Introduction Background

Appendicitis is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases. 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 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.

Pathophysiology
Obstruction of the appendiceal lumen is the primary cause of appendicitis. An anatomic blind pouch, obstruction of the appendiceal lumen leads to distension of the appendix due to accumulated intraluminal fluid. Ineffective lymphatic and venous drainage allows bacterial invasion of the appendiceal wall and, in advanced cases, perforation and spillage of pus into the peritoneal cavity.

Frequency
International 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.

Mortality/Morbidity
• • The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical intervention. Mortality rate rises above 20% in patients older than 70 years, primarily because of diagnostic and therapeutic delay.

Perforation rate is higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated with a sharp increase in morbidity and mortality rates.

Sex
• 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.

Age
• Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been reported. The emergency department clinician must maintain a high index of suspicion in all age groups.

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Clinical
History
• Variations in the position of the appendix, age of the patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent. It is important to remember that the position of the appendix is variable. Of 100 patients undergoing 3-D multidetector CT, the base of the appendix was located at McBurney's point in only 4% of patients. In 36% of patients, the base was within 3 cm of McBurney's point; in 28%, it was 3-5 cm from McBurney's point; and, in 36% of patients, the base of the appendix was more than 5 cm from McBurney's point. In addition, patients with many other disorders present with symptoms similar to those of appendicitis. Examples include the following: • • • • • • • • • • Pelvic inflammatory disease (PID) or tubo-ovarian abscess Εν δ ο µ ε τ ρ ι ο σ ι σ Ovarian cyst or torsion Ureterolithiasis and renal colic Degenerating uterine leiomyomata ∆ιϖε ρ τ ι χ υ λ ι τ ι σ Χρ ο η ν δισεασ ε

Colonic carcinoma Ρεχ τ υ σ ση ε α τ η ηεµα τ ο µ α

Χη ο λ ε χ ψ σ τ ι τ ι σ

• • • • •

Bacterial enteritis Mesenteric adenitis Omental torsion

The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases. Migration of pain from the periumbilical area to the RLQ is the most discriminating feature of the patient's history. This finding has a sensitivity and specificity of approximately 80%. When vomiting occurs, it nearly always follows the onset of pain. Vomiting that precedes pain is suggestive of intestinal obstruction, and the diagnosis of appendicitis should be reconsidered. Nausea is present in 61-92% of patients; anorexia is present in 74-78% of patients. Neither finding is statistically different from findings in ED patients with other etiologies of abdominal pain. Diarrhea or constipation is noted in as many as 18% of patients and should not be used to discard the possibility of appendicitis. Duration of symptoms is less than 48 hours in approximately 80% of adults but tends to be longer in elderly persons and in those with perforation. Approximately 2% of patients report duration of pain in excess of 2 weeks. A history of similar pain is reported in as many as 23% of cases. A history of similar pain, in and of itself, should not be used to rule out the possibility of appendicitis. An inflamed appendix near the urinary bladder or ureter can cause irritative voiding symptoms and hematuria or pyuria. Cystitis in male patients is rare in the absence of instrumentation. Consider the possibility of an inflamed pelvic appendix in male patients with apparent cystitis. Also consider the possibility of appendicitis in pediatric or adult patients who present with acute urinary retention.

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Physical
• RLQ tenderness is present in 96% of patients, but this is a nonspecific finding. Rarely, left lower quadrant (LLQ) tenderness has been the major manifestation in patients with situs inversus or in patients with a lengthy appendix that extends into the LLQ. The most specific physical findings are rebound tenderness, pain on percussion, rigidity, and guarding.

