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The appendix is a small, worm-like appendage attached to the colon.

Appendicitis occurs when bacteria invade and infect the wall of the appendix.

The most common complications of appendicitis are abscess and peritonitis.

The most common symptoms of appendicitis are abdominal pain, loss of


appetite, nauseaand vomiting, fever, and abdominal tenderness.

Appendicitis usually is suspected on the basis of a patient's history and physical


examination; however, a white blood cell count, urinalysis, abdominal X-ray, barium enema,
ultrasonography, CT scan, andlaparoscopy also may be helpful in diagnosis.

Due to the varying size and location of the appendix and the proximity of other organs to
the appendix, it may be difficult to differentiate appendicitis from other abdominal and pelvic
diseases.

The treatment for appendicitis usually is antibiotics and appendectomy (appendectomy or


surgery to remove the appendix).

Complications of appendectomy include wound infection and abscess.


Other conditions that can mimic appendicitis include Meckel'sdiverticulitis, pelvic
inflammatory disease (PID), inflammatory diseases of the right upper abdomen (gallbladder
disease, liver disease, or perforated duodenal ulcer), right-sided diverticulitis, and kidney
diseases.

What is the appendix?


The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the
cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform
appendix, means worm-like appendage.) The open central core of the appendix drains into the
cecum. The inner lining of the appendix produces a small amount of mucus that flows through
the open central core of the appendix and into the cecum. The wall of the appendix contains
lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the
colon, the wall of the appendix also contains a layer of muscle, but the layer of muscle is poorly
developed.

What is appendicitis and what causes appendicitis?


Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the
opening from the appendix into the cecum becomes blocked. The blockage may be due to a
build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum.
The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a
fecalith (literally, a rock of stool). At other times, it might be that the lymphatic tissue in the
appendix swells and blocks the opening. After the blockage occurs, bacteria which normally are
found within the appendix begin to invade (infect) the wall of the appendix. The body responds to
the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative

theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of
bacteria outside of the appendix. The cause of such a rupture is unclear, but it may relate to
changes that occur in the lymphatic tissue, for example, inflammation, that lines the wall of the
appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix can
rupture. After rupture, infection can spread throughout the abdomen; however, it usually is
confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).
Sometimes, the body is successful in containing ("healing") the appendicitis without surgical
treatment if the infection and accompanying inflammation do not spread throughout the
abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in
elderly patients and when antibiotics are used. The patients then may come to the doctor long
after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to
the scarring that occurs during healing. This lump might raise the suspicion of cancer.

What are the complications of appendicitis?


The most frequent complication of appendicitis is perforation. Perforation of the appendix can
lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of
the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is
delay in diagnosis and treatment. In general, the longer the delay between diagnosis and
surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of
symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done
without unnecessary delay.
A less common complication of appendicitis is blockage or obstruction of the intestine. Blockage
occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop
working, and this prevents the intestinal contents from passing. If the intestine above the
blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may

occur. It then may be necessary to drain the contents of the intestine through a tube passed
through the nose and esophagus and into the stomach and intestine.
A feared complication of appendicitis issepsis, a condition in which infecting bacteria enter the
blood and travel to other parts of the body. This is a very serious, even life-threatening
complication. Fortunately, it occurs infrequently.

What are the symptoms of appendicitis?


The main symptom of appendicitis isabdominal pain. The pain is at first diffuse and poorly
localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is
confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint
that when asked to point to the area of the pain, most people indicate the location of the pain
with a circular motion of their hand around the central part of their abdomen. A second, common,
early symptom of appendicitis is loss of appetite which may progress to nausea and even
vomiting. Nausea and vomiting also may occur later due to intestinal obstruction.
As appendiceal inflammation increases, it extends through the appendix to its outer covering and
then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum
becomes inflamed, the pain changes and then can be localized clearly to one small area.
Generally, this area is between the front of the right hip bone and the belly button. The exact
point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and
infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of
the abdomen becomes inflamed.

How is appendicitis diagnosed?


The diagnosis of appendicitis begins with a thorough history and physical examination. Patients
often have an elevated temperature, and there usually will be moderate to severe tenderness in
the right lower abdomen when the doctor pushes there. If inflammation has spread to the
peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse
when the doctor quickly releases his or her hand after gently pressing on the abdomen over the
area of tenderness.
White Blood Cell Count
The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a mild
elevation even early in the process. Unfortunately, appendicitis is not the only condition that
causes elevated white blood cell counts. Almost any infection or inflammation can cause this
count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used
to confirm a diagnosis of appendicitis.
Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells
and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in
the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the
appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it
can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with

appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests


appendicitis more than a urinary tract problem.
Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool
that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially
true in children.
Ultrasound
An ultrasound is a painless procedure that uses sound waves to provide images of identify
organs within the body. Ultrasound can identify an enlarged appendix or an abscess.
Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore,
not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is
helpful in women because it can exclude the presence of conditions involving the ovaries,
Fallopian tubes and uterus that can mimic appendicitis.
Barium Enema
A barium enema is an X-ray test in which liquid barium is inserted into the colon from the anus to
fill the colon. This test can, at times, show an impression on the colon in the area of the appendix
where the inflammation from the adjacent inflammation impinges on the colon. Barium enema
also can exclude other intestinal problems that mimic appendicitis, for exampleCrohn's disease.
Computerized tomography (CT) Scan
In patients who are not pregnant, a CT scan of the area of the appendix is useful in diagnosing
appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the
abdomen and pelvis that can mimic appendicitis.
Laparoscopy
Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted
into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a
direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found,
the inflamed appendix can be removed with the laparoscope. The disadvantage of laparoscopy
compared to ultrasound and CT is that it requires a general anesthetic.
There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to
suspected appendicitis may include a period of observation, tests as previously discussed, or
surgery.

