Appendicitis: Signs, Symptoms, Causes, Diagnosis, Treatment
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SAVE TIME studying with your own copy of the lecture below! Learn everything you need to know about appendicitis!
Appendicitis
The appendix is a worm-shaped tubular structure located in the right lower quadrant of the abdomen.
If the appendix becomes inflamed, then it can cause abdominal pain.
Inflammation of the appendix is known as appendicitis.
This lecture will walk you through the features of appendicitis including:
Definition
Type of Pain
Location of Pain
Signs and Symptoms
Causes
Diagnosis
Complications (Burst, Rupture, Perforation, Infection, etc.)
Treatment (Surgery, Removal of Appendix called Appendectomy, etc.)
Recovery
This lecture will also review the features of the appendix including:
Anatomy
Location
Function (Digestive System, Immune System, Lymphatic System, etc.)
Appendicitis can occur in kids, women, or men of all ages.
Therefore, the condition is important to understand.
So let’s get started!
The Appendix
The appendix is a tubular structure located in the right lower quadrant of the abdomen at the junction of the small intestine and large intestine.
The appendix comes off of the cecum, which is the pouch-like structure at the beginning of the large intestine.
On average, the appendix is approximately 9cm long.
The appendix is also referred to as the vermiform process.
“Vermiform” means worm-shaped and describes the tubular, worm-like structure of the appendix.
The function of the appendix is overall unknown, however there are a couple hypotheses for its purpose.
First, it is thought the appendix is a reservoir for gastrointestinal bacteria.
When we experience a gastrointestinal illness, the appendix serves as a “safe-house” for good intestinal bacteria as the body gets rid of the of bad bacteria.
This helps to maintain the good gut flora.
Once the illness is resolved, the good bacteria within the appendix can help replenish the gut flora throughout the gastrointestinal tract.
Second, it is thought the appendix has a role in the lymphatic and immune systems, especially when fighting off infections involving that portion of the bowel.
Image: The appendix is located in the right lower quadrant (RLQ) of the abdomen. It comes off of the cecum and on average measures 9cm long. The appendix is also known as the vermiform (worm-shaped) process. The function of the appendix is overall unknown but thought to serve as a reservoir for bacteria and is involved in the immune/lymphatic system.
Appendicitis
Unfortunately, the tubular appendix can become inflamed and/or infected, a condition known as appendicitis.
Appendicitis can occur at any age, however it is more prevalent between the ages of 10 and 30 years old.
Appendicitis is a common cause for abdominal surgery.
Image: Appendicitis is defined as inflammation of the appendix. It is most prevalent between the ages of 10 and 30 years old, and is a common reason for abdominal surgery.
Causes of Appendicitis
Appendicitis is typically caused by an obstruction of the appendix.
Obstructions may develop from a fecalith (a hard stony mass of feces), which can become lodged in the tubular appendix.
Small foods such as seeds may also have the same effect.
Another potential cause of obstruction is lymphoid hyperplasia.
The appendix contains lymphoid follicles, which are dense collections of lymphocytes.
The lymphoid follicles can grow in size during adolescence.
In some cases the follicular growth may obstruct the appendix and cause appendicitis, especially in children.
The lymphoid follicles may also enlarge during an infection, especially one that involves the gastrointestinal tract.
For example, if we experience a viral or bacterial infection in the intestines, then the lymphoid follicles within the appendix may grow in size in response to that illness.
Similar to above, the follicular enlargement may obstruct the appendix and this too can cause appendicitis.
Image: A fecalith is a stony mass of feces that can potentially obstruct the appendix. The blue stars represent lymphoid follicles, and they can also obstruct the appendix if they grow in size.
Physiology
As previously mentioned, the overarching cause of appendicitis is some kind of obstruction.
How does the obstruction lead to appendicitis?
Let’s walk through it.
A normal appendix contains mucous and bacteria.
When the appendix is obstructed, the mucous builds up and the bacteria multiply with nowhere to go due to the blockage.
As a result, increased amounts of mucous and bacteria fill the appendix thereby increasing the pressure of the structure.
The increased pressure causes the appendix to get angry, and inflammation develops.
The inflammation of the appendix is known as appendicitis.
As the inflammation increases, the blood flow to and from the appendix is compromised.
There is decreased arterial blood flow to the appendix, and there is increased venous congestion exiting the appendix.
The compromise in blood flow will eventually lead to ischemia.
As the appendix becomes ischemic, the cells that make up the wall begin to die and the wall becomes thinner as a result.
The thin ischemic appendix may rupture/burst (perforate), and the content within the appendix could leak into the abdominal cavity.
