Appendicitis: symptoms, treatment, causes
In appendicitis, strictly speaking, only the appendix, an appendage of the appendix, is inflamed. Typical symptoms are pain in the right lower abdomen, often accompanied by loss of appetite and nausea. To prevent life-threatening complications such as intestinal rupture, surgery is almost always performed in the case of appendicitis. Here you can find out everything important about appendicitis – symptoms, causes, diagnosis, treatment and prognosis.
- Symptoms: stabbing or pulling abdominal pain – usually in the right lower abdomen, loss of appetite, nausea, vomiting, diarrhea or constipation, coated tongue, fever, sometimes increased pulse and night sweats.
- Causes: Closure of the appendix by hardened faeces (faecal stone) or an unfavourable position (kink), more rarely by foreign bodies or intestinal worms. Other inflammatory bowel diseases such as an infection with enterococci, Crohn’s disease or ulcerative colitis
- Treatment: Complete removal of the inflamed appendix by classical surgery or laparoscopy (keyhole method).
- Complications: If left untreated, it can lead to intestinal perforation, followed by life-threatening peritonitis. Intestinal paralysis, bowel obstruction. The inflammation can also spread to other areas of the intestine. Fistula formation possible in Crohn’s disease patients.
- Prognosis: With rapid treatment, appendicitis usually heals completely and leaves no permanent damage.
Doctors divide appendicitis into two forms depending on its severity – simple and destructive appendicitis:
In simple appendicitis (appendicitis simplex) the tissue is inflamed but not destroyed. There are two stages of the disease here:
- In the catarrhal stage, the inflamed appendix is swollen and reddened, but no pus develops. The inflammation can regress spontaneously.
- In the seropurulent stage the appendix is inflamed and pus accumulates. Within 24 to 48 hours this can develop into destructive appendicitis:
In destructive (destructive) appendicitis (appendicitis destructiva), the inflamed tissue gradually disintegrates. The appendix can burst open (intestinal rupture, perforation). In this process, inflammatory contents (bacteria) enter the peritoneal cavity, which can also cause inflammation of the peritoneum (peritonitis).
Inflamed appendix: small but dangerous. In appendicitis, usually only the appendix, an appendage of the appendix, is inflamed.
Peritonitis can be life-threatening! The risk of this complication increases sharply with appendicitis after about 48 hours. If appendicitis is suspected, you should therefore see your doctor immediately!
Appendicitis: symptoms in the initial phase
At the beginning of an appendicitis, mostly unspecific symptoms appear, which could also indicate other diseases. For example, many patients initially experience stabbing or pulling pain in the upper abdomen or at navel level, which can initially be misinterpreted as stomach complaints. Within a few hours further symptoms are added.
Appendicitis: symptoms in the acute phase
In the acute phase, the pain moves to the right lower abdomen and increases there. They can also radiate to the left side of the lower abdomen or affect the entire abdominal area. Where exactly it hurts depends on the location of the appendix, which can vary from person to person. In addition, the appendix can change its position, for example during pregnancy.
Typical of the acute phase of appendicitis is that the pain suddenly increases, especially when walking. Moreover, affected persons cannot lift the right leg without pain, so that they put it on like a stork when walking (gentle limping). It is therefore part of the medical routine in cases of suspected appendicitis to check whether patients can hop without pain.
Other symptoms of appendicitis in the acute phase are
- Fever up to 39 degrees, rarely very high fever
- Loss of appetite
- Diarrhoea or constipation
- furred tongue
- sometimes increased pulse and night sweats
Appendicitis in children, pregnant women and senior citizens
In children, pregnant women and the elderly, appendicitis often has a different course, which can make diagnosis more difficult:
Children usually suffer from stronger synptoms than older people. In addition, the pain of the little patients often extends over the entire abdominal area and is accompanied by severe nausea.
In older people, however, appendicitis symptoms such as pain and vomiting are usually less intense. Also fever is very rare.
In pregnant women the appendix is displaced from the lower abdomen to the right upper and middle abdomen by the growing unborn child. The pain characteristic of appendicitis then occurs in untypical places, often even in the back.
Chronic appendicitis: symptoms
A chronic appendicitis is not limited to a certain period of time, but occurs again and again. The typical symptoms appear only briefly over several years and subside after a few hours. Doctors also refer to this as chronic recurrent appedincitis.
