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appendicitis

 
Medical Encyclopedia: Appendicitis
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Definition

Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch attached to the cecum, 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, and if it is left untreated the appendix may rupture and cause a potentially fatal infection.

Description

Appendicitis is the most common abdominal emergency found in children and young adults. One person in 15 develops appendicitis in his or her lifetime. The incidence is highest among males aged 10-14, and among females aged 15-19. More males than females develop appendicitis between puberty and age 25. It is rare in the elderly and in children under the age of two.

The hallmark symptom of appendicitis is increasingly severe abdominal pain. Since many different conditions can cause abdominal pain, an accurate diagnosis of appendicitis can be difficult. A timely diagnosis is important, however, because a delay can result in perforation, or rupture, of the appendix. When this happens, the infected contents of the appendix spill into the abdomen, potentially causing a serious infection of the abdomen called peritonitis.

Other conditions can have similar symptoms, especially in women. These include pelvic inflammatory

disease, ruptured ovarian follicles, ruptured ovarian cysts, tubal pregnancies, and endometriosis. Various forms of stomach upset and bowel inflammation may also mimic appendicitis.

The treatment for acute (sudden, severe) appendicitis is an appendectomy, surgery to remove the appendix. Because of the potential for a life-threatening ruptured appendix, persons suspected of having appendicitis are often taken to surgery before the diagnosis is certain.

— Caroline Andrews Helwick


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Dictionary: ap·pen·di·ci·tis   (ə-pĕn'dĭ-sī'tĭs) pronunciation
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n.
Inflammation of the vermiform appendix.

[New Latin, from Latin appendix, appendic-, appendage. See appendix.]

WORD HISTORY   Even though the word appendicitis was in use in 1885, the year in which the Oxford English Dictionary published the section "Anta-Battening" that would have contained the word, the editor, James Murray, omitted this "crack-jaw medical and surgical word" on the advice of Oxford's Regius Professor of Medicine, Sir Henry Wentworth Acland. As K.M. Elisabeth Murray, the granddaughter and biographer of James Murray, points out, "The problem of what scientific words to include was a continuing one, and James Murray was always under pressure-from his advisers . . . who thought the emphasis should be on words from good literature and from those in the [Oxford University] Press who wanted to save cost and time-not to include scientific words of recent origin." In 1902 no less a person than Edward VII had his appendix removed, and his coronation was postponed because of the operation. Appendicitis hence came into widespread use and has remained so, thereby pointing up the lexicographer's difficult task of selecting the new words that people will look for in their dictionaries.


Sci-Tech Encyclopedia: Appendicitis
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An inflammation of the vermiform appendix. Acute appendicitis is the most common cause of emergency abdominal surgery, occurring in 5–6% of the population of the United States. It develops when the lumen of the appendix becomes obstructed, usually by fecal material, a foreign body, or hyperplasia of lymphatic tissue that is normally present in the wall of the appendix. The obstructed appendix becomes distended because of continued secretion of mucus by the lining cells. Typically, acute appendicitis progresses from obstruction of the lumen and distention of the appendix to spread of the inflammation beyond the appendix. Initially, there is localized peritonitis confined to the area of the appendix. If unrecognized and untreated, this may progress to an inflammatory mass or abscess, or to perforation of the appendix with resultant diffuse peritonitis, generalized toxic reaction, and even death. See also Appendix (anatomy); Peritonitis.

The usual progression of symptoms includes pain in the region around the navel; loss of appetite, nausea, and occasionally vomiting; localization of the pain to the right lower quadrant of the abdomen; and mild fever. Although the pain typically is localized in the right lower quadrant of the abdomen, there are variations because the appendix may be located in a number of other positions within the abdominal cavity. Fever is a fairly late sign, with mild elevation the rule; a high fever increases the suspicion of perforation or of some other inflammatory process. The diagnosis of appendicitis is generally made by history and physical examination, although laboratory and radiologic studies may be helpful in differentiating appendicitis from other conditions.

The treatment of acute appendicitis is prompt surgical removal of the inflamed appendix. Prior to surgery, the patient may be given intravenous fluids to correct dehydration and electrolyte imbalances. The use of antibiotics before surgery to decrease wound infection is often recommended. Antibiotics are continued after surgery in cases where the inflammation has extended beyond the appendix. Delay in removal of the appendix increases the chance of perforation. See also Antibiotic; Gastrointestinal tract disorders.

