Appendicitis: Signs, early symptoms and treatment

In appendicitis, a small side pouch of the colon (appendix) is infected. It is a common disease. As many as 7% of people will develop an appendicitis at some point in their live. Most patients are of younger age. Patients suffer from abdominal pain; standard treatment includes surgery.

In the following text you will find information on typical signs and symptoms, diagnosis and treatment of appendicitis.

Causes

What exactly is an appendicitis?

The appendix is an 8-10 cm finger long extra bag of the colon down in the right lower part of the abdomen. Under certain situations, bacteria can get stuck and cause an infection. There are no special preventive measures against appendicitis. However, a high-fibre diet with a high-fibre content is associated with a lower rate of disease.

Kids and adolescents

Most patients with appendicitis are between 10 and 30 years old, with a peak age in primary school children between 9 and 14 years. However, appendicitis can occur at any age, even in elderly.

What are possible causes of appendicitis?

In appendicitis the stool passage is often blocked. This can be due to a faeces stone, for example, consisting of solidified stool. As one result, blood flow inside the intestinal wall of the appendix may be impaired and the appendix swells. Additionally, bacteria from the faeces are stuck inside this pouch causing a local purulent inflammation. A real infection of the bloodstream is rare.

Possible triggers of appendicitis include:

• Bending of the appendix
• Constriction and swelling of the mucous membrane due to scarring
• Foreign body (e.g. swallowed fruit stone)

Intestinal parasites like worms or tumours (rather rarely) Whether swallowed fruit seeds can lead to an appendicitis is debatable. Various experts, for example from the Professional Association of Paediatricians and Junior Doctors, dispute this. In the specialist literature, printed and digital, the cherry or fruit kernels are yet (still) included.

Different stages and forms of appendicitis

Appendicitis takes part in different stages with increasing severity, unless spontaneous healing or treatment is initiated. Therapy usually means surgical removal of the infected piece of intestine.

The stages range from simple forms of appendicitis over purulent infections that involve the surrounding and deeper tissue layers to gangrenous or even perforated stages with tissue decay or a breakthrough of the intestinal wall into the abdominal cavity.

Signs and Symptoms

What are typical symptoms and complaints of appendicitis?

With appendicitis, initially, abdominal pain occurs suddenly without any recognisable cause at irregular intervals, symptoms increase over time. Movement like jumping or even mere walking at advanced stages intensifies the pain. Children for example want to be carried around to avoid any movement and pain.

Often, they tend to lie down on their right side with their legs tightened. Another typical sign includes wondering pain from upper abdomen and umbilical region to the right lower abdomen as well as pain specific pressure points in the abdomen during the physical examine (McBurney´s sign).

The following symptoms can accompany an appendicitis:

• Cramp-like abdominal pain around the navel, typically followed by pain in the right lower abdomen
• Abdominal pain initially occurring irregularly with increasing intensity
• Pressure sensitivity of the abdomen, particularly after relieving manual pressure on the opposite side
• Pain that worsens with cough
• Loss of appetite
• Possibly vomiting, diarrhoea or constipation
• Mild to moderate fever (often just over 38 °C)
• Possibly mild diarrhoea or constipation
• Accelerated pulse
• Night sweats
• Tense belly
• Children may be very quiet and not move since the pain increases with movement and concussion
• Weakness, pallor, cold sweat, vomiting, hard or bulging abdomen, high fever in late stages of advanced inflammation

Not always the same clinical picture

Appendicitis may go along with changing symptoms and complaints; it can act like a chameleon. Although there are "typical symptoms", it does not always appear in the same way. Less than half of the people with appendicitis experience the characteristic combination of symptoms of nausea, vomiting and agonizing pain in the right lower abdomen. Since the appendix is not in the same place in all people, complaints and especially localization of pain are not always identical.

