The appendix is a tubular structure attached to the cecum, the first portion of the large intestine. It is usually located in the right lower abdomen. Appendicitis occurs when the appendix becomes infected. It is one of the most common abdominal surgical emergencies. The risk of developing appendicitis over your lifetime is about 8%.
The appendix has a natural opening that allows it to drain into the cecum. Appendicitis develops when this opening becomes obstructed. Causes of the obstruction include inflammation of the lining of the appendix, fecaliths (hard pieces of stool) and benign or malignant growths.
Appendectomy is the surgical removal of the appendix. Timely surgery is important. Untreated, the obstructed appendix can rupture. This can lead to a collection of infected fluid called an abscess, or a more severe abdominal infection called peritonitis.
Symptoms of appendicitis vary, but the most common symptom is pain. This pain can begin in the upper abdomen or around the bellybutton and then move over several hours to the right lower abdomen. The pain can also begin in the lower abdomen, especially on the right. Usually, the pain worsens over 8 – 24 hours and can be associated with nausea, vomiting, and decreased appetite. Fever may occur later in the illness. If you think you have appendicitis, you should see a physician immediately. The appendix can rupture within 48 hours of the onset of symptoms if treatment is not initiated.
The diagnosis of appendicitis starts with an examination by an experienced physician. Usually, patients will have significant tenderness in the right lower abdomen. Blood work may show an elevated white blood cell count. CT scan of the abdomen is often used to help diagnose appendicitis and can indicate whether the appendix is ruptured. Other conditions can mimic appendicitis, so a careful evaluation is important.
The most common treatment for uncomplicated appendicitis is appendectomy (removal of the appendix). This is often performed using laparoscopic or robotic surgery. Three small “keyhole” incisions are made in the abdomen. A camera (“laparoscope”) is inserted through one of the incisions. The other two incisions are for the instruments used to remove the appendix.
Laparoscopic appendectomy can usually be completed by an experienced surgeon even if the appendix is ruptured. However, severe cases of appendicitis can require more extensive “open” surgery through a larger incision.
Patients undergoing laparoscopic appendectomy for early appendicitis may be able to go home the same day or the following day. Patients with a ruptured appendicitis will require a longer hospitalization. Your surgeon may prescribe medication to help manage pain after surgery. Many patients can successfully manage their pain with just Tylenol or ibuprofen and may not need narcotics. Ice packs on the incisions can also help, and short walks are encouraged to help speed the recovery.
Nonstrenuous activity is recommended for 3 to 4 weeks after surgery. Most patients can drive a car and return to work in about a week. There are no dietary restrictions after appendectomy, but it is helpful to eat soft bland foods initially and gradually progress over a few days to your regular diet.
Complications after laparoscopic appendectomy are uncommon. As with any surgery, bleeding or infection can occur. Infection is the most common complication, and this can occur in the incision or inside the abdomen in the form of an abscess. Infection is more common in cases of ruptured appendicitis. Notify your surgeon if you notice spreading redness, increasing warmth, severe pain, or significant drainage from the incisions. Progressively worsening abdominal pain associated with fever greater than 101º F could be a sign of a developing abscess. Notify your surgeon right away if these symptoms develop.
For most patients, appendectomy is the best treatment for appendicitis. In some situations, however, appendicitis may be managed with antibiotics. An important disadvantage of this is a significant chance of recurrent appendicitis in the future. Your surgeon will discuss the different treatment options with you.
In cases of perforated appendicitis, an abscess may form. CT scan guided drainage of the abscess by a radiologist may be used initially to treat the abscess. Surgery would be delayed until a later time. In other cases, advanced appendicitis may be managed initially with antibiotics. If the patient responds well, they may be discharged home after few days of treatment, and then undergo a laparoscopic appendectomy after 8 to 12 weeks.