APPENDICITIS

DEFINITION

Appendicitis (pronounced uh-pen-di-SIE-tis) is the inflammation of the appendix, a worm-shaped pouch near the beginning of the large intestine. The appendix has no known function in the body, but it can become diseased. Appendicitis is a medical emergency. If the condition is left untreated, the appendix may rupture and cause a potentially fatal infection.

DESCRIPTION

Appendicitis is the most common abdominal emergency among children and young adults. One person in fifteen develops appendicitis in his or her lifetime. The frequency of appendicitis is highest among males between the ages of ten and fourteen and among females between the ages of fifteen and nineteen. The disease is rare among the elderly and in children under the age of two.

The main symptom of appendicitis is increasingly severe pain in the abdomen. Many different conditions can cause abdominal pain, so an accurate diagnosis of appendicitis can be difficult. A prompt diagnosis is important, however. A delay can result in perforation (rupture) of the appendix. When this happens, the infected contents of the appendix spill into the abdomen. A serious infection known as peritonitis (pronounced per-i-tuh-NIE-tiss) may result.

Other conditions produce symptoms similar to those of appendicitis, especially among women. An example is endometriosis (pronounced en-do-mee-tree-O-suhs), an infection of the lining of the uterus, or pelvic inflammatory disease, an infection of the pelvis. Some forms of stomach upset and bowel inflammation may also imitate appendicitis.

The treatment for acute (sudden, severe) appendicitis is an appendectomy, a surgical procedure to remove the appendix. Since a ruptured appendix can be life-threatening, people suspected of having appendicitis may be taken to surgery before the diagnosis is certain.

CAUSES

The causes of appendicitis are not well understood. A number of factors are thought to be responsible for the disease. One is an obstruction (blocking) within the appendix. Another is the development of an ulceration (a sore) within the appendix. A third factor is a bacterial infection.

Under any one of these conditions, disease-causing bacteria may begin to multiply within the appendix. The appendix becomes swollen and filled with pus. Pus is a fluid formed in infected tissue consisting of white blood cells and dead cells. When this happens, the appendix may rupture.

SYMPTOMS

An indication that the appendix is ready to rupture is the presence of certain symptoms that last more than twenty-four hours. These symptoms include a fever, an abnormally high white blood count, and a rapid heart rate.

The characteristic symptom of appendicitis is pain that begins around or above the navel. The pain may be severe or relatively mild. It eventually moves to the lower right-hand corner of the abdomen. There, it becomes more steady and more severe. Movement or coughing makes the pain worse. The abdomen becomes rigid (hard) and tender to the touch. An increase in these symptoms indicates an increased likelihood of perforation and peritonitis.

Loss of appetite is a common symptom of appendicitis. Nausea and vomiting occur in about half of the cases, and constipation or diarrhea may also occur. Body temperature may be slightly elevated, but a fever suggests that the appendix may already have ruptured.

An inflammed appendix. (Photograph by

Lester V. Bergman

. Reproduced by permission of the

Corbis Corporation

[Bellevue].)

DIAGNOSIS

Many abdominal problems have symptoms like those of appendicitis. The task of the doctor is to rule out other problems before diagnosing appendicitis. The first step in diagnosis usually involves a series of questions about the patient's pain: where did the pain begin; has it moved, and where is the pain now? The doctor also presses on the abdomen to find out where the soreness is and how rigid the abdomen has become.

The sequence of symptoms described occurs in about half of all patients with appendicitis. In certain cases those symptoms may be harder to detect. For example, abdominal pain is common in pregnant women and can be the result of any number of factors relating to a pregnancy. Elderly people are likely to have less pain and tenderness than younger patients. The absence of these symptoms can make diagnosis more difficult. In about 30 percent of cases involving the elderly, the appendix ruptures before a diagnosis has been made. Infants and young children often have diarrhea, vomiting, and fever in addition to pain.

Laboratory tests cannot totally determine appendicitis, but do help in the diagnosis. A blood test that shows a high white blood count may be an indication of the infection. Urine tests can rule out other possible causes of abdominal pain, such as an infection of the urinary tract.

People who are diagnosed with appendicitis are usually taken directly to surgery. The doctor then performs a laparotomy (pronounced lap-uh-ROT-uh-mee), an operation on the abdomen. The laparotomy usually confirms a diagnosis of appendicitis.

In some cases, additional tests may still be necessary. For example, an ultrasound test may help identify appendicitis or other conditions that may have the same symptoms. A computed tomography (CT) scan may also be performed to avoid surgery. A CT scan is a procedure by which X rays are directed at a patient's body from various angles and the set of photographs thus obtained assembled by a computer program. This procedure is sometimes called a computerized axial tomography (CAT) scan.

Often, a diagnosis of appendicitis is not certain until an operation is done. To avoid a ruptured appendix, surgery may be recommended without delay if the symptoms point clearly to appendicitis.

Additional procedures may be used for women of child-bearing age. Women in this age group may have problems with their reproductive organs that produce symptoms similar to those of appendicitis. In these cases, a doctor may perform a laparoscopy (pronounced lap-uh-ROS-kuh-pee). In this procedure, a small incision (cut) is made near the navel. A tube containing a light and viewing device is then inserted through the incision. This allows a surgeon to look directly into the patient's abdomen. He or she can usually determine whether the patient has appendicitis or some other condition.

A normal appendix is found in about 10 to 20 percent of all patients who have a laparotomy. Sometimes the surgeon removes a normal appendix anyway to safeguard against appendicitis in the future. In about 30 percent of these cases, surgeons find other medical problems that have caused the appendicitis-like symptoms.

TREATMENT

The treatment for appendicitis is an immediate appendectomy. This procedure can be carried out as a standard open appendectomy technique or through laparoscopy. Laparoscopy is sometimes preferred because it produces a smaller scar. It does not seem to have other advantages over an open appendectomy. In the case of a ruptured appendix, an open appendectomy must be performed. If the ruptured appendix is left untreated, the condition is fatal.

PROGNOSIS

Appendicitis is usually treated successfully with an appendectomy. Unless there are complications, patients recover without further problems. Less than 0.1 percent of patients die as a result of a standard appendectomy. In cases where the appendix has ruptured or infection has occurred, there is a higher possibility of complications and recovery occurs more slowly. Children and the elderly are more prone to such complications.

PREVENTION

Appendicitis is probably not preventable. But some authorities think the condition can be avoided with a diet rich in green vegetables and tomatoes.

FOR MORE INFORMATION

Periodicals

Van der Meer, Antonia. "Do You Know the Warning Signs of Appendicitis?" Parents Magazine (April 1997): p. 49.

Web sites

"Acute Appendicitis." HealthAnswers.com [Online] http://www.healthanswers.com/centers/body/overview.asp?id=digestive+system&filename=000256.htm# (accessed on October 16, 1999).