Brief overview
- Symptoms: stabbing or pulling abdominal pain in the right lower abdomen, loss of appetite, nausea, vomiting, diarrhea or constipation, clogged tongue, fever, sometimes elevated pulse, night sweats
- Causes: Obstruction of the appendix by hardened feces (fecal calculus) or an awkward position (kinking), less commonly by foreign bodies or intestinal worms; other inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis.
- Course: If left untreated, perforation of the intestine with life-threatening peritonitis, intestinal paralysis, intestinal obstruction, sometimes spread of the inflammation to other parts of the intestine.
- Prognosis: If treated quickly, appendicitis usually heals completely and leaves no permanent damage.
What is appendicitis?
Appendicitis is possible at any age, but the disease is particularly common between the ages of ten and 30. Boys and men are affected about twice as often as girls and women. In children, appendicitis is one of the most common surgically significant diseases of the abdominal cavity. Internationally, the incidence of the disease is about 100 per 100,000 people.
Forms and stages of appendicitis
- In the catarrhal stage, the inflamed appendix is swollen and reddened, but no pus is produced. The inflammation may regress spontaneously, so it is still reversible at this stage.
- In the phlegmonous or ulcero-phlegmonous stage, the entire wall of the appendix is severely inflamed and pus often accumulates.
- Perforated appendicitis is the most advanced stage of appendicitis. In this case, infectious intestinal contents pass through the destroyed intestinal wall into the abdominal cavity. There is a risk that the inflammation will spread to the peritoneum (peritonitis or peritonitis).
What are the symptoms of appendicitis?
At the beginning of appendicitis, there are usually unspecific symptoms that may also indicate other diseases. For example, many sufferers initially experience stabbing or pulling pains in the upper abdomen or at the level of the belly button, which can easily be mistaken for stomach complaints. Usually, other symptoms are added within a few hours.
Symptoms of acute appendicitis
A typical feature of the acute phase of appendicitis is that the pain suddenly intensifies, especially when walking. Affected persons are also unable to raise their right leg without pain, so that they pull it up in a strangulated manner when walking (Schonhinken). It is therefore part of the medical routine when appendicitis is suspected to check whether the affected person is able to hop without pain.
Other symptoms of appendicitis in the acute phase are:
- Loss of appetite
- Nausea
- Vomiting
- Diarrhea or constipation
- Coated tongue
- Sometimes increased pulse and night sweats
- Stooped posture
Appendicitis in children, pregnant women, and seniors
In infants, children, pregnant women and the elderly, appendicitis often follows a divergent course, making diagnosis difficult in some cases:
In older people, appendicitis is often gradual, appendicitis symptoms such as pain and vomiting are usually less intense. Fever occurs only rarely.
Chronic appendicitis: symptoms
Chronic appendicitis is not limited to a certain period of time, but occurs again and again. The typical symptoms appear only briefly at a time over several years and subside again after a few hours. Doctors refer to this as chronic recurrent appendicitis.
How is appendicitis diagnosed?
- where the abdominal pain is localized
- how the pain feels (for example, colicky, stabbing, etc.)
- whether there are other complaints such as nausea, vomiting or lack of appetite
- how long the symptoms have been present
- whether previous illnesses are known
- whether pregnancy is present
Physical examination
- McBurny point: It is located in the middle of the line connecting the navel and the right protrusion of the hip bone.
- Lanz point: It is located between the right and the middle third of the line connecting the two protrusions of the hip bones.
In addition, other types of pain suggest appendicitis:
- Rovsing symptom: Severe pain when the doctor extends the colon in the direction of the right lower abdomen with light pressure
- Blumberg sign: Release pain when the doctor presses on the lower abdomen and then suddenly releases it
- Sitkowski’s sign: Stretching pain in the right lower abdomen when the affected person lies on the left side
Since appendicitis is often accompanied by fever, the doctor usually takes the temperature once under the armpit and once in the rectum (rectal). The temperature difference is typical of appendicitis – the temperature measured in the rectum is at least one degree higher than that measured under the armpit.
Blood test
However, the blood test does not show where exactly the inflammation is in the body. This question can only be answered by a physical examination. In addition, the inflammation values in appendicitis are sometimes also completely inconspicuous, for example in a chronic course or sometimes in children. In addition, the blood values differ in the various stages of the disease. For example, the CRP value often only increases in the later course of the disease.