The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in the right lower quadrant precipitated by palpation at a remote location. The obturator sign (RLQ pain with internal and external rotation of the flexed right hip) suggests that the inflamed appendix is located deep in the right hemipelvis. The psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against resistance) suggests that an inflamed appendix is located along the course of the right psoas muscle. These signs are present in a minority of patients with acute appendicitis. Their absence never should be used to rule out appendiceal inflammation. Dunphy's sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in making the clinical diagnosis of localized peritonitis. Similarly, RLQ pain in response to percussion of a remote quadrant of the abdomen, or to firm percussion of the patient's heel, suggests peritoneal inflammation. The Markle sign, pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing, was studied in 190 patients undergoing appendectomy and found to have a sensitivity of 74%. There is no evidence in the medical literature that the digital rectal examination (DRE) provides useful information in the evaluation of patients with suspected appendicitis; however, failure to perform a rectal examination is frequently cited in successful malpractice claims. In 2008, Sedlak et al studied 577 patients who underwent DRE as part of an evaluation for suspected appendicitis and found no value as a means of distinguishing patients with and without appendicitis.5 Male infants and children occasionally present with an inflamed hemiscrotum due to migration of an inflamed appendix or pus through a patent processus vaginalis. This is often initially misdiagnosed as acute testicular torsion.

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Causes
• • Obstruction of the appendiceal lumen usually precipitates appendicitis. The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia. • • 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 a variety of 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 parasites (eg, Schistosomes species, Strongyloides species), foreign material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.

Laboratory Studies
Complete blood cell count Studies consistently show that 80-85% of adults with appendicitis have a WBC count greater than 10,500 cells/mm3. Neutrophilia greater than 75% occurs in 78% of patients. Fewer than 4% of patients with appendicitis have a WBC count less than 10,500 cells/mm3 and neutrophilia less than 75%.

Imaging Studies
• Computed tomography Abdominal CT has become the most important imaging study in the evaluation of patients with atypical presentations of appendicitis. Studies have found a decrease in negative laparotomy rate and appendiceal perforation rate when pelvic CT was used in selected patients with suspected appendicitis. Ultrasonography • Transabdominal sonograms are shown below

Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.

Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection Barium enema study • A single-contrast study can be performed on an unprepared bowel. Absent or incomplete filling of the appendix coupled with pressure effect or spasm in the cecum suggests appendicitis. Advantages of barium enema study are its wide availability, use of simple equipment, and potential for diagnosis of other diseases (eg, Crohn disease, colon cancer, ischemic colitis) that may mimic appendicitis. Magnetic resonance imaging • MRI plays a relatively limited role in the evaluation because of high cost, long scan times, and limited availability, though the lack of ionizing radiation makes it an attractive modality in pregnant patients. A single retrospective study assessed the accuracy of MRI in 51 pregnant patients with suspected appendicitis in whom ultrasonography was

nondiagnostic. • • MRI is far superior to transabdominal ultrasonography in evaluating pregnant patients with suspected appendicitis. When evaluating pregnant patients with suspected appendicitis, graded compression ultrasound should be the imaging test of choice. If ultrasonography demonstrates an inflamed appendix, the patient should undergo appendectomy. If graded compression ultrasonography is nondiagnostic, the patient should undergo MRI of the abdomen and pelvis.

Other Tests
Clinical diagnostic scores Several investigators have created diagnostic scoring systems in which a finite number of clinical variables is elicited from the patient and each is given a numerical value. The sum of these values is used to predict the likelihood of acute appendicitis. The best known of these is the MANTRELS score, which tabulates migration of pain, anorexia, nausea and/or vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature, leukocytosis, and shift to the left.

MANTRELS Score Characteristic M = Migration of pain to the RLQ A = Anorexia N = Nausea and vomiting T = Tenderness in RLQ R = Rebound pain E = Elevated temperature L = Leukocytosis S = Shift of WBC to the left Total Source.—Alvarado, 1986. Clinical scoring systems are attractive because of their simplicity; however, none has 1 1 1 2 1 1 2 1 10 Score

been shown prospectively to improve on the clinician's judgment in the subset of patients evaluated in the ED for abdominal pain suggestive of appendicitis. The MANTRELS score, in fact, was based on a population of patients hospitalized for suspected appendicitis, which differs markedly from the population seen in the ED.

Treatment
Emergency Department Care
• Treatment guidelines for patients with suspected acute appendicitis • • • Establish intravenous access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia. Patients with suspected appendicitis should not receive anything by mouth. Administer parenteral analgesic and antiemetic as needed for patient comfort. The administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they render the physical findings less reliable. At least 8 randomized controlled studies now demonstrate that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe; no study has shown that analgesics adversely affect the accuracy of physical examination. Consider ectopic pregnancy in women of childbearing age, and obtain a qualitative beta–human chorionic gonadotropin (beta-hCG) measurement in all cases. Administer intravenous antibiotics to those with signs of septicemia and to those who are to proceed to laparotomy.

