Introduction 

Appendicitis is the painful swelling of the appendix, a small pouch attached to the end of the large intestine. The most common form of this disease is known as acute appendicitis, which affects around 1 in every 13 people across their lifetime.¹

However, there are other types of appendicitis which are less common and are often misdiagnosed. One of these forms is called recurrent appendicitis. There is controversy over whether recurrent appendicitis is a condition in itself, or whether it can be avoided by accurate diagnosis and management of acute appendicitis.

This article delves into the causes of recurrent appendicitis and explores some of the potential ways in which you can manage the condition. 

Symptoms 

Appendicitis has a fairly consistent progression of symptoms, whether it is in the acute or recurrent form:²

• General lower belly pain, concentrated on the lower right side after a few hours 
• Nausea 
• Vomiting 
• Fever

Recurrent appendicitis involves repeated episodes of the acute form. These episodes are often separated by periods of relief from symptoms. Due to this, individuals with recurrent appendicitis are less likely to go to the hospital and tend to wait until any discomfort subsides. This is not to be confused with chronic appendicitis, which is a long-term condition associated with less intense pain that can go undiagnosed for years.³

Causes 

Infection

As with the acute form, one of the main causes of recurrent appendicitis is infection. Whilst the exact function of the appendix remains a mystery, some scientists believe that this small organ functions as a reservoir for bacteria that helps to repopulate the gut after illness.⁴ Due to the high number of bacteria existing within the appendix, it is more susceptible to infection. 

Infection can also be caused by eating contaminated food or water.⁵ Harmful bacteria are introduced to the gastrointestinal tract, which can lead to an inflammatory response in the gut, known as colitis. The infection caused by these bacteria can easily spread from the large intestine through the opening of the appendix. If left untreated, the infection is likely to cause appendicitis.⁵ 

Blockage 

Another main cause of recurrent appendicitis is blockage. Since the appendix is attached to the end of the large intestine, it can sometimes get blocked by stool (faeces). As previously mentioned, the appendix houses lots of bacteria, therefore blocking the opening of the appendix prevents bacteria from moving into the large intestine. This creates an unwanted buildup of bacteria which causes the appendix to swell and become inflamed.⁶ 

Although scientists don’t fully understand why some people get recurrent appendicitis, they believe it may be due to a partial blockage. The appendix will still become inflamed; however, the blockage is more likely to dislodge itself, causing relief from painful symptoms. 

In some rare cases, there may be a more sinister cause for the blockage, such as a tumour. Obstructions that are caused by tumours have the same impact on the appendix as blockage by stool. However, if the tumour is cancerous, it has the potential to spread if not treated early.⁷

Management and treatment

Appendectomy 

While it is thought that the appendix houses bacteria to replenish the gut, there are no long-term side effects to removing the appendix through an appendectomy.⁶ Removing it in cases of appendicitis is the most successful method of management of the disease to prevent its recurrence. There are 2 main types of appendectomy:

• Keyhole surgery 
• Open operation

Keyhole surgery 

The favoured method for managing recurrent appendicitis is the removal of the appendix through laparoscopy; widely referred to as keyhole surgery. This is a minimally invasive surgery that has several steps, including:⁸

• A few 1 cm cuts are made to the lower right belly
• A tube with a camera attached, called a laparoscope, is inserted into a cut 
• The appendix is located and tied off from the large intestine
• The appendix is removed and the small cuts are stitched closed 

Keyhole surgery is the preferred method for removing the appendix, as it is less painful and the recovery time is shorter than an open operation.

Open operation 

In some cases, appendicitis may cause the appendix to burst and the infection to spread inside the belly. For this reason, surgeons may opt for an open operation. This involves:⁸ 

• A single 5-10 cm cut to the lower right belly
• The appendix is located and tied off from the large intestine 
• The appendix is removed and the cut is stitched closed

Open operations are equally as effective as keyhole surgery in preventing the recurrence of appendicitis, however, there is an increased chance of wound infection due to the larger incision.⁹

Antibiotics

Rather than removing the inflamed appendix, it is possible for mild cases of recurrent appendicitis to be treated with a course of antibiotics to treat the infection and reduce the swelling.¹⁰ 

However, while treating with antibiotics is non-invasive, there is little evidence suggesting that antibiotic treatment alone can successfully treat recurring appendicitis. A more effective use of antibiotics is to use them to minimise infection before an appendectomy. 

If antibiotics are given to manage appendicitis without following up with an appendectomy, there is a 25-35% chance of appendicitis recurring within 1 year of the initial episode.¹¹

FAQ’s 

Who can get recurrent appendicitis?

Anyone can get appendicitis, but it is more common for people between the ages of 10 and 30 years old. Additionally, men are slightly more at risk of developing an inflamed appendix than women. Individuals who have previously had acute appendicitis that was treated with antibiotics alone are at increased risk of it recurring. 

Is recurrent appendicitis dangerous?

If left untreated, recurrent appendicitis can be dangerous. An inflamed appendix is at risk of bursting which will release harmful bacteria into the abdomen, causing peritonitis. An infection of the abdomen largely increases the risk of fatality, therefore it is important to seek medical attention if you experience sudden pain in your lower right belly. 

Can an inflamed appendix go away without treatment?

If the cause of appendicitis is a blockage, there is the potential for it to become unblocked by itself resulting in reduced swelling. However, while it is possible for appendicitis to heal itself, it is unlikely.

Summary 

Recurrent appendicitis is a condition where the appendix becomes repetitively inflamed, causing pain and discomfort to the individual. Often separated by periods of relief from symptoms, individuals temporarily believe that they have fully recovered, only to experience another episode of appendicitis later on. It is thought to be a complication of standard acute appendicitis, which can be avoided by successful treatment by an appendectomy surgery, which is the removal of the appendix after the first episode.