What is appendicitis?
Appendicitis is the inflammation of the appendix – a worm like structure attached to the beginning of your large bowel.
Although it can happen at any age, it is most common in teenagers and young adults – usually between 5 and 45 years old.
It is a common cause of tummy pain and is one of the most common surgical emergencies in both children and adults.
What is the appendix?
The appendix is a small, narrow, tube-shaped pouch that sticks out from the first part of your large bowel, the caecum.
For a long time, people believed the appendix was a useless remnant from evolution. Recent research have shown that it actually plays important roles in gut health and the immune system.
What causes appendicitis?
Appendicitis starts when something blocks the appendix.
Once the opening is blocked, pressure begins to build inside this small closed tube. As the pressure increases, the appendix fills with mucus and becomes distended and inflamed. This combination of pressure and inflammation is what makes it so painful.
If the blockage isn’t relieved, the inflammation worsens over a few hours and bacteria can begin to multiply inside.
The pressure can also reduce blood flow to the appendix wall as small blood vessels and lymph channels become compressed. When this happens, the tissue doesn’t receive enough oxygen, which can damage the wall. This is called gangrenous appendicitis.
If the process continues, the appendix may burst, allowing infection to spread throughout the abdomen.That’s why appendicitis is considered a medical emergency.
There are several things that can block the appendix. Often it’s a small, hardened piece of stool, called a faecalith or appendicolith.
Swelling of the immune tissue can be triggered by viral infections, like measles, flu or adenovirus. This swelling narrows the appendix and can trigger inflammation. Scientists are still figuring out exactly how it happens, but it’s thought that the body’s immune response to the virus plays a key role.
Less commonly, parasites or abnormal growths, like polyps or tumours in the appendix or the nearby large bowel can cause a blockage.
What are the symptoms?
Appendicitis usually starts with a vague, dull pain around your belly button, which gradually moves to the lower right part of your belly.
This happens when the blocked appendix fills and stretches. Special nerves in the appendix wall, which are part of the sympathetic nervous system, sense this stretch and send signals to the spinal cord. Your brain reads them as a dull, vague pain. This is known as visceral pain, because it comes from the internal organs.
As the inflammation reaches the lining of your abdomen over the appendix, called the peritoneum, the pain changes. Nerves in this lining, known as somatic nerves, sense the irritation and your brain interprets it as a sharper, more focused pain. This is called parietal pain, because it comes from the wall of the abdomen rather than the organs inside. This is usually when the pain settles in the lower right part of your belly, where the appendix sits. The pain can get worse when you move, walk or cough and some people even wake up from it at night.
The peritoneum is a thin layer that lines your belly and covers most of your abdominal organs.
Along with the pain, people often notice a loss of appetite, nausea, vomiting and a general feeling of being unwell. About 40% of people also have fever by the time they see a doctor.
Others may notice diarrhoea or increased frequency or urgency to urinate, which can happen when the inflamed appendix irritates nearby organs, such as the bowel or bladder.
Special cases
Some cases of appendicitis can be a bit unusual, especially in very young kids, older adults or pregnant patients.
In young children, it can be harder for them to describe exactly where it hurts, so the symptoms may look a bit different. In older adults, the pain may take longer to appear because the nerves that carry pain signals can be less sensitive.
In pregnancy, the growing baby can push the appendix upward, so the pain may show up higher in the belly than usual.
How do doctors know is appendicitis?
Most of the time, doctors diagnose appendicitis by asking about your symptoms and feeling your belly. The classic pattern of vague pain near the belly button, then nausea/vomiting, followed by tenderness on the right side and sometimes a fever, is often enough – especially in young men.
In women, it can be trickier because gynaecological issues can cause similar symptoms, so doctors may need to check a bit more carefully.
Physical signs
When examining your belly, doctors may look for a few special signs. One is the Rovsing sign – pressing the lower left side of your belly moves the nearby bowel and puts a little pressure on the inflamed appendix, which can cause pain on the right side.
They also check McBurney’s point, a spot in the lower right where the pain is usually strongest.
Sometimes the muscles around the area tighten automatically, this is called guarding. It’s your body’s natural reaction to the pain, happening without your control, even if you’re trying to relax your belly.
