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Home , Appendectomy, Appendicitis, Appendix (anatomy), Diarrhea, Laparotomy, Nausea

Appendicitis

National Digestive Information Clearinghouse

What is ? Appendicitis is of the . Appendicitis is the leading cause 1 of emergency abdominal operations. Mouth What is the appendix? The appendix is a fingerlike pouch attached to the in the lower right area of the , 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 , helps digest . 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, abdomen. created by the appendix travels through the appendiceal lumen and empties into the large intestine. The large intestine absorbs from stool and changes it from a liquid to a solid form.

1Spirt MJ. Complicated intra-abdominal : a focus on appendicitis and . Postgraduate Medicine. 2010;122(1):39–51. What causes appendicitis? • is unlike any 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 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 • • stool, parasites, or growths that clog the appendiceal lumen • • enlarged lymph tissue in the wall of the • or appendix, caused by in the • an inability to pass gas GI tract or elsewhere in the body • a low-grade that follows other • inflammatory bowel (IBD), symptoms which includes Crohn’s disease and

ulcerative , 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 : 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 • . The right psoas muscle diagnose appendicitis in people who cannot runs over the 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 • . 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 , 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 stone. lower right abdomen and then letting • 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. or 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 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 , 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 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 ; is not also may show or fluid and needed. Abdominal ultrasound creates imbalances. are images of the appendix and can show chemicals in the body fluids, including signs of inflammation, a burst appendix, sodium, , , and a blockage in the appendiceal lumen, . 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 —a -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. With most MRI machines, a CT scan. The radiation used the person lies on a table that slides in CT scans can be harmful to a into a tunnel-shaped device that may be developing fetus. open ended or closed at one end; some machines are designed to allow the How is appendicitis treated? person to lie in a more open space. An Appendicitis is typically treated with MRI can show signs of inflammation, to remove the appendix. The surgery is a burst appendix, a blockage in the performed in a hospital; general anesthesia appendiceal lumen, and other sources is needed. If appendicitis is suspected, of abdominal pain. An MRI used especially in patients who have persistent to diagnose appendicitis and other abdominal pain and fever, or signs of a sources of abdominal pain is a safe, burst appendix and infection, a health care reliable alternative to a computerized provider will often suggest surgery without tomography (CT) scan.2 conducting diagnostic testing. Prompt • CT scan. CT scans use a combination surgery decreases the chance that the of x rays and computer technology to appendix will burst. create three-dimensional (3-D) images. For a CT scan, the person may be given Surgery to remove the appendix is called a solution to and an injection of an . A performs the contrast medium. CT scans require the surgery using one of the following methods: person to lie on a table that slides into • . Laparotomy removes the a tunnel-shaped device where the x rays appendix through a single incision in the are taken. The procedure is performed lower right area of the abdomen. in an outpatient center or a hospital by an x-ray technician, and the images are • Laparoscopic surgery. Laparoscopic surgery uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. 2Heverhagen J, Pfestroff K, Heverhagen A, Klose Laparoscopic surgery leads to fewer K, Kessler K, Sitter H. Diagnostic accuracy complications, such as hospital-related of magnetic resonance imaging: a prospective evaluation of patients with suspected appendicitis infections, and has a shorter recovery (diamond). Journal of Magnetic Resonance Imaging. time. 2012;35:617–623. 5 Appendicitis With adequate care, most people recover Can appendicitis be treated from appendicitis and do not need to make changes to diet, exercise, or lifestyle. without surgery? recommend limiting physical Nonsurgical treatment may be used if activity for the first 10 to 14 days after a surgery is not available, a person is not well laparotomy and for the first 3 to 5 days after enough to undergo surgery, or the diagnosis laparoscopic surgery. is unclear. Nonsurgical treatment includes to treat infection. What are the complications and treatment of a burst What should people do appendix? if they think they have A burst appendix spreads infection appendicitis? throughout the abdomen—a potentially Appendicitis is a medical emergency that dangerous condition called . A requires immediate care. People who think person with peritonitis may be extremely they have appendicitis should see a health ill and have nausea, vomiting, fever, and care provider or go to the emergency room severe abdominal tenderness. This condition right away. Swift diagnosis and treatment requires immediate surgery through can reduce the chances the appendix will laparotomy to clean the burst and improve recovery time. and remove the appendix. Without prompt treatment, peritonitis can cause . Eating, Diet, and Nutrition Sometimes an abscess forms around a burst Researchers have not found that eating, appendix—called an appendiceal abscess. A diet, and nutrition play a role in causing or surgeon may drain the pus from the abscess preventing appendicitis. If a health care during surgery or, more commonly, before provider prescribes nonsurgical treatment for surgery. To drain an abscess, a tube is a person with appendicitis, the person will be placed in the abscess through the abdominal asked to follow a liquid or soft diet until the wall. The drainage tube is left in place for infection subsides. A soft diet is low in fiber about 2 weeks while antibiotics are given and is easily digested in the GI tract. A soft to treat infection. Six to 8 weeks later, diet includes such as , fruit juices, when infection and inflammation are under eggs, puddings, strained soups, , ground control, surgeons operate to remove what meats, fish, and mashed, boiled, or baked remains of the burst appendix. potatoes. People can talk with their health care provider to discuss dietary changes. What if the surgeon finds a normal appendix? Occasionally, a surgeon finds a normal appendix. In this case, many surgeons will remove it to eliminate the future possibility of appendicitis. Occasionally, surgeons find a different problem, which may also be corrected during surgery.

