Appendicitis – Symptoms and Treatment

Definition and Causes:

Acute appendicitis is a rapidly developing inflammation of the vermiform appendix, a small pouch attached to the large intestine. In the field of surgery, there is no disease more infamous than acute appendicitis, yet this “fame” does not make it easy to diagnose and treat. Any surgeon facing this condition frequently in their practice will attest that diagnosing acute appendicitis in each case is a challenging and varied task, relying primarily on the experience and intuition of the physician.

Location of the Appendix:
The appendix, a tubular structure approximately 4-10 cm in length and 0.5-0.7 cm in diameter, arises from the wall of the large intestine and ends blindly. It is situated in the lower right abdomen.

The appendix’s wall consists of the same four layers found in other parts of the intestines, with roughly the same thickness. Although part of the intestines, the appendix plays a minor role in digesting food.

Role of the Appendix in the Body:
Historically, the appendix was considered a vestigial and potentially dangerous part of the body, as appendicitis could occur suddenly in anyone at any moment, even in good health, disrupting all human plans.

The appendix is located in the lower right part of the abdomen

A logical and justifiable question arises: if this organ is unnecessary, wouldn’t it be better to remove it preemptively for everyone at a certain age, such as in childhood? The answer: No, it’s not better. Experience from performing prophylactic appendectomy for Nazi German soldiers in the 1930s showed that those who underwent this procedure suffered more from intestinal chronic diseases and aggressive diseases in general than others.

According to subsequent research, it became apparent that the appendix contains a high concentration of lymphoid tissue. Based on its location at the border of the small and large intestines, it could function as an organ in the immune system – a “guard” for maintaining the delicate flora balance of the intestines. There are no unnecessary organs in the human body, and the appendix is no exception.

The incidence rate of acute appendicitis is 4-6 cases per 1000 population per year. Previously considered the most common acute surgical condition, it has been surpassed in recent years by acute pancreatitis and acute cholecystitis. It occurs more frequently between the ages of 18 and 42 and affects women almost twice as often as men. It can manifest in childhood, often occurring between the ages of 6 and 12.

Causes of Appendicitis:
There is no clear and definitive cause for the development of acute appendicitis. Dietary factors, such as dietary patterns, may play a role. Note that the incidence of acute appendicitis is higher in countries with higher meat consumption. This may be explained by meats being a major cause of intestinal breakdown and disruption of bowel movements.

There are opinions suggesting that frequent consumption of sunflower seeds may cause appendicitis, but there is no data to confirm this.

In rare cases, foreign bodies in the appendix can be a cause of inflammation, such as swallowed dental fillings, fruit and vegetable seeds, or undigested plant food residues. Ninety-five percent of undigested materials pass through the digestive system without issue. However, heavier materials from the lower part of the intestines can easily reach the appendix cavity. The peristaltic movement of the appendix cannot expel the contents into the intestines, so the accumulation of foreign bodies can lead to obstruction of the cavity and subsequent inflammation.

In childhood, the presence and migration of worms in the large intestines to the appendix and their disruption of excretion can be a cause of appendicitis.

Symptoms of Appendicitis:

  1. Pain: The primary and most common symptom of acute appendicitis. Often occurs at night or in the early morning. In the early hours of the illness, the pain is localized in the thumb area, i.e., in the upper central part of the abdomen, below the rib cage. There may also be poorly localized pains throughout the abdomen. At the onset of the illness, the pain may not be severe and may come and go in spasms, and it may subside for a period. After 2-3 hours, what is known as the Kocher’s sign appears – the pain shifts and is localized in the lower right area (the lower right part of the abdomen, approximately midway between the iliac crest and the umbilicus). The mentioned pain occurs when the appendix is in its typical anatomical location.
Abdominal areas

Unconventional Forms and Symptoms:

The appendix can be located in other areas: under the liver, in the pelvic cavity, behind the deep intestines, in the abdominal area, and sometimes in rare cases – in the lower left part of the abdominal cavity when the internal organ orientation is reversed (situs viscerum inversus). In these cases, pain may be noticed on the right side below the ribs, in the upper right pelvis, above the pubic bone, in the right thigh, in the rectal area, or on the left side of the abdomen. Unconventional forms account for 5-8% of all cases of acute appendicitis.