When it becomes dangerous

Appendicitis as such is relatively harmless, but it can take a life-threatening course if the intestinal wall ruptures and the inflammation spreads into the abdominal cavity. Due to this latent danger, you or your child should consult a doctor immediately if there are symptoms of appendicitis.

Signs of an advanced stage are an emergency - then call the emergency doctor.

What should I do if I suspect appendicitis in my child?

If your child has abdominal pain that could be caused by appendicitis, follow these steps:

• Make sure your child lies down.
• Make sure you contact a doctor quickly (depending on the situation, request a visit to your home, go to a doctor's office, go straight to the hospital or call an emergency doctor).
• Do not give your child anything to eat or drink in case of a possible operation.
• Do not use a hot-water bottle. It may aggravate the inflammatory process. Instead, you may try an ice pack.
• Consider holding off pain medication until the doctor has examined the patient in order to not interfere with making the diagnosis as pain and pain location may be important for making the diagnosis. Of course, this also depends on the severity of the pain.

What are warning signs for a ruptured appendix?

A ruptured appendix is one of the most serious complications that can occur with appendicitis. Paradoxically, however, when the massively inflamed appendix ruptures, the pain in the right lower abdomen suddenly subsides. This is because, the swollen and aching intestinal section is relieved by the outflow of the accumulated pus into the abdominal cavity.

After a while, however, the pain rises again and becomes worse than before. Leakage of stool and bacteria into the abdominal cavity can cause severe inflammation and peritonitis. This is a life-threatening condition. In addition to the pain, patients develop an extremely tense belly and high fever.

Diagnosis

What are diagnostic tests and signs of appendicitis?

Typical signs of appendicitis include abdominal pain that starts around the belly button and moves towards the right lower abdomen. During the physical examine, pushing down into the left lower abdomen and then releasing the pressure may lead to typical pain in the abdomen. Yet, symptoms of appendicitis can vary greatly, also depending on your age and position of the appendix.

Some typical tests during the physical examine include:

• McBurney´s sign
• Lanz´ point
• Blumberg´s sign

McBurney´s Sign

The McBurney´s sign is a typical pressure point in appendicitis. It is located on an imaginary line between navel and the well-recognizable protrusion of the right anterior pelvic bone. It is one third of the distance between anterior pelvic bone and the belly button. Pressing here leads to particularly severe pain at this point.

Lanz´ Point

In addition to McBurney´s sign, the Lanz´ point is a commonly used sampling point for pain provocation in suspected appendicitis. It is located one third on an imaginary line between right anterior pelvic bone and left anterior pelvic bone.

Blumberg´s Sign

The Blumberg´s sign is another clinical test for appendicitis. If the doctor presses his hand into the left lower abdomen and it hurts when letting go on the right side of the abdomen, this may be a typical sign for an inflamed appendix.

What should I bear in mind when diagnosing appendicitis?

The diagnosis appendicitis is made clinically. This means that the course of the physical symptoms provides the decisive indications and not the technical examination methods such as ultrasound or CT, which may not (yet) show any suspicious findings.

• The following points are of importance for the physician:
• high variability and inconsistency of symptoms of appendicitis in childhood
• in small children typically a fast course, occasionally with press respiration
• Pressure pain and local defensive tension in the right lower abdomen above the lance and McBurney points.
• Relaxation pain on the opposite side of the abdomen, knocking pain
• Fever with temperature difference (measurement in the anus is about 1°C higher than under the armpit)
• Involuntary tightening of the right leg (due to adjacent position of the inflamed appendix to the psoas muscle; Psoas´ sign)
• painful rectal digital examination, especially on the right side

How is appendicitis further diagnosed?

There is no absolutely certain diagnostic criterion for appendicitis. The suspected diagnosis "appendicitis" results rather from the sum of different symptoms and diagnostic markers. The physical examination (pressure pain points) and the complaints subjectively described by the affected person are important. Also, trendsetting are the following points:

• Clinical monitoring: Assessment of abdominal pain and other physical symptoms as they progress
• Laboratory blood test: increase in leukocyte count (white blood cells) and CRP value (inflammatory lab values)
• Ultrasound examination
• Computer tomography

How sure do doctors recognize appendicitis?