6 Appendicitis Points to Remember Hope through Research • Appendicitis is inflammation of the The National Institute of Diabetes and appendix. Digestive and Kidney Diseases (NIDDK) and other components of the National • The appendix is a fingerlike pouch Institutes of Health (NIH) conduct and attached to the large intestine and support basic and clinical research into many located in the lower right area of the digestive disorders, including appendicitis. abdomen. The inside of the appendix is called the appendiceal lumen. Clinical trials are research studies involving • An obstruction, or blockage, of the people. Clinical trials look at safe and appendiceal lumen causes appendicitis. effective new ways to prevent, detect, or treat disease. Researchers also use clinical • The most common symptom of trials to look at other aspects of care, such appendicitis is abdominal pain. Other as improving the quality of life for people symptoms of appendicitis may include with chronic illnesses. To learn more about loss of appetite, nausea, vomiting, clinical trials, why they matter, and how to constipation, diarrhea, an inability to participate, visit the NIH Clinical Research pass gas, a low-grade fever, abdominal Trials and You website at www.nih.gov/health/ swelling, and the feeling that passing clinicaltrials. For information about current stool will relieve discomfort. studies, visit www.ClinicalTrials.gov. • A health care provider can diagnose most cases of appendicitis by taking a For More Information person’s medical history and performing American Academy of Family Physicians a physical exam. If a person does not P.O. Box 11210 have the usual symptoms, health care Shawnee Mission, KS 66207–1210 providers may use laboratory and Phone: 1–800–274–2237 or 913–906–6000 imaging tests to confirm appendicitis. Email: [email protected] • Appendicitis is typically treated with Internet: www.aafp.org surgery to remove the appendix. American College of Surgeons • Nonsurgical treatment may be used 633 North Saint Clair Street if surgery is not available, a person is Chicago, IL 60611–3211 not well enough to undergo surgery, or Phone: 1–800–621–4111 or 312–202–5000 the diagnosis is unclear. Nonsurgical Fax: 312–202–5001 treatment includes antibiotics to treat Email: [email protected] infection. Internet: www.facs.org • Appendicitis is a medical emergency American Society of Colon and Rectal that requires immediate care. Surgeons • If a health care provider prescribes 85 West Algonquin Road, Suite 550 nonsurgical treatment for a person with Arlington Heights, IL 60005 appendicitis, the person will be asked Phone: 847–290–9184 to follow a liquid or soft diet until the Fax: 847–290–9203 infection subsides. Email: [email protected] Internet: www.fascrs.org

7 Appendicitis Acknowledgments National Digestive Diseases Publications produced by the Clearinghouse Information Clearinghouse are carefully reviewed by both NIDDK 2 Information Way scientists and outside experts. This Bethesda, MD 20892–3570 publication was originally reviewed by Jason Phone: 1–800–891–5389 A. Brodsky, M.D., Shady Grove Adventist TTY: 1–866–569–1162 Hospital, Rockville, MD. Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov You may also find additional information about this topic by visiting MedlinePlus at www..gov. The National Digestive Diseases Information This publication may contain information about Clearinghouse (NDDIC) is a service of the medications and, when taken as prescribed, National Institute of Diabetes and Digestive the conditions they treat. When prepared, this publication included the most current information and Kidney Diseases (NIDDK). The available. For updates or for questions about NIDDK is part of the National Institutes of any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA Health of the U.S. Department of Health (1–888–463–6332) or visit www.fda.gov. Consult your and Services. Established in 1980, health care provider for more information. the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired. This publication is available at www.digestive.niddk.nih.gov.

NIH Publication No. 13–4547 September 2013

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