Other tests
When you go to the emergency department with belly pain, doctors usually do blood tests, which can show signs of infection, such as raised inflammatory markers.
Depending on your symptoms, they may also check your urine to make sure you don’t have a urinary infection, which can also cause lower belly pain.
Imaging is usually only needed in special cases. An abdominal ultrasound is usually the first choice, particularly in children and women. In children, it can help rule out swollen lymph nodes in the belly (called mesenteric adenitis); while in women, it’s used to check for gynaecological problems, like a ruptured ovarian cyst.
If the ultrasound isn’t clear, in older adults, overweight patients or anyone with unusual symptoms, a CT of your belly may be required.
What is the treatment?
The usual way to treat appendicitis is surgery to remove the appendix, called an appendicectomy. This prevents it from bursting and causing a serious infection in the abdomen.
Most of the time, the surgery is done with keyhole surgery, using small cuts and a camera, which means less pain and a quicker recovery.
In some cases, antibiotics may be tried first, but this isn’t the usual approach. The appendix can become inflamed again fairly quickly – about 1 in 4 people who only receive antibiotics need surgery within a year.
If the appendix has already started to die (gangrenous), antibiotics alone can’t reach the infection properly, so surgery is generally needed.
When appendicitis gets more serious
In complex cases, as when the appendix has already burst or is badly inflamed by the time of surgery you may need to stay in hospital a bit longer to receive antibiotics through a drip after the operation.
If the appendix has burst and caused an abscess – a pocket of pus nearby – you might need a procedure called percutaneous drainage.
A radiologist will place a small tube into the abscess to help the infection settle, which can make any later surgery easier.
You’ll also be on strong antibiotics for a while before the appendix can be safely removed in a planned operation. It’s important to know that this is a special situation and the exact approach is individualized based on how long you’ve been sick and how severe your symptoms are as sometimes doing the surgery right away is a better option than just drainage.
If the inflammation has spread to where the appendix meets the bowel, or if the surgeon thinks a tumour might be involved, a bigger operation may be needed. Sometimes part of the bowel also needs to be removed to fully treat the infection and prevent complications. If a tumour is found, the surgery can take care of it at the same time.
Recovery after surgery
As most appendectomies are done using keyhole surgery, with small cuts, recovery is usually quick.
If your appendicitis wasn’t complicated, you’ll often go home the next day and sometimes even the same day, depending on hospital protocols.
It’s normal to feel a bit tired for about a week, but most people are able to return to their usual routine in about a week.
If everything was straightforward, there are no specific diet restrictions and you can live perfectly well without an appendix.
In more complicated cases recovery can take a few weeks, especially if a larger operation was needed or if keyhole surgery wasn’t possible.
Although recent research suggests the appendix may play a role in gut health and immunity, most people recover fully without it and usually don’t need any long-term treatment or lifestyle changes after surgery.
Do I need to be checked after surgery?
After your appendicectomy, your doctor will usually ask you to follow up in a week or two to make sure you’re recovering well and that your wounds are healed.
The removed appendix is tested in the lab to check for hidden issues, such as a rare tumour, and your doctor will go over the results with you.
Depending on your age, family history or other risk factors, a colonoscopy may be recommended, especially if you’re over 50 and haven’t had one for a while. During surgery, the doctor can only see the outside of the bowel, not the inside, so a colonoscopy helps check for any hidden growths or problems.
For younger adults with no other risk factors, a colonoscopy just because of appendicitis is usually not needed.
The controversial chronic appendicitis
Chronic appendicitis is quite rare and some doctors even question whether it’s a true disease. It’s estimated to account for less than 2% of appendicitis cases.
It’s thought to happen when the appendix is partially blocked, causing long-lasting, low-level inflammation.
It can cause ongoing or recurring lower right belly pain that comes and goes over months or even years. Unlike typical appendicitis, blood tests and scans often look normal, which makes it hard to spot.
If chronic appendicitis is suspected, a keyhole (laparoscopic) appendicectomy is usually performed as the only way to confirm the diagnosis is by examining the removed appendix under a microscope.
The surgery not only relieves the pain if the appendix is the cause, but also allows surgeons to check for other possible reasons for your symptoms.
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