Pain in the appendix is most commonly caused by inflammation and is rarely caused by a tumor. An inflammation of the appendix is called appendicitis, and it can feel like dull pain in the middle or on the right side of the abdomen. The pain may then become sharp and migrate to the lower right of the abdomen. This type of pain occurs in about 80 percent of people with appendicitis.
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| Appendix Pain |
Other signs and symptoms of appendicitis are fever, indigestion, nausea, vomiting, abdominal swelling, constipation or diarrhea, lack of appetite, and either being unable to pass gas or passing too much gas. The pain often feels worse when sneezing, coughing, moving, and breathing. Some people may pull their knees up to their chest to lessen the pain. Less common symptoms include pain during urination, in other parts of the abdomen, the back, or the rectum.
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| Illustration by Alexandra Gordon |
Causes
The appendix is a small, tube-like organ that is connected to the large intestine. It’s somewhere between 2 and 4 inches in length and is located in the lower right quadrant of the abdomen. There are theories on what the function of the appendix might be, but there’s no definitive answer. This organ isn’t necessary to live, and it's often removed if it becomes inflamed or infected. If the large intestine is removed (a colectomy), the appendix is also removed because the two organs are connected.
The space inside the appendix has a name: the lumen. The lumen can become blocked, such as when feces manages to work its way inside the appendix. Another way the lumen can become narrowed is if there is a lymph node that is swollen, such as when there is an infection, and the node is pressing on the appendix.
Common
Appendicitis: When the lumen of the appendix becomes blocked, it builds pressure inside it, reduces blood flow to the area, and can lead to infection and inflammation. In some cases, it is feces, or even a hardened stone of feces called a fecalith or an appendicolith, that blocks the lumen. The tissue of an inflamed and infected appendix may start to die (become gangrenous). This, in turn, may cause the appendix to tear or even rupture. In rare cases, an injury to the abdomen can also cause the appendix to rupture
Abscess: An abscess (a collection of pus) may form in the area of the appendix. This is often associated with inflammation in the appendix but it may be treated prior to treating the appendicitis.
Rare
Tumor: A rare cause of pain from the appendix is a tumor. Cancer of the appendix usually doesn’t cause symptoms until it is advanced. However, when symptoms do start, it is because appendicitis has developed.
When to See a Doctor
Abdominal pain is common, which is why it is important to get new pain looked at by a physician. In particular, severe pain in the lower right abdomen is a hallmark sign of appendicitis and is a reason to seek treatment right away. In many cases, the pain starts further up in the abdomen and then migrates down to the lower right area.
Appendicitis is a medical emergency. The symptoms of appendicitis tend to start soon after the start of the blockage in the appendix, so they may come on over the course of between four and 48 hours. Appendicitis symptoms can be similar to those of other conditions, making it crucial to take them seriously and get a prompt and accurate diagnosis.
A tumor in the appendix, which is rare, may not cause any symptoms until appendicitis develops and the symptoms of that condition start.
The signs and symptoms of appendicitis that should be discussed with a physician or, more commonly, prompt a visit to the emergency room, include:
- Being unable to pass gas
- Constipation or diarrhea (in as much as 18 percent of patients)
- Fever
- Lack of appetite (in 74–78 percent of patients)
- Nausea (in 60–90 percent of patients)
- Vomiting (occurs in about half of patients)
Diagnosis
Symptoms such as abdominal pain and fever may cause a physician to suspect that the appendix is inflamed. Several different tests might then be used to determine if it is appendicitis or not.
Labs and Tests
Blood tests: There isn’t a blood test that can show the presence of appendicitis. However, white blood cells increase in the body when there is an infection, and a high white blood cell count, along with the results of a physical exam, may be used together to determine that the appendix is inflamed.
Physical exam: The physical exam is important in diagnosing appendicitis. In some cases, it may be decided that surgery to remove the appendix is necessary after a physical exam, and imaging tests might not be done. Tenderness when palpating (pressing) the lower right abdomen could indicate appendicitis. The pain may also worsen after the pressure is released. The physician conducting the exam will look for signs of pain such as tensing up or guarding the tender area. If the appendix ruptures, the abdomen might be rigid and swollen.
Imaging
Computed Tomography (CT) scan: A CT scan is a type of X-ray that shows the abdomen in a cross-section. A patient undergoing this test will lie on a table that slides into a large X-ray machine. The machine will take the images that show the structures inside the abdomen. Contrast dye may be given through an IV in order for the organs in the abdomen to better show up on the images. If the appendix is inflamed, dilated, or narrowed it might be seen on the images from a CT scan.
Ultrasound: An ultrasound uses sound waves and not radiation to visualize the structures inside the body. An ultrasound might be done more commonly in children or in pregnant women to avoid the use of radiation. During an ultrasound, a tool called a transducer is moved over the abdomen to capture images. If the appendix is dilated, it may show on the images generated from this test.
Other tests: Because appendicitis is similar to other conditions, other tests might be done to see if the abdominal pain could be from another cause. These tests can include a pelvic exam, urinalysis, pregnancy test, and chest X-ray. Tumors in the appendix are rare, and if this is the suspected reason for the abdominal pain, magnetic resonance imaging (MRI) or positron emission tomography (PET) may be used.
Differential Diagnosis
A physician may consider other reasons as a cause of appendix pain because the signs and symptoms of an inflamed appendix are similar to many other conditions, including:
- Bacterial enteritis
- Biliary colic
- Cholecystitis
- Colonic carcinoma
- Crohn's disease
- Degenerating uterine leiomyomata
- Diverticulitis
- Enterocolitis
- Gastroenteritis
- Mesenteric adenitis and ischemic
- Omental torsion
- Pancreatitis
- Perforated duodenal ulcer
- Rectus sheath hematoma
- Renal colic
- Ureterolithiasis
- Urinary tract infection (UTI)
Treatment
The treatment for appendicitis is almost always surgery to remove the organ (called an appendectomy). Prior to surgery, antibiotics are given because of the risk of spread of infection. This is because if the appendix ruptures and spills the contents into the abdominal cavity, it may cause a condition called peritonitis, which is life-threatening. If there is already an abscess, a physician may put a tube under the skin to drain it.
In some cases, antibiotics may be the only treatment given for appendicitis. Some studies have shown that appendicitis may improve after a course of antibiotics in some patients who have acute (sudden) appendicitis. However, a little over a quarter of those patients will go on to need their appendix removed in the next year because of another bout with appendicitis.
An appendectomy might be done with open surgery or it may be done laparoscopically. Open surgery will require a small incision on the lower right abdomen
Laproscopic surgery is done through the use of three or four quite small incisions. Once it’s decided to do the surgery, the appendix is almost always removed, even if it’s determined during the course of surgery that the appendix may be normal (not infected or inflamed). Most people stay in the hospital for another day after an appendectomy. Treatment with antibiotics continues for about three to five days after the surgery.
For cancer of the appendix, treatment will include an appendectomy and then continue based on how far the cancer is advanced and if it is benign or malignant.
Prevention
There’s currently no known way to prevent appendicitis. Some studies have shown that eating a high fiber diet may may lower the risk of developing appendicitis.
Avoiding complications after an appendectomy is important. Finishing the course of antibiotics after surgery is important to a full recovery. Any problems with the incision, such as redness or oozing, should be discussed with a physician right away. Symptoms such as fever, vomiting, and abdominal tenderness could indicate that there is another infection and it’s important to seek care right away if they occur.
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