Why can it be difficult to diagnose appendicitis?


It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may
vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other
parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane that attaches
the appendix to other structures within the abdomen. If the mesentery is large, it allows the
appendix to move around. In addition, the appendix may be longer than normal. The combination
of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among
the pelvic organs in women). It also may allow the appendix to move behind the colon (called a

retro-colic appendix). In either case, inflammation of the appendix may appear to be more like
the inflammation of other organs, for example, a woman's pelvic organs.
The diagnosis of appendicitis also can be difficult because other inflammatory problems may
mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a
period of time to see if the problem will resolve on its own or develop characteristics that more
strongly suggest appendicitis or, perhaps, another condition.

What other conditions can mimic appendicitis?


The surgeon faced with a patient suspected of having appendicitis always must consider and
look for other conditions that can mimic appendicitis. Among the conditions that mimic
appendicitis are:

Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small


intestine which usually is located in the right lower abdomen near the appendix. The
diverticulum may become inflamed or even perforate (break open or rupture). If inflamed
and/or perforated, it usually is removed surgically.

Pelvic inflammatory disease. The right Fallopian tube and ovary lie near the appendix.
Sexually active women may contract infectious diseases that involve the tube and ovary.
Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary
are not necessary.

Inflammatory diseases of the right upper abdomen. Fluids from the right upper
abdomen may drain into the lower abdomen where they stimulate inflammation and mimic
appendicitis. Such fluids may come from a perforated duodenal ulcer, gallbladder disease, or
inflammatorydiseases of the liver, for example, a liver abscess.

Right-sided diverticulitis. Although most diverticuli are located on the left side of the
colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures it
can provoke inflammation they mimics appendicitis.

Kidney diseases. The right kidney is close enough to the appendix that inflammatory
problems in the kidney-for example, an abscess-can mimic appendicitis.

How is appendicitis treated?


Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics
almost always are begun prior to surgery and as soon as appendicitis is suspected.
There is a small group of patients in whom the inflammation and infection of appendicitis remain
mild and localized to a small area. The body is able not only to contain the inflammation and
infection but to resolve it as well. These patients usually are not very ill and improve during
several days of observation. This type of appendicitis is referred to as "confined appendicitis" and
may be treated with antibiotics alone. The appendix may or may not be removed at a later time.
On occasion, a person may not see their doctor until appendicitis with rupture has been present
for many days or even weeks. In this situation, an abscess usually has formed, and the
appendiceal perforation may have closed over. If the abscess is small, it initially can be treated
with antibiotics; however, the abscess usually requires drainage. A drain (a small plastic or rubber
tube) usually is inserted through the skin and into the abscess with the aid of an ultrasound or CT

scan that can determine the exact location of the abscess. The drain allows pus to flow from the
abscess out of the body. The appendix may be removed several weeks or months after the
abscess has resolved. This is called an interval appendectomy and is done to prevent a second
attack of appendicitis.

How is an appendectomy done?


During an appendectomy, an incision two to three inches in length is made through the skin and
the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen
and looks for the appendix which usually is in the right lower abdomen. After examining the area
around the appendix to be certain that no additional problem is present, the appendix is
removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen
and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an
abscess is present, the pus can be drained with drains that pass from the abscess and out
through the skin. The abdominal incision then is closed.
Newer techniques for removing the appendix involve the use of the laparoscope. The
laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the
inside of the abdomen through a small puncture wound (instead of a larger incision). If
appendicitis is found, the appendix can be removed with special instruments that can be passed
into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since much of the post-surgery pain
comes from incisions) and a speedier return to normal activities. An additional advantage of
laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in
cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially
helpful in menstruating women in whom a rupture of an ovarian cyst may mimic appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent
home from the hospital after surgery in one or two days. Patients whose appendix has perforated
are sicker than patients without perforation, and their hospital stay often is prolonged (four to
seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the
hospital to fight infection and assist in resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the
patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in
these cases is that it is better to remove a normal-appearing appendix than to miss and not treat
appropriately an early or mild case of appendicitis.

What are the complications of appendectomy?


The most common complication of appendectomy is infection of the wound, that is, of the
surgical incision. Such infections vary in severity from mild, with only redness and perhaps some
tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring
antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis
are so severe that the surgeon will not close the incision at the end of the surgery because of
concern that the wound is already infected. Instead, the surgical closing is postponed for several
days to allow the infection to subside with antibiotic therapy and make it less likely for infection to
occur within the incision. Wound infections are less common with laparoscopic surgery.

Another complication of appendectomy is an abscess, a collection of pus in the area of the


appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical
techniques, as previously discussed.

Are there long-term consequences of appendectomy?


It is not clear if the appendix has an important role in the body in older children and adults. There
are no major, long-term health problems resulting from removing the appendix although a slight
increase in some diseases has been noted, for example,Crohn's disease.

What is new about appendicitis?


