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About Appendicitis

Posted Jun 02 2009 4:40pm 1 Comment

General Info about Appendicitis

The vermifom appendix or appendix in short, is a small part of the bowel or intestine. It is situated on the right side of the abdomen at the junction of the small and large intestines . It is a small narrow sac approximately 10 cm long and 1 cm wide. The appendix is a vestigial organ, that is, it serves no useful purpose.

General abdominal pain is often all that the patient will complain of during the first few hours of his attack But after the first few hours it becomes more evident that the chief seat of pain is at [the iliac fossa], and the general pain then usually subsides. In every case the seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus.
-Charles McBurney, 1889



Appendix

What happens in Appendicitis?

Appendicitis occurs when the appendix becomes inflamed. Appendicitis usually occurs as a result of faecal material and other debris getting stuck inside the appendix. Sometimes, worms can also cause a blockage of the narrow sac leading to appendicitis.

The danger with appendicitis is that the blocked appendix can burst leading to peritonitis. Peritonitis is infection of the peritoneum, the lining of the abdominal cavity.

Who is at risk in Appendicitis

Appendicitis is the most common cause for a child to need emergency abdominal surgery.

A risk factor is anything that increases a person’s chance of getting a disease such as Appendicitis.

Risk factors for Acute Appendicitis are factors that do not seem to be a direct cause of the disease, but seem to be associated in some way. Having a risk factor for Acute Appendicitis makes the chances of getting the condition higher but does not always lead to Acute Appendicitis.

Age: Appendicitis can occur in all age groups but it is more common between the ages of 11 and 20.

Gender: A male preponderance exists, with a male to female ratio ( 1.4: 1 ) and the overall lifetime risk is 8.6% for males and 6.7% for females. A male child suffering from cystic fibrosis is at a higher risk for developing appendicitis.

Diet: People whose diet is low in fiber and rich in refined carbohydrates have an increased risk of getting appendicitis.
Hereditary: A particular position of the appendix, which predisposes it to infection, runs in certain families. Having a family history of appendicitis may increase a child's risk for the illness.

Seasonal variation: Most cases of appendicitis occur in the winter months - between the months of October and May.

Infections: Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis, Mumps, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.

Appendix

Appendix

What are the symptoms of Appendicitis?

The most common symptom of appendicitis is abdominal pain on the right lower side of the abdomen.

Features of abdominal pain

The most common early symptom is an aching pain around the navel.

The pain often shifts later to the lower right abdomen.

As the inflammation in the appendix spreads to nearby tissues, especially the inner lining (peritoneum) of the abdomen, the pain may become sharper and more severe.

Eventually, the pain tends to settle in the lower right abdomen — near the appendix known as McBurney point. This point is about halfway between the navel and the top of the right pelvic bone.

Pain will also tend to get worse on coughing, walking or with other jarring movements.

The pain may lessen on lying to one side or on pulling up the knees towards the chest.

In addition to pain, the patient may have one or more of the following signs and symptoms:

Nausea and sometimes vomiting

Loss of appetite

A low-grade fever that starts after other signs and symptoms appear

Constipation

An inability to pass gas

Diarrhea

Abdominal swelling

In appendicitis these symptoms tend to become more severe as time passes. Not everyone with appendicitis has all the symptoms. A laxative or enema should not be taken if appendicitis is suspected.

How is Appendicitis diagnosed ?

Appendicitis is usually a clinical diagnosis and investigations are done to rule out other causes of abdominal pain.

A history of a patient's symptoms is often the key to making an appendicitis diagnosis. When gathering the medical history, the doctor will ask about the nature, timing, location, pattern, and severity of the pain and other possible appendicitis symptoms like nausea, vomiting, fever and constipation.

It is important to tell your doctor about:

Medications

Any previous medical conditions and surgeries

Allergies

Any previous family history of medical conditions and surgeries

Use of alcohol, tobacco, and any other drugs.

Before the physical examination , a nurse or doctor will usually measure vital signs, which include:

Pulse rate

Temperature

Blood pressure

Breathing rate.

The abdomen is next examined to confirm his suspicion. Location of the pain and tenderness is important.

Pain is a symptom described by a patient; tenderness is the response to being touched. Certain specific signs will help to diagnose appendicitis.

McBurney's sign - deep tenderness at McBurney’s point is a sign of acute appendicitis.

Rebound tenderness - If gentle pressure is applied at the McBurney’s point, it will feel tender. If the pressure is released suddenly appendicitis pain often will feel worse which is due to inflammation of the peritoneum overlying the appendix area.

Treatment for Appendicitis

The treatment of appendicitis is an immediate appendectomy, which may be done by the standard Open Appendectomy Technique, or through Laparoscopy.