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Nonsurgical treatment of appendicitis • Anecdotal reports describe the success of intravenous antibiotics in treating acute appendicitis in patients without access to surgical intervention (eg, submariners, individuals on ships at sea). Nonsurgical treatment may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure.

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Preoperative antibiotics • Preoperative antibiotics have demonstrated efficacy in decreasing postoperative wound infection rates in numerous prospective controlled studies. Broad-spectrum gram-negative and anaerobic coverage is indicated.

• • •

Preoperative antibiotics should be given in conjunction with the surgical consultant. Penicillin-allergic patients should avoid beta-lactamase type antibiotics and cephalosporins. Carbapenems are a good option in these patients. Pregnant patients should receive pregnancy category A or B antibiotics.

Consultations
• Consult a general surgeon.

Medication
The goals of therapy are to eradicate the infection and to prevent complications.

Antibiotics
These agents are effective in decreasing the rate of postoperative wound infection and in improving outcome in patients with appendiceal abscess or septicemia. The Surgical Infection Society recommends starting prophylactic antibiotics before surgery, using appropriate spectrum agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis. Regimens are of approximately equal efficacy, so consideration should be given to features such as medication allergy, pregnancy category (if applicable), toxicity, and cost.

Metronidazole (Flagyl) Used in combination with aminoglycoside (eg, gentamicin); broad gram-negative and anaerobic coverage. Appears to be absorbed into cells; intermediate metabolized compounds bind DNA and inhibit protein synthesis, causing cell death. Gentamicin (Gentacidin, Garamycin) Aminoglycoside antibiotic for gram-negative coverage. Used in combination with agent against gram-positive organisms and one against anaerobes. Not DOC. Consider if penicillins or other less toxic drugs contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Numerous regimens; adjust dose for CrCl and changes in volume of distribution. May be given IV/IM. Cefotetan (Cefotan) Second-generation cephalosporin used as single-drug therapy for broad gram-negative and anaerobic coverage. Half-life is 3.5 h. Give with cefoxitin to achieve effectiveness of single dose.

Cefoxitin (Mefoxin) Second-generation cephalosporin indicated as single agent for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Half-life is 0.8 h. Meropenem (Merrem) Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Used as a single agent, effective against most gram-positive and gram-negative bacteria. Piperacillin and tazobactam sodium (Zosyn) Drug combination of beta-lactamase inhibitor with piperacillin. Activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. Used as a single agent, inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication. Ampicillin and sulbactam (Unasyn) Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Used as a single agent. Activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.

Analgesics
These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting to the ED. Morphine sulfate (Astramorph, Duramorph, MS Contin, MSIR, Oramorph) DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; commonly titrated to desired effect.

Follow-up
Further Inpatient Care
• Open versus laparoscopic appendectomy • Initially performed in 1987, laparoscopic appendectomy has been performed in thousands of patients and is successful in 90-94% of attempts. Recent experience has also demonstrated that laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis.

Advantages of laparoscopic appendectomy include increased cosmetic satisfaction and a decrease in the postoperative wound-infection rate. Some studies show that laparoscopic appendectomy shortens the hospital stay and convalescent period compared with open appendectomy. Disadvantages of laparoscopic appendectomy are increased cost and an operating time approximately 20 minutes longer than that of open appendectomy. The latter may resolve with increasing experience with laparoscopic technique. Laparoscopic appendectomy is contraindicated in patients with significant intra-abdominal adhesions.

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Emergent versus urgent appendectomy • One retrospective study suggests that the risk of appendiceal rupture is minimal in patients with less than 24-36 hours of untreated symptoms.56 Another recent retrospective study suggests that appendectomy within 1224 hours of presentation is not associated with an increase in hospital length of stay, operative time, advanced stages of appendicitis, or complications compared to appendectomy within 12 hours of presentation. Additional studies are needed to demonstrate whether initiation of antibiotic therapy followed by urgent appendectomy is as effective as emergent appendectomy for patients with unperforated appendicitis.

