http://www.medicinenet.com/appendicitis/article.htm The appendix is a small, worm-like appendage attached to the colon. Appendicitis occurs when bacteria invade and infect the wall of the appendix. The most common complications of appendicitis are abscess and peritonitis. The most common symptoms of appendicitis areabdominal pain, loss of appetite,nauseaandvomiting,fever, and abdominal tenderness. Appendicitis usually is suspected on the basis of a patient's history and physical examination; however, a white blood cell count,urinalysis, abdominal X-ray,barium enema, ultrasonography,CT scan, andlaparoscopyalso may be helpful in diagnosis. Due to the varying size and location of the appendix and the proximity of other organs to the appendix, it may be difficult to differentiate appendicitis from other abdominal and pelvic diseases. The treatment for appendicitis usually is antibiotics and appendectomy (appendectomy or surgery to remove the appendix). Complications of appendectomy include wound infection and abscess.

Other conditions that can mimic appendicitis include Meckel'sdiverticulitis,pelvic inflammatory disease(PID), inflammatory diseases of the right upper abdomen (gallbladder disease,liver disease, or perforated duodenal ulcer), right-sided diverticulitis, and kidney diseases.

What is the appendix?

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The open central core of the appendix drains into the cecum. The inner lining of the appendix produces a small amount of mucus that flows through the open central core of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the layer of muscle is poorly developed.

What is appendicitis and what causes appendicitis?

Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, it might be that thelymphatic tissuein the appendix swells and blocks the opening. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside of the appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that lines the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion ofcancer.

What are the complications of appendicitis?

The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuseperitonitis(infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.

A less common complication of appendicitis is blockage or obstruction of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine.

A feared complication of appendicitis issepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

What are the symptoms of appendicitis?

The main symptom of appendicitis isabdominal pain. The pain is at first diffuse and poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. A second, common, early symptom of appendicitis isloss of appetitewhich may progress to nausea and even vomiting.Nausea and vomitingalso may occur later due to intestinal obstruction.

As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called theperitoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen becomes inflamed.

How is appendicitis diagnosed?

The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his or her hand after gently pressing on the abdomen over the area of tenderness.

White Blood Cell CountThewhite blood cell countin the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early in the process. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used to confirm a diagnosis of appendicitis.

UrinalysisUrinalysisis a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem.

Abdominal X-RayAn abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.

UltrasoundAnultrasoundis a painless procedure that uses sound waves to provide images of identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, Fallopian tubes and uterus that can mimic appendicitis.

Barium EnemaAbarium enemais an X-ray test in which liquid barium is inserted into the colon from the anus to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude other intestinal problems that mimic appendicitis, for exampleCrohn's disease.

Computerized tomography (CT) ScanIn patients who are notpregnant, aCT scanof the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.

LaparoscopyLaparoscopyis a surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparoscope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.

There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery.

Why can it be difficult to diagnose appendicitis?

It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large, it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women). It also may allow the appendix to move behind the colon (called a retro-colic appendix). In either case, inflammation of the appendix may appear to be more like the inflammation of other organs, for example, a woman's pelvic organs.

The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a period of time to see if the problem will resolve on its own or develop characteristics that more strongly suggest appendicitis or, perhaps, another condition.

What other conditions can mimic appendicitis?

The surgeon faced with a patient suspected of having appendicitis always must consider and look for other conditions that can mimic appendicitis. Among the conditions that mimic appendicitis are:

Meckel's diverticulitis.AMeckel's diverticulumis a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate (break open or rupture). If inflamed and/or perforated, it usually is removed surgically.

Pelvic inflammatory disease.The right Fallopian tube and ovary lie near the appendix. Sexually active women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary.

Inflammatory diseases of the right upper abdomen.Fluids from the right upper abdomen may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis. Such fluids may come from a perforated duodenal ulcer,gallbladder disease,or inflammatorydiseases of the liver, for example, a liver abscess.

Right-sided diverticulitis.Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures it can provoke inflammation they mimics appendicitis.

Kidney diseases.The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic appendicitis.

How is appendicitis treated?

Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected.

There is a small group of patients in whom the inflammation and infection of appendicitis remain mild and localized to a small area. The body is able not only to contain the inflammation and infection but to resolve it as well. These patients usually are not very ill and improve during several days of observation. This type of appendicitis is referred to as "confined appendicitis" and may be treated with antibiotics alone. The appendix may or may not be removed at a later time.

On occasion, a person may not see their doctor until appendicitis with rupture has been present for many days or even weeks. In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. A drain (a small plastic or rubber tube) usually is inserted through the skin and into the abscess with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The drain allows pus to flow from the abscess out of the body. The appendix may be removed several weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack of appendicitis.

How is an appendectomy done?

During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially helpful in menstruating women in whom a rupture of anovarian cystmay mimic appendicitis.

If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess.

Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix than to miss and not treat appropriately an early or mild case of appendicitis.

What are the complications of appendectomy?

The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. Wound infections are less common with laparoscopic surgery.

Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques, as previously discussed.

Are there long-term consequences of appendectomy?

