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If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the
abdomen; however, it usually is confined to a small area surrounding the
appendix (forming a peri-appendiceal abscess).
The main symptom of appendicitis is abdominal pain. The pain is at first diffuse
and poorly localized, that is, not confined to one spot. (Poorly localized pain is
typical whenever a problem is confined to the small intestine or colon, including
the appendix.) The pain is so difficult to pinpoint that when asked to point to the
area of the pain, most people indicate the location of the pain with a circular
motion of their hand around the central part of their abdomen. A second,
common, early symptom of appendicitis is loss of appetite which may progress to
nausea and even vomiting. Nausea and vomiting also may occur later due to
intestinal obstruction.
The white blood cell count in the blood usually becomes elevated with infection.
In early appendicitis, before infection sets in, it can be normal, but most often
there is at least a mild elevation even early. Unfortunately, appendicitis is not the
only condition that causes elevated white blood cell counts. Almost any infection
or inflammation can cause this count to be abnormally high. Therefore, an
elevated white blood cell count alone cannot be used as a sign of appendicitis.
Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells,
white blood cells and bacteria in the urine. Urinalysis usually is abnormal when
there is inflammation or stones in the kidneys or bladder. The urinalysis also may
be abnormal with appendicitis because the appendix lies near the ureter and
bladder. If the inflammation of appendicitis is great enough, it can spread to the
ureter and bladder leading to an abnormal urinalysis. Most patients with
appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis
suggests appendicitis more than a urinary tract problem.
Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-
sized piece of stool that blocks the appendiceal opening) that may be the cause
of appendicitis. This is especially true in children.
Ultrasound
Barium Enema
A barium enema is an x-ray test where liquid barium is inserted into the colon
from the anus to fill the colon. This test can, at times, show an impression on the
colon in the area of the appendix where the inflammation from the adjacent
inflammation impinges on the colon. Barium enema also can exclude other
intestinal problems that mimic appendicitis, for example Crohn's disease.
In patients who are not pregnant, a CT Scan of the area of the appendix is useful
in diagnosing appendicitis and peri-appendiceal abscesses as well as in
excluding other diseases inside the abdomen and pelvis that can mimic
appendicitis.
Laparoscopy
There is no one test that will diagnose appendicitis with certainty. Therefore, the
approach to suspected appendicitis may include a period of observation, tests as
previously discussed, or surgery.
Why can it be difficult to diagnose appendicitis?
The surgeon faced with a patient suspected of having appendicitis always must
consider and look for other conditions that can mimic appendicitis. Among the
conditions that mimic appendicitis are:
• Pelvic inflammatory disease. The right fallopian tube and ovary lie near
the appendix. Sexually active women may contract infectious diseases
that involve the tube and ovary. Usually, antibiotic therapy is sufficient
treatment, and surgical removal of the tube and ovary are not necessary.
• Kidney diseases. The right kidney is close enough to the appendix that
inflammatory problems in the kidney-for example, an abscess-can mimic
appendicitis.
On occasion, a person may not see their doctor until appendicitis with rupture
has been present for many days or even weeks. In this situation, an abscess
usually has formed, and the appendiceal perforation may have closed over. If the
abscess is small, it initially can be treated with antibiotics; however, the abscess
usually requires drainage. 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. The appendix may be removed several
weeks or months after the abscess has resolved. This is called an interval
appendectomy and is done to prevent a second attack of appendicitis.
Newer techniques for removing the appendix involve the use of the laparoscope.
The laparoscope is a thin telescope attached to a video camera that allows the
surgeon to inspect the inside of the abdomen through a small puncture wound
(instead of a larger incision). If appendicitis is found, the appendix can be
removed with special instruments that can be passed into the abdomen, just like
the laparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since much of the post-
surgery pain comes from incisions) and a speedier return to normal activities. An
additional advantage of laparoscopy is that it allows the surgeon to look inside
the abdomen to make a clear diagnosis in cases in which the diagnosis of
appendicitis is in doubt. For example, laparoscopy is especially helpful in
menstruating women in whom a rupture of an ovarian cysts may mimic
appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient
generally is sent home from the hospital after surgery in one or two days.
Patients whose appendix has perforated are sicker than patients without
perforation, and their hospital stay often is prolonged (four to seven days),
particularly if peritonitis has occurred. Intravenous antibiotics are given in the
hospital to fight infection and assist in resolving any abscess.