Appendectomy is usually performed as an emergency procedure.

Preoperative preparations

Informed consent- written consent is obtained from the patient prior to performing the surgery.

While awaiting surgery, the patient will be given IV fluids for hydration.

He is kept nil orally to prevent aspiration during anesthesia.

The patient will be initiated on appropriate antibiotics.

Painkillers may be prescribed before the procedure.

The Abdomen and genital area may be shaved and prepared for the surgery.

If Appendectomy is an elective procedure

Certain hospital formalities maybe required before hospitalization especially if you have private health insurance . Clarify the issue with the doctor or with the administrator. Sometimes authorization maybe required from your insurance service provider for the procedure.

You may require packing your usual toiletries and a few clothes including undergarments, night wears for hospital stay. If the operation is done using Laparoscopy the stay in hospital may only be for a day or two whereas an open surgical procedure may require a 5 to 7 days stay.

Before surgery or during the previous night a bath maybe advisable. During the bath thorough cleaning of the abdomen and genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery.

Appendicitis Open Surgery

The Open Appendectomy Technique is the surgery of choice if perforation of the appendix or appendicular abscess is suspected.

Steps of surgery:

After administering anesthesia the abdomen is prepared with an antibacterial solution.

A McBurney’s incision (at the Mc Burney’s point) or a transverse incision about 5 cms or two to three inches in length is made through the skin and the layers of the abdominal wall in the area of the appendix .

The tissues are dissected to locate the appendix, which is present in the right lower abdomen.

The area around the appendix is examined to be certain that no complications of appendicitis

The appendix is then removed which is done by freeing the appendix from its attachment to the abdomen and to the colon.

The appendix is cut from the colon and sutures are placed over the hole in the colon.

If an abscess is present, the pus is drained with drains (rubber tubes) that go from the abscess and out through the skin.

After ensuring complete haemostasis the abdominal incision then is closed in layers.
are present.

Appendicitis Laparoscopic Surgery

Laparoscopic Appendectomy is often used if the diagnosis of Appendicitis is in doubt, or if it is desirable to hide the scars of surgery .

A laparoscope is a thin telescope tube (from 5 to 10 mm diameter) with a magnifying glass-like eyepiece at one end to which a video camera is attached. Through the camera the view inside the abdomen can be seen on a television monitor.

Steps of surgery:

After administering anesthesia the abdomen is prepared with an antibacterial solution.

In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide).

The surgery begins with a small abdominal incision below to the belly button in the skin crease, which allows the insertion of the laparoscope. Another two or three small incisions may be necessary to insert the laparoscopic instruments to dissect and remove the appendix.

Using the laparoscopic surgical l tools, the tissues and vessels surrounding the appendix are cut and tied.

The appendix is reduced in size by cutting into smaller sections before being removed through the small incision.

The abdominal cuts are all closed with stitches, which are likely to leave small scars.

The removed appendix is sent to a pathology lab to be analyzed.

Appendicitis After Care

Recovery from a simple appendectomy is usually complete and rapid. Most patients can go home the day after the operation, and resume normal activities.

The usual stay in the hospital after an appendectomy for an uncomplicated appendicitis is 1-3 days, depending on the age, other medical problems and physical condition of the patient. If the appendix is gangrenous or ruptured, the hospital stay may be 7 days or longer.

Movement - Right on the next day after the surgical intervention the patient is allowed to get up and slowly take a few steps through the hospital. Although itmay seem like a torment for a just operated person, movement is essential for the resumption of the intestinal transit and will also prevent the occurrence of pneumonia by inhalation of digestive content.

Diet - To allow the digestive tract to rest after surgery , patients will not be given anything to eat or drink for the first 24 hours after an appendectomy. After that, they gradually will be given small amounts of water, then clear liquids, and then some solid foods, until finally they are able to handle a regular diet .

Medications - Patients usually are given a dose of antibiotic intravenously (into a vein) during surgery and the antibiotic is continued until the day after surgery. If the appendix ruptured, the patient will need to take antibiotics for a week or more.

Activity - Light activity at home is encouraged after surgery. The patient can expect to return to normal activities, such as showering, driving, walking up stairs, light lifting, and work within a few days. If he is taking narcotic medications for pain, he should not drive.

Be sure to call your doctor if any of the following symptoms appear:

Fever

Worsening pain

Redness or swelling around the incision

The incision is warm to the touch

Drainage from the incision

Complications of Surgery

Complications are rare following an appendectomy.

The most common complication of appendectomy is infection of the wound

Wound infection can cause the skin to become red and inflamed and pus to leak from the incision site. In this case, antibiotics are started and discharge from the hospital may be delayed, depending on the severity of the infection. On rare occasions, the site must be reopened to allow the wound to drain. Wound infections are less common with laparoscopic surgery .