Dental Dictionary: appendicitis
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n

An inflammation of the vermiform appendix, usually acute, which, if undiagnosed and not surgically removed, leads rapidly to perforation and peritonitis.

Alternative Medicine Encyclopedia: Appendicitis
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Definition

Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch attached to the cecum, 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, and if it is left untreated, the appendix may rupture and cause a potentially fatal infection.

Description

Appendicitis is the one of the most common abdominal emergencies found in the United States. More males than females develop appendicitis. It is rare in the elderly and in children under the age of two. The hallmark symptom of appendicitis is increasingly severe abdominal pain. Since many different conditions can cause abdominal pain, an accurate diagnosis of appendicitis can be difficult. Other conditions can have symptoms similar to appendicitis, especially in women. These include pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, tubal pregnancies, and endometriosis. Various forms of stomach upset and bowel inflammation may also mimic appendicitis.

A timely diagnosis of appendicitis is important, because a delay can result in perforation, or rupture, of the appendix. When this happens, the infected contents of the appendix spill into the abdomen, potentially causing a serious infection of the abdomen called peritonitis. Very rarely, the inflammation and symptoms of appendicitis may disappear but recur again later. If appendicitis is suspected, the following activities should be avoid, as they may cause the appendix to rupture:

  • consuming food or drink
  • taking pain medication, laxatives, or antacids
  • the use of a heating pad on the affected area

Causes & Symptoms

The causes of appendicitis are not totally understood, but are believed to occur as a result of blockage of the appendix. This blockage may be due to fecal matter, a foreign body in the large intestine, cancerous tumors, a parasite infestation, or swelling from an infection.

The distinguishing symptom of appendicitis is the migration of pain to the lower right corner of the abdomen. The abdomen often becomes rigid and tender to the touch. The patient may bend the knees in reaction to the pain. Increased rigidity and tenderness indicate an increased likelihood of perforation and peritonitis. Loss of appetite is very common, accompanied by a low–grade fever, and occasionally there is constipation or diarrhea, as well as nausea. Unfortunately, these signs and symptoms may vary widely. Atypical symptoms are particularly present in pregnant women, the elderly, and young children.

If bacteria multiply unchecked within the appendix, it will become swollen and filled with pus, and may eventually rupture. This produces an inflammation of the lining of the abdominal wall, or peritonitis, which is a medical emergency. Signs of rupture include the presence of symptoms for more than 24 hours, a high fever, a distended abdomen, a high white blood cell count, and an increased heart rate.

Diagnosis

A careful examination is the best way to diagnose appendicitis. It is often difficult even for experienced physicians to distinguish the symptoms of appendicitis from those of other abdominal disorders. The physician will ask questions regarding the nature and history of the pain, as well doing an abdominal exam to feel for inflammation, tenderness, and rigidity. Bowel sounds will be decreased or absent. A blood test will be given, because an increased white cell count may help confirm a diagnosis of appendicitis. Urinalysis may help to rule out a urinary tract infection that can mimic appendicitis. In cases with a questionable diagnosis, other tests, such as a computed tomography scan (CT) or ultrasound may be performed to help with diagnosis without resorting to surgery. Abdominal x rays, however, are not of much value except when the appendix has ruptured.

Patients whose symptoms and physical examination are compatible with a diagnosis of appendicitis are usually hospitalized and a surgical exploration of the abdomen, called a laparotomy, is done immediately to confirm the diagnosis. A normal appendix is discovered in about 10–20% of patients who undergo laparotomy. Because of the potential for a life–threatening ruptured appendix, persons suspected of having appendicitis are often taken to surgery before the diagnosis is certain. If the symptoms are not clear, surgery may be postponed until they progress enough to confirm a diagnosis. Sometimes the surgeon will remove a normal appendix as a safeguard against appendicitis in the future.

Treatment

Appendicitis must be treated by a surgeon in a hospital setting. However, acupressure can be helpful for recuperation. One dose of homeopathic phosphorus 30c can be taken before surgery to help reduce nausea, light-headedness, and disorientation due to anesthesia. Phosphorus 6c can be also taken two to three times in the hours following surgery. Other appropriate remedies may include Aconite napellus 30c, Arnica montana 30c, Gelsemium 6c, and Staphysagria 30c.