There is no diagnostic certainty until the surgeon holds the inflamed appendix in his hands. However, experienced doctors can make the correct diagnosis 70-80% of cases.

Are there any other diseases that can mimic an appendicitis?

Diseases that can manifest themselves in a similar way to appendicitis and should be considered as a differential diagnosis include:

• Inflammation of the abdomen (acute abdomen) of another cause
• Intestinal obstruction (Ileus)
• Intestinal entanglement (invagination)
• Gallbladder inflammation
• Pneumonia (pneumonia)
• Rotavirus infection

X-rays and urine examinations can help

In order to rule out possible other diseases as a cause of the discomfort, your physician may initiate further examinations like ultrasound tests, chest X-rays or urinary examines.

Treatment & Surgery

How is an appendicitis treated?

An appendicitis is usually treated with an operation. Non-surgical treatment (conservative therapy) is dispensed with few exceptions like accompanying appendicitis in Crohn's disease.

However, if appendicitis is only suspected but the clinical picture not completely clear, physicians may tend to wait a while. Often during this time patients have to stay in bed and get tight controls of physical and laboratory testing. This observation time is spent in the hospital.

Crohn's disease, as said above, is one of the few circumstances in which the surgical removal of an inflamed appendix is considered with restraint. These patients are prone to develop so called fistulas, connections between different intestinal sections including the appendix. In these patients, medical therapy may be tried first, and surgery will only take place if further aggravation sets in.

Is surgery always necessary?

In general, standard medical treatment of appendicitis includes the surgical removal of the inflamed appendix. In practice and everyday life, however, the problem is rather to determine whether the appendix is really inflamed or not.

The term "negative" appendectomy stands for the removal of a healthy appendix. If its rate exceeds 15% e.g. in one hospital, physicians speak of "overdiagnosis". It is often associated with a remarkably high proportion of young female patients.

Regional differences

International comparisons between Germany and England for example show, that appendectomies (surgical removal of the appendix) are traditionally performed (too) frequently in Germany. However, the number of operations has already halved since the 1970s (reportedly from 300,000 to 150,000). Also, in current years, numbers continued to drop. For example, in the year 2000 nationwide 570 out of 100 000 children under the age of 15 received an appendectomy. In 2008 this number had dropped to 245 out of 100.000.

Often young women

The number of operations (appendectomies) is by far the highest in the second decade of life and reaches the maximum at the age of about 20 years. At the same time, the male sex has a much flatter distribution curve, with a peak between ages 20 and 30 years.

Can appendicitis heal without surgery?

Light and less severe appendicitis or "irritation of the appendix" may in fact heal on its own, spontaneously. However, this is not always the case and cannot be predicted with certainty. Because of the risk of potentially life-threatening complications like perforation and peritonitis, rapid medical clarification is recommended in case of suspicious symptoms.

Appendicitis: Does naturopathy help?

Normally, naturopathic treatment cannot help against appendicitis. If appendicitis is suspected, we strongly advise you to see a medical doctor quickly. In early stages, without pus development, ice bags and withdrawing food for a while may calm down the inflammatory process. But, in order to avoid life-threatening complications, surgical removal of the appendix is the only safe treatment option.

How is appendectomy performed?

• There are two surgical methods for the removal of the appendix:
• The classic operation with abdominal incision and free access to the abdominal cavity (laparotomy)

The minimal invasive access by performing a laparoscopy with three small incisions for an optic system and instruments In both cases, the inflamed appendix is exposed and separated. The operation is performed in general anaesthesia. The "minimally invasive" procedure is nowadays increasingly used. In the case of emergency operations, however, open intervention is still standard treatment.

