Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly. (Am Fam Physician 1999;60:2027-34.)
Your appendix is a small, finger-shaped pouch that projects out from your colon on the lower-right side of your abdomen. The appendix has no known purpose, but that doesn't mean it can't cause problems.
The main symptom of appendicitis is pain that typically begins around the navel and then shifts to the lower-right abdomen. The pain usually increases over a period of six to 12 hours, and eventually may become very severe.
Anyone can develop appendicitis, but it most often strikes people between the ages of 10 and 30 and is one of the most common reasons for emergency abdominal surgery in children.
The standard treatment for appendicitis is surgical removal of the appendix. In many cases the surgery is straightforward, and you recover quickly. But if your appendix has ruptured, the surgery may be more complicated and you'll take longer to heal. A ruptured appendix that's not promptly treated can lead to serious complications such as infection. In rare instances a ruptured appendix can be fatal.
Signs and symptoms
Appendicitis can cause a variety of symptoms that may change over time. The most common early symptom is an aching pain around your navel that often shifts later to your lower-right abdomen. As the inflammation in your appendix spreads to nearby tissues, especially the inner lining (peritoneum) of your abdomen, the pain may become sharper and more severe.
Eventually, the pain tends to settle in your lower-right abdomen — just above your appendix at what's known as McBurney's point. This point is about halfway between your navel and the top of your right pelvic bone. But the location of your pain may vary, depending on your age and the position of your appendix. Young children, especially, may have appendicitis pain in different places.
If you apply gentle pressure to the area that hurts, it will feel tender. As you release the pressure, appendicitis pain often will feel worse (rebound tenderness). It will also tend to get worse if you cough, walk or make other jarring movements. This is particularly true if the inflamed appendix is touching the peritoneum. The pain may lessen somewhat if you lie on your side and pull your legs up beneath you.
In addition to pain, you may have one or more of the following signs and symptoms:
It's not always clear why appendicitis occurs. Sometimes it's the result of an obstruction when food waste or a hard piece of stool (fecal stone) becomes trapped in an orifice of the cavity that runs the length of your appendix.
Appendicitis may also follow an infection, such as a gastrointestinal viral infection, or it may result from other types of inflammation. In both cases, bacteria may subsequently invade rapidly, causing the appendix to become inflamed and filled with pus. If not treated promptly, your appendix eventually may rupture.
Screening and diagnosis
The pain from appendicitis may change over time, so establishing a diagnosis can sometimes be difficult. In addition, abdominal pain can arise from a number of health problems other than appendicitis. This is particularly true for young women who may have pain from a pregnancy that occurs outside the lining of the uterus (ectopic pregnancy) or from the rupture of a right-sided ovarian cyst. Occasionally, a stone from the right kidney will pass into the ureter, which runs from the kidney to the bladder, and get stuck there. This causes considerable pain that may mimic appendicitis, especially in adults.
To help diagnose appendicitis, your doctor will likely take your temperature and examine your abdomen. When gentle pressure on the painful area is suddenly released, appendicitis pain will often feel worse if the adjacent peritoneum is inflamed. Your doctor may also perform a rectal exam — and, if you're female, a pelvic exam — to determine the extent and exact location of your pain.
In addition, doctors usually recommend a blood test to check for a high white blood cell count, which may indicate an infection. He or she may also want you to have a urinalysis to make sure that a urinary tract infection or a kidney stone isn't causing your pain.
Your doctor also may recommend an abdominal X-ray or ultrasound scan to help confirm appendicitis or find other causes for your pain. An ultrasound scan uses high-frequency sound waves and computer technology to provide images of your internal organs. Sometimes a computerized tomography (CT) scan also may be done. A CT scan is a diagnostic imaging procedure that uses a series of computer-generated X-rays to provide a more comprehensive view of your internal organs than conventional X-rays do. However, these tests can be normal in the presence of appendicitis.
The most serious complication of appendicitis is an infection of the lining of your abdominal cavity (peritonitis). This may occur if your appendix ruptures (perforates), and the contents of your intestines as well as the infection invade the peritoneal cavity. When this happens, you may suddenly feel somewhat better temporarily. But soon after, your entire abdomen may become distended with gas and fluid and will likely feel tight, hard and tender to the touch. You'll also have pain throughout your abdomen, but may not have the severe, localized pain of appendicitis. In addition, you may not be able to pass gas or have a bowel movement because of the inflammation. You may also have a fever, thirst and a low urine output.
Peritonitis is a medical emergency. If you or a family member develops signs of this abdominal infection, go to an emergency room immediately. Even with prompt treatment, peritonitis can be extremely serious.
Children are more likely to have a ruptured appendix than adults are. They don't always have typical symptoms of appendicitis, and parents may delay getting treatment. For that reason, it's best not to take abdominal pain lightly. Even if you suspect a "stomachache" isn't serious, call your doctor just to make sure.
Sometimes, the seepage of intestinal contents and infection may occur as an abscess, a walled-off area of infection. The abscess may be as small as a walnut or as large as a grapefruit. But no matter what its size, it requires surgery before the abscess itself perforates, causing peritonitis.
If you have acute appendicitis, you'll need to have your appendix surgically removed (appendectomy). Your surgeon may perform traditional open surgery, using a single long abdominal incision, or choose laparoscopic surgery, which requires only a few small abdominal incisions.
In a laparoscopic procedure, your surgeon inserts a laparoscope — a pencil-thin tube with its own lighting system and miniature video camera — into your abdomen through a hollow instrument (cannula). Only a small incision is needed. The video camera then produces a magnified view of the inside of your abdomen on an outside video monitor. This allows your surgeon to see the surgery in detail. To remove your appendix, your surgeon uses tiny instruments inserted through one or two other small abdominal incisions.
In general, laparoscopic surgery allows you to recover faster and heal with less scarring. But if your appendix has ruptured and infection has spread beyond the appendix, or if an abscess is present, you'll need a larger incision so that your surgeon can clean the abdominal cavity. You'll receive intravenous antibiotics and will need to stay in the hospital during your recovery.