Appendicitis
Overview
Appendicitis is a condition characterized by inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of the appendix
Vermiform appendix
The appendix is a blind-ended tube connected to the cecum , from which it develops embryologically. The cecum is a pouchlike structure of the colon...

. It is classified as a medical emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...

 and many cases require removal of the inflamed appendix, either by laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 or laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...

. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

 and shock. Reginald Fitz
Reginald Heber Fitz
Reginald Heber Fitz was an American physician.He graduated in 1864 from Harvard University, where, after studying in Vienna, Berlin, and Paris, he was instructor in pathological anatomy in 1870–1873, assistant professor in 1873–1878, and professor from 1878 to 1908...

 first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute
Acute (medicine)
In medicine, an acute disease is a disease with either or both of:# a rapid onset, as in acute infection# a short course ....

 abdominal pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

 worldwide.
Encyclopedia
Appendicitis is a condition characterized by inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of the appendix
Vermiform appendix
The appendix is a blind-ended tube connected to the cecum , from which it develops embryologically. The cecum is a pouchlike structure of the colon...

. It is classified as a medical emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...

 and many cases require removal of the inflamed appendix, either by laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 or laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...

. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

 and shock. Reginald Fitz
Reginald Heber Fitz
Reginald Heber Fitz was an American physician.He graduated in 1864 from Harvard University, where, after studying in Vienna, Berlin, and Paris, he was instructor in pathological anatomy in 1870–1873, assistant professor in 1873–1878, and professor from 1878 to 1908...

 first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute
Acute (medicine)
In medicine, an acute disease is a disease with either or both of:# a rapid onset, as in acute infection# a short course ....

 abdominal pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

 worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis
Rumbling appendicitis
Rumbling appendicitis is a name for chronic appendicitis. Exhibited symptoms can vary from a mild pain to a severe pain as in acute appendicitis; however, patients do not usually experience vomiting, fever, or gastritis. A rumbling appendix is inflamed, but not infected; hence, there is no need...

".

The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis. It can be associated with Yersinia enterocolitica
Yersinia enterocolitica
Yersinia enterocolitica is a species of gram-negative coccobacillus-shaped bacterium, belonging to the family Enterobacteriaceae. Yersinia enterocolitica infection causes the disease yersiniosis, which is a zoonotic disease occurring in humans as well as a wide array of animals such as cattle,...

.

Signs and symptoms

Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen, and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs and can be severe.
Signs include localized findings in the right iliac fossa
Iliac fossa
The iliac fossa is a large, smooth, concave surface located on the internal surface of the ilium...

. The abdominal wall becomes very sensitive to gentle pressure (palpation
Palpation
Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...

). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen (rebound tenderness
Rebound tenderness
Rebound tenderness is a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen...

). In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum
Cecum
The cecum or caecum is a pouch, connecting the ileum with the ascending colon of the large intestine. It is separated from the ileum by the ileocecal valve or Bauhin's valve, and is considered to be the beginning of the large intestine. It is also separated from the colon by the cecocolic...

, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination
Rectal examination
A rectal examination or rectal exam is an internal examination of the rectum such as by a physician or other healthcare professional.-Procedure:...

 elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point
McBurney's point
McBurney's point is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the navel...

) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

 requiring urgent surgical intervention.

Not typical Pain is usually not typical in some patients, who may just only have lower right abdominal pain no mid-upper abdominal pain at the beginning. Often, the pain is not prominent in the elderly or children below 3-year-old. Or the pain point moves to other locations, especially just below the liver in pregnant woman. In this case, the inflamed appendix is pushed up by enlarged uterus.

Rovsing's sign

Continuous deep palpation starting from the left iliac fossa
Iliac fossa
The iliac fossa is a large, smooth, concave surface located on the internal surface of the ilium...

 upwards (counterclockwise along the colon) may cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. This is the Rovsing's sign
Rovsing's sign
thumb|right|Rovsing's sign is pain in the [[RLQ]] experienced when the [[left lower quadrant|LLQ]] is palpated.Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing, is a sign of appendicitis...

