Acute Appendicitis: Complete Guide to Symptoms, Diagnosis, and Treatment

Overview

Acute appendicitis is a medical emergency that can become life-threatening if not treated promptly. Sudden and extreme abdominal pain (which is usually felt near the navel) is the first sign that something is wrong. As the condition progresses, the pain will continue to intensify.

The appendix is a small pouch attached to the caecum, near the beginning of the large intestine.  When the appendix gets clogged up, bacteria begin to multiply. If left untreated, the appendix will fill with pus and eventually burst.

When the appendix bursts, infected material spills throughout the abdominal cavity. The resulting infection is called peritonitis. Peritonitis is a serious, potentially life-threatening infection that requires urgent treatment 

Prompt treatment by way of surgery is almost always recommended. The surgeon will remove the affected appendix in a procedure called an appendectomy. Appendectomies are common procedures that are being performed today.

What Is Acute Appendicitis?

An abrupt onset of inflammation of the appendix occurs when acute appendicitis strikes. Symptoms associated with acute appendicitis develop rapidly — in many instances, they occur within 24 to 48 hours. Typically, acute appendicitis begins when the opening of the appendix becomes obstructed, causing the buildup of bacteria and infection.

The bacteria grow in number; therefore, the appendix becomes enlarged with pus. This increase in pressure inside the appendix results in a decrease in blood supply. If left untreated, the appendix will rupture and release the infectious materials into the abdominal cavity. Rupture of the appendix leads to a severe infection of the abdominal cavity called peritonitis.

A surgeon considers acute appendicitis a surgical emergency. A doctor typically recommends the immediate removal of the inflamed appendix (appendectomy) to avoid rupture. Removal of the appendix via surgery is a safe procedure that is widely practiced throughout the world.

Causes of Acute Appendicitis

A variety of things can cause appendicitis. Probably the most common cause of appendicitis is a hard piece of stool getting stuck in the appendix. This is called a fecalith.

Once the fecalith blocks the appendix, bacteria can multiply inside. Swelling of the lymph nodes caused by infection in the digestive system could also block off the appendix.

Occasionally, foreign objects or parasites get stuck in the appendix and cause a blockage. Very rarely, tumors may block the appendix and lead to inflammation.

Regardless of what is blocking the appendix, the outcome is always the same: increased pressure, increased bacteria (infection), and increasing inflammation.

While certain lifestyle choices may put someone at higher risk for developing appendicitis (for example, eating a low-fiber diet), anyone can develop appendicitis, regardless of their lifestyle.

Symptoms of Acute Appendicitis

The most apparent symptom of appendicitis is abdominal pain. The pain initially comes near the belly button area. Then, it migrates down towards the bottom right side of your abdomen. Eventually, the pain becomes sharp and excruciating.

Bending, coughing, or taking a walk may exacerbate the pain. Nausea, vomiting, decreased appetite, and slight fever are also common signs​ of acute appendicitis. Diarrhea or constipation may also occur.

As time goes on, symptoms become more pronounced. Extreme fever, chills, and great abdominal sensitivity may be indicative of an impending rupture.

However, while many people exhibit symptoms consistent with appendicitis, others may not display them consistently. People who are elderly or pregnant may not demonstrate symptoms consistent with appendicitis, making it harder to detect the problem.

Diagnosis of Acute Appendicitis

Diagnosing appendicitis involves both clinical assessment and various diagnostic tests. The physician's initial step is usually to collect information regarding your past medical history and conduct a physical examination.

The physician will check for tenderness in your lower right abdomen. There are specific findings that might indicate appendicitis. The physician may examine your other symptoms as well, including fever and heart rate.

Blood tests are utilized extensively for diagnosing appendicitis. Blood tests can reveal elevated levels of white blood cells, indicating infection. Your urine test(s) can help eliminate other potential sources of infection (such as urinary tract infections).