Immediate versus interval appendectomy for appendicitis with perforation • • Historically, immediate (emergent) appendectomy was recommended for all patients with appendicitis, whether perforated or unperforated. Recent clinical experience suggests that patients with perforated appendicitis with mild symptoms and localized abscess or phlegmon on abdominopelvic CT scans can be initially treated with intravenous antibiotics and percutaneous or transrectal drainage of any localized abscess. If the patient's symptoms, WBC count, and fever satisfactorily resolve, therapy can be changed to oral antibiotics and the patient can be discharged home. Delayed (interval) appendectomy can then be performed 4-8 weeks later. This approach is successful in the vast majority of patients with perforated appendicitis and localized symptoms. Some have suggested that interval appendectomy is not necessary unless the patient presents with recurrent symptoms. Further studies are needed to clarify whether routine interval appendectomy is indicated. Further studies are necessary to identify the optimal treatment strategy in patients with perforated appendicitis.

Complications
Complications of appendicitis may include the following: • • • • • • Wound infection Dehiscence Bowel obstruction Abdominal/pelvic abscess Stump appendicitis - Although rare, approximately 36 reported cases of appendicitis in the surgical stump after prior appendectomy exist. Death (rare)

Prognosis
• The prognosis is excellent.

Miscellaneous
Medicolegal Pitfalls
• • For approximately 10% of adults with appendicitis, the condition is not diagnosed correctly on their first visit to the health care provider. Failure to diagnose appendicitis is the leading cause of successful malpractice claims and the fifth most expensive source of claims against emergency physicians.

Special Concerns
• Pregnant women • • The incidence of appendicitis is unchanged in pregnancy, but the clinical presentation is more variable than at other times. During pregnancy, the appendix migrates in a counterclockwise direction toward the right kidney, rising above the iliac crest at about 4.5 months' gestation. RLQ pain and tenderness dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain must be considered a possible sign of appendiceal inflammation. Nausea, vomiting, and anorexia are common in uncomplicated first trimester pregnancies, but their reappearance later in gestation should be

viewed with suspicion. • Physiologic leukocytosis during pregnancy makes the WBC count less useful in the diagnosis than at other times, and no reliable distinguishing WBC parameters are cited in the literature. One study of 22 pregnant women in the first and second trimesters showed that graded compression ultrasonography had a sensitivity of 66% and specificity of 95%. Diagnostic laparoscopy has also been suggested for pregnant patients in the first trimester with suspected appendicitis. Although negative appendectomy does not appear to adversely affect maternal or fetal health, diagnostic delay with perforation does increase fetal and maternal morbidity. Therefore, aggressive evaluation of the appendix is warranted in this group.

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Nonpregnant women of childbearing age • Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age. The most frequent misdiagnoses are PID, followed by gastroenteritis and urinary tract infection. In distinguishing appendiceal pain from that of PID, anorexia and onset of pain more than 14 days after menses suggests appendicitis. Previous PID, vaginal discharge, or urinary symptoms indicates PID. On physical examination, tenderness outside the RLQ, cervical motion tenderness, vaginal discharge, and positive urinalysis support the diagnosis of PID.

Children • • • Appendicitis is misdiagnosed in 25-30% of children, and the rate of initial misdiagnosis is inversely related to the age of the patient. The most common misdiagnosis is gastroenteritis, followed by upper respiratory infection and lower respiratory infection. Children with misdiagnosed appendicitis are more likely than their counterparts to have vomiting before pain onset, diarrhea, constipation, dysuria, signs and symptoms of upper respiratory infection, and lethargy or irritability. Physical findings less likely to be documented in children with a misdiagnosis than in others include bowel sounds; peritoneal signs; rectal findings; and ear, nose, and throat findings.

Elderly patients • • • • Appendicitis in patients older than 60 years accounts for 10% of all appendectomies. The incidence of misdiagnosis is increased in elderly patients. In patients with comorbid conditions, diagnostic delay is correlated with increased morbidity and mortality. Older patients tend to seek medical attention later in the course of illness; therefore, a duration of symptoms in excess of 24-48 hours should not dissuade the clinician from the diagnosis.

Appendicitis
Appendicitis means inflammation of the appendix. The appendix is a small pouch that comes off the gut wall. Appendicitis is common. Typical symptoms include abdominal pain and vomiting that gradually get worse over 6-24 hours. Some people have less typical symptoms. An operation to remove the inflamed appendix is usually done before it perforates (bursts). A perforated appendix is serious.

