The appendix is a small finger-like projection that comes off the cecum of the large intestine and has no apparent function in the human. When the opening in the sac is blocked, it leads to an inflammation of the appendix called appendicitis. This condition occurs most commonly in the young, between childhood and young adulthood. Appendicitis is an emergency condition and requires urgent surgical removal of the appendix.

Anatomy

• The appendix is a small projection that develops from a portion of the large intestine called the cecum. As the appendix develops it lengthens and the tip can be found in almost any position about the cecum (Figure 1)

Figure 1 - The appendix is a finger-like projection from the beginning of the large bowel called the cecum. The blood supply for the appendix lies in a fatty tissue, the mesoappendix.

• The appendix lies in the right lower portion of the abdomen
• The length of the appendix may vary from one to eight inches (2 to 20 cms.) in length
• The wall of the appendix has layers similar to the large bowel. These layers include
  1. a velvety mucous secreting inner layer called the mucosa
  2. a firmer supporting layer containing lymphoid tissue under the mucosa called the submucosa. (Lymphoid tissue contains lymphocytes, one form of white blood cells, and is part of the body's immune system)
  3. a layer of muscle called the muscularis
  4. a shiny thin outer layer, the serosa
• The blood supply to the appendix is from the appendiceal artery a branch of the ileocolic artery, which supplies blood to the end of the small bowel and the beginning of the large bowel
• The blood supply lies in a fatty tissue called the mesoappendix

Pathology

• When the opening to the appendix is blocked the mucosa continues to make a mucinous (like thin jelly) fluid which causes a build up of pressure within the appendix
• When the pressure in the appendix becomes greater than the pressure in the appendix, blood flow to the appendix stops
• The appendix becomes rotten and the wall of the appendix dies. This is a gangrenous appendix
• Eventually a hole forms in the dead wall of the appendix and the appendix ruptures
• When rupture occurs, the bacteria present within the appendix spills into the abdomen. The bacteria can lead to formation of an infection that is localized, called an abscess, or infection throughout the entire abdominal cavity, called peritonitis
• The blockage in the opening of the appendix can come from many sources such as
  1. hardened stool (fecolith)
  2. wollen lymph node tissue secondary to an infection from a virus or parasites
  3. sometimes disease outside of the appendix, such as a tumor or inflammation in the cecum can block the opening of the appendix leading to appendicitis
  4. worms
  5. tumor

History

• There is frequently nausea, loss of appetite and vomiting
• A vague pain develops around the umbilicus This pain comes from stretching of the wall of the appendix
• As the appendix becomes inflamed and touches the lining of the abdominal cavity, the pain shifts to the area where the appendix is touching the abdominal wall. This area of pain is typically over the right lower abdominal area
• As the appendix becomes more inflamed, the abdominal wall will become tender to touch in the right lower abdomen. The patient may avoid riding in a car or walking as this may increase the pain
• Sometimes a patient will sit with the hips flexed because this may relieve some of the discomfort if the appendix is behind the cecum

Physical Examination

• There may be a low grade fever (99.5 degrees F. or 37.5 degrees C.)
• There is tenderness in the right lower abdomen in the area where the appendix is typically found
• There is guarding on touching the abdomen. Guarding is firming of the abdominal wall muscles with touch
• Tapping the abdominal wall away from the pain produces tenderness. This is called percussion tenderness
• There may be tenderness on rectal exam
• The patient may looked flushed
• Other conditions that may mimic appendicitis are
  1. infection in the urinary tract
  2. inflammation of pelvis
  3. ruptured or hemorrhagic ovarian cyst
  4. other inflammation of the bowel
  5. ectopic pregnancy (pregnancy outside the uterus)
  6. kidney stones

Tests

• Laboratory
  1. White blood cell count. The white blood cells are cells that fight off infection in the blood stream. An increase in the white blood cells, particularly neutrophils, are indicative of an infection within the body
  2. An analysis of the urine is helpful to rule out a urinary tract infection which may give symptoms similar to appendicitis. A person, however, can have blood present in the urine when the inflamed appendix is located adjacent to the ureter, the tube that runs from the kidney to the bladder. However, an urinary infection also shows additional chemical findings such as glucocyte estrace or nitrites
  3. X-ray tests
• Flat plate (plain film) of the abdomen. An abdominal x-ray is rarely useful for diagnosing appendicitis. On rare occasion a hardened piece of stool with calcification, called an appendicolith may show up on a plain x-ray. The plain x-ray, however, may rule out other reasons for the abdominal pain, such as a dilated bowel seen with a bowel obstruction. If the appendix has ruptured there may be evidence of air in the abdomen
• Occasionally an ultrasound of the abdomen (picture of the inside of the abdomen using sound waves) may be useful when the appendix is dilated. In females, this test gives helpful information regarding the state of the uterus, tubes, ovaries and pelvis
• A CT (Computerized Tomography) scan of the abdomen has been increasingly used for the diagnosis of appendicitis
• It can detect either a distended appendix or inflammation around the appendix, which can be indicative of appendicitis
• A newer technique places X-ray contrast material up the rectum to fill the large bowel. It also normally fills the inside of the appendix. If the opening in the appendix is blocked, then no contrast fills the appendix. This is highly suggestive of acute appendicitis
• A CAT scan is also useful for finding other diseases which may be causing abdominal pain
• A barium containing enema may be used in a manner similar to the CT scan with the rectal contrast. If the appendix fills with contrast as seen on an X-ray of the abdomen then there is no appendicitis. This has largely been replaced by the CT scan with rectal contrast