Allopathic Treatment

The treatment for sudden, severe appendicitis is surgery to remove the appendix, called an appendectomy. An appendectomy may be done by opening the abdomen in the standard operating technique, or through laparoscopy, in which a small incision is made through the navel. Recovery may be faster with a laparoscopy than with an ordinary appendectomy. An appendectomy should be performed within 48 hours of the first appearance of symptoms, to avoid a rupture of the appendix and peritonitis. Antibiotics are given before surgery in case peritonitis has already taken hold. If peritonitis is discovered, the abdomen must also be irrigated and drained of pus, and then treated with multiple antibiotics for 7-14 days.

Expected Results

Appendicitis is usually treated successfully by appendectomy. Unless there are complications, the patient should recover without further problems. The mortality rate in cases without complications is less than 0.1%. When an appendix has ruptured, or a severe infection has developed, the likelihood is higher for complications, with slower recovery, or death from disease. There are higher rates of perforation and mortality among children and the elderly.

Prevention

Appendicitis is probably not preventable, although there is some indication that a diet high in leafy green vegetables may help prevent appendicitis.

Resources

Books

The Editors of Time–Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. Virginia: Time–Life, Inc., 1996.

Lininger, D.C., Skye, editor–in–chief, et al. The Natural Pharmacy. California: Prima Health, 1998.

Yamada, Tadataka, ed. et al. Textbook of Gastroenterology. Philadelphia: J.B. Lippincott, 1995.

Periodicals

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

Wagner J.M., et al. "Does This Patient Have Appendicitis?" JAMA: The Journal of the American Medical Association 276 (1996).

[Article by: Patience Paradox]

Children's Health Encyclopedia: Appendicitis
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Definition

Appendicitis is an inflammation of the appendix, which is the small, finger-shaped pouch attached to the beginning of the large intestine on the lower-right side of the abdomen. Appendicitis is a medical emergency, and if left untreated, the appendix may rupture and cause a potentially fatal infection.

Description

In children, appendicitis is the most common abdominal medical emergency and most common pediatric emergency surgical procedure. Although the appendix has no known function, it can become inflamed and diseased. This condition, called appendicitis, can rapidly evolve into a life-threatening or fatal infection of the abdominal cavity (peritonitis) if not treated immediately. Appendicitis usually involves emergency consultation with a physician and evaluation in a hospital emergency department.

Demographics

Appendicitis is the most common abdominal emergency found in children and young adults. One person in 15 develops appendicitis in his or her lifetime. The incidence is highest among males aged 10 to 14, and among females aged 15 to 19. More males than females develop appendicitis between puberty and age 25. It is rare in infants and children under the age of two. In the United States, appendicitis occurs in four out of 1,000 children.

Causes and Symptoms

Appendicitis is usually caused by a blockage of the inside of the appendix, which is called the lumen. Most often, the lumen is blocked by fecal material. Lymphoid tissue, which is present in mucosal lining of the appendix and intestines to help fight bacterial and viral infections, can swell and lead to obstruction of the appendix. This condition, called lymphoid hyperplasia, may also be associated with a variety of inflammatory and infectious diseases, such as Crohn's disease, gastroenteritis, respiratory infections, mononucleosis, and measles. Appendicitis can also be caused by foreign bodies (e.g., intrauterine device or something swallowed), traumatic abdominal injury, or tumors. In addition, genetics may play a role in appendicitis; some children may inherit genes that make them more susceptible to blockage of the appendiceal lumen. Having cystic fibrosis also increases a child's risk for appendicitis.

Blockage of the appendix then causes inflammation, increased pressure, and restricted blood flow, leading to abdominal pain and tenderness in the right lower quadrant of the abdomen. If the appendix is not removed, bacteria and inflammation within the appendix rapidly expand, the wall of the appendix stretches, and perforation can occur. Once the appendix is perforated, bacteria-filled fluid is released into the abdominal cavity and peritonitis then develops. Perforation is more common in younger children. Perforation can occur as soon as 48 to 72 hours after symptoms first begin and can become life-threatening.

