Appendicitis is one of the medical conditions that many people minimize or take for granted. Patients have gotten good at recognizing the symptoms and doctors have gotten so much better at accurately diagnosing it that people think of it as a minor illness. A minor illness it is not! The potential for serious complications still exists. The appendix can still rupture and life-threatening peritonitis is still a reality. Just because someone has an appendectomy less than 24 hours after the start of symptoms, goes home right after the operation, and returns to work within a week of surgery, It doesn’t mean it’s a minor problem.
The Vermiform Appendix, as it is professionally known, is a “vestigial” structure at the lower end of the large intestine on the right side of the abdomen. Vermiform means worm-like and describes the shape of the appendix. It closely resembles a worm extending downward from the tip of the right side of the colon. Thus, a surgeon I once worked with always referred to Appendicitis as “a hot worm!” Instead of “Appendicitis” he said the patient has “a hot worm.”
“Vestigial” means the appendix is a remnant of the embryonic development of the colon. As the colon was evolving in the mother’s womb, the appendix was the last part to develop and did not completely expand. It could be described as an afterthought, or a tail that was not fully developed, and should have withered and disappeared.
But the human appendix did not wither. It remains a nemesis. It is a blind tube-like structure that serves no real purpose but to exist. We all could live happily ever after without an appendix, and those who have appendicitis and an appendectomy are prime examples. But the appendix, like the tonsils, has a tendency to become infected. Bacteria live in our intestinal tracts and under certain circumstances, collect in the appendix, multiply, and cause infection.
The circumstances that cause appendicitis are well-known. The most important fact is that the lumen, or opening, of the appendix becomes blocked, and bacteria are trapped in the appendix. This happens when a patient is constipated, has infectious diarrhea, becomes dehydrated, has a parasitic infection, has inflammatory bowel disease, ie. Crohn’s disease, has a tumor of the appendix, or suffers abdominal trauma. Most of the time, the actual causative event is undetermined.
The oldest patient I had with appendicitis was 73, but I know of many others who were older. The youngest of my patients was 3 years old. Most often patients are in the 15-50 age range. It knows no race or gender preference. Women, however, make it more difficult to diagnose because of confusion surrounding ovarian and Fallopian tube problems. Distinguishing between appendicitis and an ovarian cyst, tubal (ectopic) pregnancy, and tubal infection can be difficult. Today’s diagnostic technologies greatly help to get the pre-operative diagnosis right. Men, on the other hand, confuse the doctor by having a kidney stone in the right ureter that sits just behind the appendix. CT scans will identify the problem here, too.
The hallmarks of diagnosis for me were localized abdominal pain in the right lower quadrant of the abdomen, loss of appetite, abdominal pain with movement, ie walking, jumping, tenderness of the right lower abdomen localized to a small area, and a mildly increased white blood cell count in the blood. If a patient had those symptoms, I was 99% sure they had appendicitis. For the past 15 or so years, confirmation of the diagnosis was made by doing a CT scan of the lower abdomen and pelvis. CT will find appendicitis 98.5% of the time, and has led to a decreased number of surgeries that find a normal appendix (negative laparotomies) and a decrease in the rate of rupture (perforation) of the appendix.
Other symptoms such as bloating, gas, nausea and vomiting, constipation or diarrhea, and fever can occur but are less frequently seen than the hallmark symptoms.
It used to be said by surgeons that “ if you don’t remove a few normal appendices, your missing cases of Appendicitis.” Routine use of CT has made that phrase sound naive. Some doctors do other confirmatory tests, but in most cases what I’ve said is adequate. But the doctor’s “index of suspicion” (diagnostic intuition) has to be tuned to its highest sensitivity or the diagnosis and treatment will be delayed. And delay leads to leaking or rupture which lead to peritonitis.
Appendicitis has phases or stages of involvement. They are:
1. Early Appendicitis—blockage of the opening leads to swelling, inflammation, and
pain.
2. Suppurative Appendicitis—swelling increases, bacteria and fluid leak from the
appendix and inflammation worsens—the so-called “leaky appendix,” abdominal wall
becomes tender
3. Gangrenous Appendicitis—appendix is dark and near rupture
4. Perforated Appendicitis—appendix wall erodes, infection leaks into abdominal
cavity.
5. Phlegmonous Appendicitis—infection from perforation collects in a walled-off
There is a stage called Chronic Appendicitis, but it occurs only 1% of the time. Here, patients have right lower abdominal pain for at least 3 weeks without finding another cause. They end up having an appendectomy and on microscopic examination have “chronic active inflammation.”
The biggest mimicker of Appendicitis is Mesenteric Adenitis. Within the wall of the appendix and around it are small lymph nodes. These nodes become inflamed and swollen as a result of a viral infection. Mesenteric adenitis causes pain similar to, but less severe than, that of Appendicitis. Abdominal tenderness is less severe and appetite is less significantly affected. The major factor that separates Mesenteric adenitis from appendicitis is the absence of an elevated white blood cell count. CT imaging will differentiate between the two.
The cure for Appendicitis is surgical removal of the appendix, either laparoscopically or through an open incision. The surgeon directly sees the appendix, assesses if it’s leaking or ruptured, and removes what is necessary. If the appendix has ruptured and a walled-off abscess formed, it is important to drain the abscess to help clear up infection. Then IV antibiotics and good nursing care are started. I’ve never seen Appendicitis treated with anything other than surgery. Some doctors advocate a course of intravenous antibiotics, but in my opinion this is fool hardy. It is far easier on the patient to remove an infected appendix in a 30 minute operation than it is to receive 14 or more days of IV antibiotics. You may still have to operate. I’m sure there are studies supporting this premise, but as for me “give me surgery, or give me trouble.”
Dr. G’s Opinion: I saw 1-5 cases of Appendicitis each year. It isn’t rampant in its frequency, but patients who have it “have a look.” You can see it in their face, their color, their actions. If a guy comes in, walking bent at the waist, hand on the right lower abdomen, frowning, and pale, he has appendicitis until proven otherwise. Then when you examine his abdomen and McBurnie’s point—the spot halfway between the navel and the right pelvic bone—is exquisitely tender, your suspicions are raised. His urine is normal, but his white blood cell count is 11,000 or 12,000 (not the normal 500-10,000), and you know what your dealing with.
Calling a surgeon is the next step. He/she may or may not want a CT, but medicolegally, I think it should be done. The CT will tell the surgeon the definitive diagnosis and helps him decide for or against surgery.
Recovery time from an appendectomy is all over the map. Two days to six months has been my experience. Many factors are involved such as severity of involvement, duration of symptoms, presence of leaking or perforation, and patient personality and response to illness. They all play a role. Some patients take a long time to recover while others are unfazed. It’s an individual response.
My Advice: Don’t ignore vague pain that intensifies and localizes to the right lower abdomen, hurts when you walk, and ruins your appetite. You probably have “a hot worm.”
References: Craig S, Brenner D. Appendicitis. Https://emedicine.medscape.com/article/773895