Indication/Contraindications for Surgery

• Allowing an appendicitis to rupture greatly increases the complications and risk of death, therefore, a surgeon must proceed with removal of the appendix if a high suspicion exists for appendicitis
• This is why it is better to remove a normal appendix then allow an inflamed appendix go on to rupture
• Approximately 20% of removed appendices are normal
• The only contraindication to removing the appendix is a situation where perforation has occurred and the abdomen is so inflamed that the appendix is not recognizable. In this situation the infection needs to be drained but the appendix is not removed
• In a situation where the diagnosis is in question, a laparoscopy may be carried out
  1. The laparoscope is a long tube containing fiber optics with a lens at one end and a small TV camera at the other. It is placed through a small opening in the abdomen just below the umbilicus called a port
  2. With laparoscopy, the appendix can be seen. If a disease other than acute appendicitis is causing the pain, this can be discovered, and if the appendix is found to be diseased, it can be removed
  3. If a normal appendix is found and there is no evidence of other abdominal disease, the appendix is still removed. This will prevent someone from coming back with pain that could possibly be an appendicitis in the future

The Procedure

• Using a Laparoscopy
  1. In addition to the port below the umbilicus, extra ports are placed in the abdomen to allow removal of the appendix using instruments placed through the small ports
  2. This technique does take longer than a standard open appendectomy and costs slightly more because of the instruments required for the surgery
• Open appendectomy remains the standard of care for appendicitis
  1. An incision is made in the skin over the area of the appendix in the right lower abdomen
  2. The muscles are spread and the abdomen is entered
  3. The large bowel or cecum is located and followed to its end where the appendix is found
  4. The appendix is pulled up through the incision (Figure 2)

     Figure 2 - Operative photograph showing a swollen appendix.

  5. The mesoappendix is separated off of the appendix, clamped and tied off (Figure 3A)
  6. The appendix is then tied off at its base next to the cecum (Figure 3B)

     Figure 3a - The blood supply to the appendix is controlled by clamping the mesoappendix.	Figure 3b - The appendix is tied at its base near the cecum, cut and removed.

  7. The remainder of the appendix is clamped, cut and removed
  8. Care is taken to prevent spillage of bacteria from the cut end
  9. The muscle layers are then sutured back together over the stump of the appendix
  10. If the appendix has ruptured, a drain is placed in the region of the appendix to allow bacteria to drain out and the skin is left open and packed with gauze. The gauze and drain are removed when the infection is cleared
• Using a Laparoscope
  1. In addition to the port below the umbilicus, extra ports are placed in the abdomen to allow removal of the appendix using instruments placed through the small ports
  2. This technique does take longer than a standard open appendectomy and costs slightly more because of the instruments required for the surgery

Complications

• Wound infection
• Abdominal abscess due to spillage of bacteria after a ruptured appendicitis
• Bowel obstruction
• Urinary tract infection
• Hemorrhage
• Injury to the large or small bowel, ovary or other abdominal organs requiring removal

Post-Operative Care

• Unruptured appendix
  1. The patient is started on a liquid diet the morning after the surgery and progressed to a soft and then regular diet
  2. Additional antibiotics are also given to prevent wound infection
  3. Often the patient can leave the hospital in 1-2 days after the surgery
• Ruptured appendix
  1. The hospital stay is usually at least 4 days and possibly longer
  2. If there was spilling of bacteria from the appendix, recurrent abdominal abscesses and infections may occur
  3. The bowel frequently stops normal function (ileus) causing bowel fluid and gas to distend the bowel. This distention is relieved by placing a tube through the nose and into the stomach for approximately 2-3 days. Once there is evidence that the intestines are active again, such as passing gas or having a bowel movement, the tube is removed
  4. The patient is then be started on a liquid diet which is advanced to a regular diet as tolerated
  5. If the appendix has ruptured, a drain is placed in the region of the appendix to allow bacteria to drain out and the skin is left open and packed with gauze. The gauze and drain are removed when the infection is cleared
  6. Antibiotics are continued for approximately one week after the surgery. Initially this will be through a vein while in the hospital and then typically by pill after being sent home

After Discharge Care

• Recovery after appendectomy requires about 4-6 weeks
• During that time heavy lifting and strenuous activity should be limited to prevent hernia formation at the incision
• If the appendix was ruptured and the wound was left open, daily dressing changes will be required until the wound is healed
• There are no specific dietary restrictions after an appendectomy
• Pain medication is prescribed as necessary. The pain medication may slow down the bowel function and lead to constipation. It is often helpful to take a stool softener to prevent constipation