.

Psoas sign

Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the hypogastrium
Hypogastrium
The hypogastrium is an area of the human abdomen located below the navel. The pubis bone constitutes its lower limit....

.

Kocher's (Kosher's) sign

From the history given, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with a subsequent shift to the right iliac region.

Sitkovskiy (Rosenstein)'s sign

Increased pain in the right iliac region as patient lies on his/her left side.

Bartomier-Michelson's sign

Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient was on supine position.

Aure-Rozanova's sign

Increased pain on palpation with finger in right Petit triangle
Lumbar triangle
The lumbar triangle can refer to either the inferior lumbar triangle, which lies superficially, or the superior lumbar triangle, which is deep and superior to the inferior triangle...

 (can be a positive Shchetkin-Bloomberg's sign) - typical in retrocecal position of the appendix.

Blumberg sign

Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis.

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen
Lumen (anatomy)
A lumen in biology is the inside space of a tubular structure, such as an artery or intestine...

 (the inside space of a tubular structure). Once this obstruction occurs the appendix subsequently becomes filled with mucus
Mucus
In vertebrates, mucus is a slippery secretion produced by, and covering, mucous membranes. Mucous fluid is typically produced from mucous cells found in mucous glands. Mucous cells secrete products that are rich in glycoproteins and water. Mucous fluid may also originate from mixed glands, which...

 and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis
Thrombosis
Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets and fibrin to form a blood clot to prevent blood loss...

 and occlusion
Vascular occlusion
Vascular occlusion is a sudden blockage of a blood vessel, usually with a clot. It differs from thrombosis in that it can be used to describe any form of blockage, not just one formed by a clot. When it occurs in a major vein, it can, in some cases, cause deep vein thrombosis. The condition is...

 of the small vessels, and stasis of lymphatic flow
Lymphatic system
The lymphoid system is the part of the immune system comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectionally toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated...

. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...

 and then necrotic
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

. As bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...

 begin to leak out through the dying walls, pus
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...

 forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

, which may lead to septicemia
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...

 and eventually death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....

.

The causative agents include foreign bodies, trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

, intestinal worms
Intestinal parasite
Intestinal parasites are parasites that populate the gastro-intestinal tract in humans and other animals. They can live throughout the body, but most prefer the intestinal wall. Means of exposure include: ingestion of undercooked meat, drinking infected water, and skin absorption...

, lymphadenitis
Lymphadenopathy
Lymphadenopathy is a term meaning "disease of the lymph nodes." It is, however, almost synonymously used with "swollen/enlarged lymph nodes". It could be due to infection, auto-immune disease, or malignancy....

, and most commonly calcified fecal deposits known as appendicoliths or fecaliths The occurrence of an obstructing fecalith
Fecaloma
A fecaloma, also called fecalith, fecolith and coprolith, i.e., a "stone" made of feces, is a hardening of feces into lumps of varying size inside the colon, which may appear whenever chronic obstruction of transit occurs, such as in megacolon and chronic constipation...

 has attracted attention since their presence in patients with appendicitis is significantly higher in developed than in developing countries, and an appendiceal fecalith is commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls.
The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis
. This is in accordance with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces transit time.

Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant, where tenderness develops. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/or CT scanning. A pregnancy test is vital in all women of child bearing age, as ectopic pregnancies
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...

 and appendicitis present with similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated.

Blood Test

Most patients suspected of having appendicitis would be asked to do a blood test. 50% of the time, the blood test may be normal, so it is not foolproof in diagnosing appendicitis.

Two form of blood tests are commonly done:
FBC (Full blood count) or CBC (Complete blood count), is an inexpensive and commonly requested blood test. It involves measuring the blood for its richness in red blood cells as well as the number of the various white blood cell constituents in it. The number of white cells in the blood is a usually less than 10,000 cells per cubic millimeter. An abnormal rise in the number of white blood cells in the blood is a crude indicator of infection or inflammation going on in the body. Such rise is not specific to appendicitis alone. If it is abnormally elevated, with a good history and examination findings pointing towards appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal elevation of white blood cells, without any infection present.