Recently it has been hypothesized that some episodes of appendicitis-like symptoms, especially
recurrent symptoms, may be due to an increased sensitivity of the intestine and appendix from a
prior episode of inflammation. That is, the recurrent symptoms are not due to recurrent episodes
of inflammation. Rather, prior inflammation has made the nerves of the intestines and appendix
or the central nervous system that innervate them more sensitive to normal stimuli, that is, with
stimuli other than inflammation. This will be a difficult, if not impossible, hypothesis to confirm.
Additional resources from WebMD Boots UK on Appendicitis
REFERENCE:
Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States:
McGraw-Hill Professional, 2008.
Original author and editor: Dennis Lee, M.D. and Jay W. Marks, M.D.

http://emedicine.medscape.com/article/773895-overview

Background
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads
to its other parts. This condition is a common and urgent surgical illness with protean manifestations,
generous overlap with other clinical syndromes, and significant morbidity, which increases with
diagnostic delay (see Clinical Presentation). In fact, despite diagnostic and therapeutic advancement
in medicine, appendicitis remains a clinical emergency and is one of the more common causes of
acute abdominal pain.
No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal
inflammation in all cases, and the classic history of anorexia and periumbilical pain followed by
nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases (see Clinical
Presentation).
Appendicitis may occur for several reasons, such as an infection of the appendix, but the most
important factor is the obstruction of the appendiceal lumen (see Pathogenesis and Etiology). Left
untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and
may even cause death (see Prognosis and Complications). However, the differential diagnosis of
appendicitis is often a clinical challenge because appendicitis can mimic several abdominal conditions
(see Diagnostic Considerations and Differentials).[1]
Appendectomy remains the only curative treatment of appendicitis (see Treatment and Management).
The surgeon's goals are to evaluate a relatively small population of patients referred for suspected
appendicitis and to minimize the negative appendectomy rate without increasing the incidence of
perforation. The emergency department (ED) clinician must evaluate the larger group of patients who
present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity
for the diagnosis in a time-, cost-, and consultation-efficient manner.
Go to Pediatric Appendicitis for more information on this topic.

Anatomy
The appendix is a wormlike extension of the cecum and, for this reason, has been called the
vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The
appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in its
mucosa. Such follicles increase in number when individuals are aged 8-20 years. A normal appendix
is seen below.

Normal appendix; barium enema radiographic examination. A complete


contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.

The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer
is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath

these layers lies the submucosal layer, which contains lymphoepithelial tissue. The mucosa consists
of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells.
Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal
base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within
which courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an
accessory appendicular artery (deriving from the posterior cecal artery) may be found.

Appendiceal vasculature
The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The
appendicular artery is contained within the mesenteric fold that arises from a peritoneal extension
from the terminal ileum to the medial aspect of the cecum and appendix; it is a terminal branch of the
ileocolic artery and runs adjacent to the appendicular wall. Venous drainage is via the ileocolic veins
and the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic nodes along the
course of the superior mesenteric artery to the celiac nodes and cisterna chyli.

Appendiceal location
The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a
dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or as a
funnel-shaped opening (2-3% of patients). The appendix has a retroperitoneal location in 65% of
patients and may descend into the iliac fossa in 31%. In fact, many individuals may have an appendix
located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending
colon, or liver. Thus, the course of the appendix, the position of its tip, and the difference in
appendiceal position considerably changes clinical findings, accounting for the nonspecific signs and
symptoms of appendicitis.

Congenital appendiceal disorders


Appendiceal congenital disorders are extremely rare but occasionally reported (eg, agenesis,
duplication, triplication).

Pathophysiology
Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes
(see Etiology). Independent of the etiology, obstruction is believed to cause an increase in pressure
within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the
mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix
multiply, leading to the recruitment of white blood cells (see the image below) and the formation of pus
and subsequent higher intraluminal pressure.

Technetium-99m radionuclide scan of the abdomen shows focal uptake of


labeled WBCs in the right lower quadrant consistent with acute appendicitis.

If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the
appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall
ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the
appendiceal wall.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular
artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a
periappendicular abscess or peritonitis may occur.

Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal
obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or infections
(more common during childhood and in young adults), fecal stasis and fecaliths (more common in
elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and
neoplasms.
Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated
fecal material located within the appendix. Lymphoid hyperplasia is associated with various
inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory
infections, measles, and mononucleosis.
Obstruction of the appendiceal lumen has less commonly been associated with bacteria
(Yersinia species, adenovirus, cytomegalovirus,
actinomycosis,Mycobacteria species, Histoplasma species), parasites (eg, Schistosomesspecies,
pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue
stud, activated charcoal), tuberculosis, and tumors.

Epidemiology
Appendicitis is one of the more common surgical emergencies, and it is one of the most common
causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually,
representing 1 million patient-days of admission. The incidence of acute appendicitis has been
declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000
population. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000
people per year. Some familial predisposition exists.
In Asian and African countries, the incidence of acute appendicitis is probably lower because of the
dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in
cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of feces,
decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to
obstructions of the appendiceal lumen.
In the last few years, a decrease in frequency of appendicitis in Western countries has been reported,
which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is
believed to be related to poor fiber intake in such countries.
There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of
appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary
appendectomy is approximately equal in both sexes.
The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually
declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is
6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is
responsible for the increased incidence of appendicitis in these age groups. Younger children have a
higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22
years. Although rare, neonatal and even prenatal appendicitis have been reported. Clinicians must
maintain a high index of suspicion in all age groups.
Go to Pediatric Appendicitis for more information on this topic.

