Appendicitis - MITR

Appendicitis

Introduction

The appendix is a blind ended tube-like organ arising at the junction of the small and large intestine. It extends for almost 6 to 10 cm long. It does not have any function. In the event of an infection, it tends to get swollen and there are chances of rupture with spread of infection into the abdominal cavity. In view of this complication, an infected appendix needs urgent removal by surgery.

Location

The appendix is located on the right lower abdomen, usually lying behind the cecum (first part of the large intestine). Less commonly, it can lie in front of the small intestine or in the pelvis.

Problems

The appendix can get an infection from the stomach. The other possibility is from stools entering it, as it is located close to the large intestine. In some situations, the stool particle can remain in the appendix and is seen on x-ray or a barium test as a stone. Infections of the appendix cause a swelling which has a higher chance of burst in the presence of a stone. This may lead to spread of pus from inside the appendix to the entire abdomen and the blood stream to affect other distant organs of the body like lungs, kidney.

Symptoms

Appendicitis usually starts with tummy pain around the belly-button. In the first one or two days, it is vague, can be severe at times. Later, the pain becomes more intense and stays on the right lower abdomen. In the presence of a stone in the appendix, this typical duration is lesser and more severe pain may be present within 24-48 hrs. The pain becomes constant and quite severe requiring injectable medication. The other symptoms may be present like nausea, vomiting, fever, constipation, loss of appetite.

When to worry

Any pain gradually increasing in intensity and spreading to all over the abdomen, not responding to local remedies, feeling ill should make one alert and prompt you to see your physician.

Tests to diagnose appendicitis

A typical presentation makes it easy to diagnose appendicitis. Some patients may not have typical symptoms especially when it is located behind the large intestine, in the pelvis or extending as long as to reach the liver. Other conditions causing similar pain are urine infection, right urine stone, colon infection. To aid diagnosis, tests might be required like

1. Blood test – WBC count – May be elevated to suggest infection

2. Urine examination – To check for urine infection

3. Ultrasound examination – Can help visualize swollen appendix, any reactionary fluid.

4. CT Abdomen – In cases of doubt, Computerized Tomography is advised.

Treatment

Initial treatment consists of admission, intravenous antibiotics and painkillers. In the presence of vomiting, intravenous fluids also need to be administered. Surgery is planned after taking consent and explaining the nature of surgery and anesthesia.

Options in surgical treatment

Removal of appendix called as appendectomy is one of the most common surgeries performed worldwide. There are different ways to perform the surgery.

1. Open surgery

2. Conventional Laparoscopic surgery

3. Single Incision Laparoscopic surgery

Table 1.

Comparison of Traditional Laparoscopic surgery vs SILS

Open Surgery
Single Incision Laparoscopic Surgery
Single Incision Laparoscopic Surgery
Anesthesia
General / Spinal
General
General
Cut of Surgery
2 – 4 inches
3 cuts (5mm each)
1.5 - 2cm
Site of cut
Right lower abdomen
Belly-button, Right lower abdomen, Above the Pubic area
Belly-button
Pain
Yes
Less
Least
Scar
Large
Multiple small
Minimal
Recovery time
Long
Less
Least
Burst Appendix
Possible
Possible
Possible
Previous surgery
Possible
Possible
Difficult