APPENDICITIS – AN OVERVIEW

Characteristically, an inflamed appendix causes a dull to severe lower right side abdominal pain, which may originally start around the umbilicus or navel (belly button), and then move to the right lower abdomen.

The abdominal pain is often associated with fever, nausea, vomiting (only after the pain has commenced) and poor or loss of appetite. There may also be a mild diarrhoea or constipation.

It is a very common cause of right side abdominal pain in all age groups, especially in the first three decades of life.

The appendix, located in the lower right side of the abdomen, is a redundant worm like organ, whose function in man is not known.

Like other parts of the bowel, it has a lumen. On the wall of the lumen, we have some lymph glands like the glands in the neck which become swollen when we have cold or flu. The cells on the wall of the appendix also secret mucus to keep the appendix lubricated inside.

Appendicitis occurs if the lumen of the appendix becomes blocked and bugs (bacteria) then multiply and infects the wall of the appendix.

Blockade leads to reduction of the blood supply to the part of the appendix below the level of the obstruction. Once the blood supply of any part of the body is reduced, bacteria tend to grow fast there, and colonize the tissue. This is understandable because the blood provides nutrients as well as regular supply of white blood cell which act to curtail infection.

The causes of appendicitis are legion, and one or a combination of these can precipitate an acute attack. They range from blockade caused by small piece of hard faeces (faecoliths), to even worms in developing countries.

There is no single known test or laboratory investigation or imaging technique that can confirm the presence of an inflammation of the appendix. Diagnosis is mainly based on a good history, physical examination of the patient and use of ancillary blood test.

While ultra sound scan and a CT -Scan can help to further give weight to a suspected case, laparoscopy provides the most convincing evidence of the presence of an inflamed appendix.

Treatment is by surgical operation, called appendectomy or appendicectomy.

There is no place of the use of antibiotics in treatment of appendicitis, even though some have tried it in the past.

It is a common surgical problem world wide. About 70,000 appendix operation is done in the UK yearly.

In the US, it is said that 1 in every ten (10%) persons will come down with appendicitis. The incidence of this disease is falling in the industrialized world, but sharply rising in developing countries.

Inflammation of the appendix is one and a half times commoner in men than in women. Women on the other hand are more likely to have "unnecessary" operation for a presumed appendicitis because of diagnostic difficulties.

In pregnancy, the diagnosis of an inflamed appendix may also be difficult due to the rising uterus pushing the appendix up, and altering the traditional position of the pain in appendicitis.

Appendicitis can occur in a child of any age, and a high index of suspicion is needed to avoid missing the diagnosis

It is commoner within the first and second decades of life (20 – 30 yrs of age).

Because it is not frequently seen in extremes of life, those in this group who develop the problem are often not diagnosed on time and frequently end up with severe complications (rupture or perforation of the appendix), as the case of an acute attack below shows:

Claire is 15. She woke up with a dull central abdominal pain.

At lunch time, the pain has worsened, and she could barely eat. By bed time she felt sick and actually vomited. She started feeling cold, and when she saw her GP by the next morning, the pain has become much more severe, and moved over to the lower right abdomen. She refused breakfast.

She had a single episode of loose bowel motion. Temperature was 37.6 degree centigrade.

She was referred to the local district hospital’s emergency department. The pain has subsided once she got to the hospital, lying still in bed, waiting to be seen by a doctor.

She was assessed and thought to have had food poisoning, and sent home, with advice to come back if pain does not resolve after two days.

By the next day, Claire was brought back to the hospital, now unable to walk straight, with intense pain and very unwell.

A diagnosis of acute appendicitis attack was made, and Claire was taken to theatre within minutes of arrival.

At operation, the appendix was found ruptured, spilling faces all over the abdomen.

She was hospitalized for four weeks, dealing with one complication after the other.

Claire was eventually discharged.

Acute inflammation of the appendix is common and can be confused with a host of other causes of abdominal pain. See a list of the differential diagnosis of appendicitis here