What is appendicitis?
Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked.
The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock
is called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix. Bacteria which normally are found within the appendix then begin to invade
(infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called
inflammation. (An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread
of bacteria outside the appendix.. The cause of such a rupture is unclear, but it may relate to changes that occur in the
lymphatic tissue that line the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).
How is appendicitis treated?
Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are
begun prior to surgery and as soon as appendicitis is suspected.
There is a small group of patients in whom the inflammation and infection of appendicitis remain mild and localized to
a small area. The body is able not only to contain the inflammation and infection but to resolve it as well. These patients
usually are not very ill and improve during several days of observation. This type of appendicitis is called "confined appendicitis"
and may be treated with antibiotics alone. The appendix may or may not be removed at a later time.
On occasion, a person may not see their doctor until appendicitis with rupture has been present for many days or even weeks.
In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is
small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. A drain usually is inserted
with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The appendix is removed several
weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack
of appendicitis.
How is an appendectomy done?
During an appendectomy, an incision two to three inches in length is made through the skin and the layers of
the abdominal wall in the area of the appendix. The surgeon enters the abdomen and looks for the appendix, usually located
in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present,
the appendix is removed. This is done by freeing the appendix from its attachment to the abdomen and to the colon, cutting
the appendix from the colon and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains
(rubber tubes) that go from the abscess and out through the skin. The abdominal incision then is closed.
Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen
through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with
special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits
of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions)
and a speedier recovery. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to
make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially
helpful in menstruating women in whom a rupture of an ovarian cysts may mimic appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital
in one or two days. Patients whose appendix has perforated generally are sicker than patients without perforation. After surgery,
their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation,
the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix
than to miss and not treat appropriately an early or mild case of appendicitis.
What are the complications of appendicitis?
The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal
abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment.
A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents
the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen
distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the
nose and esophagus and into the stomach and intestine.
A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even
life-threatening complication. Fortunately, it occurs infrequently.