Prognosis
Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy
carries a complication rate of 4-15%, as well as associated costs and the discomfort of hospitalization
and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis as early as possible.

Delayed diagnosis and treatment account for much of the mortality and morbidity associated with
appendicitis.
The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to
surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than 70
years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay.
Appendiceal perforation is associated with increased morbidity and mortality compared with
nonperforating appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than
0.1%, but the risk rises to 0.6% in gangrenous appendicitis. The rate of perforation varies from 16% to
40%, with a higher frequency occurring in younger age groups (40-57%) and in patients older than 50
years (55-70%), in whom misdiagnosis and delayed diagnosis are common. Complications occur in 15% of patients with appendicitis, and postoperative wound infections account for almost one third of
the associated morbidity.

Abdominal Pain in Adults Overview


Abdominal pain can range in intensity from a mild stomach ache to severe acute pain. The pain is
often nonspecific and can be caused by a variety of conditions. Many organs are found within the
abdominal cavity. Sometimes the pain is directly related to a specific organ such as the bladder or
ovary, while other times it is more diffuse or non-specific.. Usually, abdominal pain originates in the
digestive system. For example, the pain can be caused by appendicitis, diarrheal cramping, or food
poisoning.
The type and location of pain may help the physician find the cause. The intensity and duration of pain
must also be considered when making a diagnosis. A few general characteristics of abdominal pain
are as follows:

Character of Pain: Abdominal pain can be sharp, dull, stabbing, cramp-like, knifelike,
twisting, or piercing. Many other types of pain are possible.

Duration of Pain: Abdominal pain can be brief, lasting for a few minutes, or it may persist for
several hours and longer. Sometimes abdominal pain comes on strongly for a while and then
lessens in intensity for a while.

Triggering Events: The pain may be worsened or relieved by certain events, such as worse
after meals, better with a bowel movement, better after vomiting, or worse when lying down.
Abdominal pain can make a person want to stay in one place and not move a muscle. Or the pain can
make them so restless they want to pace around trying to find "just the right position."
The health care practitioner will try to pinpoint the area of the abdomen where the pain originates
when determining the cause of abdominal pain. This is done by combining questions such as - "When
you first had the pain, where did you feel it?" - with examination of the abdomen. Softly pressing on
certain areas to elicit the pain and perhaps palpating other areas to examine the size and exact
location of an organ are other parts of the physical examination.
When this is combined with general questions about the pain such as "Is the pain dull or sharp?"
"How long have you had the pain?" and questions about your state of health - "Did you have to
vomit?" - the health care practitioner can narrow down the possible causes of the pain.
Once the questions and physical exam are completed, the health care practitioner will either give the
patient a diagnosis and advise on follow-up recommendations or order blood tests, and possibly Xrays and imaging studies to further help identify why the patient is in pain.

Abdominal Pain in Adults Causes


Many acute (short-term) and chronic (long-term) diseases cause abdominal pain.

Diseases people worry about most areappendicitis, gallbladder disease, duodenal


and gastric ulcers, infections, andpregnancy-associated problems.

Doctors also worry about the following conditions: ruptured blood vessels, heart attack, liver
and pancreas inflammation, kidney stones, problems with the blood circulation to the
intestine, diverticulitis, and other diseases.
Abdominal pain may not arise from the abdomen.

Some heart attacks and pneumonias can cause abdominal pain.

Diseases of the pelvis or groin can also cause a pateint's abdomen to hurt.

Certain skin rashes, such as shingles, can feel like abdominal pain, even though the person
has nothing wrong inside their body.

Even some poisonings, such as a black widow spider bite, can cause severe abdominal
pain.
From the above it is apparent that abdominal pain can have many causes, some linked directly to the
abdomen and others caused by non-abdominal disease. Sometime the cause of abdominal pain is not
found by the patient's health care practitioner during the initial evaluation. In some cases, no specific
cause is determined, and the pain gets better in hours or days.

Abdominal Pain in Adults Symptoms


Abdominal pain is a symptom. It may mean that the person has a medical problem that needs
treatment.
Abdominal pain may go along with other symptoms. Try to keep track of the symptoms,
because this will help the health care practitioner's find the cause of the person's pain
Pediatric Appendicitis
Abdominal Pain in Adults Symptoms
Abdominal pain is a symptom. It may mean that the person has a medical
problem that needs treatment.

Abdominal pain may go along with other symptoms. Try to keep track of
the symptoms, because this will help the health care practitioner's find
the cause of the person's pain.

Anatomy
The vermiform appendix is generally 5-10 cm in length. It arises from the cecum, which in most
children is located in the right lower quadrant of the abdomen.
Although the base of the appendix is fixed to the cecum, the tip can be located in the pelvis,
retrocecum, or extraperitoneum. Note that the anatomic position of the appendix determines the
symptoms and the site of tenderness when the appendix becomes inflamed.
The appendix is lined by typical colonic epithelium. The submucosa contains lymphoid follicles, which
are very few at birth. This number gradually increases to a peak of about 200 follicles at age 10-20
years and then subsequently declines. In persons older than 30 years, less than half that number is
present, and the number continues to decrease throughout adulthood.