CRP is an acronym for C-reactive protein
C-reactive protein
C-reactive protein is a protein found in the blood, the levels of which rise in response to inflammation...

. It is an acute phase response protein produced by the liver in response to any infection or inflammatory process in the body. Again, like the FBC, it is not a specific test. It is another crude marker of infection or inflammation. Inflammation at ANY site can lead to the CRP to rise.
A significant rise in CRP with corresponding signs and symptoms of appendicitis is a useful indicator in the diagnosis of appendicitis.It is said that if CRP continues to be normal after 72 hours of the onset of pain, it is likely that the appendicitis will resolve on its own without intervention. A worsening CRP with good history is a sure signal of impending perforation or rupture and abscess formation.

Urine Test

Urine test in appendicitis is usually normal. It may however show blood if the appendix is rubbing on the bladder, causing irritation
A urine test or urinalysis is compulsory in women, to rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and thought to be acute appendicitis is not in fact, due to ectopic pregnancy.

X–Ray

In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard formed feces in the lumen of the appendix (Fecolith).
It is agreed that the finding of Fecolith in the appendix on X – ray alone is a reason to operate to remove the appendix, because of the potential to cause worsening symptoms. In this respect, a plain abdominal X-ray may be useful in the diagnosis of appendicitis, though plain abdominal x- ray is no longer requested routinely in suspected cases of appendicitis.
An abdominal X – ray may be done with a barium enema contrast to diagnose appendicitis.
Barium enema is whitish fluid that is passed up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is shot. In appendicitis, the lumen of the appendix will not be visible on the barium film.

Ultrasound

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children and shows free fluid collection in right iliac fossa along with a visible appendix without blood flow in color Doppler. In some cases (15% approximately), however, ultrasonography of the iliac fossa
Iliac fossa
The iliac fossa is a large, smooth, concave surface located on the internal surface of the ilium...

 does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis and other diseases with very similar symptoms such as inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.

Computed tomography

In places where it is readily available, CT scan
Computed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...

 has become frequently used, especially in adults whose diagnosis is not obvious on history and physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and children. A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in cross sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital.

Ultrasound and CT compared

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%, a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27).

Alvarado score

Alvarado score
Migratory right iliac fossa
Iliac fossa
The iliac fossa is a large, smooth, concave surface located on the internal surface of the ilium...

 pain
1 point
Anorexia
Anorexia (symptom)
Anorexia is the decreased sensation of appetite...

1 point
Nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 and vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...

1 point
Right iliac fossa tenderness
Tenderness (medicine)
In medicine, tenderness is pain or discomfort when an affected area is touched.Rebound tenderness is an indication of peritonitis....

2 points
Rebound tenderness
Rebound tenderness
Rebound tenderness is a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen...

1 point
Fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...

1 point
Leukocytosis
Leukocytosis
Leukocytosis is a raised white blood cell count above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, and is observed in certain parasitic infections...

2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points

A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used is Alvarado score
Alvarado score
The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10 points.-The score:...

.
A score below 5 is strongly against a diagnosis of appendicitis, while a score of 7 or more is strongly predictive of acute appendicitis. In patients with an equivocal score of 5-6, CT scan is used to further reduce the rate of negative appendicectomy.

Other data

Tzanakis Scoring: Tzanakis and colleagues, in 2005 published a simplified system, now called the Tzanakis scoring system for appendicitis, to aid the diagnosis of appendicitis. It incorporates the presence 4 variables made up of specific signs and symptoms (presence of right lower abdominal tenderness = 4points and rebound tenderness = 3), laboratory findings (presence of white blood cells greater than 12,000 in the blood = 2) as well as ultrasound findings (presence of positive ultrasound scan findings of appendicitis = 6), to which scores are allocated, in the computing of a scoring to predict the presence of appendicitis.
A total score of 15 is the maximum that can be scored. Where a patient scores 8 or more points, there is greater than 96 percent chance that appendicitis exists.