Classic symptoms of appendicitis include the following:

  • abdominal pain, first around the navel then moving to the lower right quadrant of the abdomen
  • nausea
  • vomiting
  • loss of appetite
  • diarrhea, constipation, and/or inability to pass gas
  • fever beginning after other symptoms
  • abdominal swelling and tenderness

Other possible symptoms are pain on urination, inability to urinate, or frequent urge to urinate if the swollen appendix is near the urinary tract and bladder. When perforation occurs, abdominal pain becomes more intense and involves the whole abdominal area, and fever may be very high.

Symptoms of appendicitis vary, and not every child will have all the symptoms. In children younger than age two years, the most common symptoms are vomiting and a bloated or swollen abdomen. Toddlers with appendicitis may have difficulty eating and may seem very tired. Children may have constipation, but may also have small stools that contain mucus. Although infants and children younger than two years may also have abdominal pain and other symptoms, they are too young to effectively communicate their symptoms to adults, who may then miss the symptoms of appendicitis.

When to Call the Doctor

Appendicitis is a medical emergency. A doctor should be called immediately if appendicitis is suspected so that children can receive prompt medical treatment before perforation occurs. Parents who suspect that their child has appendicitis should not give the child any pain medication because it may interfere with the results of a doctor's physical examination for appendicitis. In addition, parents should not give their child anything to eat or drink in case surgery is required immediately.

Symptoms in combination that require a doctor's immediate attention include significant abdominal pain, fever, diarrhea, nausea and vomiting, swollen or bloated abdomen, and loss of appetite. If abdominal pain begins before nausea and vomiting, rather than after, appendicitis rather than intestinal infection is more likely.

Diagnosis

Appendicitis is diagnosed by physical examination, laboratory tests, and imaging tests. During a physical examination, the doctor palpates the abdomen to find tender and painful spots. A physical examination can also include a rectal examination, examination of the genitals in boys, and a gynecologic examination in girls, because other conditions, such as testicular torsion and ectopic pregnancy may have symptoms similar to appendicitis. Laboratory tests involve an analysis of white blood cell count to determine whether infection is present, urinalysis to rule out urinary tract or kidney infection, and other tests, such as pregnancy and liver function tests, to rule out other causes of abdominal pain. Imaging tests can include abdominal x rays, ultrasound, and computed tomography (CT).

In 2004, a new imaging technique that uses nuclear medicine imaging and an injection of an imaging agent called NeutroSpec was introduced for the diagnosis of appendicitis. This technique provides images of infected areas and may help physicians decide which children are candidates for surgery to remove the appendix. Up to 20 percent of appendectomies are performed on infants and children with a normal appendix.

Abdominal pain is a common complaint in children, and making a timely diagnosis of appendicitis before perforation is often difficult. Up to 30 percent of children with appendicitis are misdiagnosed, even by experienced physicians. In infants, diagnosis is often not possible and not made until after perforation. Appendicitis is most often misdiagnosed as gastroenteritis or respiratory infection.

Treatment

Appendicitis is treated by immediate surgery to remove the appendix, called an appendectomy. Appendectomy is the most common emergency surgery performed by pediatric surgeons. In an open appendectomy, the appendix is removed through a standard abdominal incision. In laparoscopic appendectomy, surgeons insert a small scope through tiny abdominal incisions to remove the appendix. A laparoscopic appendectomy results in less postoperative pain and fewer surgical incision infections. However, the procedure is longer and requires specialized surgical experience in operating on pediatric patients. In female teen patients, laparascopy has the added benefit of being able to diagnose and treat gynecologic conditions and ectopic pregnancy during the appendectomy if the appendix is found to be normal.

Preoperative antibiotics are given to children with suspected appendicitis and stopped after surgery if there is no perforation. Antibiotic treatment kills bacteria, and stronger and longer courses of antibiotics are required if peritonitis occurs.

If the appendix is removed before perforation occurs, the hospital stay is usually two to three days. A child with a perforated appendix and peritonitis must remain in the hospital up to a week.

Prognosis

Appendicitis is usually treated successfully by appendectomy, and unless there are complications, children should recover without further problems. The mortality rate in cases without complications is less than 0.1 percent. Perforated and ruptured appendix, as well as peritonitis, occur at higher rates among children. When the appendix has ruptured or a severe infection has developed, the likelihood for developing complications is higher, and recovery is longer. Peritonitis is a life-threatening condition, and death occurs in about 1 percent of cases.