Pathophysiology
Once the appendix becomes obstructed, bacteria trapped within the appendiceal lumen begin to
multiply, and the appendix becomes distended. The increased intraluminal pressure obstructs venous
drainage, and the appendix becomes congested and ischemic.
The combination of bacterial infection and ischemia produce inflammation, which progresses to
necrosis and gangrene. When the appendix becomes gangrenous, it may perforate. The progression
from obstruction to perforation usually takes place over 72 hours.
One study noted that appendiceal perforation is more common in children, specifically younger
children, than in adults. A substantial risk of perforation within 24 hours of onset was noted (7.7%) and
was found to increase with duration of symptoms. While perforation was directly related to the
duration of symptoms before surgery, the risk was associated more with prehospital delay than with
in-hospital delay.[1]
During the initial stage of appendicitis, the patient feels only periumbilical pain due to the T10
innervation of the appendix. As the inflammation worsens, an exudate forms on the appendiceal
serosal surface. When the exudate touches the parietal peritoneum, a more intense and localized
pain develops.
Perforation results in the release of inflammatory fluid and bacteria into the abdominal cavity. This
further inflames the peritoneal surface, and peritonitis develops. The location and extent of peritonitis
(diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can
contain the spillage of luminal contents.
If the contents become walled off and form an abscess, the pain and tenderness may be localized to
the abscess site. If the contents are not walled off and the fluid is able to travel throughout the
peritoneum, the pain and tenderness become generalized.

Etiology
Acute appendicitis is due to obstruction of the blind ending appendix, resulting in a closed loop. In
children, obstruction usually results from lymphoid hyperplasia of the submucosal follicles. The cause
of this hyperplasia is controversial, but dehydration and viral infection have been proposed. Another
common cause of obstruction of the appendix is a fecalith.
Rare causes include foreign bodies, parasitic infections (eg, nematodes), and inflammatory strictures.

Epidemiology
Appendicitis has an incidence of 70,000 pediatric cases per year in the United States. The incidence
between birth and age 4 years is 1-2 cases per 10,000 children per year. The incidence increases to
25 cases per 10,000 children per year between 10 and 17 years of age. Overall, 7% of people in the

United States have their appendix removed during their lifetime. The male-to-female ratio is
approximately 2:1.
Appendicitis is much more common in developed countries. Although the reason for this discrepancy
is unknown, potential risk factors include a diet low in fiber and high in sugar, family history, and
infection.
Appendicitis occurs in all age groups but is rare in infants. Appendicitis is most common in the second
decade of life (age 10-19 y), occurring at a rate of 23.3 cases per 10,000 per year. Thereafter, the
incidence continues to decline, although appendicitis occurs in adulthood and into old age.

Prognosis
Generally, the prognosis is excellent. At the time of diagnosis, the rate of appendiceal perforation is
20-35%. The rate of perforation is 80-100% for children younger than 3 years, compared with 10-20%
in children 10-17 years old. Children with ruptured appendicitis are at risk for intra-abdominal abscess
formation and small bowel obstruction, and they can have a prolonged hospital stay (several weeks or
more). The mortality rate for children with appendicitis is 0.1-1%.
Death from appendicitis is most common in neonates and infants for the following 2 reasons:

Appendicitis is rare in this age group; thus, unless the physicians index of suspicion is high,
appendicitis is often low on the list of suspected differential diagnoses.
Very young patients are unable to communicate the location and nature of their pain. Some
neonates may not even become febrile. Often, the patients only symptom is irritability or
inconsolability.

History
The classic history of anorexia and vague periumbilical pain, followed by migration of pain to the right
lower quadrant (RLQ) and onset of fever and vomiting, is observed in fewer than 60% of patients. [2] If
the appendix perforates, an interval of pain relief is followed by development of generalized abdominal
pain and peritonitis. Although some patients progress in the classical fashion, some patients deviate
from the classic model. Atypical presentations are common in neurologically impaired and
immunocompromised patients, as well as in children who are already on antibiotics for another illness.
In patients with a retrocecal appendix, who constitute 15% of cases, signs and symptoms may not
localize to the RLQ but instead to the psoas muscle. In other patients, the tip of the appendix is deep
in the pelvis, and the signs and symptoms localize to the rectum or bladder.
Certain features of a child's presentation may suggest a perforated appendix. A child younger than 6
years with symptoms for more than 48 hours is much more likely to have a perforated appendix. The
child may have generalized abdominal pain and may have a temperature higher than 38C.
A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study and was found
to increase with duration of symptoms. While perforation was directly related to the duration of
symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital
delay.[1]

Pain
All patients with appendicitis have abdominal pain, and many have anorexia; absence of both of these
findings should place the diagnosis of appendicitis in question. A child who states that the ride to the
hospital is painful when the vehicle hits bumps in the road may have peritoneal irritation.
Acute onset of severe pain is not typical of acute appendicitis but is seen with acute ischemic
conditions such as volvulus, testicular torsion, ovarian torsion, or intussusception. If the pain is initially
located in the right lower quadrant, severe constipation should be considered.
After a few hours, the pain migrates to the RLQ due to inflammation of the parietal peritoneum. This
pain is more intense, continuous, and localized than the initial pain. This shift of pain rarely occurs in
other abdominal conditions.

Atypical pain is common and occurs in 40-45% of patients. This includes children who initially have
localized pain and those with no visceral symptoms. Pain on urination can be seen with pelvic
appendicitis.