There are a set of symptoms associated with pain in appendicitis and named after the doctors who discovered them:

  • Rovsing’s sign: Appearance or exacerbation of pain in the lower right side when the doctor performs pushing movements in the left lower quadrant of the abdomen.
  • Cope’s sign: Appearance or exacerbation of pain in the lower left side of the abdomen when the patient lies on the left side.
  • Psoas sign (shirt sign or slide sign): The doctor performs a quick and gentle sliding motion across the shirt with the fingertips from top to bottom towards the lower right side, where the pain increases at the end of the movement.
  • Obturator sign: Appearance of pain in the lower right side when the patient raises their straight right leg.
  • Kocher’s sign: Appearance of pain in the deep pelvis on the right side and above the pubic bone when the patient bends their right leg at the knee joint and rotates it outward.

When the patient is transferred to the hospital, the alternate surgeon in the emergency department performs some of these necessary procedures to examine for the presence of typical pain signs of appendicitis.

  1. Nausea and Vomiting: Do not always occur, approximately in 2/3 of cases. Nausea usually occurs soon after the onset of initial pain, followed by vomiting, which may be infrequent but severe. Vomiting is a natural reflex and is a result of irritation of the nerves in the lining of the abdomen in the advanced inflammatory area. If not relieved, vomiting can resume after two days of onset of the illness, often in the context of peritonitis and systemic poisoning.
  2. Fever: In the first 12 hours of the inflammatory process, body temperature is usually between 37.2-37.5°C. In 3-7% of cases, it can reach 38°C or higher.

Development of Appendicitis:

How does appendicitis develop?

Appendicitis almost always starts from the inside – from the mucous membrane, and later extends to the outer layers. This pattern can be breached in cases of blockage (blood clot) of the blood vessels supplying the appendix, leading to necrosis (tissue death) in all layers of the organ.

The main pathway for the development of appendicitis is the digestive artery, meaning infection with certain types of bacteria from the inner side of the intestines. In 90% of cases, the causative agent of acute inflammation is anaerobic flora, which does not require oxygen to thrive, and in the remaining cases – aerobic microorganisms requiring oxygen, including well-known coliform bacteria.

There is also a theory of infection via the bloodstream (through blood vessels) and the lymphatic route (through lymphatic channels and nodes) to the walls of the appendix from other inflammatory foci. However, the likelihood of these events is low and is only possible in patients with weakness and individuals with immune deficiency. Clearance deviation is considered an important factor in the path of infection and the development of appendicitis: when the opening of the appendix is blocked by feces, worms, or congestion due to colonic infections.

Acute peritonitis (acute inflammation of the abdominal membrane)

Classification and Stages of Appendicitis Development:

Typical Acute Appendicitis Forms:

  1. Superficial Appendicitis (simple, superficial): Affects only the mucous membrane of the appendix.
  2. Purulent Appendicitis: Affects all layers, with fibrin protein appearing on the outer membrane.
  3. Gangrenous Appendicitis: Necrosis of all layers in the appendix.
  4. Perforated Appendicitis: Rupture of the appendix wall.
  5. Abscessed Appendicitis: A subtype of purulent inflammation that occurs due to scarring or obstruction by fecal stones in the appendix cavity, filled with pus.

Unconventional Appendicitis Forms include:

  1. Retrocecal Appendix: Positioned along the back surface of the intestine.
  2. Subhepatic: Located under the liver.
  3. Pelvic Appendix: Located in the pelvic cavity.
  4. Left-sided Appendix: Located on the left side.

