Introduction
The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. (See image below and Image 1.)
Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Appendicitis is inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important step is the obstruction of the appendiceal lumen.
Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain. In the last few years, though, the incidence and mortality rate of appendicitis has markedly decreased.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Appendicitis and Abdominal Pain in Adults.
History of the Procedure
The first report of an appendectomy came from Amyan, a surgeon of the English army. Amyan performed an appendectomy in 1735 without anesthesia to remove a perforated appendix. Reginald H. Fitz, an anatomopathologist at Harvard who advocated early surgical intervention, first described appendicitis in 1886. Because he was not a surgeon, his advice was ignored for a time.
Then, at the end of the 19th century, the English surgeon H. Hancock successfully performed the first appendectomy in a patient with acute appendicitis. Some years after this, the American C. McBurney published a series of reports that constituted the basis of the subsequent diagnostic and therapeutic management of acute appendicitis.
Appendectomy, either open or laparoscopic, currently remains the treatment of noncomplicated appendicitis.
Problem
Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency. In fact, appendicitis is one of the more common causes of acute abdominal pain. Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death.
The diagnosis of appendicitis is clinical and essentially is based on history and clinical examination findings. The classic form of appendicitis may be promptly diagnosed and treated. When appendicitis appears with atypical presentations, it remains a clinical challenge. In such cases, laboratory and imaging investigation may be useful in establishing a correct diagnosis of appendicitis. (See images below and Images 2, 3, 4.)
Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
Computed tomography (CT) study of appendicitis. Intravenous (IV) contrast was administered to the patient, who had gram-negative sepsis but no abdominal pain on examination. Left, an inconclusive CT scan after administration of oral contrast but no IV contrast. Right, a repeat CT scan study following administration of IV contrast demonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. The retrocecal location of the appendix may have attenuated abdominal symptoms.
Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.
Statistics report that 1 of 5 cases of appendicitis is misdiagnosed; however, a normal appendix is found in 15-40% of patients who have an emergency appendectomy.
Although many antibiotics to control infections are available, appendicitis remains a surgical disease. In fact, appendectomy is the only rational therapy for acute appendicitis. It avoids clinical deterioration and may avoid chronic or recurrent appendicitis.
Although difficult, prompt recognition and immediate treatment of appendicitis prevent complications.
Frequency
The incidence of acute appendicitis is around 7% of the population in the United States and in European countries. In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary habits of the inhabitants of these geographic areas.
In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed to be related to poor fiber intake in such countries.
Persons of any age may be affected, with highest incidence occurring during the second and third decades of life. Rare cases of neonatal and prenatal appendicitis have been reported.
Appendicitis occurs more frequently in males than in females, with a male-to-female ratio of 1.7:1.
Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstruction include lymphoid hyperplasia secondary to irritable bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms.
Lymphoid hyperplasia of the appendix may be related to Crohn disease, mononucleosis, amebiasis, measles, and GI and respiratory infections. Fecaliths are solid bodies within the appendix that form after precipitation of calcium salts and undigested fiber in a matrix of dehydrated fecal material.
Pathophysiology
Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes. Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white cells and the formation of pus and subsequent higher intraluminal pressure. (See image below and Image 5.)
Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis.
If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall.
Various specific bacteria, viruses, fungi, and parasites can be responsible agents of infection that affect the appendix, including Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species, Schistosoma species, pinworms, and Strongyloides stercoralis.
Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess or peritonitis may occur.
Presentation
The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen. Later, a worsening progressive pain along with vomiting, nausea, and anorexia are described by the patient. Usually, a fever is not present at this stage.
In addition to recording the history of the abdominal pain, obtain a complete summary of the recent personal history surrounding gastroenterologic, genitourinary, and pneumologic conditions. Also, consider gynecologic history in female patients.
The differential diagnosis of appendicitis is often a clinical challenge because appendicitis can mimic several abdominal conditions. The differential diagnosis of appendicitis must include cholecystitis and biliary colic, gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforated duodenal ulcer, renal colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric lymphadenitis and intussusception. In women of childbearing age who are not pregnant, the differential diagnosis of appendicitis must also include ovarian cyst torsion, mittelschmerz, ectopic pregnancy, and pelvic inflammatory disease. Small bowel obstruction, Crohn disease, Meckel diverticulitis, tumors, Henoch-Schönlein purpura, and rectus sheath hematoma are more rare conditions that mimic appendicitis.
Usually, patients are lying down, flexing their hips, and drawing their knees up to reduce movements and to avoid worsening the pain.