Nausea and vomiting


A unique feature of appendicitis is gradual onset of pain followed by vomiting. Vomiting first is more
typical of gastroenteritis.
Generally, vomiting that occurs prior to pain is unusual. However, in patients with retrocecal
appendices, particularly those that extend cephalad along the posterior surface of the right colon,
inflammation of the appendix irritates the nearby duodenum, resulting in nausea and vomiting prior to
the onset of RLQ pain.

Diarrhea
Significant diarrhea is atypical in appendicitis, and the physician should consider other diagnoses,
while not ruling out appendicitis. In patients with an appendix in a pelvic location, inflammation of the
appendix occasionally results in an irritative stimulation of the rectum. These patients often report
diarrhea. However, upon closer questioning, such patients usually describe frequent, small-volume,
soft stools rather than true diarrhea.

Fever
Most children with appendicitis are afebrile or have a low-grade fever and characteristic flushing of
their cheeks. Severe fever is not a common presenting feature unless perforation has occurred, and
even then it may still be rare. According to one study, vomiting and fever are more frequent findings in
children with appendicitis than in children with other causes of abdominal pain.

Physical Examination
The physical examination findings in children may vary depending on age. Irritability may be the only
sign of appendicitis in a neonate. Older children often seem uncomfortable or withdrawn. They may
prefer to lie still because of peritoneal irritation. Teenaged patients often present in a classic or nearclassic fashion.
Examination of the child requires skill, patience, and warm hands. Initial and continued observation of
the child is of critical importance. An ill-appearing quiet child who is lying very still in bed, perhaps with
the legs flexed, is much more a cause for concern than a child who is laughing, playing, and walking
around the room.
The examination should be thorough and start with areas other than the abdomen. Because lower
lobe pneumonias can cause abdominal findings, a history of such should be elicited and a thorough
chest examination performed. It is also important to exclude urinary tract infection (UTI) as a cause of
abdominal pain.
Children vary in their ability to cooperate with the physical examination. It is important to tailor the
physical examination to the child's age and developmental stage.

General examination
Patients general state and gait should be observed before interacting with them. The patients state of
activity or withdrawal may lend information into their condition. A patient in obvious distress with
abdominal pain gives the impression of an infectious process; however, other causes must be ruled
out.

Cardiac and pulmonary examination


The findings on evaluation of the heart and lungs typically reflect the patients overall state more than
they may suggest appendicitis. Patients are often dehydrated or in pain and may be tachycardic or
tachypneic. Pediatric patients have great physiological reserves and may not show any general
symptoms until they are very ill.

Abdominal examination

Full exposure of the abdomen is key. Before examining the abdomen, ask the child to point with one
finger to the site of maximal pain. Begin palpation of the abdomen at a site distant to this, with the
most tender area examined last. If the child is particularly anxious, palpation may be performed with a
stethoscope.
Distracting questions concerning school and family members may be helpful to relieve anxiety during
the examination. Observing the child's facial expressions during this questioning and palpating is
critical.
Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary
guarding of the rectus or oblique muscles. In early appendicitis, children may not have significant
guarding or peritoneal signs. Younger children are much more likely to present with diffuse abdominal
pain and peritonitis, perhaps because their omentum is not well developed and cannot contain the
perforation.
Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass may be
palpable in the RLQ if the appendix is perforated.
However, the appendix may lie in many positions. Patients with a medially positioned appendix may
present with suprapubic tenderness. Patients with a laterally positioned appendix often have flank
tenderness. Patients with a retrocecal appendix may not have any tenderness until appendicitis is
advanced or the appendix perforates.
Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or percussion)
strongly suggests peritoneal irritation.
To assess for the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A
positive response suggests an inflammatory mass overlying the psoas muscle (retrocecal
appendicitis).
Check for the obturator sign by internally rotating the flexed right thigh. A positive response suggests
an inflammatory mass overlying the obturator space (pelvic appendicitis).
During the abdominal examination, try to avoid eliciting rebound tenderness. This is a painful practice
and certainly destroys any trust that has been garnered during the examination. Peritonitis can be
confirmed with gentle percussion over the right lower quadrant. Involuntary contraction of the
abdominal wall musculature (involuntary guarding) and tenderness can be elicited with minimal stress
or discomfort to the child.
Other methods can be used to establish that the patient has peritoneal irritation. Asking the patient to
sit up in bed, cough, jump up and down, or bounce his or her pelvis off the bed while in the supine
position may elicit pain in the presence of peritoneal irritation. Alternatively, other acceptable
maneuvers are tapping the patient's soles and shaking the stretcher. A child with advanced
appendicitis typically prefers to lie still due to peritoneal irritation.

Rectal examination
The digital rectal examination is often deferred but can be helpful in establishing the correct diagnosis,
especially in sexually active adolescent girls. The patient should be told that the examination is
uncomfortable but should not cause sharp pain. The caliber of the patient's anus should be taken into
consideration, and smaller digits should be used for examining younger patients.
The rectal examination is particularly important in the child with a pelvic appendix, in whom the
findings on the abdominal examination for appendicitis may be equivocal and indicative of peritoneal
irritation.
Objective information to ascertain includes impacted stool or an inflammatory mass. Right-sided
tenderness of the rectum is the classic finding in patients with pelvic appendicitis or in those with pus
that pools in the pelvis from an inflamed appendix elsewhere in the abdomen.
Patients who are able to communicate should be asked if they have tenderness in different areas of
the rectum. The rectal examination in a young child may have to be completely objective because

they may not be able to communicate variations in tenderness or may have general discomfort from
the examination.