Pathologic diagnosis

The definitive diagnosis is based on pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

. The histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

 findings of appendicits are neutrophils in the muscularis propria.

Periappendicits, inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of tissues around the appendix, is often found in conjunction with other abdominal pathology.

Differential diagnosis

In children:
Gastroenteritis
Gastroenteritis
Gastroenteritis is marked by severe inflammation of the gastrointestinal tract involving both the stomach and small intestine resulting in acute diarrhea and vomiting. It can be transferred by contact with contaminated food and water...

, mesenteric adenitis, Meckel's diverticulitis
Meckel's diverticulum
A Meckel's diverticulum, a true congenital diverticulum, is a small bulge in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct , and is the most frequent malformation of the gastrointestinal tract...

, intussusception
Intussusception
Intussusception may refer to:* Intussusception * Intussusception...

, Henoch-Schönlein purpura
Henoch-Schönlein purpura
Henoch–Schönlein purpura is a disease of the skin and other organs that most commonly affects children. In the skin, the disease causes palpable purpura ; often with joint and abdominal pain...

, lobar pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...

, urinary tract infection
Urinary tract infection
A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...

 (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset Crohn's disease
Crohn's disease
Crohn's disease, also known as regional enteritis, is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms...

 or ulcerative colitis
Ulcerative colitis
Ulcerative colitis is a form of inflammatory bowel disease . Ulcerative colitis is a form of colitis, a disease of the colon , that includes characteristic ulcers, or open sores. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset...

, pancreatitis
Pancreatitis
Pancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...

, and abdominal trauma from child abuse
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...

; distal intestinal obstruction syndrome
Distal intestinal obstruction syndrome
Distal intestinal obstruction syndrome involves blockage of the intestines by thickened stool and occurs in individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with...

 in children with cystic fibrosis; typhlitis in children with leukemia;


In girls:
menarche
Menarche
Menarche is the first menstrual cycle, or first menstrual bleeding, in female human beings. From both social and medical perspectives it is often considered the central event of female puberty, as it signals the possibility of fertility....

, dysmenorrhea, severe menstrual cramps, Mittelschmerz
Mittelschmerz
Mittelschmerz is a medical term for "ovulation pain" or "midcycle pain". About 20% of women experience mittelschmerz, some every cycle, some intermittently.-Symptoms and diagnosis:...

, pelvic inflammatory disease
Pelvic inflammatory disease
Pelvic inflammatory disease is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most...

, ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...



In adults:
regional enteritis, renal colic
Renal colic
Renal colic is a type of abdominal pain commonly caused by kidney stones.-Presentation:The pain typically begins in the abdomen and often radiates to the hypochondrium or the groin. The pain is often colicky due to ureteric peristalsis, but may be constant...

, perforated peptic ulcer
Peptic ulcer
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...

, pancreatitis
Pancreatitis
Pancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...

, rectus sheath hematoma
Rectus sheath hematoma
A rectus sheath hematoma is an accumulation of blood in the sheath of the rectus abdominis muscle. It causes abdominal pain with or without a mass....

; in men: testicular torsion
Testicular torsion
Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it...

, new-onset Crohn's disease
Crohn's disease
Crohn's disease, also known as regional enteritis, is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms...

 or ulcerative colitis
Ulcerative colitis
Ulcerative colitis is a form of inflammatory bowel disease . Ulcerative colitis is a form of colitis, a disease of the colon , that includes characteristic ulcers, or open sores. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset...

; in women: pelvic inflammatory disease
Pelvic inflammatory disease
Pelvic inflammatory disease is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most...

, ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...

, endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...

, torsion/rupture of ovarian cyst
Ovarian cyst
An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an orange....