What and where is the appendix?
The appendix is a small 'dead end' pouch, like a little tube, that comes off the caecum. The caecum is the first part of the large intestine (large bowel) just before the colon. The small intestine digests and absorbs food. The parts of the food that are not digested begin to be formed into faeces (motions) in the caecum. The appendix is normally about 5-10 cm long and quite thin. The appendix appears to have no function. The reason it is there is a bit of a mystery. pic no.3 Appendicitis means inflammation of the appendix. The inflamed appendix becomes infected with bacteria (germs) from the intestine. The inflamed appendix gradually swells and fills with pus. Eventually, if not treated, the swollen appendix might perforate (burst). This is very serious as the contents of the intestine then spill into the abdominal cavity. This can cause a serious infection of the membrane that lines the abdomen (peritonitis), or an abscess in the abdomen. So, if appendicitis is suspected, early treatment is best before it bursts.

Who gets appendicitis?
Appendicitis is common and can affect anyone of any age. Teenagers and young adults

are the most commonly affected. About 6 in 100 people in the UK have appendicitis sometime in their life. Appendicitis is the cause of the most common abdominal surgical emergency admission to hospital in the UK. It is slightly more common in men than women. It is much more common in western countries. This is thought to be partly due to the western diet which is often low in fibre.

What causes appendicitis?
The reason why the appendix becomes inflamed in the first place is not known in most cases. Some cases are thought to be due to a blockage that occurs somewhere along the short appendix. This may be due to some hard faeces (sometimes called motions, stools or poo) that get stuck. Bacteria may then thrive and cause inflammation behind the blockage in the 'dead end' of the appendix.

What are the symptoms of appendicitis?
Pain in the abdomen (tummy pain) is usually the main symptom. Commonly, the pain starts in the middle of the abdomen. The pain normally develops quickly, over an hour or so. Over the next few hours the pain typically 'travels' to the lower right-hand side of the abdomen. This is over where the appendix normally lies. Typically the pain becomes worse and worse over 6-24 hours. The pain may become severe. The pain tends to be more sharp if you cough or make any jarring movements. The pain may ease a bit if you pull your knees up towards your chest. The lower abdomen is usually tender, particularly in the lower right-hand side. Other symptoms that may occur include the following. • • • • Feeling sick and being off food is typical. You may vomit. Fever and generally feeling unwell. Constipation may occur. Sometimes diarrhoea. Frequent passing of urine may develop. This is thought to be due to the inflammation 'irritating' the nearby ureter (the tube between the kidney and bladder).

If the appendix perforates (bursts) then severe pain can spread to all the abdomen. You also become very ill. In some cases, the symptoms are not so typical. For example, in some cases the pain may develop more slowly and run a more 'smouldering' course. The pain may also start in the lower right-hand side of the abdomen. Also, the pain may not become severe until the

appendix perforates. The site of the pain may not be typical if the appendix lies in an unusual place.

How is appendicitis diagnosed?
A doctor may diagnose appendicitis quite easily if you have the typical symptoms. However, as described above, not everyone has typical symptoms. Sometimes it is difficult for doctors to be sure that appendicitis is the cause of the symptoms. Some people develop pain that is similar to appendicitis, but which is caused by other conditions. For example, pelvic inflammatory disease or a urine infection. Some people have surgery only to find that the appendix is normal and not inflamed. There is no easy and foolproof test to confirm appendicitis. A surgeon often has to make a judgement whether to operate or not. It depends on whether the symptoms and also the findings when you are examined suggest that appendicitis is the probable diagnosis. Your doctor will examine your abdomen to assess where you are tender. Sometimes a surgeon advises 'wait and see' for a few hours or so while you are being monitored in hospital. This allows some time to see if your symptoms progress to a more definite diagnosis, or even if they change or go away. Sometimes tests are used if there is doubt about the diagnosis. For example, an ultrasound scan or a CT scan may help to clarify the cause of the symptoms in some cases. Blood tests are also done when you are admitted to hospital. A new urine test has recently been assessed in clinical trials which looks promising to help the diagnosis of appendicitis. This is not yet widely available though. However, doing scans takes time and may get in the way of doing prompt surgery, which is often the top priority (see below).

