Appendicitis is a medical condition characterized by inflammation of the appendix, a small, finger-shaped pouch attached to the large intestine on the lower right side of the abdomen. It is a common surgical emergency and typically requires urgent medical attention, as a delayed diagnosis can lead to complications such as perforation, abscess formation, or peritonitis. The condition can occur at any age but is most common among individuals between the ages of 10 and 30.
Causes and Pathophysiology
The exact cause of appendicitis is often multifactorial, but it generally arises from obstruction of the lumen of the appendix. Common causes of obstruction include:
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Fecaliths (hardened stool): The most common cause, which blocks the lumen and prevents normal drainage.
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Lymphoid hyperplasia: Common in children and adolescents, where enlarged lymphoid follicles compress the lumen.
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Infections: Viral, bacterial, or gastrointestinal infections can trigger inflammation.
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Foreign bodies: Rarely, swallowed objects may obstruct the appendix.
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Tumors: In rare cases, carcinoid tumors or other growths may block the appendix.
Once the lumen is obstructed, mucus and bacteria accumulate inside the appendix, leading to increased pressure, restricted blood flow, bacterial overgrowth, and eventual inflammation. If untreated, this may result in gangrene, rupture, and peritonitis.
Symptoms
The symptoms of appendicitis vary but typically follow a classic progression:
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Abdominal pain: Initially diffuse around the umbilical area, later localizing to the right lower quadrant (McBurney’s point).
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Loss of appetite
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Nausea and vomiting
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Fever (usually low-grade, but may increase if perforation occurs)
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Constipation or diarrhea
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Abdominal tenderness and guarding
In atypical cases (such as in young children, elderly patients, or pregnant women), the pain may not localize clearly, making diagnosis challenging.
Diagnosis
Diagnosis of appendicitis relies on a combination of clinical assessment, laboratory tests, and imaging.
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Clinical examination: Palpation of the abdomen may reveal tenderness at McBurney’s point, rebound tenderness, and guarding.
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Laboratory tests: Elevated white blood cell count and C-reactive protein (CRP) indicate infection and inflammation.
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Imaging:
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Ultrasound (useful in children and pregnant women)
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CT scan (high sensitivity and specificity in adults)
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MRI (alternative in pregnancy if ultrasound is inconclusive)
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Complications
If not treated promptly, appendicitis may lead to:
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Perforation: Rupture of the appendix with leakage of pus and bacteria into the abdomen.
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Peritonitis: Infection of the abdominal lining, which can be life-threatening.
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Appendiceal abscess: A localized pocket of pus within the abdominal cavity.
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Sepsis: Systemic infection, a severe complication.
Treatment
The definitive treatment for appendicitis is usually surgical removal of the appendix (appendectomy). In selected cases, non-surgical management with antibiotics may be considered, but surgery remains the gold standard.
1. Surgical Management
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Open appendectomy: A small incision is made in the right lower abdomen to remove the appendix.
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Laparoscopic appendectomy: Minimally invasive procedure using small incisions and a camera, offering faster recovery and less scarring.
2. Antibiotic Therapy
Antibiotics are given to control infection, either before surgery (to prevent complications) or as primary treatment in uncomplicated cases where surgery is deferred. Common regimens include:
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Ceftriaxone (1–2 g IV once daily) plus Metronidazole (500 mg IV every 8 hours).
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Ampicillin-sulbactam (1.5–3 g IV every 6 hours).
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Ciprofloxacin (400 mg IV every 12 hours) plus Metronidazole (500 mg IV every 8 hours), particularly in penicillin-allergic patients.
Duration of antibiotics depends on whether the appendix is perforated:
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Uncomplicated appendicitis: 24–48 hours post-op.
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Complicated appendicitis (rupture or abscess): 5–7 days or longer.
3. Supportive Care
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Pain management: Paracetamol (500–1000 mg every 6–8 hours) or Ibuprofen (400 mg every 6–8 hours).
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Intravenous fluids: To maintain hydration and electrolyte balance.
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Bowel rest: Patients are kept nil per os (NPO) until surgery.
Prevention
There are no guaranteed preventive measures for appendicitis, but maintaining a high-fiber diet with fruits and vegetables may reduce the risk of fecalith formation. Regular health check-ups may help in early detection of abdominal conditions.
Prognosis
With timely surgical intervention, the prognosis of appendicitis is excellent. Most patients recover fully within 2–4 weeks post-surgery. However, delays in diagnosis or treatment increase the risk of rupture and complications, leading to longer recovery times and higher morbidity.
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