Symptoms of appendicitis and surgical intervention

Appendicitis (appendicitis) means the inflammation of the appendix vermiformis of the appendix. The inflamed appendix becomes infected with bacteria (germs) from the intestine, gradually swells and fills with pus.

If left untreated, the swollen appendix could burst (perforate). This possibility is very serious, because then intestinal contents leak into the abdominal cavity.

This can cause severe inflammation of the peritoneum lining the abdomen or an abscess in the abdomen. Therefore, if appendicitis is suspected, early therapy is important before perforation occurs.
In general, children are affected, but rarely older people also suffer from appendicitis.


What is the appendix and where is it located?

The appendix is a small and blind-ended protuberance in the form of a worm that originates from the appendix (caecum) (hence the common, but inaccurate name “appendicitis”). The appendix is the first part of the colon and lies directly in front of the rectum (colon). The small intestine digests and absorbs the food. The food components that are not digested form the faeces in the large intestine.

The appendix is about 5-10 cm long and quite thin.
A benefit of the appendix is not known.

Phases of appendicitis

Appendicitis can be divided into early purulent, gangrenous, perforated, phlegmonous, spontaneously healed, recurrent and chronic phase.

Appendicitis in the early phase — in the initial phase of appendicitis, narrowing of the appendix causes inflammation and ulceration of the mucosa, as well as displacement due to fluid retention.
The patient has mild abdominal pain around the navel area that lasts about four to six hours.

Purulent appendicitis — the increase in internal pressure exceeds capillary pressure, lymphatic and vein outflow are impeded, and this favors the penetration of bacteria and inflammation of the appendix wall.
The penetration of the bacteria through the wall causes acute purulent appendicitis.
The pain shifts from the middle of the abdomen to the lower right flank and becomes very strong.

Perforated appendicitis — the persistent ischemia of the tissue leads to infarction and perforation of the appendix. Perforation can be the cause of local or generalized peritonitis.

Phlegmonous appendicitis or focal abscess — phlegmonous appendicitis or a focal abscess occurs when the inflamed or perforated appendix separates from the adjacent large mesh (omentum majus) or intestine and pus forms inside the appendix and in its walls.

Gangrenous appendicitis — arterial and venous thrombosis occur in the wall of the appendix, gangrene forms due to reduced blood flow or complete loss of blood flow.

Spontaneous healing — once the constipation has resolved, acute appendicitis can heal spontaneously. This occurs when the cause of symptoms is lymphoid hyperplasia or when the stool mass is expelled from the inside.
In this case, there is no need for surgery.

Recurrent appendicitis — the incidence of recurrent (recurrent) appendicitis is 10 percent.

Chronic appendicitis – it occurs with an incidence of 1 percent and has the following characteristics:
Chronic appendicitis is an inflammation of the appendix that can last for weeks, months or even years.
There are different views on this, but the symptoms of appendicitis (especially the pain in the lower right abdominal region) may disappear and recur at a future time.
Sometimes the abdominal pain in chronic appendicitis is the only symptom, so it is fundamental to rule out other ailments, such as a contracture of the lumbar iliac muscle (iliopsoas muscle) or gynaecological disorders (such as an ovarian cyst or fallopian tube inflammation).
In other cases, the typical symptoms of acute appendicitis may occur, such as nausea, fever and diarrhea.

What are the symptoms of appendicitis?

The classic symptoms of appendicitis include:

  1. Dull pain near the navel or in the upper abdomen, which becomes stabbing and retracts to the right lower abdomen. Usually this is a first sign.
  2. Anorexia.
  3. Nausea and/or vomiting immediately after the onset of abdominal pain.
  4. Bloated abdomen.
  5. Fever of 38/39° C.
  6. Inability to drain intestinal gases.

In almost half of cases, other symptoms appear, including:

  1. Painful urination,
  2. Constipation or diarrhea.

The location of the pain varies depending on the age and location of the appendix. Children or pregnant women may feel pain of appendicitis in various places.
There are several variants of position regarding the seat of the appendix: in the pelvis, retrocecal, below the liver, mesoceliac.