What is the treatment for appendicitis?
You will be admitted to hospital if appendicitis is suspected. An operation to remove the inflamed appendix is usually done quite quickly once the diagnosis is made. It is much better to remove an inflamed appendix before it bursts. The inflamed appendix is found and cut off the caecum. The 'hole' left in the caecum is stitched up to stop any contents from the gut leaking out. Removal of the appendix is one of the most commonly performed operations in the UK. In most cases, the operation is done before the appendix perforates. This is usually a straightforward and successful operation needing just a short recovery. However, surgery can be more difficult and you will take longer to recover if the appendix has perforated. This is usually done by a 'keyhole' operation as the recovery is quicker compared to

having an open operation. The operation is performed through three tiny cuts, the largest of which is only around 1.5 cm in size. There are usually no long-term complications after the operation. As with any operation there is a small risk of complications from the operation itself and from the anaesthetic. However, if you don't have an operation, an inflamed appendix is likely to perforate and cause a serious infection in the abdomen (peritonitis) which can be life-threatening.

References
• • • Humes DJ, Simpson J; Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4. Χρ α ι γ Σ ; Appendicitis, Acute. eMedicine, October 2006.

Κεν τ σ ι σ Α, Λ ι ν Ψ Ψ, Κ υ ρ ε κ Κ, ε τ α λ ; Discovery and Validation of Urine Markers of Acute Pediatric Appendicitis Using HighAccuracy Mass Spectrometry. Ann Emerg Med. 2009 Jun 25. [abstract]

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

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.

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 abdomen—a potentially dangerous condition called peritonitis.

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.

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

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 jarred—for 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.

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 appendix—called 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.

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.

surgery appendicitis
Appendicitis is a condition where the appendix is inflamed, swollen and infected. The appendix is located in the lower right area of the abdomen. It is a small protrusion in the shape of a worm like pouch and is attached to the large intestine. The function of the appendix is unclear, especially since its removal does not seem to affect a person’s health in any way. However, new studies are exploring the possibility that the appendix may contain and protect bacteria that are beneficial in the function of the human colon. 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. Appendicitis is caused when the appendiceal lumen becomes obstructed. Feces, parasites, or growths that clog the appendiceal lumen can obstruct it. Other reasons for

development of appendicitis are enlarged lymph tissue in the wall of the appendix (caused by infection), inflammatory bowel disease (such as Crohn’s diseasee and ulcerative colitis) or trauma to the abdomen. The mucus which is usually secreted gets pushed back into the appendiceal lumen, and this results in the multiplication of the bacteria that normally live inside the appendix. This chain of activity ends in the appendix which makes it infected and swollen. An infected appendix might burst if it is not removed. Bursting spreads infection throughout the abdomen, and gives rise to a potentially dangerous condition called peritonitis. The most common form of treatment for appendicitis is surgery and removal of the appendix. A doctor will determine the seriousness of the condition through a physical examination or tests. Prompt surgery decreases the likelihood that the appendix will burst. If a person exhibits classic symptoms and appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. In a case which is difficult to diagnose, a doctor may use laboratory and imaging tests to confirm appendicitis. There are two ways to perform an appendix surgery or appendectomy. Laparotomy is the older method and involves removal of 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. As Laparoscopic surgery uses a more advanced method, it leads to fewer complications that result out of hospital-related infections, and has a shorter recovery time. A rare occurrence, but one that take place nonetheless is the finding of a normal appendix during surgery. In these circumstances, many surgeons will remove the healthy appendix to eliminate the possibility of appendicitis in the future. In case surgery reveals a different problem, if the situation permits, then it may be corrected there and then. If treatment is not prompt, an appendix may burst and an abscess forms around it called an appendiceal abscess. This abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. This can also be remedied through surgery or is more commonly drained before surgery. The abscess which is found with the help of CT is drained by placing a tube in the abscess through the abdominal wall. This process goes on for about 2 weeks, during which the drainage tube is left in place and antibiotics are administered to treat infection. Usually, within a period of six to eight weeks the inflammation subsides and the infection is brought under control. At this time, surgery is usually performed to remove what remains of the burst appendix. In certain cases, non-surgical treatment is an option, like where the person is not well enough to undergo surgery, or if the diagnosis is unclear. This course of treatment includes administration of antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and breaks down easily in the gastrointestinal tract. However, a doctor would be the best judge as to which treatment is

required. For 4 to 6 weeks post surgery, a patient needs to take proper care, restricting physical activity to allow the tissues to heal. A complete recovery can easily be achieved and leaves no need for changes to diet, exercise, or lifestyle.