Appendicular abscess another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques, like insertion of a drain. A drain (a small plastic or rubber tube) usually is inserted through the skin and into the abscess with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The drain allows pus to flow from the abscess out of the body.

Paralytic ileus may occur following the operation. The bowel is normally in constant motion, digesting food and absorbing nutrients. Disturbing the bowel during surgery can cause the motion to come to a standstill. Fluid and gas may then cause the bowel to swell or distend. A nasogastric tube is passed through the nose and into the stomach to relieve the distension.

When bowel function returns to normal (evident by passing gas or having a bowel movement), the tube is removed. Until that time, food and liquid are not permitted by mouth , and hydration is maintained intravenously. Paralytic ileus is more common when the appendix has perforated.

Appendicitis FAQs

Who treats appendicitis?
A general surgeon or a gastroenterologist treats appendicitis.

Is appendicitis preventable?
There is no known way to prevent appendicitis. However, if you are able to recognize appendicitis symptoms, you can prevent serious appendicitis complications from occurring.

Removing the appendix is the only sure cut way of preventing appendicitis. This may be done if intrabdominal surgery is being performed for other reasons and the appendix is removed incidentally but it is not practiced as a routine.

Does appendicitis always present with typical symptoms?
Immunosuppressive therapy, Diabetes Mellitus, Chemotherapy and Obesity are some of the special conditions in which the patients may not have the typical set of symptoms for appendicitis and may simply experience a general feeling of being unwell.

What are the Complications of appendicitis?
The most serious complication of appendicitis is an infection of the lining of your abdominal cavity (peritonitis). This may occur if your appendix ruptures (perforates) and the contents of your intestines and infectious organisms invade the peritoneal cavity. Peritonitis is a medical emergency.

Sometimes, infection and the seepage of intestinal contents may form an abscess, a walled-off area of infection (appendiceal abscess), it requires surgery before the abscess itself perforates, causing peritonitis.

What are the symptoms of peritonitis?
When the appendix ruptures, the patient may suddenly feel better. But soon after, the entire abdomen may become distended with gas and fluid and will likely feel tight, hard and tender to the touch. He may also have pain throughout the abdomen, but may not have the severe, localized pain of appendicitis. In addition, he may not be able to pass gas or have a bowel movement because of the inflammation. Other signs and symptoms may include a fever, thirst and a low urine output.

Can appendicitis be treated with medicines?
In some cases, infections may cause the same symptoms as appendicitis. Therefore, if an appendicitis diagnosis is uncertain, people may be watched and sometimes receive antibiotics as appendicitis treatment. If the cause of the pain is an infection, symptoms should resolve with intravenous antibiotics and intravenous fluids. However, if the patient has appendicitis, the condition cannot be treated with antibiotics alone and will require surgery.

Are there long-term consequences of appendectomy?
It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example, Crohn's disease.

Appendicitis Glossary

Abdomen: The belly, that part of the body that contains all of the structures between the chest and the pelvis. The abdomen is separated anatomically from the chest by the diaphragm, the powerful muscle spanning the body cavity below the lungs.

Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior.

Anesthetic: A substance that causes lack of feeling or awareness. A local anesthetic causes loss of feeling in a part of the body. A general anesthetic puts the person to sleep.

Antibiotic: A drug used to treat infections caused by bacteria and other microorganisms. Originally, an antibiotic was a substance produced by one microorganism that selectively inhibits the growth of another. Synthetic antibiotics, usually chemically related to natural antibiotics, have since been produced that accomplish comparable tasks.

Appendix: A small out pouching from the beginning of the large intestine (the ascending colon). Formally called the vermiform appendix because it was thought to be wormlike.

Complication: In medicine, an additional problem that arises following a procedure, treatment or illness and is secondary to it. A complication complicates the situation.

CAT or CT scan: Computerized Axial Tomography scan. Pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them into pictures on a screen. CT stands for computerized tomography.

Fecolith: A hard stony mass of feces. A fecolith can obstruct the appendix, leading to appendicitis.

Fever: Although a fever technically is any body temperature above the normal of 98.6 degrees F. (37 degrees C.), in practice a person is usually not considered to have a significant fever until the temperature is above 100.4 degrees F (38 degrees C.).

Incision: A cut. When making an incision, a surgeon is making a cut.

Infection: The growth of a parasitic organism within the body. (A parasitic organism is one that lives on or in another organism and draws its nourishment there from.) A person with an infection has another organism (a "germ") growing within him, drawing its nourishment from the person.

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Can adrenal fatigue cause appendicitis or at least be a possible contributor
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