In the case of appendicitis, surgery is usually performed: The surgeon removes the inflamed appendix (appendectomy).
Today, appendicitis is rarely treated non-operatively (conservatively) (without food, bed rest, antibiotics). Untreated, it can lead to complications relatively quickly.
Two methods are available for appendectomy: the classic appendectomy with a large abdominal incision (laparotomy) and the minimally invasive (laparoscopic) method. Both are performed under general anesthesia and last about 20 minutes.
In the classic open surgery, the surgeon opens the right lower abdomen with an approximately five centimetre long incision (laparotomy). He cuts out the inflamed appendix and then sutures the edges of the wound. This method can leave a scar on the lower abdomen.
Laparoscopy is also known as operative laparoscopy or keyhole method. In this procedure three very small abdominal incisions are made. Through one of the incisions, the surgeon inserts a rod-like device (the laparoscope) into the abdomen. A light source and a camera are connected to the laparoscope. The camera transmits the image of the abdomen live to a monitor so that the surgeon can see what he is doing. Via the other two incisions, the physician introduces the required instruments. He removes the appendix – as in classical surgery – and then sutures the wound.
For a better view, the abdominal cavity is filled with gas (carbon dioxide) for the procedure.
The laparoscopic method has several advantages: For example, the small abdominal incisions usually leave no visible scars. The pain after laparoscopic surgery is generally less than after open surgery. In addition, wound infections occur less frequently. However, possible internal bleeding cannot be stopped as well as with open surgery. In addition, the operation time is slightly longer than in the open procedure.
The keyhole method is particularly suitable in the early stages of appendicitis. If the inflammation is more advanced, doctors usually prefer the classic surgical method.
After the operation
After the removal of the appendix, you usually have to stay in hospital for a few days. During this time, the physicians monitor the intestinal function: they check whether the intestine is quickly resuming its normal activity. Sometimes you are given infusions to ensure that your body is supplied with sufficient nutrients and fluids.
As a rule, you are allowed to drink something in the evening after the operation. However, you should not eat solid food again until the following day.
After the procedure, walking may be painful at first and you should rest for a few days. For this purpose, you will usually be put on sick leave for two to three weeks.
Many clinics today use self-dissolving sutures to suture the abdominal wall. Stitches that do not dissolve by themselves are usually removed in the week after the operation. This can also be done on an outpatient basis.
Sometimes the surgeon places a drainage during the appendectomy, i.e. a thin tube that drains any wound fluid or pus from the abdominal cavity to the outside. This tube is removed a few days after the procedure.
As after any other operation, bleeding or infection may occur after the appendectomy. However, the risk of this is relatively low because the procedure is performed very frequently and is therefore routine for many surgeons.
A few days after the operation, pus may accumulate under the abdominal wall and must be drained. Doctors then speak of an abdominal wall abscess.
If there is a sudden rise in fever and pain in the intestinal region about a week after the operation, this may indicate a so-called abdominal abscess. Then pus has accumulated in the deepest part of the abdominal cavity. The abdominal cavity abscess is treated by another operation.
Rare but serious complications after an appendectomy are scarring (adhesions) in the abdomen. They stick together the abdominal organs, such as the intestinal loops, so that the stool can no longer be transported unhindered. This complication becomes apparent in the first three weeks after the operation. Usually a new operation is then necessary.
Appendicitis: causes and risk factors
The term appendicitis is common, but medically incorrect. This is because it is actually an inflammation of the appendix, which is attached to the appendix. It is about the size of a little finger and has no function for digestion.
Inflammation of the appendix (appendicitis) is usually caused by a blockage in the connection between the appendix and appendix. This occlusion can be caused by faeces stones (hardened faeces), more rarely also by foreign bodies such as cherry or melon seeds. Then secretions accumulate in the appendix, which allows colon bacteria to multiply there and trigger the inflammation. Even if the appendix is unfavourably located and, for example, bends, secretions can accumulate in it and cause inflammation.
Only very rarely are tumours or intestinal worms responsible for appendicitis.
Appendicitis can also accompany chronic inflammatory bowel diseases (Crohn’s disease, ulcerative colitis). Inflammation can spread from the point of origin (primary focus of inflammation) to the appendix.