Symptoms vary and can be confused with other abdominal pain sources, including:

  • Ileus or intestinal obstruction
  • Inflammatory bowel disease such as ulcerative colitis
  • Pelvic inflammatory disease and other gynecological disorders
  • Intestinal adherences
  • Constipation
  • Pain in the ovaries

What are the causes of appendicitis?

A narrowing at the entrance of the appendix causes appendicitis. The mucus collects in the appendix, causing an increase in the bacteria that normally live there.

The result is that the appendix swells and becomes infected. Causes of obstruction include:

  • feces (feces), parasites or growths that narrow the connection of the appendix with the intestine;
  • swelling of lymphoid tissue in the wall of the appendix;
  • inflammatory bowel disease, including Crohn’s disease and ulcerative colitis;
  • Abdominal trauma.

An inflamed appendix could perforate if not removed. A rupture spreads the infection throughout the abdomen, a condition that is potentially fatal and is called peritonitis.

My child has abdominal pain. Could this be appendicitis?

Appendicitis is very rare in young children, but not impossible. Appendicitis can be difficult for parents to diagnose. At first, it might seem like intestinal flu or gastroenteritis. The classic symptoms are abdominal pain, fever and vomiting. (In rare cases, diarrhea may also occur.)

The child’s abdomen may be bloated and sensitive to pressure, the child may limp or remain bent to the right side if his appendicitis irritates the muscles leading to the leg.
Another relevant sign — which usually does not occur until school age — is pain, which begins near the navel, then worsens and shifts to the lower right side of the abdomen. Depending on the age of the child and his verbal ability to communicate, he may be able to describe these complaints.
Young children may often feel the need to urinate.

What are the complications of appendicitis?

If the appendix bursts and empties infectious material into the patient’s abdomen, peritonitis can develop. The peritoneum becomes inflamed. The peritoneum (peritoneum) is a membrane in the abdominal cavity that covers most of the abdominal organs.
Peritonitis leads to intestinal obstruction, because the muscular activity of the intestine (peristalsis) is stopped and the intestine is blocked. Fever occurs, the patient could fall into a state of shock. Peritonitis must be treated immediately, as it can also lead to death.

If the infection gets outside the appendix and mixes with the intestinal contents, an abscess can form. If the abscess is left untreated, it can cause peritonitis. Sometimes the abscesses are treated with antibiotics. Often they are drained surgically with the help of a tube that is inserted into the abdomen.

How is the diagnosis of appendicitis made?

It can be difficult to diagnose appendicitis. The symptoms are often vague or extremely similar to those of other conditions, including gallbladder problems, urinary tract or bladder infections, Crohn’s disease, intestinal infections, and ovarian disease.

The following examinations are usually performed to establish the diagnosis:

  1. Examination of the abdomen to reveal inflammation.
    The patient has a launching pain and tenses the muscles for self-protection. It is therefore very difficult to palpate the abdomen.
  2. Urine test to rule out urinary tract infection.
  3. Rectal examination.
  4. Blood test to see if the body is fighting an infection, the white blood cells and the BKS (erythrocyte sedimentation) would be very high in this case.
  5. CT and/or ultrasound.

The visit to the doctor with the physical examination is extremely important.
Unfortunately, nowadays many doctors have given up the habit of examining patients and limit themselves only to the instrumental examinations (CT, MRI, etc.).
In this way, time is often lost, because the apparatus examinations do not show everything. For example, they cannot tell if the muscles are tense or if their consistency is normal or changed.

The details about the abdominal pain are fundamental for the diagnosis of appendicitis. The doctor evaluates the pain by applying pressure to specific areas of the abdomen.
The reactions that may indicate appendicitis are:

Defensive tension occurs when a person unconsciously tenses the abdominal muscles during the examination. The unconscious defense manifests itself at the moment when the doctor’s hand touches the abdomen. In fact, the unconscious defensive tension occurs even before the doctor touches the patient.
To solve this problem, it is necessary to put one’s hand lightly on the stomach and wait for the patient to relax.

of letting go 
A doctor assesses the pain of letting go by pressing his hand on the patient’s stomach and then quickly taking it away. The pain caused after letting go refers to the pain of letting go. A person may also feel this pain after trauma – for example, when someone has bumped into something.