Further examinations
Imaging techniques also help further identify appendicitis if the diagnosis is unclear: Ultrasound (sonography) shows appendicitis as a shadow in the image. However, sonography alone is not sufficient to rule out appendicitis with certainty. In complicated cases, where the symptoms cannot be clearly assigned and complications are also to be expected, a computer tomography is sometimes advisable.
However, only laparoscopy can provide final certainty in the case of an uncertain diagnosis of appendicitis: The view inside the abdomen allows the doctor to clearly see whether appendicitis is present or not. If so, the inflamed tissue can be removed immediately during the laparoscopy (laparoscopic appendectomy).
How does appendicitis develop?
Even if the appendix is in an unfavorable position and bends, for example, secretions may accumulate in it and cause inflammation. Only very rarely are tumors or intestinal worms responsible for appendicitis. Factors such as stress do not normally play a role in appendicitis.
Treatment
Treatment of appendicitis usually requires surgery: the surgeon removes the inflamed appendix (appendectomy).
Two methods are available for appendectomy: the classic appendectomy with a large abdominal incision (laparotomy) and the minimally invasive (laparoscopic) method. Both take place under general anesthesia and last about 20 minutes. In most cases, surgery is performed early in the acute stage, usually within twelve to 24 hours after diagnosis. On the other hand, in the case of a complicated course with perforation, immediate surgery is required.
Classic appendectomy
In the classic, open surgery, the surgeon opens the right lower abdomen with an incision about five centimeters long (laparotomy). He cuts out the inflamed appendix and then sutures the wound edges. This method usually leaves a scar on the lower abdomen.
Laparoscopic appendectomy
The camera transmits the image of the abdomen live to a monitor so that the surgeon can see what he is doing. The surgeon inserts the necessary instruments through the other two incisions. With these, he removes the appendix – as in classic surgery – and then sutures the wound.
For better visibility, the abdominal cavity is filled with gas (carbon dioxide) for the procedure.
However, any internal bleeding cannot be stopped as well as with open surgery. In addition, the operation time is somewhat longer than with the open procedure.
The keyhole method is particularly suitable in the early stages of appendicitis. If the inflammation is more advanced, doctors usually prefer the classic surgical method.
Appendicitis: Treatment in children
After the operation
After appendectomy, affected patients usually stay in the hospital for a few days. During this time, doctors monitor intestinal function: they look to see if the intestines resume their normal activity quickly. Sometimes, sufferers receive infusions to ensure that the body is supplied with sufficient nutrients and fluids.
After the procedure, walking sometimes hurts at first. It is therefore advisable to take it easy for a few days. As a rule, patients are given a sick note by their doctor for two to three weeks. The pain can be relieved with the help of suitable painkillers.
Many clinics now use self-dissolving sutures to suture the abdominal wall. Stitches that do not dissolve themselves are usually removed the week after surgery. This is also possible on an outpatient basis.
Possible complications
As after any other surgery, some cases of bleeding or infection occur after appendectomy. However, the risk of this is relatively low because the procedure is very common and therefore routine for many surgeons.
A few days after the operation, there is a possibility of pus accumulating under the abdominal wall, which the doctor has to drain. Doctors then speak of an abdominal wall abscess.
Rare but serious complications after appendectomy are scarring (adhesions) in the abdominal cavity. They stick together the abdominal organs, such as the intestinal loops, so that the stool is no longer transported unhindered. This complication becomes apparent in the first three weeks after surgery. In most cases, a new operation is then necessary.
Appendicitis: course and prognosis
However, if appendicitis is only recognized and treated at a late stage, it can be life-threatening in some cases. Due to the increasing pressure in the appendix, about ten percent of those affected suffer a perforation of the intestine. This creates a hole in the intestinal wall through which feces and bacteria enter the surrounding abdominal cavity. This leads to life-threatening peritonitis, which requires immediate surgery.
Peritonitis may be life-threatening! The risk of this complication increases sharply in appendicitis after about 48 hours. If you suspect appendicitis, you should therefore see a doctor immediately!
Such complications of appendicitis occur very rarely.