, Mittelschmerz
Mittelschmerz
Mittelschmerz is a medical term for "ovulation pain" or "midcycle pain". About 20% of women experience mittelschmerz, some every cycle, some intermittently.-Symptoms and diagnosis:...

 (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle)


In elderly:
diverticulitis
Diverticulitis
Diverticulitis is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches on the outside of the colon...

, intestinal obstruction, colonic carcinoma, mesenteric ischemia
Mesenteric ischemia
Mesenteric ischemia is a medical condition in which inflammation and injury of the small intestine result from inadequate blood supply. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot...

, leaking aortic aneurysm
Aortic aneurysm
An aortic aneurysm is a general term for any swelling of the aorta to greater than 1.5 times normal, usually representing an underlying weakness in the wall of the aorta at that location...

.

Management

Largely surgical, any conservative management is done at the threshold of operation theater as the acutely inflamed appendix is liable to rupture during such treatment.
The treatment begins by keeping the patient from eating or drinking
Nil per os
Nil per os is a medical instruction meaning to withhold oral food and fluids from a patient for various reasons. It is a Latin phrase which translates as "nothing through the mouth". In the United Kingdom it is translated as nil by mouth .Typical reasons for NPO instructions are the prevention...

 in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...

s given intravenously such as cefuroxime
Cefuroxime
Cefuroxime is a second-generation cephalosporin antibiotic that has been widely available in the USA as Ceftin since 1977. GlaxoSmithKline sells the antibiotic in the United Kingdom under the name Zinnat.-Indications:As for the other cephalosporins, although as a...

 and metronidazole
Metronidazole
Metronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....

 may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia
Spinal anaesthesia
Spinal anaesthesia , also called spinal analgesia or sub-arachnoid block , is a form of regional anaesthesia involving injection of a local anaesthetic into the subarachnoid space, generally through a fine needle, usually 9 cm long...

 may be used.

Once the decision to perform an appendectomy has been made, the preparation procedure takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries there are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%. The most usual complications that can occur are pneumonia, hernia
Hernia
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm....

 of the incision, thrombophlebitis
Thrombophlebitis
Thrombophlebitis is phlebitis related to a thrombus . When it occurs repeatedly in different locations, it is known as "Thrombophlebitis migrans" or "migrating thrombophlebitis".-Signs and symptoms:...

, bleeding or adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...

. Recent evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in patient outcomes

The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in order to avoid complications that may appear regarding the incision.
In most of the cases patients experience nausea or vomiting which requires specific medication before surgery. Antibiotics along with pain medication may also be administrated prior to appendectomies.

Pain management

Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain medications) are recommended for pain management prior to surgery. Morphine is generally the standard of care in adults and children in the treatment of pain from appendicitis prior to surgery.

In the past (and in some medical textbooks that are still published today), it was commonly accepted among the majority of academic sources that pain medication not be given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical examination. This line of practice, combined with the fact that surgeons may sometimes take hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to drive in from home, often leads to a situation that is ethically questionable at best. More recently, due to better understanding of the importance of pain control in patients, it has been shown that the physical examination is actually not that dramatically disturbed when pain medication is given prior to medical evaluation. Individual hospitals and clinics have adapted to this new approach of pain management of appendicitis by developing a compromise of allowing the surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain management is initiated. Many surgeons also advocate this new approach of providing pain management immediately rather than only after surgical evaluation.

Surgery

The surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 procedure for the removal of the appendix is called an appendicectomy
Appendicectomy
An appendectomy is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis...

(also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 may be necessary. An open laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

 incision if required most often centers on the area of maximum tenderness, McBurney's point
McBurney's point
McBurney's point is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the navel...

, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.

According to a meta-analysis
Meta-analysis
In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...

 from the Cochrane Collaboration
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...

 comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio
Odds ratio
The odds ratio is a measure of effect size, describing the strength of association or non-independence between two binary data values. It is used as a descriptive statistic, and plays an important role in logistic regression...

