Appendicitis (Causes, Symptoms, Diagnosis, Treatment)

Inflammation of the appendix is known as Appendicitis. It is a medical emergency and mostly requires surgical removal of the appendix. The appendix is located on the lower right abdomen and is a part of large intestine. The point where appendix lies is called McBurney's point. Appendicitis can be fatal if left untreated. If surgery is not performed on time, appendix may rupture leading to inflammation and infection of peritoneum (Intestinal lining). This condition is clinically known as Peritonitis.

Common Causes of Appendicitis

The primary cause of acute appendicitis is the obstruction of appendix. Due to the obstruction of appendix lumen, appendix becomes filled with mucus which results in the swelling. Later on, thrombosis and occlusion of small vessels occur due to which appendix becomes ischemic and necrotic.

The most common causative agents are foreign bodies. Besides that, trauma, fecoliths, and lymphadenitis can also cause the obstruction. Intestinal worms are also known to block the appendix but this is very rare.

Clinical presentation “ How do the patients suffering from appendicitis present?

The classical presentation of clinical appendicitis:

• Pain in the abdomen
• Vomiting
• And fever

Pain begins around the umbilicus (belly button) which later on radiates to right lower quadrant. The pain exaggerates when patient coughs.

How is appendicitis diagnosed?

Diagnosis is mainly clinical based on patient's history. However following test are usually performed to confirm the diagnosis.

Lab Tests

Complete Blood Count (CBC): In half the cases, blood test is normal. So it is not significant in confirmation of the diagnosis of appendicitis. In some cases, white blood cells count may be raised (>10,000) which indicates infection or inflammation in the body.

Normal WBC count doesn't rule out appendicitis. WBCs are usually raised during pregnancy.

C-Reactive Protein (CRP): A protein released by the liver in response inflammation and infection in the body. This test is not diagnostic.

Pregnancy Test: A pregnancy test must be performed in the women of child bearing age to rule out ectopic pregnancy. This is because both cases present with acute abdomen.

Imaging

• X-Ray: In only 10% of the cases, x-ray films show the presence of fecolith or any obstruction.
• Ultrasound: Ultrasonography (USG) has sensitivity of 86% and is specific in 81% of the cases.
• Magnetic Resonance Imaging (MRI): It has 96% sensitivity and specificity.

USG & MRI are known to be very helpful in the diagnosis of appendicitis.

What are the signs of Appendicitis?

There are various signs that indicate appendicitis. Below are the commonly used signs of appendicitis in today's practice.

1. Bloomberg's Sign: Also referred as rebound tenderness. Relief of pain on deep palpation of right iliac fossa (RIF) or right lower abdomen, and severe pain on sudden release indicated positive Bloomberg's sign.
2. Obturator sign: Severe pain on flexion and internal rotation of the hip is considered as positive Obturator sign.
3. Dunphy's sign: Elevation of pain in right iliac fossa with coughing.
4. Psoas sign: Pain in right lower abdomen with passive extension or active flexion of the patient's right hip in supine position is positive Psoas sign.
5. Rovsing's sign: Constant deep palpation of left iliac fossa may cause pain in right iliac fossa.

Scoring systems for the diagnosis of appendicitis

Alvarado scoring system is the most commonly used scoring system for the diagnosis of appendicitis.

The division of points in Alvarado scoring system is given below.

• Pain in right lower abdomen “ 2 points
• Leukocytosis (Raised WBCs) “ 2 points
• Migratory RIF pain “ 1 point
• Nausea & Vomiting “ 1 point
• Fever “ 1 point
• Anorexia (loss of appetite) “ 1 point
• Rebound tenderness “ 1 point
• Shift to left (segmented neutrophils) “ 1 point
• Total score “ 10 points

A total score of 7 or more strongly indicates appendicitis which can be confirmed with the help of CT or MRI, while a score below 5 is against the diagnosis of appendicitis. If the total score is 5 or 6, further investigations such as CBC, CT, or MRI along with the detailed history help in the diagnosis.

Management of appendicitis

As acute appendicitis is a medical emergency, it must be aggressively treated. Delaying the treatment may result in the rupture of inflamed appendix leading to peritonitis and severe infection which can spread to other viscera. Appendicitis can cause death if left untreated.

Appendicitis is typically managed by surgery. If caught in early stages, appendicitis can be treated with antibiotics only but there is a great risk of recurrence.

Medication

• Pain killers such as morphine are given at early stages.
• Anti emetics: to prevent nausea and vomiting.
• Anti-pyretics are given in case of fever.

None of these drugs are known to cause conflicts with the diagnosis of appendicitis.

Surgery

Surgical removal of appendicitis is the typical treatment of this disease. The surgical procedure involved in the removal of appendix is called Appendectomy. The appendix is removed during the surgery. There are no known complications involved in the surgical procedure. However, the patients with hypertension, diabetes, and hematological diseases must be operated carefully.

References

https://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/

https://www.nlm.nih.gov/medlineplus/ency/article/002921.htm

https://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Appendicitis