As the content within the appendix enters the abdominal cavity, further complications may occur.
These complications include abscess formation, peritonitis (inflammation of the peritoneum of the abdominal cavity), or sepsis/worsening infection.
Image: The obstructed appendix can lead to an increase in mucous buildup and bacteria, which increases the pressure of the appendix, which compromises blood flow to the appendix, which can lead to ischemia of the appendix, which can lead to further complications.
Symptoms
Abdominal pain is usually present in most cases of appendicitis.
The pain may first be generalized or periumbilical (around the belly button) due to the visceral nature of the pain.
As the appendicitis progresses, the pain can migrate to the right lower quadrant and become localized to the area due to the parietal nature of the pain.
Individual may also experience nausea, vomiting, fever, poor appetite, or urinary symptoms.
Image: Abdominal pain may start generalized or periumbilical before migrating and localizing to the right lower quadrant.
Examination and Signs
As previously mentioned, the appendix is located in the right lower quadrant of the abdomen.
McBurney’s point corresponds with the typical location of the appendix, and is commonly where the pain is located in appendicitis (especially in its later stages).
McBurney’s point is defined by 1/3 the distance from the right anterior superior iliac spine (hip bone) toward the umbilicus (belly button) - see image below!
It is important to note that the pain from appendicitis is not always at McBurney’s point.
Some reasons why the pain may not be at McBurney’s point include:
Early Appendicitis (Generalized/Periumbilical Pain)
Pregnancy (Gravid uterus can displace appendix upward causing pain similar to gallbladder pain)
Retrocecal Appendix (Appendix is located behind the cecum - may present as flank or pelvic pain)
There are several techniques that can be performed on physical examination to assess for appendicitis as well:
Rovsing’s Sign - Pain in the RLQ when the LLQ is palpated
Psoas Sign - Pain when the patient is lying on their left side and their right leg is passively extended at the hip
Obturator Sign - Pain when the patient is supine and the right thigh is rotated internally at the flexed hip
Image: McBurney’s point (red star) is 1/3 the distance from the right anterior superior iliac spine (blue star) and the umbilicus (blue star), and corresponds with the typical location of the appendix.
Rovsing’s Sign = Pain in the RLQ when the LLQ is palpated
Psoas Sign = Pain when the patient is lying on their left side and their right leg is passively extended at the hip
Obturator Sign = Pain when the patient is supine and the right thigh is rotated internally at the flexed hip
Diagnosis
The workup for appendicitis typically involves blood tests and imaging.
Standard blood work for abdominal pain may involve a complete blood count (CBC), chemistry, liver function tests, lipase, urinalysis, and a pregnancy test if applicable.
If appendicitis is the cause of the abdominal pain, then the white blood cell (WBC) count may be elevated due to the inflammation and/or infection present.
It is important to note that a normal white blood cell count DOES NOT rule out appendicitis.
When assessing for appendicitis, imaging is usually performed as well.
There are several different imaging modalities available.
First, ultrasound can potentially detect appendicitis and is typically the test of choice for pediatric patients or pregnant females as there is no radiation.
A CT scan of the abdomen and pelvis can also diagnose appendicitis and is frequently used in adult males and non-pregnant females.
Finally, MRI imaging can also diagnose appendicitis.
MRI is more time consuming, but may be necessary when appendicitis is not identified on ultrasound and radiation is being avoided.
Image: Elevated white blood cell count (leukocytosis) may be present in appendicitis, but not always. Typical imaging modalities to diagnose appendicitis include ultrasound, CT, or MRI.
Complications
As previously mentioned, the appendix can become ischemic and rupture/perforate during appendicitis.
The content from the appendix can then leak into the abdominal cavity and cause abscess formation, peritonitis, and/or sepsis.
Image: Complications of appendicitis include perforation (rupture), abscess formation, peritonitis (inflammation of the peritoneum of the abdominal cavity), or sepsis/worsening infection.
Treatment
The treatment for appendicitis usually involves surgical removal of the appendix, known as an appendectomy.
The patient as a result will need to be NPO (nothing by mouth) so they are prepared surgically.
The patient may also require antibiotics in addition to a surgical consultation, especially if a complicated appendicitis is present (perforation, abscess, etc).
Antibiotic choices include (but are not limited to) piperacillin/tazobactam, ampicillin/sulbactam, ertapenem, metronidazole, and cephalosporins such as ceftriaxone or cefepime.
The patient’s pain and symptoms (such as nausea and vomiting) should be controlled.
The patient may also receive IV fluids if necessary.
Summary
Hopefully this was a good overview of appendicitis.
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