Imaging studies aid in confirming the diagnosis of appendicitis. Ultrasonography is very useful for children and pregnant women since it does not expose them to radiation. Computed Tomography (CT) scanning provides much better pictures of your internal organs than ultrasonography and thus is very reliable for detecting appendicitis.

Accurate and timely diagnosis of acute appendicitis significantly reduces the likelihood of complications and enhances the quality of care available for each patient.

Treatment Options for Acute Appendicitis

The usual method of treating acute appendicitis is surgically removing the inflamed appendix through an operation known as an appendectomy. Appendectomies are among the most frequently performed emergency operations in hospitals.

An appendectomy can be completed in either an open or laparoscopic manner. With an open appendectomy, one major incision in your abdomen is made. During a laparoscopic appendectomy, multiple small incisions are created in your abdomen through which a camera will be inserted to view your internal organs as instruments are used to dissect your inflamed appendix.

Since it produces fewer post-operative pain complaints, smaller scarring, and quicker recovery times, laparoscopic surgery is typically favored over open surgery. On occasion, however, open surgery is required to address more complex problems such as a ruptured appendix.

Only occasionally do surgeons use antibiotic therapy alone to treat appendicitis that is milder or earlier in its development. Antibiotic therapy may be successful in decreasing inflammation and infection; however, there is always a possibility that the inflammation will recur if you do not undergo surgery to remove the inflamed appendix.

Antibiotics are typically administered alongside supportive care, including analgesics and intravenous fluids, both before and after surgery to reduce the risk of infection and support recovery 

Recovery After Appendicitis Surgery

Your ability to recover from an appendectomy will depend upon whether you underwent an open or laparoscopic appendectomy, as well as your general state of health before undergoing surgery.

Most individuals recover quickly following a laparoscopic appendectomy. Post-surgically, most patients will leave the hospital within one to three days and will be advised to gradually resume their regular activities.

After surgery, you may feel some level of post-operative pain, which can be controlled with prescribed pain relievers. Additionally, you will likely be asked to refrain from lifting anything heavy or engaging in strenuous activities for at least a couple of weeks.

Generally speaking, most people are back to their normal routine within 1-3 weeks, depending on how well they followed their physician's orders and how quickly they were able to heal.

Post-surgical appointments are crucial so that your healthcare provider can monitor your progress toward complete recovery. Be sure to report immediately to your healthcare provider if you notice any signs of infection (redness, swelling, or fever) after returning home from the hospital.

Complications of Acute Appendicitis

Untreated appendicitis can lead to severe complications. Rupture of the appendix is probably the worst complication associated with untreated appendicitis.

When an appendix ruptures, bacteria spill into the abdominal cavity, creating a serious infection referred to as peritonitis. Peritonitis can prove fatal without immediate medical intervention. Often, a patient suffering from peritonitis will require emergency surgery and potent antibiotics.

Another potential complication from untreated appendicitis is the formation of an abscess. Abscesses are pockets of pus surrounding a ruptured appendix. Surgeons may need to drain an abscess prior to surgery or during surgery itself.

Delays in seeking medical assistance greatly enhance your chances of experiencing complications, as well as lengthening your recovery period. Early detection of symptoms coupled with prompt medical interventions is a critical element for minimizing complications related to untreated appendicitis.

References

Andersson, R. E. (2004). Meta-analysis of the clinical and laboratory diagnosis of appendicitis. British Journal of Surgery, 91(1), 28–37. 

Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278–1287. 

Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., Boermeester, M., Sartelli, M., Coccolini, F., Tarasconi, A., De’ Angelis, N., Weber, D. G., Tolonen, M., Birindelli, A., Biffl, W., Moore, E. E., Kelly, M., Soreide, K., Kashuk, J., … Catena, F. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15(1), Article 27. 

Flum, D. R. (2015). Acute appendicitis — appendectomy or the “antibiotics first” strategy. New England Journal of Medicine, 372(20), 1937–1943. 

Snyder, M. J., Guthrie, M., & Cagle, S. (2018). Acute appendicitis: Efficient diagnosis and management. American Family Physician, 98(1), 25–33.