Genitourinary examination
An external genitourinary (GU) examination is helpful to rule out testicular or scrotal tenderness in
males and hematocolpos in pubertal girls.

Pelvic examination
A pelvic examination should be considered in sexually active adolescent girls to evaluate for
tenderness (adnexal and/or cervical motion tenderness), masses, bleeding, or discharge.

Atypical findings
Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or more of the
following atypical features[3] :

No fever
Absence of Rovsing sign
Normal or increased bowel sounds
No rebound pain
No migration of pain
No guarding
Abrupt onset of pain
No anorexia
Absence of maximal pain in the RLQ
Absence of percussive tenderness

Diagnostic Considerations
Do not diagnose gastroenteritis rather than appendicitis unless the patient has nausea, vomiting, and
diarrhea. Even with the presence of vomiting and diarrhea, consider the unusual presentations of
retrocecal or pelvic appendicitis. Additionally, appendicitis can develop as a sequela of gastroenteritis
associated with lymphoid hyperplasia.
Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal symptoms.
Instruct patients to be reevaluated in 8-12 hours by their primary care physician or to return to the
emergency department. Patients with equivocal examination findings should be admitted for
observation for serial abdominal examinations or to undergo imaging with ultrasonography or
abdominal CT scanning.
If constipation is diagnosed and treated with enemas and/or stool softeners with resolution of the
signs and symptoms, inform the patient and family that recurrence of the abdominal pain in the future
could be recurrent constipation or acute appendicitis and to seek medical advice.
Appendicitis should be considered in special patient populations, such as the immunocompromised
and developmentally delayed. Appendicitis is rare in infants. If an infant has appendicitis, the
diagnosis ofHirschsprung disease should also be considered.
Other problems to consider include the following:

Ovarian cyst
Ovarian torsion
Pelvic inflammatory disease (PID)
Pregnancy
Ectopic pregnancy
Renal calculi
Mesenteric lymphadenitis
Mittelschmerz

Pneumonia (right lower lobe)


Neutropenic typhilitis
Lymphoma
Epiploic appendagitis
Paratubal cysts
Volvulus
Typhlitis
The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and
malignancy.

Differentials

Constipation
Ectopic Pregnancy
Hemolytic-Uremic Syndrome
Henoch-Schoenlein Purpura
Meckel Diverticulum
Ovarian Cysts
Ovarian Torsion
Pancreatitis
Pediatrics, Gastroenteritis
Pediatrics, Intussusception
Pediatrics, Urinary Tract Infections and Pyelonephritis
Pelvic Inflammatory Disease
Pregnancy Diagnosis
Pregnancy, Ectopic
Pyelonephritis
Renal Calculi
Testicular Torsion
Urinary Tract Infection

http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/

National Digestive Diseases


Information Clearinghouse (NDDIC)
A service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National
Institutes of Health (NIH

What is appendicitis?
Appendicitis is a painful swelling and infection of the appendix.
[Top]

What is the appendix?


The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of
the abdomen. Scientists are not sure what the appendix does, if anything, but removing it does not
appear to affect a person's health. The inside of the appendix is called the appendiceal lumen. Mucus
created by the appendix travels through the appendiceal lumen and empties into the large intestine.

The appendix is a fingerlike pouch attached to the large intestine in the lower right area of the abdomen.

[Top]

What causes appendicitis?


Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen,
causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and
becomes infected. Sources of obstruction include

feces, parasites, or growths that clog the appendiceal lumen

enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal
tract or elsewhere in the body

inflammatory bowel disease, including Crohn's disease and ulcerative colitis

trauma to the abdomen


An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the
abdomena potentially dangerous condition called peritonitis.
[Top]

Who gets appendicitis?


Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis
leads to more emergency abdominal surgeries than any other cause.
[Top]

What are the symptoms of appendicitis?


Most people with appendicitis have classic symptoms that a doctor can easily identify. The main
symptom of appendicitis is abdominal pain.
The abdominal pain usually

occurs suddenly, often causing a person to wake up at night

occurs before other symptoms

begins near the belly button and then moves lower and to the right

is new and unlike any pain felt before

gets worse in a matter of hours

gets worse when moving around, taking deep breaths, coughing, or sneezing
Other symptoms of appendicitis may include

loss of appetite

nausea

vomiting

constipation or diarrhea

inability to pass gas

a low-grade fever that follows other symptoms

abdominal swelling

the feeling that passing stool will relieve discomfort


Symptoms vary and can mimic other sources of abdominal pain, including

intestinal obstruction

inflammatory bowel disease

pelvic inflammatory disease and other gynecological disorders

intestinal adhesions

constipation
[Top]

How is appendicitis diagnosed?


A doctor or other health care provider can diagnose most cases of appendicitis by taking a person's
medical history and performing a physical examination. If a person shows classic symptoms, a doctor
may suggest surgery right away to remove the appendix before it bursts. Doctors may use laboratory
and imaging tests to confirm appendicitis if a person does not have classic symptoms. Tests may also

help diagnose appendicitis in people who cannot adequately describe their symptoms, such as
children or the mentally impaired.
Medical History
The doctor will ask specific questions about symptoms and health history. Answers to these questions
will help rule out other conditions. The doctor will want to know when the pain began and its exact
location and severity. Knowing when other symptoms appeared relative to the pain is also helpful. The
doctor will ask questions about other medical conditions, previous illnesses and surgeries, and use of
medications, alcohol, or illegal drugs.
Physical Examination
Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by
touching or applying pressure to specific areas of the abdomen.
Responses that may indicate appendicitis include

Guarding. Guarding occurs when a person subconsciously tenses the abdominal muscles
during an examination. Voluntary guarding occurs the moment the doctor's hand touches the
abdomen. Involuntary guarding occurs before the doctor actually makes contact.

