Appendicitis National Digestive Diseases Information Clearinghouse What is appendicitis? Appendicitis is inflammation of the appendix. Appendicitis is the leading cause 1 of emergency abdominal operations. Mouth What is the appendix? The appendix is a fingerlike pouch attached to the large intestine in the lower right area of the abdomen, the area between the chest and hips. The large intestine is part of the body’s gastrointestinal (GI) tract. The Large intestine GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. The movement of muscles in the GI tract, along with the release of hormones and enzymes, helps digest food. The appendix does not appear to have a specific Anus Appendix function in the body, and removing it does not seem to affect a person’s health. The appendix is a fingerlike pouch attached to The inside of the appendix is called the the large intestine in the lower right area of the appendiceal lumen. Normally, mucus abdomen. created by the appendix travels through the appendiceal lumen and empties into the large intestine. The large intestine absorbs water from stool and changes it from a liquid to a solid form. 1Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgraduate Medicine. 2010;122(1):39–51. What causes appendicitis? • is unlike any pain felt before An obstruction, or blockage, of the • gets worse in a matter of hours appendiceal lumen causes appendicitis. • gets worse when moving around, taking Mucus backs up in the appendiceal lumen, deep breaths, coughing, or sneezing causing bacteria that normally live inside the appendix to multiply. As a result, the Other symptoms of appendicitis may include appendix swells and becomes infected. • loss of appetite Sources of blockage include • nausea • stool, parasites, or growths that clog the appendiceal lumen • vomiting • enlarged lymph tissue in the wall of the • constipation or diarrhea appendix, caused by infection in the • an inability to pass gas GI tract or elsewhere in the body • a low-grade fever that follows other • inflammatory bowel disease (IBD), symptoms which includes Crohn’s disease and ulcerative colitis, long-lasting disorders • abdominal swelling that cause irritation and ulcers in the • the feeling that passing stool will relieve GI tract discomfort • trauma to the abdomen Symptoms vary and can mimic the following conditions that cause abdominal pain: An inflamed appendix will likely burst if not removed. • intestinal obstruction—a partial or total blockage in the intestine that prevents Who gets appendicitis? the flow of fluids or solids. Anyone can get appendicitis, although it is • IBD. more common among people 10 to 30 years • pelvic inflammatory disease—an old.1 infection of the female reproductive organs. What are the symptoms of • abdominal adhesions—bands of tissue appendicitis? that form between abdominal tissues The symptoms of appendicitis are typically and organs. Normally, internal tissues easy for a health care provider to diagnose. and organs have slippery surfaces that The most common symptom of appendicitis let them shift easily as the body moves. is abdominal pain. Adhesions cause tissues and organs to stick together. Abdominal pain with appendicitis usually • constipation—a condition in which a • occurs suddenly, often waking a person person usually has fewer than three at night bowel movements in a week. The bowel movements may be painful. • occurs before other symptoms • begins near the belly button and then moves lower and to the right 2 Appendicitis How is appendicitis Responses that may indicate appendicitis diagnosed? include A health care provider can diagnose most • Rovsing’s sign. A health care provider cases of appendicitis by taking a person’s tests for Rovsing’s sign by applying hand medical history and performing a physical pressure to the lower left side of the exam. abdomen. Pain felt on the lower right side of the abdomen upon the release If a person does not have the usual of pressure on the left side indicates the symptoms, health care providers may use presence of Rovsing’s sign. laboratory and imaging tests to confirm appendicitis. These tests also may help • Psoas sign. The right psoas muscle diagnose appendicitis in people who cannot runs over the pelvis near the appendix. adequately describe their symptoms, such Flexing this muscle will cause abdominal as children or people who are mentally pain if the appendix is inflamed. A impaired. health care provider can check for the psoas sign by applying resistance to the Medical History right knee as the patient tries to lift the right thigh while lying down. The health care provider will ask specific questions about symptoms and health • Obturator sign. The right obturator history. Answers to these questions will help muscle also runs near the appendix. rule out other conditions. The health care A health care provider tests for the provider will