In perforated appendicitis, the abdominal cavity is rinsed, and a sufficient secretion flow is ensured by inserting a drainage. Antibiotic treatment is further started in order to protect against peritonitis. It must be continued for 5-7 days after the operation.

What complications can occur during appendectomy?

In general, an appendectomy has a low complication rate. Is it a common routine operation and a hospital stay of only a few days is to be expected, followed by a quick recovery.

Postponing an operation instead is much riskier than the surgery itself, since an inflamed appendix may burst within less than 24 hours after the onset of symptoms. In fact, about half a century ago, this often ended fatally.

Nowadays, the use of antibiotics can keep many patients even in this high-risk group alive. Thus, the risk of complications is higher than with early removal of an inflamed appendix. Scarring, constrictions and glued intestinal slings are possible complications. Complications observed after appendectomy include:

• Adhesions and scarring, possibly with resulting intestinal obstruction (Ileus)
• Mechanical damage to abdominal organs and other structures
• Bleeding and post-bleeding
• Inflammation of the inner abdomen (peritonitis)
• Abscess formation
• Wound healing disorders
• Permeability of the intestinal wall
• Excessive scarring
• Scar fractures in the abdominal area
• Sensory disorders (usually temporary)
• Chronic pain
• Allergic reactions
• Follow-up surgery, re-opening of the wound The risk of surgery and anaesthesia is usually low and depends to a large extent on the severity of appendicitis and to concomitant diseases.

What, if a healthy appendix is removed accidentally?

In 15% of cases, surgical removal of the appendix turns out to have been "false alarm". In these situations, appendectomy would not have been necessary. On the other hand, since the potentially life-threatening appendicitis cannot be diagnosed without surgery with 100% certainty, the removal takes often part on "blind suspicion”.

Is the appendix also removed prophylactically?

Sometimes yes, it depends. For example, in some abdominal operations like gynaecological surgeries, the appendix may be removed simultaneously during the operation.

The human body does not necessarily need the appendix itself, so it seems reasonable to remove it once you open the abdomen for another reason. The risk of surgery under controlled conditions is lower than that of possible appendicitis in later life. Solely prophylactic operations, in contrast, are discussed very controversially.

Are antibiotics necessary after surgery?

In the case of uncomplicated appendicitis, antibiotic treatment is usually not required. The situation is somewhat different with ruptured appendicitis (perforating appendicitis). In this potentially life-threatening case, antibiotics are prescribed for 5-7 days to protect against peritonitis.

When can I eat something again?

After an uncomplicated appendectomy, eating may be resumed as soon as the patient is fully awake. However, digestion problems may occur including intestinal obstruction, which itself may even require treatment with a gastric probe. In those cases, eating must be postponed until the problem is solved.

How long does my child have to rest after appendicitis surgery?

Children usually recover quite well and quickly after an appendectomy. If no complications have occurred and the food intake returns to normal, the small patients are allowed go back home after a few days (half to full week). At home they should be treated with care for a few more days before returning to kindergarten or school. Sports and physical activity on the contrary are only allowed after 4-6 weeks, after the abdominal wound has completely healed.

What to look out for after appendectomy in children

Independently on whether your child received a classic open operation or was treated minimally invasive with keyhole technique, you should always keep an eye on the surgical wound(s) at home. Contact your doctor if one or more of the following signs of wound infection occur:

• Reddish skin or warmth at the seam and stitching side
• Pus draining out of the wound
• Fever

How do I support the recovery process after appendicitis surgery?

You can do the following to support the recovery process after an appendectomy:

• Your child should rest and stay at home for some time after consultation with the doctor.
• Make sure you or your child have enough sleep.
• Desired food is allowed unless the doctor says otherwise.
• Eat smaller instead of larger portions.
• The level of movement should be gradually increased. Physical exertion is allowed about 4-6 weeks after surgery.
• Keep stitches and surgical seam clean (as well as your hands).
• Wash your hands before and after bandage change.