Complications of Appendicitis:

  • Peritonitis: Abdominal inflammation (acute inflammation of the peritoneum): Local inflammation begins in the affected area first (the appendix) in a purulent manner. Later, if containment of the process does not occur, it progresses and spreads to other parts of the abdomen, becoming purulent after 3-4 days. Without treatment, severe life-threatening outcomes may occur.
  • Peri-appendiceal leakage: Biological leakage is an attempt to limit acute inflammation in the affected area from the rest of the abdominal organs and the body’s attempt to protect itself from peritoneal inflammation. The leakage represents loops of the small and large intestines with their fatty loops and fat tissue in the abdomen.
  • Appendiceal abscess: The internal oval abscess is the incarcerated appendix within the abdomen resulting from appendix rupture.
  • Abdominal abscesses: Oval abscesses confined within the abdomen due to peritoneal inflammation.
  • Peritoneal wall suppuration: Disseminated fatty inflammation occurs when the appendix or abscess approaches the abdominal wall. Fasciitis in the abdominal wall – dissemination of purulent inflammation into abdominal tissues occurs when the appendix or abscess approaches the abdominal wall.
  • Venous vascular inflammation: A rare but highly dangerous complication, where septic thrombophlebitis occurs in the large veins of the abdominal intestines – the superior mesenteric vein and the portal vein. Purulent inflammation is transferred vascularly from the blood vessels in the appendix.
  • Blood poisoning: Blood infection by infectious agents and their toxins.

Diagnosis of Appendicitis:

Self-intervention and self-treatment when appendicitis is suspected can be dangerous. If abdominal pain persists for more than 1.5-2 hours and there are other symptoms of appendicitis, the best option is to contact the emergency department at a licensed clinic to receive necessary care. These are usually large government hospitals (central hospitals in regions and cities and regional hospitals). Most private clinics do not provide assistance in cases of appendicitis and refer patients to specialized institutions.
Diagnosis of appendicitis relies on examination results, complete blood analysis, and abdominal ultrasound.

Examination and medical history collection:
The examination includes a palpation examination by the doctor and collection of the patient’s medical history, which involves identifying the characteristics and symptoms of appendicitis, taking body temperature, palpating the abdomen to detect sensitivity areas, identifying signs of peritoneal irritation, and performing what is known as “appendicitis signs”. There are clinical scales that show the likelihood of appendicitis when collected together. For example, in Western countries, the Alvarado scale is used.

  • 0-4 points – low probability of appendicitis.
  • 5-6 points – undetermined probability.
  • 7-8 points – medium probability of appendicitis.
  • 9-10 points – high probability of appendicitis.
    Questions the doctor may ask:
  • Where is the pain located?
  • How does the pain manifest?
  • When did the pain start and where did it start from?
  • Conditions of pain occurrence (related to eating, physical activity, stress).
  • Was there nausea, vomiting, or fever?
  • Has there been confirmation of normal digestive and urinary function?
  • Have you undergone previous surgeries (including appendix removal)?
  • For women – menstrual cycle stage and possibility of pregnancy?
  • Are there any accompanying diseases?

Laboratory tests for appendicitis:
Complete blood analysis can reveal:

  • Increased white blood cell count (within the first two days to 11-15 thousand/μL, and later the level may be higher).
  • Left shift in the composition of white blood cells – the appearance of immature forms of white blood cells.
  • There may also be an increase in the number of neutrophils.
  • Ultrasound (Sonography) for abdominal organs:
  • It does not have 100% sensitivity and specificity in diagnosing appendicitis, but it should always be performed when there is abdominal pain of unclear origin to differentiate between appendicitis and other diseases. If performed by an experienced specialist using high-precision devices, ultrasound can provide appendicitis diagnosis information up to 90%.
  • Computed Tomography (CT) imaging for the abdomen:
  • Used in cases of complex diagnosis, including atypical types of appendicitis. CT diagnosis rates can reach up to 95%.

Can the diagnosis be determined accurately immediately?

Even with all the tests performed, doubts about the correct diagnosis may persist even in experienced doctors. In such cases, admission to the hospital and undergoing diagnostic laparoscopy under general anesthesia is indicated.