 (OR) 0.45; confidence interval
Confidence interval
In statistics, a confidence interval is a particular kind of interval estimate of a population parameter and is used to indicate the reliability of an estimate. It is an observed interval , in principle different from sample to sample, that frequently includes the parameter of interest, if the...

 (CI) 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale
Visual Analogue Scale
A visual analogue scale is a psychometric response scale which can be used in questionnaires. It is a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. When responding to a VAS item, respondents specify their level of agreement to a statement by...

. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups.

There is debate whether emergency appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study no significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. This finding is important not simply for the convenience of the surgeons and staff involved but for the fact that there have been other studies that have shown that surgeries taking place during the night, when people may be more tired and there are fewer staff available, have higher rates of surgical complications.

Findings at the time of surgery are less severe in typical appendicitis. With atypical histories, perforation is more common and findings suggest perforation occurs at the beginning of symptoms. These observations may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. (1)

Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in complicated cases.

Laparotomy explained

Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in the removal of the infected appendix through a single larger incision in the lower right area of the abdomen. The incision in a laparotomy is usually 2-3 inches long. This type of surgery is used also for visualizing and examining structures inside the abdominal cavity
Abdominal cavity
The abdominal cavity is the body cavity of the human body that holds the bulk of the viscera. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm , and its oblique floor is the pelvic inlet...

 and it is called exploratory laparotomy.

During a traditional appendectomy procedure, the patient is placed under general anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...

 in order to keep his/her muscles completely relaxed and to keep the patient unconscious. The incision is two to three inches (76 mm) long and it is made in the right lower abdomen, several inches above the hip bone
Hip bone
The hip bone, innominate bone or coxal bone is a large, flattened, irregularly shaped bone, constricted in the center and expanded above and below...

. Once the incision opens the abdomen cavity and the appendix is identified, the surgeon
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...

 removes the infected tissue and cuts the appendix from the surrounding tissue. After the surgeon inspects carefully and closely the infected area and there are no signs that surrounding tissues are damaged or infected, he will start closing the incision. This means sewing the muscles and using surgical staple
Surgical staple
Surgical staples are specialized staples used in surgery in place of sutures to close skin wounds, connect or remove parts of the bowels or lungs. A more recent development, from the 1990s, uses clips instead of staples for some applications; this does not require the staple to penetrate.Stapling...

s or stitches to close the skin up. In order to prevent infections the incision is covered with a sterile bandage
Dressing (medical)
A dressing is an adjunct used by a person for application to a wound to promote healing and/or prevent further harm. A dressing is designed to be in direct contact with the wound, which makes it different from a bandage, which is primarily used to hold a dressing in place...

.
The entire procedure does not last longer than an hour if complications do not occur.

Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

. This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 in (6.4 to 12.7 mm) long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments.
Laparoscopic surgery also requires general anesthesia and it can last up to two hours.
The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there is no incision on the external skin and SILS( Single incision laparoscopic Surgery)where a single 2.5 cm incision is made to perform the surgery.

After surgery

Hospital lengths of stay typically range from a few hours to a few days, but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally a lot faster if the appendix did not rupture. It is important that patients respect their doctor's advice and limit their physical activity so the tissues
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...

 can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change.

After surgery occurs, the patient will be transferred to an Post-anesthesia care unit so his or her vital signs can be closely monitored in order to detect anesthesia and/or surgery related complications. Pain medication may also be administrated if necessary. After patients are completely awake, they are moved into a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery and then progress to a regular diet when the intestines start to function properly. It is highly recommended that patients sit up on the edge of the bed and walk short distances for several times a day. Moving is mandatory and pain medication may be given if necessary. Full recovery from appendectomies takes about 4 to 6 weeks but it can prolong to up to 8 weeks if the appendix had ruptured.

Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...

 occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e., outside of a proper hospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated.
Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period, operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition.

An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy.

Epidemiology

 

External links

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