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.
Appendectomy At A Glance
• The appendix is a small, worm-like appendage attached to the colon.
• Appendicitis occurs when bacteria invade and infect the wall of the
appendix.
• The most common complications of appendicitis are abscess and
peritonitis.
• The most common manifestations of appendicitis are pain, fever, and
abdominal tenderness.
• Appendicitis usually is suspected on the basis of a patient's history and
physical examination; however, a white blood cell count, urinalysis,
abdominal x-ray, barium enema, ultrasonography, CT, and laparoscopy
also may be helpful in diagnosis.
• Due to the varying size and location of the appendix and the proximity of
other organs to the appendix, it may be difficult to differentiate appendicitis
from other abdominal and pelvic diseases.
• The treatment for appendicitis usually is antibiotics and appendectomy
(surgery to remove the appendix).
• Complications of appendectomy include wound infection and abscess.
• Major surgery
• Critical illnesses such as serious injuries, major burns, and bodywide
infections (sepsis)
• Intravenous feedings for a long time
• Fasting for a prolonged time
• A deficiency in the immune system
It can occur in young children, perhaps developing from a viral or another
infection.
Symptoms
A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain.
The pain of cholecystitis is similar to that caused by gallstones (biliary colic) but
is more severe and lasts longer—more than 6 hours and often more than 12
hours. The pain peaks after 15 to 60 minutes and remains constant. It usually
occurs in the upper right part of the abdomen. The pain may become
excruciating. Most people feel a sharp pain when a doctor presses on the upper
right part of the abdomen. Breathing deeply may worsen the pain. The pain often
extends to the lower part of the right shoulder blade or to the back. Nausea and
vomiting are common.
Within a few hours, the abdominal muscles on the right side may become rigid.
Fever occurs in about one third of people with acute cholecystitis. The fever
tends to rise gradually to above 100.4° F (38° C) and may be accompanied by
chills. Fever rarely occurs in people with chronic cholecystitis.
In older people, the first or only symptoms of cholecystitis may be rather general.
For example, older people may lose their appetite, feel tired or weak, or vomit.
They may not develop a fever.
Diagnosis
Doctors diagnose cholecystitis based mainly on symptoms and results of imaging
tests. Ultrasonography is the best way to detect gallstones in the gallbladder.
Ultrasonography can also detect fluid around the gallbladder or thickening of its
wall, which are typical of acute cholecystitis. Often, when the ultrasound probe is
moved across the upper abdomen above the gallbladder, people report
tenderness.
Liver blood tests are often normal unless the person has an obstructed bile duct.
Other blood tests can detect some complications such as a high level of a
pancreatic enzyme (lipase or amylase) in pancreatitis. A high white blood cell
count suggests inflammation, an abscess, gangrene, or a perforated gallbladder.
Treatment
People with acute or chronic cholecystitis need to be hospitalized. They are not
allowed to eat or drink and are given fluids and electrolytes intravenously. A
doctor may pass a tube through the nose and into the stomach, so that
suctioning can be used to keep the stomach empty and reduce fluid
accumulating in the intestine if the intestine is not contracting normally. Usually,
antibiotics are given intravenously, and pain relievers are given.
If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder
is usually removed within 24 to 48 hours after symptoms start. If necessary,
surgery can be delayed for 6 weeks or more while the attack subsides. Delay is
often necessary for people with a disorder that makes surgery too risky (such as
a heart, lung, or kidney disorder). If a complication such as an abscess,
gangrene, or perforated gallbladder is suspected, immediate surgery is
necessary.
In chronic cholecystitis, the gallbladder is usually removed after the acute
episode subsides.
Pain After Surgery: A few people have new or recurring episodes of pain that feel
like gallbladder attacks even though the gallbladder (and the stones) have been
removed. The cause is not known, but it may be malfunction of the sphincter of
Oddi, the muscles that control the release of bile and pancreatic secretions
through the opening of the bile and pancreatic ducts into the small intestine. Pain
may occur because pressure in the ducts is increased by sphincter spasms,
which hinders the flow of bile and pancreatic secretions. Pain also may result
from small gallstones that remain in the ducts after the gallbladder is removed.
More commonly, the cause is another problem, such as irritable bowel syndrome
or even peptic ulcer disease.