Rebound tenderness. A doctor tests for rebound tenderness by applying hand pressure to a
patient's abdomen and then letting go. Pain felt upon the release of the pressure indicates
rebound tenderness. A person may also experience rebound tenderness as pain when the
abdomen is jarredfor example, when a person bumps into something or goes over a bump in a
car.

Rovsing's sign. A doctor tests for Rovsing's sign by applying hand pressure to the lower left
side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of
pressure on the left side indicates the presence of Rovsing's sign.

Psoas sign. The right psoas muscle runs over the pelvis near the appendix. Flexing this
muscle will cause abdominal pain if the appendix is inflamed. A doctor can check for the psoas
sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying
down.

Obturator sign. The right obturator muscle also runs near the appendix. A doctor tests for the
obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the
bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the

appendix is inflamed.
Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological
conditions, which sometimes cause abdominal pain similar to appendicitis.
The doctor may also examine the rectum, which can be tender from appendicitis.
Laboratory Tests
Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests
may also show dehydration or fluid and electrolyte imbalances. Urinalysis is used to rule out a urinary
tract infection. Doctors may also order a pregnancy test for women.
Imaging Tests
Computerized tomography (CT) scans, which create cross-sectional images of the body, can help
diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for
signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful
in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of

childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use
radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not
harmful to a fetus.
[Top]

How is appendicitis treated?


Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will
often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the
likelihood the appendix will burst.
Surgery to remove the appendix is called appendectomy and can be done two ways. The older
method, called laparotomy, removes the appendix through a single incision in the lower right area of
the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and
special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to
fewer complications, such as hospital-related infections, and has a shorter recovery time.
Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the
healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a
different problem, which may also be corrected during surgery.
Sometimes an abscess forms around a burst appendixcalled an appendiceal abscess. An abscess
is a pus-filled mass that results from the body's attempt to keep an infection from spreading. An
abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an
abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the
abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat
infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is
performed to remove what remains of the burst appendix.
Nonsurgical Treatment
Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to
undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get
better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft
diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal
tract.
Recovery
With adequate care, most people recover from appendicitis and do not need to make changes to diet,
exercise, or lifestyle. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity
during this time allows tissues to heal.
[Top]

What should people do if they think they have appendicitis?


Appendicitis is a medical emergency that requires immediate care. People who think they have
appendicitis should see a doctor or go to the emergency room right away. Swift diagnosis and
treatment reduce the chances the appendix will burst and improve recovery time.
[Top]

Points to Remember

Appendicitis is a painful swelling and infection of the appendix.


The appendix is a fingerlike pouch attached to the large intestine and located in the lower
right area of the abdomen.
Symptoms of appendicitis may include abdominal pain, loss of appetite, nausea, vomiting,
constipation or diarrhea, inability to pass gas, low-grade fever, and abdominal swelling.

A doctor can diagnose most cases of appendicitis by taking a person's medical history and
performing a physical examination. Sometimes laboratory and imaging tests are needed to
confirm the diagnosis.
Appendicitis is typically treated by removing the appendix.
Appendicitis is a medical emergency that requires immediate care.

[Top]

Hope through Research


The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and
supports basic and clinical research into many digestive disorders.
Participants in clinical trials can play a more active role in their own health care, gain access to new
research treatments before they are widely available, and help others by contributing to medical
research. For information about current studies, visit www.ClinicalTrials.gov.
[Top]

For More Information


American Academy of Family Physicians
P.O. Box 11210
Shawnee Mission, KS 662071210
Phone: 18002742237 or 9139066000
Email: fp@aafp.org
Internet: www.aafp.org
American College of Surgeons
633 North Saint Clair Street
Chicago, IL 606113211
Phone: 18006214111 or 3122025000
Fax: 3122025001
Email: postmaster@facs.org
Internet: www.facs.org
American Society of Colon and Rectal Surgeons
85 West Algonquin Road, Suite 550
Arlington Heights, IL 60005
Phone: 8472909184
Fax: 8472909203
Email: ascrs@fascrs.org
Internet: www.fascrs.org

http://www.nlm.nih.gov/medlineplus/appendicitis.html

The appendix is a small, tube-like organ attached to the first part of the large intestine, also called the
colon. It is located in the lower right area of the abdomen. It has no known function. A blockage inside
of the appendix causes appendicitis. The blockage leads to increased pressure, problems with blood
flow and inflammation. If the blockage is not treated, the appendix can break open and leak infection
into the body.
Symptoms may include

Pain and/or swelling in the abdomen


Loss of appetite

Nausea and vomiting

Constipation or diarrhea

Inability to pass gas

Low fever

Not everyone with appendicitis has all these symptoms.


Appendicitis is a medical emergency. Treatment almost always involves removing the appendix.
Anyone can get appendicitis. It happens most often to people between the ages of 10 and 30.
National Institute of Diabetes and Digestive and Kidney Diseases