What is the appendix?
The appendix is a tube which is narrow and closed-ended and extends up to several inches in length. This will attach to the cecum which is the first part of the colon similar to a worm. Vermiform appendix which is the anatomical name of the appendix means an appendage similar to a worm. The middle core of the appendix which is open will drain into the cecum. The interior lining of the appendix will produce a tiny amount of mucus which will flow through the open middle core of the appendix directly into the cecum. The wall of the appendix has a lymphatic tissue that is a component of the immune system of the body to make the antibodies. Similar to the rest of the colon, the wall of the appendix also has a muscle layer even if this is inadequately developed.
Appendicitis and its causes
Appendicitis is a term used to describe inflammation of the appendix. It is believed that appendicitis starts when the opening from the appendix into the cecum has been obstructed. The obstruction can be due to accumulation of thick mucus in the appendix or because of stool which enters the appendix coming from the cecum. The mucus or stool will become hard similar to a rock and will obstruct the opening. This rock is termed fecalith which literally means a rock of stool. In some instances, appendicitis is a result of swelling of the lymphatic tissue in the appendix that will block the opening. When the blockage takes place, bacteria which are usually found in the appendix will start invading or infecting the wall of the appendix. Inflammation refers to the response of the body to the invasion by preparing an attack on the bacteria. Another alternative theory for the cause of appendicitis is primary rupture of the appendix which is preceded by bacterial spread at the exterior of the appendix. Although, the cause of the rupture is not clear yet, this may be related to changes which occur in the lymphatic tissue. For instance, the presence of inflammation located at the wall of the appendix.
If both infection and inflammation will spread all through the wall of the appendix, there is a possibility that the appendix will rupture. Infection will then spread all through the abdomen following infection. But this is typically confined to a tiny area around the appendix which forms a peri-appendiceal abscess.
At times, the body is successful in controlling the appendicitis with no surgical treatment necessary especially if infection together with inflammation will not spread all over the abdomen. Pain, inflammation and other symptoms will disappear. This is specifically true with patients who are old and when antibiotics are utilized. Then, patients will visit the doctor long after the incident of appendicitis along with a lump or mass located at the right lower abdomen. This occurs because of scarring while healing. The presence of lump can raise the hint of malignancy.
Complications of appendicitis
Perforation is considered to be the most recurrent complication of appendicitis. Perforation of the appendix will result to peri-appendiceal abscess which is a collection of infected pus or diffuse peritonitis which is an infection of the whole lining of both pelvis and abdomen. The most important reason for a perforated appendicitis is a delay in both diagnosis and treatment. Generally speaking, if the delay in diagnosis and surgery is extensive, there is the possibility of perforation. About fifteen percent is the risk of perforation thirty six hours following the onset of symptoms. Thus, when appendicitis is diagnosed, surgical procedure should be performed with no avoidable delays.
Obstruction or blockage of the intestine is a complication of appendicitis that occurs less frequently. Blockage takes place when the inflammation around the appendix will make the muscle of the intestine to stop functioning. As a result, the contents in the intestine will not be able to pass. When the intestine over the blockage starts to be filled with gas and liquid, there will be abdominal distention and nausea and vomiting will take place. It may be necessary that the contents of the intestine be drained using a tube which passes from the nose and esophagus and all through the stomach and intestine.
Sepsis is considered to be a feared complication of appendicitis. In this condition, bacterial infection has entered the blood and has spread to other areas of the body. This kind of complication is extremely serious and life-threatening. Luckily, this occurs only not too often.
Appendicitis Symptoms
The chief symptom of appendicitis is pain in the abdomen. At first, the pain is diffused and poorly localized and is usually not confined to one area. Pain that is poorly localized is common every time a problem involves the small intestine or colon and also the appendix. Since the pain will be very difficult to isolate when the person is asked where the area of pain is, majority of people will indicate the painful area using a circular motion of their hand surrounding the middle part of the abdomen. Loss of appetite is the second and common symptom which occurs early. This can even be followed with nausea and vomiting. But both symptoms will only occur later because of obstruction to the intestine.
As the inflammation of the appendix increase, this will extend all through the outer covering of the appendix and also to the lining of the abdomen which is a thin membrane termed as peritoneum. When there is inflammation on the peritoneum, it is then that the pain will change and can already be plainly localized to a specific small area. In general, this area is located between the front part of the right hip bone and the belly button. The specific point is called McBurney’s point after the famous doctor, Dr. Charles McBurney. In case, the appendix ruptures and infection spreads all through the abdomen, there will be diffuse pain again since the entire abdominal lining is also inflamed.
Appendicitis Diagnosis
The diagnosis of appendicitis starts with a thorough physical and history assessment. Oftentimes, the patients will have high fever. Usually, they will also have moderate to severe tenderness at the right area of the lower abdomen when the physician pushes the area. When the inflammation has infected the peritoneum, there will be regular rebound tenderness. This is a type of pain which becomes worse when the physician will make a quick release of his hand after he has gently pressed on the abdomen above the area where tenderness is present.
