (RLQ) tenderness: Since the appendix is located in the RLQ, around 96% of patients with appendicitis will experience pain in this area. However, this is not a specific find. This is because many other conditions can cause pain in this area too.
- Left lower quadrant (LLQ) tenderness: Rare, but it can be present in patients with a long appendix that extends to the LLQ.
Other signs present in appendicitis and can be helpful for the diagnosis, including:
- Rovsing sign: Pain in the RLQ with the palpation of the LLQ. It can be a sign of peritoneal inflammation.
- Obturator sign: The patient with a right flexed hip performs an internal and external rotation. This causes pain in patients with an inflamed appendix in the deep pelvis.
- Psoas sign: The patient performs an extension of the right hip or flexion against resistance. This causes pain in the RLQ and suggests the appendix is somewhere along with the curse of a muscle called the psoas.
- Dunphy sign: Suggests localized peritonitis. The patient experiences pain in the RLQ with voluntary cough.
Your doctor can indicate some laboratory studies to confirm the diagnosis. However, these tests don’t have specific findings for appendicitis. Usually, these are done to rule out other conditions that may be causing similar symptoms to appendicitis. Some of these include:
- Complete blood count: To see the white blood cells that may indicate there is an infection going on.
- C-reactive protein: This protein indicates an inflammatory process is taking place in your body. Therefore, it should be above its normal levels when the patient has appendicitis.
- Liver and pancreatic Function tests: To rule out conditions like hepatitis and pancreatitis.
- Urinalysis: To rule out urinary tract conditions.
- Urinary beta-hCG: Most commonly known as a pregnancy test to rule out an early ectopic pregnancy.
Also, imaging studies are very useful for getting the final diagnosis of appendicitis. It includes:
- Abdominal ultrasound: It helps look at the structures inside the abdominal cavity. A healthy appendix usually can’t be seen in an ultrasound. So, in the case of appendicitis, the doctor will probably find a tubular structure of 7-9mm in diameter. In the abdominal ultrasound, doctors can also find other alterations that can cause abdominal pain. Kidney and gallbladder stones, pancreatitis, and ectopic pregnancies can be ruled out with an ultrasound.
- Computed tomography or CT scan: When an ultrasound is negative or inconclusive, your doctor may recommend a CT scan. This study is especially useful for patients with an unusual presentation of appendicitis.
What is the treatment for appendicitis?
The only curative treatment for appendicitis is the surgical removal of the appendix. The name of the procedure is an appendectomy, and there are two techniques available to perform it.
There is the open appendectomy, which is basically an open surgery. Here, doctors cut through your abdominal wall to get to the appendix for removal. However, this open surgery is considered a keyhole surgery. This means that the incision made is very small. Since the appendix is a small organ and this way surgery works great.
The other technique is through laparoscopic surgery. In laparoscopy, doctors cut small incisions in your abdomen to get a camera and tiny surgical instruments. This way, they can see inside your abdomen and remove the appendix.
Laparoscopic surgery is preferred in patients with uncomplicated appendicitis, obesity, and elderly patients. Another advantage of laparoscopy is that doctors can use it as a diagnostic method. This lowered the rates of negative appendectomy (appendectomy in which doctors discovered there wasn’t appendicitis after all).
Some other therapies can help in the treatment of appendicitis, like antibiotic therapy. However, this is reserved for patients who, for whatever reason, can’t get surgery right away. It is still in study, but antibiotics are also recommended for appendicitis. This way, the chances of developing a wound infection or an intra-abdominal infection after appendectomy are lower.
What are the risks and complications of an appendectomy?
The appendectomy is a really safe procedure with a low rate of complications. However, as in any other surgical procedure, complications can happen. Some of the most common complications include:
- Wound infection
- Bowel obstruction
- Dehiscence: Separation of the wound or the tissues closing the wound.
- Abdominal and pelvic abscesses
The rate of complications is lower in the case of laparoscopic appendectomy. This is why it is preferred over open appendectomy in some cases.
Can you fart with appendicitis?
Yes, you can fart with appendicitis. However, a common symptom among these patients is the difficulty to pass gas. This symptom, like many other appendicitis symptoms, is not exclusive to this condition.
In fact, many other conditions may present themselves with the inability to fart. Remember that appendicitis pain can aggravate when coughing or straining. So, when you fart with appendicitis, you will experience pain too.
Farting is a normal process, so you should worry if you are not able to do it. Keep in mind that difficulty for farting is not the same as the total absence of farts. This is important because a total absence of farts could be a sign of bowel obstruction, another life-threatening condition.
What foods can cause appendicitis?
There are no foods that can cause appendicitis directly. However, some studies have found that seeds present in some fruits can be a cause of appendicitis. These seeds are sometimes not entirely digested in your stomach, getting to your intestine and colon unchanged.
Fruits like strawberries have seeds that are so tiny that we don’t see a problem ingesting them. But, as small as they are, they can obstruct the appendiceal lumen. And, as you already know, obstruction results in an infected appendix. However, there is no need for you to stop eating fruits with seeds. The chance of getting appendicitis this way is very small, so don’t worry.
On the other side, a high fiber diet can result indirectly in appendicitis too. This happens because high fiber diets, with not enough water intake, produce constipation. Constipation is a risk factor for both fecal stasis and fecaliths, two common causes of appendicitis.
Do you have symptoms of this disease?
This is an Appendicitis Symptoms Checker. It gathers the most important signs, symptoms, and risk factors of this disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of appendicitis. Using the tool is free and would take a few minutes.