want to know obturator sign by asking the patient to lie down with the right leg bent at the • when the abdominal pain began knee. Moving the bent knee left and • the exact location and severity of the right requires flexing the obturator pain muscle and will cause abdominal pain if the appendix is inflamed. • when other symptoms appeared • Guarding. Guarding occurs when • other medical conditions, previous a person subconsciously tenses the illnesses, and surgical procedures abdominal muscles during an exam. • whether the person uses medications, Voluntary guarding occurs the moment alcohol, or illegal drugs the health care provider’s hand touches the abdomen. Involuntary guarding Physical Exam occurs before the health care provider Details about the person’s abdominal pain actually makes contact and is a sign the are key to diagnosing appendicitis. The appendix is inflamed. health care provider will assess the pain by touching or applying pressure to specific areas of the abdomen. 3 Appendicitis • Rebound tenderness. A health care or sent to a laboratory for analysis. provider tests for rebound tenderness Urinalysis is used to rule out a urinary by applying hand pressure to a person’s tract infection or a kidney stone. lower right abdomen and then letting • Pregnancy test. Health care providers go. Pain felt upon the release of the also may order a pregnancy test for pressure indicates rebound tenderness women, which can be done through a and is a sign the appendix is inflamed. blood or urine test. A person may also experience rebound tenderness as pain when the abdomen Imaging Tests is jarred—for example, when a person Imaging tests can confirm the diagnosis bumps into something or goes over a of appendicitis or find other causes of bump in a car. abdominal pain. Women of childbearing age may be asked • Abdominal ultrasound. Ultrasound to undergo a pelvic exam to rule out uses a device, called a transducer, gynecological conditions, which sometimes that bounces safe, painless sound cause abdominal pain similar to appendicitis. waves off organs to create an image The health care provider also may examine of their structure. The transducer the rectum, which can be tender from can be moved to different angles to appendicitis. make it possible to examine different organs. In abdominal ultrasound, the Laboratory Tests health care provider applies gel to the Laboratory tests can help confirm the patient’s abdomen and moves a hand­ diagnosis of appendicitis or find other causes held transducer over the skin. The gel of abdominal pain. allows the transducer to glide easily, and it improves the transmission of the • Blood tests. A blood test involves signals. The procedure is performed drawing a person’s blood at a health in a health care provider’s office, care provider’s office or a commercial an outpatient center, or a hospital facility and sending the sample to a by a specially trained technician, laboratory for analysis. Blood tests can and the images are interpreted by a show signs of infection, such as a high radiologist—a doctor who specializes white blood cell count. Blood tests in medical imaging; anesthesia is not also may show dehydration or fluid and needed. Abdominal ultrasound creates electrolyte imbalances. Electrolytes are images of the appendix and can show chemicals in the body fluids, including signs of inflammation, a burst appendix, sodium, potassium, magnesium, and a blockage in the appendiceal lumen, chloride. and other sources of abdominal pain. • Urinalysis. Urinalysis is testing of Ultrasound is the first imaging test a urine sample. The urine sample performed for suspected appendicitis is collected in a special container in infants, children, young adults, and in a health care provider’s office, a pregnant women. commercial facility, or a hospital and can be tested in the same location 4 Appendicitis • Magnetic resonance imaging (MRI). interpreted by a radiologist; anesthesia MRI machines use radio waves and is not needed. Children may be given magnets to produce detailed pictures a sedative to help them fall asleep for of the body’s internal organs and the test. A CT scan of the abdomen soft tissues without using x rays. The can show signs of inflammation, procedure is performed in an outpatient such as an enlarged appendix or an center or a hospital by a specially abscess—a pus-filled mass that results trained technician, and the images are from the body’s attempt to keep an interpreted by a radiologist. Anesthesia infection from spreading—and other is not needed, though children and sources of abdominal pain, such as people with a fear of confined spaces a burst appendix and a blockage in may receive light sedation, taken by the appendiceal lumen. Women mouth. An MRI may include the of childbearing age should have a injection of special dye, called contrast pregnancy test before undergoing medium.