About Appendicitis

Appendicitis, a common surgical emergency, has a global age-standardized incidence rate of around 229.9 per 100,000 population, with peaks in the 15-19 age group and a lifetime risk of 8.6% in males and 6.7% in females. 

What is Appendicitis?

Appendicitis is the inflammation of the appendix, a small pouch connected to the large intestine. It is typically caused by obstruction of the appendix due to fecal matter, infections, or other blockages, leading to swelling, pain, and potential rupture. Appendicitis is a medical emergency requiring prompt treatment, usually through surgery.

• Fever : Up to 40% of people develop a fever. This means your immune system is kicking into a higher gear. It may also mean inflammation is increasing or it may mean infection is spreading.
• Malaise : You may just notice that you feel generally unwell. You may lack energy or motivation and feel like staying in bed, the way you do when you’re sick.
• Swollen belly : Your abdomen may look distended or feel bloated. This is usually an advanced symptom and may indicate your appendix has ruptured.
• Urinary symptoms : You may feel like you have to pee more often or more urgently. This can happen if appendicitis irritates nerves connected to your bladder.
• Bowel paralysis : When your body redirects blood flow from your bowels to your appendix, your bowels can temporarily stop moving. Some people develop constipation and feel that they can’t pass gas. You may have the sense that a bowel movement would relieve your symptoms.
• Diarrhea : Some people may have overactive bowels and more frequent poops. This may be because inflammation from your appendix is irritating the end portion of your colon beside it.

Causes of Appendicitis

The size and location of your appendix make it easy for it to become clogged and infected. Your large intestine is home to many bacteria, and if too many become trapped in your appendix, they overgrow and cause an infection. Sometimes, appendicitis begins with an infection, and sometimes, the infection is secondary. Swelling in your appendix can reduce or close the opening and trap more bacteria inside.

Common causes of inflammation, swelling, obstruction and infection in your appendix include:

• Hardened poop (appendix stones) : Hard, calcified fecal deposits known as fecaliths, appendicoliths or appendix stones can get stuck in the opening to your appendix. They carry bacteria and can also trap bacteria that was already there inside your appendix.
• Lymphoid hyperplasia : Your lymphatic system, which is part of your immune system, helps fight infections by producing and releasing white blood cells into your tissues. This can cause the lymphoid tissue in your appendix to swell, even when the original infection is elsewhere in your body. The swollen tissue in your appendix can obstruct it and lead to infection inside.
• Colitis : Inflammation in your colon from an infection or inflammatory bowel disease can affect your appendix. The infection may spread, or the inflammation itself may irritate it.

Other factors that could block the opening to your appendix include:

• Tumors
• Parasites
• Cystic Fibrosis

Appendicitis Complications

• Ischemia and necrosis: Severe swelling in your appendix cuts off the blood supply (ischemia,) which increases inflammation and eventually causes the tissues to start to decay (necrosis).
• Gangrene/perforation: Once necrosis sets in, infection can spread. It may spread slowly through internal gangrene or quickly when your appendix tears or bursts (perforation).
• Abscess/phlegmon: At first, the infection might not spread far beyond your appendix. It might form an abscess, a pocket of pus, on the outside of your appendix. The appendix can also develop a mass around itself called a phlegmon. These masses contain the infection, but they can burst.
• Peritonitis and spreading infection: When infection spreads into your peritoneal cavity (peritonitis), it can spread to other organs and even to your bloodstream (septicemia). Infection in your bloodstream can lead to sepsis and septic shock, which can be fatal.

Appendicitis Diagnosis

Appendicitis is diagnosed through a combination of clinical evaluation, lab tests, and imaging to confirm inflammation or infection of the appendix and rule out other conditions.

Clinical Evaluation

• Medical history: Focus on onset, location, and severity of abdominal pain (typically lower right quadrant).
• Physical Exam:
  • Rebound tenderness: Pain worsens when pressure is released (peritonitis sign).
  • Guarding: Involuntary abdominal muscle rigidity.
  • Special maneuvers: Pain during right leg movement (e.g., psoas sign) or rectal/pelvic exam .

Lab Tests

• Blood tests: Elevated white blood cell count (infection marker) and CRP levels (inflammation).
• Urinalysis: Excludes urinary tract infections or kidney stones.
• Pregnancy test: For women of childbearing age to rule out ectopic pregnancy.

Imaging

• Ultrasound: First-line for children, pregnant women, and young adults due to no radiation exposure. Limited by bowel gas or atypical appendix position.
• CT Scan: Preferred for adults (high accuracy) but involves radiation. Requires IV contrast and pregnancy testing beforehand.
• MRI: Safe for pregnant patients and children when ultrasound is inconclusive

Appendicitis Treatment Options

1. Appendectomy (Surgical Removal)

• 3D Laparoscopic:
  • Procedure: 3–4 small incisions; camera-guided removal.
  • Advantages: Shorter recovery (1–2 weeks), minimal scarring.
• Open surgery:
  • Procedure: Single incision (2–4 inches) for complex cases (e.g., ruptured appendix).
  • Use case: Severe infection, abscess, or perforation.

2. Percutaneous Drainage

• For abscesses: CT-guided drainage followed by delayed appendectomy.