Appendicitis Symptoms and Treatment
Appendicitis is the inflammation of the vermiform appendix, a small pencil-like structure connected with the cecum, the first part of the large intestine. Appendicitis is caused by an obstruction and infection in the appendix and interference with the blood supply there.
As in most types of inflammation, appendicitis occurs in either an acute, subacute, or chronic form. In most instances, appendicitis is acute, developing suddenly and rapidly in a previously undiseased appendix and running a relatively brief course. In subacute appendicitis, the onset is less abrupt and violent, or, after an initial onset of the acute type, the process partially subsides. Chronic inflammation of the appendix is the residual disease following in the wake of untreated but self-controlled acute or subacute appendicitis. The changes in this form of the disease usually are so mild that the individual is not aware of the condition.
Cause of Appendicitis
The appendix is a sac four to five inches (10 to 12.7 cm) long and open only at one end. It is made up of the same tissue layers as the large intestine. Its function is not known.
In most cases of appendicitis, the cause of the inflammation is interference with free drainage from the appendix. Inflammation usually develops when the opening through which the appendix communicates with the intestine is obstructed or narrowed. The obstruction causes the pressure to rise in the appendix since more material is being secreted into the appendix (from its lining) than is being absorbed from it. As a result, the increased pressure sets the stage for inflammation. A common obstruction found in cases of acute appendicitis is a small piece of hardened fecal residue. Also, accumulations of lymphoid tissue, which are found in the appendix as in other areas of the intestinal tract, may swell up under certain conditions and obstruct the opening of the appendix. Whatever the basic factors that lead to appendicitis, the inflammation itself is provoked by bacteria that are permitted to invade the wall of the organ.
Symptoms and Nature of Appendicitis
The signs and symptoms of appendicitis are determined by two factors: the type of inflammation (acute, subacute, or chronic) and the location of the appendix.
Type of Inflammation
In acute appendicitis, the victim develops a characteristic stomach ache, followed, shortly after, by nausea and frequently by vomiting. After a variable period of 1 to 12 hours, the diffuse abdominal discomfort changes to a pain localized to a restricted area on the right side of the lower abdomen. At this point, the individual is aware of the localized discomfort if he moves or coughs. A slight elevation of one or two degrees of temperature then may appear. These symptoms may progress to the stage that is described as peritonitis (see Complications, below), or improvement will take place with partial or complete recovery.
In the very early stages of acute appendicitis, the appendix, which usually has a pearly white appearance^ becomes thickened and reddened. The fatty tissue through which its blood vessels run becomes markedly swollen. As the acute process progresses, the organ becomes more enlarged, and eventually one area becomes dark, indicating the point at which perforation will take place. This rupture leads to the peritonitis.
If these symptoms abate only partially and there is continued but less severe pain, the condition is subacute appendicitis. In this condition, the appendix is walled off from the rest of the peritoneal cavity by the swelling of the adjacent abdominal organs.
Finally, complete recovery may seem to take place; however, the appendix usually does not return to a normal state, and it remains chronically infected in most cases. The symptoms of this chronic type of infection are characteristically ill-defined and difficult to interpret. Commonly, there is mild intermittent pain in the lower abdomen. The appendix itself is scarred and chronically inflamed.
Location of the Appendix
In most people, the appendix is situated normally. Thus when it becomes inflamed, the maximal tenderness is found at a point between the umbilicus and the sharp front edge of the right hip bone. This is known as McBurney's point, and localized tenderness in this area usually is characteristic of acute appendicitis.
However, in a considerable number of people, the appendix is located in an abnormal position, and as a result the physical findings as well as the subjective complaints may be altered, making the diagnosis difficult and often confusing. The so-called retrocecal appendix is one located behind the cecum. In this position, very pronounced acute inflammation of the appendix may develop with little or no perceptible abdominal tenderness. In fact, the maximum tenderness in these instances may be found in the flank on the right side of the body. In other cases, the appendix is located toward the midline of the abdomen and may rest on the urinary bladder. In this instance, inflammation commonly will be associated with a frequent and urgent desire to urinate, and on urinalysis, pus cells may be discovered in the urine.
Diagnosis of Appendicitis
The diagnosis of appendicitis rests principally on physical findings instead of laboratory aids. Although many believe that an elevated white blood cell count is necessary for a diagnosis of appendicitis, this is not true. While the white blood count usually is elevated in appendicitis, an identical elevation may occur in other acute inflammatory conditions within the abdomen. Therefore, the white blood count is significant only when it is correlated with the physical findings as determined by the physician.
In acute appendicitis, the total white blood cell count is elevated to the range of 15,000 to 25,000 per cubic millimeter of blood (7,000 to 8,000 per cu mm is normal). But an increase of immature forms of white cells, better known as "a shift to the left," gives the physician a good index of the severity of the inflammation in appendicitis.