White Blood Cell Count
Typically, the white blood cell count in the blood is elevated when there is infection. During the early phase of appendicitis before the infection begins, this may be normal. But usually, there will be a mild elevation even during the early stage of the condition. Unluckily, appendicitis is not only the condition which will result to elevated counts of white blood cell. Any kind of infection or inflammation will lead to an abnormally high count. Thus, it will not be reasonable to use an elevated white blood cell count in confirming the diagnosis of appendicitis.
Urinalysis
This is a microscopic examination of the urine which is capable of detecting the presence of bacteria, red and white blood cells in the urine. More often than not, urinalysis is abnormal if inflammation is present or there are stones in the bladder or kidneys. The result will also be abnormal with appendicitis since the appendix is located close to the bladder and ureter. Abnormal result of urinalysis is also possible once the inflammation has spread to the ureter and the bladder. However, a lot of people suffering from appendicitis will have normal urinalysis. Hence, normal result of the urinalysis will be more indicative of appendicitis than a problem with the urinary tract.
Abdominal X-ray
This may be able to detect the presence of fecalith which is causing the appendicitis. This is a pea-sized piece of stool which becomes hard and calcified and has obstructed the opening of the appendix. This is particularly common among children.
Ultrasound
This is a painless procedure which makes use of sound waves in order to provide images in identifying organs in the body. Ultrasound is able to determine whether the appendix is enlarged or there is abscess. But only about fifty percent of patients suffering from appendicitis will have a clear image of their appendix. Thus, if the appendix will not be visible during an ultrasound, this does not mean that appendicitis is already excluded. In addition, ultrasound is beneficial to women since this can rule out other conditions which involve the uterus, ovaries and fallopian tubes. All of these conditions will mimic appendicitis.
Appendicitis Treatment
Appendectomy is usually done once the diagnosis of appendicitis is already made. Almost always, antibiotics are taken before the surgical procedure and even at the earliest when appendicitis is suspected.
A small group of patients experience only mild inflammation and infection of the appendix and both are localized to a tiny area. Not only the body contained the inflammation and infection but it also resolves the symptoms. Usually, these patients are not extremely ill and symptoms will improve after several days of observation. This condition is called confined appendicitis and treatment may only include the use of antibiotics. Removal of the appendix may or may not be done at a later time.
Occasionally, an individual will not go see his doctor until the appendix has already ruptures for several days or even more. An abscess has already formed in this kind of situation and the perforation of the appendix has already closed over. Initially, antibiotics are used when the abscess is small but the abscess will usually necessitate drainage. A drain using a small plastic or rubber tube is commonly inserted into the skin and directly into the abscess. An ultrasound or CT scan can help in determining the precise location of the abscess. Using the drain will allow the pus to flow from the abscess and out of the person’s body. After the abscess has been resolved several weeks or months after, the appendix can already be taken out. This procedure is termed as interval appendectomy and is usually performed to prevent another appendicitis attack.
How is Appendectomy performed on patients?
In the course of appendectomy, a two to three inches incision is made into the skin and also into the abdominal wall layers above the area of the appendix. The surgeon penetrates the abdomen and search for the appendix which is typically located at the right portion of the lower abdomen. Once the area surrounding the appendix has been examined to be sure that there are no additional problems, the appendix is then removed. This is performed by releasing the appendix from its mesenteric attachment to both colon and abdomen. The appendix is cut from the colon and a hole is sewn over in the colon. When an abscess is detected, draining of pus can be done with drains passing from the abscess and out into the skin. After that, the incision in the abdomen will be closed.
Most recent techniques for the removal of the appendix involve the use of laparoscope. This is a thin telescope that is attached to a video camera to allow the surgeon to inspect the interior of the abdomen. A small puncture wound is made rather than making a bigger incision. If appendicitis is detected, the appendix can be taken out using special instruments. These can be passed into the abdomen similar to laparoscope through the tiny puncture wounds. The advantages of the laparoscopic technique are pain after the operation is less because the incision is only small and return to normal activities will be quick and easy. Another benefit of laparoscopy is that it will be easy for the surgeon to look closely the interior of the abdomen. This is to make a clear diagnosis of the condition most especially if the diagnosis of appendicitis is not certain. For instance, laparoscopy is particularly useful in women who have their menstrual cycle. A ruptured cyst in the ovary can mimic appendicitis.
If at the time of surgery, the appendix has not ruptured or not perforated, the patient will be sent home from the hospital a day or two days after the surgery. Patients who have perforated appendix are sicker than those with no perforation and their hospital stay would even be longer for several days. This is especially true if peritonitis has taken place. During their stay in the hospital, antibiotics administered intravenously are provided in fighting against infection and in helping resolve the abscess.
In some occasions, the surgeon may detect an appendix that is normal in appearance and no other cause that will lead to the problem of the patient. With such condition, the surgeon will remove the appendix. The primary reason for such removal is that it is better to remove an appendix that looks normal than to miss out and not be able to treat properly an early or mild appendicitis condition.