Prevention

In general, appendicitis cannot be prevented. The incidence of appendicitis is lower in cultures where people eat more daily dietary fiber, which is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions within the appendix.

Parental Concerns

Because the appendix is more likely to perforate in children than adults, parents should not hesitate to call the doctor if their child develops symptoms that may indicate appendicitis. Parents should feel free to ask their doctor and other medical staff questions about any medical tests or treatments their child receives.

Resources

Books

Majumdar, P. C. Appendicitis. New Delhi, India: B. Jain, 2003.

Tilden, J. H. Appendicitis: The Etiology, Hygienic, and Dietetic Treatment. Pahrump, NV: Library of New Atlantis, 2003.

Harvard Medical School. Medical Tests: A Practical Guide to Common Tests. Boston, MA: Harvard Health Publications, 2004.

Periodicals

Kosloske, A. M., et al. "The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on Pediatric Surgical Evaluation." Pediatrics 113 (January 2004): 29–34.

McCullough, M. "Targeting Appendicitis: A New Tool Offers Wider Promise." Philadelphia Inquirer (July 7, 2004).

Zitsman, J. L. "Current Concepts in Minimal Access Surgery for Children." Pediatrics 111 (June 2003): 1239–52.

Organizations

American College of Emergency Physicians. Web site: www.acep.org.

American College of Radiology. Web site: www.acr.org.

Web Sites

"Appendicitis." Available online at (accessed October 24, 2004).

"Appendicitis." National Digestive Diseases Information Clearinghouse. Available online at (accessed October 24, 2004).

Trevino, M. "CT for Appendicitis Diagnosis in Children Gains Popularity." Available online at www.dimag.com/dinews/2003050901.shtml (accessed October 24, 2004).

Tucker, J. "Pediatrics: Appendicitis." Emedicine. Available online at www.emedicine.com/emerg/topic361.htm (accessed October 24, 2004).

[Article by: Jennifer E. Sisk, M.A.]


Health Dictionary: appendicitis
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(uh-pen-duh-seye-tis)

Inflammation of the appendix.

Veterinary Dictionary: appendicitis
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Inflammation of the vermiform appendix. Occurs in humans and the great apes. The syndrome includes abdominal pain, fever and leukocytosis.

Wikipedia: Appendicitis
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Appendicitis
Classification and external resources

An acutely inflamed and enlarged appendix, sliced lengthwise.
ICD-10 K35. - K37.
ICD-9 540-543
DiseasesDB 885
MedlinePlus 000256
eMedicine med/3430 emerg/41 ped/127 ped/2925
MeSH C06.405.205.099
Location of the appendix in the digestive system

Appendicitis is a condition characterized by inflammation of the appendix. It is a medical emergency. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock.[1] Reginald Fitz first described acute and chronic appendicitis in 1886,[2] and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

Contents

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen.[3][4] Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death.

Among the causative agents, such as foreign bodies, trauma, intestinal worms, and lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. The prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing countries[5], and an appendiceal fecalith is commonly associated with complicated appendicitis[6]. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls[7]. The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time[8]. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis[9][10]. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum[11]. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis[12] [13][14]. This is in accordance with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces transit time[15].

Symptoms

Signs and symptoms of acute appendicitis can be classified into two types, typical and atypical.[16] The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing (spatial) property of visceral nerves from the mid-gut, followed by the involvement of somatic nerves (parietal peritoneum) as the inflammation progresses. The pain is usually associated with loss of appetite and fever, although the latter isn't a necessary symptom. Nausea or vomiting may occur, and also the feeling of drowsiness and the feeling of general bad health.

Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course. If an inflamed appendix lies in contact with the bladder, there is frequency of urination. With post-ileal appendix, marked retching may occur. Tenesmus or "downward urge" (the feeling that a bowel movement will relieve discomfort) is also experienced in some cases.[17]

Unlike acute appendicitis, chronic appendicitis symptoms can vary from patient to patient—so much so that "There are no typical findings or routine diagnostic modalities to diagnose chronic relapsing appendicitis. It is a diagnosis of exclusion..."[18]

Signs

These include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.

Other signs are:

Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen.[19]

Psoas sign

This is right lower-quadrant pain that is reproduced with the patient lying on his left side and then extending the hip. Because extension elicits pain, the patient will lie with the right hip flexed for pain relief.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain in the hypogastrium.