How to differentiate between appendicitis and other diseases:

There are diseases that present a similar picture to appendicitis, such as kidney stones, acute kidney inflammation, acute gallbladder inflammation, acute pancreatitis, gastric ulcers, Crohn’s disease, constipation, acute ovarian inflammation, salpingitis, and others. To differentiate between appendicitis and other diseases, a differential diagnosis is performed, comparing specific symptoms. Additional tests may be needed, such as blood chemistry analysis, upper endoscopy, pelvic and kidney ultrasound, comprehensive urinalysis, and imaging studies.

Treatment of Appendicitis:
Initial first aid when appendicitis develops:

  • Initial first aid does not require special interventions in appendicitis. Consultation with a doctor is necessary if appendicitis is suspected.

Surgery Indications:

  • Acute appendicitis without treatment poses a health risk, so a confirmed diagnosis of appendicitis is a sufficient indication for surgery.
  • Diagnosing “acute appendicitis” indicates urgent surgical intervention: appendectomy. The first 24-48 hours of illness usually pass without complications, so the operation is limited to removing the appendix only. The operation can be performed by making an incision in the abdominal wall in the upper right area about 5-7 cm long (access according to McBurney – Volkovich – D’yakonov).

Laparoscopy in Appendicitis:

  • Laparoscopy is a more modern method and preferred for appendectomy. Laparoscopy is considered more directive, allowing diagnostic phase execution first, with examination of abdominal organs and the appendix. In the case of confirmed diagnosis of acute appendicitis, appendectomy can be performed using laparoscopy. If the diagnosis is not confirmed, laparoscopy can avoid the need for unnecessary incisions in the abdominal wall. Generally, this method is considered gentler and more aesthetically pleasing than traditional incisions.
Drug Therapy:
  • In the case of catarrhal appendicitis, drug therapy is not considered necessary. However, in cases of phlegmonous or gangrenous appendicitis and perforated appendicitis, antibiotic therapy is preferred immediately after surgery.
  • When perforated appendicitis or other complications are discovered, a bacteriological analysis from the intervention site is performed for subsequent treatment adjustment.

Management of Perforated Appendicitis:

  • In the case of perforated appendicitis discovery, defending the subsequent surgical procedure (after 1-3 months of initial treatment) is indicated to reduce inflammatory phenomena and eliminate the relative “cold” environment.

Preoperative Medical Therapy in Acute Appendicitis Cases:

  • Tumor-like swelling (detected during clinical examination, as well as through ultrasound and CT scans):
  • When appendicitis presents as a tumor-like swelling, where the operation is limited and requires the use of antibiotics.

Serious accompanying diseases significantly increase the risk of complications after surgery and the mortality rate:

  • In such cases, antibiotic therapy is also allowed to start.

Recovery after Appendectomy:

  • During the first five to seven days after the operation, a light diet is preferred. Restricting physical activity for approximately one month is advised, whether after traditional surgery or laparoscopic surgery.
  • It is strongly advised to avoid strenuous exercises and sports training for 2-3 months.

References: (1) “Emergency Surgery of the Chest and Abdomen: A Guide for Physicians” / Ed. by L. N. Bisenkov, P. N. Zubarev. — St. Petersburg: Hippocrates, 2006. — 560 p. (2) “50 Lectures on Surgery” / Ed. by V.S. Saveliev. — Moscow: Triada-Kh, 2004. — 516 p. (3) “Clinical Surgery, National Guidelines” / Ed. by V.S. Saveliev and A.I. Kirienko. Volume 2. — Moscow: Geotar-Media, 2009. (4) Evtikhov R.M., Putin M.E., Shultko A.M. “Clinical Surgery: A Textbook.” — Moscow, 2006. (5) Bhangu A., Søreide K., Di Saverio S., Assarsson J.H., Drake F.T. “Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management” // Lancet. — 2015; 386(10000): 1278-1287.