A careful physical examination, not limited to the abdomen, must be performed in any patient with suspected appendicitis. GI, genitourinary, and pulmonary systems must be studied. Perform a rectal examination in any patient with an unclear clinical picture, and perform a pelvic examination in all women with abdominal pain.
Tenderness on palpation in the RLQ over the McBurney point is the most important sign in these patients. Additional signs, such as increasing pain with cough (ie, Dunphy sign), rebound tenderness related to peritoneal irritation elicited by deep palpation with quick release (ie, Blumberg sign), and guarding, may or may not be present.
Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time, especially when the appendix is located in an unusual place (see Relevant Anatomy). In such cases, imaging studies may be important but not always available. Patients with appendicitis usually have accessory signs that may be helpful for diagnosis. For example, the obturator sign is present when the internal rotation of the thigh elicits pain (ie, pelvic appendicitis), and the psoas sign is present when the extension of the right thigh elicits pain (ie, retroperitoneal or retrocecal appendicitis).
In regard to variations in clinical presentation, Niwa et al reported an interesting case of recurrent pain in a young woman referred for appendicitis and treated with antibiotics.1 After 12 months, the woman underwent a laparotomy, demonstrating appendiceal diverticulitis associated with a rare pelvic pseudocyst, probably due to diverticular perforation of the pseudocyst.1
Indications
Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present.
If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help to hasten diagnosis. However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct the patient to return for continued or recurrent symptoms, and the patient may benefit from a follow-up examination in 24 hours.
Relevant Anatomy
The appendix is a wormlike extension of the cecum, and the average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and its wall has an inner mucosal layer, 2 muscular layers, and a serosa. Several lymphoid follicles are scattered in its mucosa. The number of follicles increases when individuals are aged 8-20 years.The inner muscular layer is circular, and the outer layer is longitudinal and derives from the taenia coli. Taenia coli converge on the posteromedial area of the cecum. This site is the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix. Within the mesoappendix courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found.
The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The course of the appendix and the position of its tip may vary widely, accounting for the nonspecific signs and symptoms of appendicitis. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver.
Contraindications
Patients with appendicitis always need urgent referral and prompt treatment. No contraindications to appendectomy are known for patients with suspected appendicitis, except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage followed by appendectomy later.
Certain contraindications exist for laparoscopic appendectomy. These contraindications are extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy.
Rarely, an appendiceal mucocele may occur. It is a collection of mucus within the appendiceal lumen. Occasionally, patients may present with a low-grade carcinoma of the appendix or the cecum. In such cases, the surgeon must avoid perforation during dissection because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.
More on Appendicitis |
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Further Reading
Related eMedicine topics:
Acute Abdomen and Pregnancy
Appendicitis [Pediatrics: General Medicine]
Appendicitis [Radiology]
Appendicitis, Acute
Appendicitis, Surgical Treatment
Pediatrics, Appendicitis
Peritonitis and Abdominal Sepsis
Typhlitis
Vermiform Appendix
Clinical guidelines:
ACR Appropriateness Criteria® acute abdominal pain and fever or suspected abdominal abscess. American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 7 pages. NGC:005138
ACR Appropriateness Criteria® right lower quadrant pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2005). 7 pages. [NGC Update Pending] NGC:004780
Ultrasonographic examinations: indications and preparation of the patient. Finnish Medical Society Duodecim - Professional Association. 2000 Apr 18 (revised 2007 Jan 11). Various pagings. NGC:005501
Clinical trials:
Early Versus Interval Appendectomy for Ruptured Appendicitis in Children (RAPTOR)
Emergency Department CT Scanning for Appendicitis
Initial Versus Delayed Operation for Treatment of Complicated Appendicitis In Children
Effect of Pain Control on the Diagnosis of Acute Appendicitis on the Diagnostic Accuracy of General Surgeon
Irrigation Versus No Irrigation for Perforated Appendicitis
Magnetic Resonance Imaging (MRI) of Appendicitis in Children
Study on Laparoscopic Operation for Perforated Appendicitis
Study on the Difference of Axilo-Rectal Temperature in Appendicitis
Keywords
appendicitis, appendix, appendectomy, appendix pain, symptoms of appendicitis, appendix symptoms, appendicitis signs, appendix side, human appendix, abdominal pain, appendicitis children, appendix surgery, after appendectomy, acute appendicitis, acute abdominal pain, perforated appendix, peritonitis, appendix inflammation, acute inflammation of the appendix, appendiceal lumen, vermiform appendix, typhlitis, lymphoid hyperplasia, irritable bowel disease, IBD, fecal stasis, fecaliths, lymphoid hyperplasia of the appendix, obstruction of the appendiceal lumen, periappendicular abscess