Investigations

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Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Atypical histories often require imaging with ultrasound and/or CT scanning.[16] A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated.

Ultrasound image of an acute appendicitis.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis and other diseases with very similar symptoms such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.

In places where it is readily available, CT scan has become the diagnostic test of choice, especially in adults whose diagnosis is not obvious on history and physical. (The use of CT in pregnant women and children is significantly limited, however, by concerns regarding radiation exposure.) A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in diameter on cross section), and appendiceal wall enhancement (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital.

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%, a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27).[20]

Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture among patients with acute appendicitis according to a cohort study.[21] MMP-1 was higher in gangrenous (p<0.05) and perforated appendicitis (p<0.01) compared with controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with controls (p<0.001).

A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score.

Alvarado score

Symptoms
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points

A score below 5 is strongly against a diagnosis of appendicitis[22], while a score of 7 or more is strongly predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan further reduces the rate of negative appendicectomy.

Treatment

Inflamed appendix removal by open surgery

The treatment begins by keeping the patient from eating or drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

The stitches on a patient the day after having his appendix removed by surgery.

The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.

In March 2008, an American woman had her appendix removed via her vagina, in a medical first.[23]

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups. [24]

There is debate whether emergency appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study [25] no significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. These findings may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. Findings at the time of surgery suggest that perforation occurs at the onset of symptoms in atypical cases.(1)

Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in complicated cases. Hospital lengths of stay typically range from overnight to a few days, but can be a few weeks if complications occur.

Differential diagnosis

In children:

In adults:

In elderly:

Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old) the recovery takes three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e. outside of a proper hospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition.

An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy.[26]

