Appendicitis

Large Bowel Conditions
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Inflamed appendix in the right illiac fossa
The common cause of appendicitis is a fecalith obstructing the lumen

The condition where the appendix becomes inflamed is called appendicitis. The appendix is a finger like projection of the first part of the large bowel (the caecum), it is approx. 4-10 cm in length and its function is unknown. It is an important structure within the large bowel as it is supplied by an end artery, this means that it is only supplied by one blood vessel and as such if this was to become affected it could result in ischaemia (lack of blood supply) resulting in tissue death (necrosis) which is a hub for infection and if not treated urgently can burst and result in the infection spreading within the abdominal cavity resulting in sepsis which can be fatal.

Anatomical location of an inflamed appendix (appendicitis)
The condition where the appendix becomes inflamed is called appendicitis

Symptoms of appendicitis

Appendicitis is a common presentation in the emergency department, usually presenting in the ages of 4 – 40 years (but can affect any age). Patients will experience pain typically starting around the umbilical region but with time the pain will become localised to the right lower quadrant (right iliac fossa). Other symptoms include fever due to an infective source, nausea and vomiting and loss of appetite.  It is important that urgent medical advice is sought so that complications can be avoided and appropriate treatment received.

Appendicitis symptoms include sudden pain on the right side of the body, nausea and vomiting, loss of appetite, fever, constipation or diarrhoea and abdominal bloating
Presenting symptoms of appendicitis include central abdominal pain that becomes localised to the right iliac fossa

Diagnosis of appendicitis

The diagnosis of this condition is typically based around the clinical picture and clinical examination, which is usually tenderness of McBurney’s point, with the gold standard for treatment being urgent/emergency surgery in combination with antibiotics. If there is doubt in the diagnosis, imaging can be used as a supplementary aid and includes the use of ultrasound or abdominal CT scanning.

An abdominal CT scan demonstrating an inflamed appendix signposted by arrow)
An abdominal CT scan can be used if there is doubt in the diagnosis of appendicitis

In certain cases other conditions can mimic appendicitis for example Meckel’s diverticulum which is inflammation of the last part of the small bowel and can be seen in children, an acute presentation of inflammatory bowel disease, but this can be excluded based on the patients history and if there is clinical suspicion then further imaging is performed as management will differ. 

Treatment for appendicitis

As mentioned the gold standard of treatment is urgent/emergency surgery which can be done either as open surgery or laparoscopic surgery (keyhole) with the removal of the appendix (appendectomy).  Commonly the keyhole approach is used however in certain cases this is not possible and an open approach is taken.

Laparoscopic surgery involving the removal of the appendix (appendectomy)
Simplified illustration of a Laparoscopic appendectomy

In the keyhole approach three small incisions are made, allowing for the abdominal cavity to be inflated and instruments to be used to allow inspection and surgery to be performed. In an open approach a 10 cm incision is made over the right iliac fossa (below and to the right of the belly button), but in an emergency a full abdominal incision may be needed (down the midline of the abdomen), however this is not common.

Recovery after surgery

After surgery, you will be on a course of intravenous antibiotics for 48hours, with evidence of fever settling, and then complete a 2 week course of oral antibiotics. The appendix that is removed is sent for analysis to ensure that any underlying sinister causes are ruled out for example cancer.

Recovery will depend on the type of surgery, the length of infection prior to medical intervention and underlying co-morbidities (e.g. diabetes, the use of immunosuppressant’s and steroid medication which cause poor wound healing). Typically a hospital stay of approximately 5 days if all goes well is normal.