Appendicitis Miles of trouble originating from a centimetre

Appendix is a tube shaped organ believed to be a remnant from a time that our ancestors relied on plants as their main source of energy. To aid them in digestion, they had a large ‘cecum’, a part of the large intestine. In those glory days, we had the ability to digest cellulose, or ‘fibers’ as the story goes. But with the expansion of our diet, our need to digest fibers for energy dwindled and so did the organ. This resulted in the shrinkage of the appendix over several generations to the size that it is today. This organ is said to act as a store for good bacteria, though the subject is controversial.  The appendix is situated at the junction where ileum or the terminal part of the small intestine meets the cecum of the large intestine. It’s usually 7.5-10 mm long. The beginning usually lies in a fixed point below the navel called the ‘McBurny’s point) though it’s length and the lie of the blind end can vary.  

1. Definition 

However insignificant functional wise, this little troublemaker still manages to make its presence known to us in the form of ‘appendicitis’ or the inflammation of the appendix. It’s usually believed to be caused by the obstruction of the lumen by various means such as mass of digested food and other material, by a tumour and on rare occasions is caused when intestinal worms block the tube. Therefore the secretions inside the now enclosed surface get collected. This condition then locks the venous supply to the appendix that removes the excess tissue fluid which provides the ideal environment for bacteria to grow.

If not treated at the appropriate time, the lack of blood supply may cause the appendix to necrose, thus releasing the bacteria into the abdominal cavity. 

This condition is more common in children and young adults. 

     2.Symptoms

Lack of appetite, nausea and vomiting accompanied by fever and right lower abdominal pain are the usual signs. The duration of the abdominal pain is interesting. In most cases, the pain initially appearing is dull  and is experienced around the navel area and later moves to the McBurny’s point in the form of a sharp severe pain. 

The patient may have tenderness over that area and he may be reluctant to move, preferring to lie still in a curled up position.  

But the saying ‘Nothing is set in stone’ is especially true when it comes to medicine. Therefore even though the textbooks describe the above as the common presentation, there are many other ways that an appendicitis patient can describe his condition. For an example, they can complain about the left side or of apoorly localized abdominal pain.  

Diagnosis is mainly clinical, with investigations done to further confirm the diagnosis.

   3. Treatment  

Surgery is recommended in almost all cases. Appendectomy is one of the commonest abdominal surgeries where the inflamed appendix is removed through a small incision in the abdomen.   

  4. Ruptures  

If treatment is delayed by more than two days, there is a risk of the inflamed and oedematous appendix bursting. This will then release infectious material to the outside of bowel loop. Even though our gastrointestinal system contains plenty of micro organisms, all of them are contained inside the bowel tubes. In case of a ruptured appendix, the infectious material is released in to the sterile abdominal cavity. Imagine a sewage pipe bursting and releasing its content into a sterile room.  

This in turn gives rise to another, more serious condition called peritonitis. Peritonitis needs immediate aggressive antibiotic therapy to be cured. Even then this condition might lead to future complications like bowel obstruction.   

   5. Differential diagnosis 

When a person enters the Emergency Room at the onset and complains of sudden severe persistent abdominal pain, it is called acute abdomen. This may be due to various pathophysiologies of which one of the commonest is appendicitis.   

When a patient is presented with suspected appendicitis, it’s important to exclude other serious conditions that need immediate intervention. In females of childbearing age, a pregnancy is always excluded because a tubal ectopic pregnancy-which also causes similar symptoms to those of appendicitis-may be fatal if ruptured. In adolescent males, testicular torsion can present as appendicitis and if not reversed back to its previous position within a few hours, it may result in removal of that testicle.  

   6. Advice

• The pain is severe,
• Pain lasts for more than six hours  
• Pain is aggravated by movements  
• Abdominal pain that starts centrally later moves to a distinct area in the right (rarely does this pain shifts to the left lower abdomen)