References

  1. ^ Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement" ([dead link] – Scholar search). Permanente Medical Journal 2 (2). http://xnet.kp.org/permanentejournal/spring98pj/Spring98.pdf#page=7. 
  2. ^ Fitz RH (1886). "Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment". Am J Med Sci (92): 321–46. 
  3. ^ Wangensteen OH, Bowers WF (1937). "Significance of the obstructive factor in the genesis of acute appendicitis". Arch Surg 34: 496–526. 
  4. ^ Pieper R, Kager L, Tidefeldt U (1982). "Obstruction of appendix vermiformis causing acute appendicitis. An experimental study in the rabbit". Acta Chir Scand 148 (1): 63–72. PMID 7136413. 
  5. ^ Jones BA, Demetriades D, Segal I, Burkitt DP (1985). "The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa". Ann. Surg. 202 (1): 80–2. doi:10.1097/00000658-198507000-00013. PMID 2990360. 
  6. ^ Nitecki S, Karmeli R, Sarr MG (1990). "Appendiceal calculi and fecaliths as indications for appendectomy". Surg Gynecol Obstet 171 (3): 185–8. PMID 2385810. 
  7. ^ Arnbjörnsson E (1985). "Acute appendicitis related to faecal stasis". Ann Chir Gynaecol 74 (2): 90–3. PMID 2992354. 
  8. ^ Raahave D, Christensen E, Moeller H, Kirkeby LT, Loud FB, Knudsen LL (2007). "Origin of acute appendicitis: fecal retention in colonic reservoirs: a case control study". Surg Infect (Larchmt) 8 (1): 55–62. doi:10.1089/sur.2005.04250. PMID 17381397. 
  9. ^ Burkitt DP (1971). "The aetiology of appendicitis". Br J Surg 58 (9): 695–9. doi:10.1002/bjs.1800580916. PMID 4937032. 
  10. ^ Segal I, Walker AR (1982). "Diverticular disease in urban Africans in South Africa". Digestion 24 (1): 42–6. doi:10.1159/000198773. PMID 6813167. 
  11. ^ Arnbjörnsson E (1982). "Acute appendicitis as a sign of a colorectal carcinoma". J Surg Oncol 20 (1): 17–20. doi:10.1002/jso.2930200105. PMID 7078180. 
  12. ^ Burkitt DP, Walker AR, Painter NS (1972). "Effect of dietary fibre on stools and the transit-times, and its role in the causation of disease". Lancet 2 (7792): 1408–12. doi:10.1016/S0140-6736(72)92974-1. PMID 4118696. 
  13. ^ Adamis D, Roma-Giannikou E, Karamolegou K (2000). "Fiber intake and childhood appendicitis". Int J Food Sci Nutr 51: 153–7. doi:10.1080/09637480050029647. 
  14. ^ Hugh TB, Hugh TJ (2001). "Appendicectomy--becoming a rare event?". Med. J. Aust. 175 (1): 7–8. PMID 11476215. http://www.mja.com.au/public/issues/175_01_020701/hugh/hugh.html. 
  15. ^ Gear JS, Brodribb AJ, Ware A, Mann JI (1981). "Fibre and bowel transit times". Br. J. Nutr. 45 (1): 77–82. doi:10.1079/BJN19810078. PMID 6258626. http://journals.cambridge.org/abstract_S0007114581000111. 
  16. ^ a b Hobler, K. (Spring 1998). "Acute and Suppurative Appendicitis: Disease Duration and its Implications for Quality Improvement" ([dead link] – Scholar search). Permanente Medical Journal 2 (2). http://xnet.kp.org/permanentejournal/spring98pj/Spring98.pdf#page=7. 
  17. ^ http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/#1 National Digestive Diseases Information Clearinghouse (NDDIC)
  18. ^ Van Winter Jo T (1998). "Chronic appendicitis: does it exist?". Journal of Family Practice 46 (6): 507–9. http://findarticles.com/p/articles/mi_m0689/is_n6_v46/ai_20842646. 
  19. ^ N. T. Rovsing: Indirektes Hervorrufen des typischen Schmerzes an McBurney's Punkt. Ein Beitrag zur diagnostik der Appendicitis und Typhlitis. Zentralblatt für Chirurgie, Leipzig, 1907, 34: 1257-1259
  20. ^ Terasawa T, Blackmore CC, Bent S, Kohlwes RJ (2004). "Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents". Ann. Intern. Med. 141 (7): 537–46. PMID 15466771. 
  21. ^ Solberg A, Holmdahl L, Falk P, Palmgren I, Ivarsson ML (2008). "A local imbalance between MMP and TIMP may have an implication on the severity and course of appendicitis". Int J Colorectal Dis 23: 611. doi:10.1007/s00384-008-0452-x. PMID 18347803. 
  22. ^ "BestBets: The Alvarado Scoring System is an accurate diagnostic tool for appendicitis". http://www.bestbets.org/bets/bet.php?id=1671. 
  23. ^ Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (March 2008). "Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES-world's first report". Surg Endosc 22: 1343. doi:10.1007/s00464-008-9811-5. PMID 18347865. ScienceDaily report
  24. ^ Sauerland S, Lefering R, Neugebauer EA (2004). "Laparoscopic versus open surgery for suspected appendicitis". Cochrane Database Syst Rev (4): CD001546. doi:10.1002/14651858.CD001546.pub2. PMID 15495014. 
  25. ^ Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG (2004). "Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night?". J. Pediatr. Surg. 39 (3): 464–9; discussion 464–9. doi:10.1016/j.jpedsurg.2003.11.020. PMID 15017571. 
  26. ^ Liang MK, Lo HG, Marks JL (2006). "Stump appendicitis: a comprehensive review of literature". The American surgeon 72 (2): 162–6. PMID 16536249. 

External links

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Inflammation
Acute
Chronic
Processes
Specific types

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Translations: Appendicitis
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Home > Library > Literature & Language > Translations

Dansk (Danish)
n. - appendicitis, blindtarmsbetændelse

Nederlands (Dutch)
blindedarmont- steking

Français (French)
n. - appendicite

Deutsch (German)
n. - Blinddarmentzündung

Ελληνική (Greek)
n. - (παθολ.) σκωληκοειδίτιδα

Italiano (Italian)
appendicite

Português (Portuguese)
n. - apendicite (f) (Med.)

Русский (Russian)
аппендицит

Español (Spanish)
n. - apendicitis

Svenska (Swedish)
n. - blindtarmsinflammation (med.)

中文（简体）(Chinese (Simplified))
阑尾炎, 盲肠炎

中文（繁體）(Chinese (Traditional))
n. - 闌尾炎, 盲腸炎

한국어 (Korean)
n. - 충수염

日本語 (Japanese)
n. - 盲腸炎, 虫垂炎

العربيه (Arabic)
‏(الاسم) التهاب الزائده الدوديه‏

עברית (Hebrew)
n. - ‮דלקת התוספתן‬

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