Appendicitis

1. Introduction

• Definition: Appendicitis is the acute inflammation of the appendix, a small, finger-shaped pouch attached to the large intestine. It is a medical emergency that requires prompt treatment, usually through surgery.
• Epidemiology: Affects 5–9% of the population worldwide, most commonly between ages 10–30.
• Significance: If untreated, appendicitis can lead to complications such as perforation, peritonitis, or sepsis, which can be life-threatening.

2. Causes and Risk Factors

• Causes:
  • Blockage of the appendix due to:
    • Fecaliths (hardened stool).
    • Enlarged lymphoid tissue (common after infections).
    • Tumours (rare but possible).
  • Bacterial infection leading to inflammation and pus accumulation.
• Risk Factors:
  • Low-fibre diet, leading to hardened stool and obstruction.
  • Family history of appendicitis.
  • Gastrointestinal infections.

3. Pathophysiology

• Obstruction of the appendix leads to bacterial overgrowth, causing inflammation and swelling.
• If untreated, the increasing pressure restricts blood flow, leading to ischemia, necrosis, and perforation, which can result in peritonitis or abscess formation.

4. Symptoms and Features

• Classic Symptoms:
  • Sudden onset of pain starting around the navel and shifting to the right lower abdomen (McBurney’s point).
  • Nausea, vomiting, and loss of appetite.
  • Low-grade fever.
• Other Symptoms:
  • Pain worsens with movement, coughing, or deep breathing.
  • Diarrhoea or constipation.
  • Swollen or bloated abdomen (in advanced cases).
• Atypical Presentations:
  • In pregnant women: Pain may be in the upper abdomen due to organ displacement.
  • In elderly patients: Less pronounced pain and fever, making diagnosis challenging.

5. Complications

• Perforation (ruptured appendix) → Leads to widespread infection in the abdomen (peritonitis).
• Abscess formation → Localised collection of pus requiring drainage.
• Sepsis → Infection spreads throughout the bloodstream, causing life-threatening complications.
• Bowel obstruction → Scar tissue or inflammation blocking the intestines.

6. Diagnosis

• Clinical Features:
  • Physical examination for tenderness at McBurney’s point.
  • Rebound tenderness (pain upon release of pressure).
  • Rovsing’s sign (pain in the right lower quadrant when pressing the left side).
• Laboratory Tests:
  • Complete Blood Count (CBC): Elevated white blood cells (WBC) indicating infection.
  • C-reactive Protein (CRP): Elevated in inflammation.
• Imaging:
  • Ultrasound: First-line in children and pregnant women.
  • CT Scan (gold standard): Provides high accuracy in confirming appendicitis.
  • MRI: Used in pregnant women when CT is not advisable.

7. Management Overview

• Goals: Remove the inflamed appendix, prevent complications, and control infection.
• Approach:
  • Uncomplicated Appendicitis → Early surgical removal (appendectomy).
  • Complicated Appendicitis (perforation, abscess) → Antibiotics first, then delayed surgery.

8. Treatment Options with Cost (USD)

• Surgical:
  • Laparoscopic appendectomy: ~$10,000–$25,000.
  • Open appendectomy (for ruptured appendix): ~$15,000–$30,000.
• Non-Surgical (for selected cases):
  • IV antibiotics (e.g., ceftriaxone + metronidazole): ~$500–$1,500.

9. Advanced Treatment Options with Cost (USD)

• Percutaneous abscess drainage: ~$3,000–$5,000.
• Intensive Care Unit (ICU) admission for sepsis: ~$5,000–$15,000 per day.

10. Pharmacological Treatment

• First-line (pre-surgery antibiotics):
  • Ceftriaxone + Metronidazole to prevent post-surgical infections.
• Second-line (if allergic to cephalosporins):
  • Clindamycin + Ciprofloxacin.
• Supportive Medications:
  • Pain relievers (paracetamol, ibuprofen).
  • Antiemetics (ondansetron) for nausea.

11. Medication Tables

Table 1: Doses and Side Effects

Drug	Indication	Dose	Common Side Effects
Ceftriaxone	Pre-operative antibiotic	1–2 g IV once daily	Diarrhoea, allergic reactions
Metronidazole	Anaerobic bacterial coverage	500 mg IV every 8 hours	Nausea, metallic taste
Clindamycin	Alternative antibiotic	600 mg IV every 8 hours	GI upset, risk of C. difficile infection
Ondansetron	Anti-nausea	4–8 mg IV every 8 hours	Headache, constipation

Table 2: Brand Names and Approximate Costs (USD)

Drug	Brand Names	Approx. Cost
Ceftriaxone	Rocephin	$50–$150 per course
Metronidazole	Flagyl	$20–$50 per course
Clindamycin	Cleocin	$50–$100 per course
Ondansetron	Zofran	$10–$30 per course

12. Lifestyle Interventions

• Dietary Changes (After Surgery):
  • Start with clear liquids and progress to solid foods gradually.
  • Avoid fatty, greasy, or heavy meals post-surgery.
• Physical Activity:
  • Avoid strenuous activities for 4–6 weeks after surgery.
• Hydration: Drink plenty of fluids to aid recovery.

13. Monitoring Parameters

• Post-surgery wound healing: Look for signs of infection (redness, pus, swelling).
• Pain management: Monitor pain levels and adjust medications accordingly.
• Signs of complications: Watch for persistent fever, severe pain, vomiting, or swelling.

14. Patient Counseling Points

• Seek immediate medical attention for severe abdominal pain, especially if it starts around the navel and moves to the lower right side.
• Avoid taking painkillers (NSAIDs) before diagnosis, as they may mask symptoms.
• Post-surgery, follow wound care instructions and avoid heavy lifting.
• Discuss antibiotic treatment vs. surgery with your doctor for early appendicitis.

15. Special Populations

• Children: Higher risk of perforation; ultrasound preferred for diagnosis.
• Pregnant Women: Symptoms can be atypical; MRI may be required for diagnosis.
• Elderly: Higher risk of misdiagnosis and delayed treatment.

16. Prevention

• Maintain a high-fibre diet to prevent fecalith formation.
• Treat gastrointestinal infections promptly.
• Avoid smoking, which may be linked to an increased risk of appendicitis.

17. FAQs

1. What is appendicitis? → Inflammation of the appendix, often requiring surgery.
2. What causes appendicitis? → Blockage of the appendix by stool, infection, or tumours.
3. What are the early signs of appendicitis? → Abdominal pain, nausea, fever, and loss of appetite.
4. How is appendicitis diagnosed? → Based on symptoms, blood tests, ultrasound, or CT scan.
5. Is appendicitis a medical emergency? → Yes, untreated appendicitis can lead to life-threatening complications.
6. How is appendicitis treated? → Surgery (appendectomy) or, in some cases, antibiotics.
7. Can appendicitis go away on its own? → Rarely; most cases require treatment.
8. What happens if the appendix bursts? → It can cause peritonitis, requiring emergency surgery.
9. How long does recovery take after an appendectomy? → 1–2 weeks for laparoscopic surgery, 4–6 weeks for open surgery.
10. Can I live without an appendix? → Yes, the appendix has no essential function in adults.