Make sure your child takes the prescribed medications. This applies to possible antibiotics in order to avoid the development of resistance of the germs. If you have any side effects or problems, consult your doctor.

Prognosis

What is the prognosis for appendicitis?

The prognosis of appendicitis depends on factors like any underlying diseases, complications during surgery and extent of the infection. Simple and very mild cases of appendicitis or "blind intestinal irritation" may even heal spontaneously under certain circumstances. However, this is not always the case.

A ruptured appendicitis on the other hand is a fundamental danger to life. Therefore, it is important to quickly identify the symptoms and ensure timely surgery. The prognosis is usually very good and a complete recovery of the normal case.

Low mortality

The mortality rate of appendicitis is very low and below 0.1%. Less than one in 1,000 people die from appendicitis, with the elderly and seriously ill in particular at risk. However, the risk of death in ruptured appendicitis is higher, again especially for the elderly, and reaches 6-15%.

Other surgical complications?

Even if the removal of the appendectomy is comparatively harmless routine operation, complications can never be ruled out. Among the most relevant are:

• Wound infections and wound abscesses in 5-20%; especially frequent after ruptured appendicitis (perforating appendicitis)
• Repeated abdominal surgery (re-laparotomy) due to intestinal obstruction (ileus) in 1-2%, usually in the 1st year after the surgery
• deaths: 0.1-0.25%

At what age is the risk of a ruptured appendicitis particularly high?

If the appendix is inflamed, the risk of rupture (perforation) is highest with over 40% in young children between age 1 and 3. With increasing age, this risk decreases and reaches less than 10% among 14- to 19-year-olds.

The overall risk of rupture in appendicitis lies around 10-15% considering the total population and all ages, with most appendicitis occurring in adolescents and younger adults. Beyond the age of 60, the perforation rate rises again and exceeds 30%. One in three patients with appendicitis over the age of 60 thus suffers from this complication.

What complications can occur with appendicitis?

The dangerous aspects of appendicitis lie in possible complications of a purulent inflammation that spreads to surrounding tissue, adjacent organs or further into the abdominal cavity. They include:

• Ruptured appendicitis including perforation (colloquially appendicitis) and in an advanced stage gangrenous appendicitis with peritonitis or abscess formation as consequences.
• Reactive intestinal paralysis of the entire intestine (intestinal paralysis) or intestinal obstruction (ileus), rather rarely.
• Fistula formation in people with Crohn's disease

Is later fertility endangered by appendicitis in childhood?

In contrast to older women, appendicitis in childhood normally does not pose a risk of reduced fertility as a result of complications.

Appendix surgery and sick certificate

In Germany, patients get a sick certificate when they cannot go to work because of an acute (or chronic) illness. The duration of leave from work in appendicitis depends on both the surgical method and the degree of appendicitis. With open surgery, patients are usually slightly longer sick and spend more days in the hospital than patients who are treated with a minimal invasive operation.

Leave from work for 7 to 28 days

As a rule, you will have to stay in the hospital for two to five days after a routine surgical procedure. The situation is different, for example, with ruptured or complicated appendicitis. In such cases, antibiotic treatment and maybe even gastric tube therapy may be required, which prolongs the hospital stay.

Depending on the further course of the disease and depending on your professional situation, you may even have to stay at home for some weeks. For example, patients with physically stressful jobs must wait a little longer until they can return to work than people with an office job. Carrying heavy objects and early exercising can lead to tearing of fresh wounds.

In Germany, experts advise not to carry and lift heavy objects for at least four weeks after an open appendectomy and respectively at least two weeks after laparoscopic removal of the appendix. Lighter physical activities may be allowed beforehand but should be discussed with the attending physician.

Author: Dr. Hubertus Glaser, Dr. med. Sonia Trowe

Sources:

• Pediatricians on the Net
• Gorter, R.R. et al., Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 30, 4668 (2016).