recovery after surgery
Appendicitis is a medical condition, which is characterized by inflammation and swelling of the appendix (an extended finger-shaped tube connected to the cecum). There are two types of appendicitis - acute (severe) and chronic (mild). The most probable cause of appendicitis condition is blockage at the appendix opening due to mucus or stool accumulation. Over a period of time, these unwanted materials harden and bacterial infection occurs, leading to inflammation of the appendix. Though appendicitis occurs in any age group, the chances of appendicitis is high among people who are between 10-30 years. Read more on appendicitis in children. Symptoms and Treatment of Appendicitis Some of the noticeable signs of appendicitis include nausea, vomiting, diarrhea, constipation and discomfort in the abdominal area, which usually progresses to severe, unbearable pain. Timely diagnosis and treatment of appendicitis is essential in order to prevent health complications such as periappendiceal abscess (pus collection), peritonitis (abdominal lining infection) and intestinal blockage. Based on the age of the patient and diagnostic result, the doctor may recommend either nonsurgical method or surgical procedure for treating appendicitis. Also, it is to be borne in mind that appendicitis recovery after surgery may vary from one patient to another. Read more on appendicitis causes and treatment. In some cases, the body succeeds in healing the inflammation of appendix after proper administration of antibiotics. Thus, appendicitis recovery is possible without the intervention of surgical procedures. Such a nonsurgical treatment of appendicitis is also recommended for patients who are not in a condition to undergo surgery or whose diagnostic results are not clear. During the appendicitis recovery period, the patient is restricted to consumption of easily digestible foods such as clear liquid, semi liquid and soft foods. In other words, a patient should abstain from food items that take longer time for digestion, until infection in the appendix is cured. Appendicitis Recovery After Surgery Appendectomy or appendicitis surgery is often recommended for treatment of acute appendicitis. Basically, there are two common surgical methods for treating appendicitis, namely laparotomy and laparoscopic surgery. In the former type, a single incision is made in the lower right abdomen to remove the inflamed appendix, whereas in case of the latter technique, appendix is removed by making many small incisions in the

abdominal area. The concerned physician may prescribe certain changes in the lifestyle to be followed during the appendectomy recovery period. Appendicitis recovery after surgery is usually achieved within 4 - 6 weeks, provided that the patient follows the prescriptions carefully, as suggested by the physician. Nevertheless similar to any other treatment methods, acute appendicitis recovery time may differ from one patient to another based on the overall health condition of the patient and the type of appendectomy performed. For example, if appendix bursting occurs prior to surgery, then the recovery time may be longer than other regular cases of appendectomy. Read more on complications of ruptured appendix. Tips on Appendicitis Recovery After Surgery As per data, appendicitis recovery after laparoscopic surgery is shorter in comparison to the laparotomy method. Also, there are less chances of appendicitis complications after surgery such as hospital related infections in case of laparoscopic procedure. Following are some of the important steps that should be followed during appendicitis recovery period: • • • • • Do not indulge in strenuous physical activities or household works at least for 1 2 weeks after appendectomy, or as directed by the surgeon. Proper rest and sleep are necessary until the body heals completely. While getting up from sitting or sleeping position, get up gently and walk slowly in small paces and at the same time, go for short walks. If there are any signs of soreness and infection at the incision site, one should immediately call the doctor. Regarding appendicitis recovery food, one should consume healthy food items (including solid foods) and drink ample quantity of water.

With proper health care, appendicitis recovery complications can be avoided completely. During the time period of appendicitis recovery after surgery, alcohol and heavy foods that slow down digestion are strictly not recommended. Last but not the least, consult the doctor before going to work or resuming normal activities. On the brighter side, majority of people recover fully after the treatment of appendicitis without having to make any major lifestyle changes.