Bacterial infections are also possible causes of appendicitis. They can affect various parts of the intestine, including the appendix.
Appendicitis: examinations and diagnosis
The first step is to take a medical history (anamnesis): the doctor asks the patient to describe his symptoms in detail and asks about any underlying or previous illnesses. Among the possible questions the physician may ask:
- Where exactly do you feel stomach ache?
- Can you describe the type of pain in more detail (colicky, stabbing, etc.)?
- Do you have any other complaints like nausea, vomiting or lack of appetite?
- How long have you had your complaints?
- Do you have any pre-existing conditions?
- Have you ever had abdominal surgery?
- With women: Are you pregnant?
The anamnesis interview is followed by a physical examination: First, the doctor palpates the lower abdomen with a view to pain points that are typical for appendicitis:
- McBurny point: It is located in the middle of the connecting line between the navel and the right projection of the hip bone.
- Lance point: It is located between the right and middle third of the connecting line between the two protrusions of the hip bones.
If the doctor presses lightly on these two points, a healthy person does not feel any particular pain. In the case of appendicitis, on the other hand, the pressure causes severe pain, so that the patient tenses the abdominal wall reflexively – an almost certain indication of appendicitis.
In addition, other types of pain may indicate appendicitis:
- Rovsing’s symptom: severe pain when the large intestine is stroked out towards the right lower abdomen with slight pressure
- Blumberg’s sign: Pain of release, when the doctor presses on the lower abdomen and then suddenly lets go
- Sitkowski sign: Stretching pain in the right lower abdomen when the patient lies on the left side.
- Psoas sign: severe pain when the affected person should lift the right leg against a resistance
Since appendicitis is often accompanied by fever, the temperature is usually measured once under the armpit and once in the rectum (rectally). Typical for appendicitis is the temperature difference – the temperature measured in the rectum is at least one degree higher than the temperature measured under the armpit.
If appendicitis is suspected, a blood test is performed. If certain values such as the number of white blood cells (leukocytes) are elevated, this can indicate an inflammation in the body. The same applies to an increased blood cell sedimentation rate (BSG) and an increased CRP value (C-reactive protein).
However, the blood test does not reveal exactly where the inflammation is located in the body. Only a physical examination can answer this question.
In children, pregnant women and the elderly, appendicitis is often more difficult to diagnose because the symptoms are not always clear. Then a urine examination can be useful to exclude diseases of the kidneys and urinary tract as the cause of the complaints.
Imaging techniques can also help in cases of unclear diagnosis: In ultrasound, appendicitis appears as a shadow in the image. In complicated cases, where the symptoms cannot be clearly assigned and complications are to be expected, computer tomography may be indicated.
Gynaecological diseases such as ovarian or fallopian tube inflammation can cause similar symptoms to appendicitis. Therefore, a gynaecological examination is advisable for patients with suspected appendicitis.
However, only a laparoscopy can provide ultimate certainty in the case of an uncertain appendicitis diagnosis: A look inside the abdominal cavity allows the doctor to clearly determine whether appendicitis is present or not. If so, he can also remove the inflamed tissue immediately during laparoscopy (laparoscopic appendectomy).
Appendicitis: course and prognosis
Basically, appendicitis can occur at any age. Mostly, however, young people between the ages of 10 and 19 are affected. Infants and elderly people get appendicitis less frequently. Every year, an average of 110 out of 100,000 inhabitants fall ill with appendicitis.
The prognosis of appendicitis depends on how early it is detected and treated. If the inflamed appendix is removed early and completely, the prognosis is usually good – the appendicitis usually heals without consequential damage.
However, if appendicitis is detected and treated late, it can become life-threatening. The increasing pressure in the appendix can lead to intestinal perforation. This creates a hole in the intestinal wall through which faeces and bacteria enter the surrounding abdominal cavity. This can lead to life-threatening peritonitis, which must be operated on immediately.
An untreated appendicitis can also spread to surrounding intestinal tissue. Usually a larger and more difficult operation is then necessary. In rare cases, appendicitis can also lead to intestinal paralysis (intestinal paralysis) or intestinal obstruction (ileus). Fistulas can also form in patients with Crohn’s disease. These are tubular connections between organs, in this case between appendix and other parts of the intestine.
However, such complications of appendicitis occur only very rarely.