Rovsing sign
The examining physician creates pressure on the lower left abdomen with his hand for the rovsing sign.
The perceived pain on the right lower abdomen, after the pressure on the left lower abdomen is removed, indicates the presence of the rovsing sign. This is a specific test for appendicitis.

The psoas muscle originates from the lumbar vertebrae and attaches to the thigh. In its course it passes above the basin and near the appendix. When this muscle is contracted, it causes abdominal pain when the appendix is inflamed.
For the test, the patient must lie on his back.
A doctor can assess the condition of the psoas if the right knee automatically raises while the patient tries to pull the left knee up to the chest.
This muscle is often tense due to its location in people with improper nutrition.
On the right side of the abdomen there are organs leaning against the psoas: liver, intestines and appendix.
If these organs are thickened or stressed, the psoas must apply force to counteract the pressure of the organs.

Obturator sign
The right inner hip hole muscle (Obturator internus) originates near the appendix. The examining physician asks the patient to lie down with his right knee bent.
By shifting the bent knee to the right and left, the obturator muscle contracts and causes abdominal pain when the appendix is inflamed.
Women of fertile age should undergo a pelvic exam to rule out gynecological diseases that sometimes cause abdominal pain similar to appendicitis.
The doctor may also examine the rectum.

What is the therapy for appendicitis?

Doctors may decide to treat the patient with antibiotics. This treatment is rare and the infection should be mild. In most cases, an appendectomy, i.e. the surgical removal of the appendix, is performed.

What should you eat?

Nutrition is important in the prevention and treatment of appendicitis.
You can follow the same diet as with colitis, in general, certain foods should be better avoided:

  • Chocolate and Nutella
  • Spicy and spicy foods
  • Sausage
  • Fermented and fatty cheeses
  • Fatty fish and meat, crustaceans (prawns, lobsters)
  • Nutritious desserts
  • Coffee, tea and other caffeinated beverages
  • Carbonated drinks, cocktails and alcohol

Laparoscopy (minimally invasive surgery)

Surgical laparoscopy is also known as minimally invasive surgery. The surgeon inserts a very thin tube (laparoscope) into the abdomen, which has a small video camera and a light source.
Thanks to the small camera, the surgeon can see all the inner areas of the abdomen with magnification on one monitor. The small instruments respond to the surgeon’s hand movements and the appendix is removed through small incisions in the abdominal wall.

Thanks to the precision of this surgical procedure, blood loss is minimal and the very small incisions allow the patient to recover much faster and retain fewer scars than with traditional open surgery.
In most cases, it is not necessary to make a large incision in the patient’s abdomen.

Three small incisions are needed to remove the appendix. The advantage of minimally invasive surgery is minimal scarring and a short recovery time.
Most people can leave the hospital a few days after surgery, and full recovery takes a week or two.

However, a report in the Journal of American College of Surgeons states that traditional open appendectomy is preferable to laparoscopic appendectomy for most patients with acute appendicitis, contrary to current trends.
Laparotomic surgery increases costs and can also increase the risk of complications for most patients.

Traditional Open Surgery

If the appendix is perforated and there is a diffuse infection or an abscess has formed, one can make a larger incision to clean the abdominal cavity.
Traditional appendectomy is also used if the patient has a tumor in the digestive system, is a woman in the last trimester of pregnancy, or the patient has already had many abdominal surgical procedures.

After surgery, the patient is given antibiotics intravenously.
After a surgical appendectomy, the recovery time is usually 2-3 weeks with an inpatient hospital stay of 2-3 days.
Before and after surgery, the fluids and antibiotics administered intravenously help prevent complications and reduce the risk of postoperative infection of the wound.
If necessary, the doctor may prescribe a painkiller to children.

An infected appendix that is perforated must be surgically removed. A longer hospital stay may be required to allow the antibiotics to kill all the bacteria that have spread diffusely throughout the body.

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