An X-ray of the abdomen is helpful in certain circumstances because it reveals significant changes. In chronic appendicitis, examination of the colon by means of a barium enema often indicates localized tenderness in the region of the appendix.
After a careful diagnostic survey is completed, the diagnosis may remain in doubt in a small percentage of cases. In these instances, the astute physician may withhold a final diagnosis during an observation period of 8 to 24 hours in the hope that further developments may clarify the problem.
In the great majority of cases, the diagnosis of appendicitis is a relatively simple one based on the symptoms described. However, the characteristic symptoms do not develop in about one third of appendicitis cases. For example, diagnosis is difficult in individuals whose appendix is in an abnormal position. Also, there are many acute inflammatory conditions of other organs that may simulate appendicitis. Inflammation of the lymph glands of the mesentery of the small intestine (acute mesenteric adenitis) in young patients is almost indistinguishable from appendicitis because the lymph glands in a child are conspicuous in the region of the intestine where the appendix is located. Disease of the right uterine tube or ovary in the female may be extremely difficult to differentiate from appendicitis because these organs are near the appendix. Inflammatory disease of the end portion of the small intestine (regional enteritis) sometimes is identified for the first time when the patient is operated on with a pre-operative diagnosis of acute appendicitis. In the older patient, cancer of the cecum may simulate acute appendicitis. In addition, it may cause appendicitis if the tumor obstructs the intestine where the appendix branches off.
Treatment of Appendicitis
The treatment of appendicitis primarily and basically is surgery in which the diseased organ is removed. This operation is called an appendectomy.
An appendectomy usually is carried out under general anesthesia. Spinal anesthesia may be preferable under certain circumstances, and there are clinical situations in which local anesthesia using novocaine or a similar agent is employed after appropriate preoperative medication.
When the diagnosis of appendicitis is clear, a small two- to three-inch oblique, muscle-splitting incision is used in the male patients. However, in the female and in instances where the diagnosis is not definite, a larger vertical incision permittng exploration is made. The operation itself consists of tying off the blood vessels that supply the appendix and then removing the appendix.
The operative procedure commonly requires 30 to 45 minutes. The patient has relatively little postoperative discomfort for a period of one to two days and, barring complications, leaves the hospital on the fifth to seventh day.
There are a few instances in which this standard surgical treatment is inadvisable. For example, if appendicitis occurs in a hemophiliac, the danger of uncontrolled bleeding must be weighed against the likelihood that the appendicitis will progress to a fatal stage. An extremely debilitated, aged person may be such a poor operative risk that treatment with antibiotics is substituted for surgery. In those unusual circumstances in which a surgeon is not available, the patient with acute appendicitis should be treated with antibiotics and other conservative measures rather than undergo surgery by untrained and inexperienced personnel.
When the diagnosis of appendicitis is in doubt, surgery usually is delayed temporarily. While this practice involves the danger that an acute appendicitis will progress to an advanced stage, it ordinarily can be used safely if the individual is under continual medical observation. In suc'h instances, it is a common procedure to place the patient in the hospital where repeated examinations and laboratory tests during a period of 8 to 24 hours may clarify the diagnosis of appendicitis or one of the other conditions mentioned. Under such circumstances, prompt and alert surgical intervention must be undertaken once the diagnosis becomes clear. After a reasonable period of observation, surgery occasionally is undertaken in spite of the fact that the diagnosis remains somewhat clouded.
Removal of the inflamed appendix is as clearly recommended in the case of subacute appendicitis as in acute appendicitis. Also, removal of a chronically diseased appendix ordinarily is indicated. However, this diagnosis must be based on a clear history of one or more previous acute attacks, and the complaints of the individual must be persistent or recurrent.
The complications of appendicitis may be fatal in neglected cases. These are avoided by prompt removal of the appendix early in the course of the disease. The most feared and lethal complication is perforation of the appendix leading to contamination of the peritoneal cavity and the development of peritonitis. Peritonitis is identified by the spreading of the tenderness from a localized area to the entire abdomen. The abdomen becomes distended, the fever becomes more elevated, and the patient appears extremely ill. In the "pre-antibiotic" days, the majority of these victims died. However, at the present time, the use of antibiotics, even in the far-advanced cases, has reduced this mortality to an extremely small figure. Thus the surgeon can remove the appendix even after it has ruptured, in order to prevent continued contamination of the peritoneal cavity.
Another serious complication is the development of an intraperitoneal abscess. This is the body's method of localizing the products of perforation into a confined area, thereby avoiding infection of the entire peritoneum (peritonitis). Such an abscess develops most commonly in the region near the appendix and is known as a peri-appendiceal abscess. If this abscess does not respond to intensive antibiotic treatment, an operation must be performed to drain it.
A final but extremely lethal complication is that resulting from the spread of the infection of the appendix to the veins that drain the organ. Known as septic pyelophlebitis, this infection results in abscesses of the liver. These abscesses often do not respond to specific antibiotic therapy and in many cases terminate fatally.
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