Introduction

Definition 

Appendicitis is when there is an infection and swelling in your appendix, which is an organ that is attached to your large intestine. It causes pain in the lower right side of your abdomen. The specific function and purpose of the appendix are not known, but if the infection is left untreated, it can create serious life-threatening issues.

Epidemiology

Appendicitis can happen to anyone at any age, but it is more commonly found in children over the age of ten years of age and young adults.¹

Pathophysiology

Progression from simple to complicated appendicitis

Appendicitis happens when you have an inflamed appendix. The appendix is a small pouch that comes out from the lower right end of the large intestine. When faeces moves through the large intestine, it can block and or infect the appendix, resulting in an infection. This infection can then cause the appendix to swell and ultimately burst. When the appendix bursts, it is very serious because the bacteria from the bowel can spread to other parts of the body. This is known as peritonitis, which can then spread through the bloodstream, leading to sepsis. 

Clinical presentation

Some of the symptoms that are found in complicated appendicitis include: 

• Severe abdominal pain 
• Abdominal pain that worsens while coughing, jumping, sneezing or walking
• Swollen abdomen
• Tenderness in the abdomen
• Fever
• Decrease in appetite 
• Constipation
• Nausea
• Vomiting

Physical examination findings

While assessing for appendicitis, your doctor can check for certain signs specific for appendicitis, including:

• McBurney’s sign - checking for tenderness at McBurney’s point
• Dunphy’s sign- checking for pain on the lower right side of the abdomen when the person coughs
• Blumberg's sign - Pressure is applied on the sore area, and the patient is asked if the pain feels worse when the pressure is removed. This is also known as rebound tenderness
• Psoas signs - Pain in the lower right abdomen when you either stretch or contract the psoas muscles 
• Rovsing's sign - Checks for pressure on the lower left side, producing pain on the right side

Diagnostic methods 

When you visit your doctor, they will perform a physical exam to check for signs and symptoms of appendicitis, such as pain and guarding. Appendicitis is possible to diagnose with just the physical examination, but for confirmation of the diagnosis, your doctor may do some tests, including:

• Laboratory Tests - might include white blood cell count, C-reactive protein
• Abdominal Ultrasound
• CT scan
• MRI scan 

Differential diagnosis 

Some of the conditions that can mimic appendicitis include:

• Endometriosis
• Kidney stones
• Gastroenteritis
• Intestinal obstruction 
• Ovarian cysts
• Pancreatitis
• Inflammatory bowel disease
• Pelvic inflammatory disease

Management 

Non-surgical management

In most cases, antibiotics are used as the first step of management if you have very early and mild symptoms of appendicitis. But if your symptoms worsen, which happens in most cases, then the surgical approach is used.²

Surgical management - appendectomy 

There are two ways in which appendicitis can be surgically treated. In cases of complicated appendicitis, the Open approach is most commonly used.

• Open surgery - This is done under anaesthesia, where a cut is made on the lower right side of the abdomen. The appendix is then taken out. A drain is then inserted to clean and drain the pus and other fluids out of the abdomen. The drain is then taken out after a few days 
• Laparoscopic approach- This is also done under anaesthesia. Several small incisions are made, and a camera is used to look inside your abdomen. The appendix is taken out through the use of different tools³ 

Complications and outcomes 

There are some complications that can happen after the surgery, including:

• Infection at the surgical site or in the abdomen 
• Fever
• Abscess
• Pain in the abdomen⁴

Summary

Complicated appendicitis is more common than you think, but also very serious, so if you think you are having any of the symptoms that resemble appendicitis, it is important to seek help immediately or go to the nearest hospital. After an initial assessment, if the diagnosis is confirmed, you may need to undergo immediate surgery. It is essential that you seek help at the earliest time to avoid serious complications.