It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example,Crohn's disease.

What is new about appendicitis?

Recently it has been hypothesized that some episodes of appendicitis-like symptoms, especially recurrent symptoms, may be due to an increased sensitivity of the intestine and appendix from a prior episode of inflammation. That is, the recurrent symptoms are not due to recurrent episodes of inflammation. Rather, prior inflammation has made the nerves of the intestines and appendix or the central nervous system that innervate them more sensitive to normal stimuli, that is, with stimuli other than inflammation. This will be a difficult, if not impossible, hypothesis to confirm.

Additional resources from WebMD Boots UK onAppendicitisREFERENCE:

Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.

Original author and editor:Dennis Lee, M.D.andJay W. Marks, M.D.http://emedicine.medscape.com/article/773895-overviewBackground

Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay (see Clinical Presentation). In fact, despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is one of the more common causes of acute abdominal pain.

No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases, and the classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases (see Clinical Presentation).

Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the obstruction of the appendiceal lumen (see Pathogenesis and Etiology). Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death (see Prognosis and Complications). However, the differential diagnosis of appendicitis is often a clinical challenge because appendicitis can mimic several abdominal conditions (see Diagnostic Considerations and Differentials).[1]Appendectomy remains the only curative treatment of appendicitis (see Treatment and Management). The surgeon's goals are to evaluate a relatively small population of patients referred for suspected appendicitis and to minimize the negative appendectomy rate without increasing the incidence of perforation. The emergency department (ED) clinician must evaluate the larger group of patients who present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.

Go toPediatric Appendicitisfor more information on this topic.

Anatomy

The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. A normal appendix is seen below.

Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath these layers lies the submucosal layer, which contains lymphoepithelial tissue. The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells.

Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found.

Appendiceal vasculature

The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The appendicular artery is contained within the mesenteric fold that arises from a peritoneal extension from the terminal ileum to the medial aspect of the cecum and appendix; it is a terminal branch of the ileocolic artery and runs adjacent to the appendicular wall. Venous drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac nodes and cisterna chyli.

Appendiceal location

The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or as a funnel-shaped opening (2-3% of patients). The appendix has a retroperitoneal location in 65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and the difference in appendiceal position considerably changes clinical findings, accounting for the nonspecific signs and symptoms of appendicitis.

Congenital appendiceal disorders

Appendiceal congenital disorders are extremely rare but occasionally reported (eg, agenesis, duplication, triplication).

Pathophysiology

Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes (see Etiology). Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white blood cells (see the image below) and the formation of pus and subsequent higher intraluminal pressure.

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent with acute appendicitis.If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess orperitonitismay occur.

Etiology

Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms.

Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix. Lymphoid hyperplasia is associated with various inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with bacteria (Yersiniaspecies, adenovirus, cytomegalovirus, actinomycosis,Mycobacteriaspecies,Histoplasmaspecies), parasites (eg,Schistosomesspecies, pinworms,Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.

Epidemiology

Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission. The incidence of acute appendicitis has been declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000 population. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists.

In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions of the appendiceal lumen.

In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed to be related to poor fiber intake in such countries.

There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes.

The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been reported. Clinicians must maintain a high index of suspicion in all age groups.

Go toPediatric Appendicitisfor more information on this topic.

Prognosis

Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy carries a complication rate of 4-15%, as well as associated costs and the discomfort of hospitalization and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis as early as possible. Delayed diagnosis and treatment account for much of the mortality and morbidity associated with appendicitis.

The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than 70 years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay.

Appendiceal perforation is associated with increased morbidity and mortality compared with nonperforating appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than 0.1%, but the risk rises to 0.6% in gangrenous appendicitis. The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40-57%) and in patients older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis are common. Complications occur in 1-5% of patients with appendicitis, and postoperative wound infections account for almost one third of the associated morbidity.

Abdominal Pain in Adults Overview

Abdominal pain can range in intensity from a mild stomach ache to severe acute pain. The pain is often nonspecific and can be caused by a variety of conditions. Many organs are found within the abdominal cavity. Sometimes the pain is directly related to a specific organ such as the bladder or ovary, while other times it is more diffuse or non-specific.. Usually, abdominal pain originates in the digestive system. For example, the pain can be caused by appendicitis, diarrheal cramping, orfood poisoning.

The type and location of pain may help the physician find the cause. The intensity and duration of pain must also be considered when making a diagnosis. A few general characteristics of abdominal pain are as follows:

Character of Pain:Abdominal pain can be sharp, dull, stabbing, cramp-like, knifelike, twisting, or piercing. Many other types of pain are possible.

Duration of Pain:Abdominal pain can be brief, lasting for a few minutes, or it may persist for several hours and longer. Sometimes abdominal pain comes on strongly for a while and then lessens in intensity for a while.

Triggering Events:The pain may be worsened or relieved by certain events, such as worse after meals, better with a bowel movement, better after vomiting, or worse when lying down.

Abdominal pain can make a person want to stay in one place and not move a muscle. Or the pain can make them so restless they want to pace around trying to find "just the right position."

The health care practitioner will try to pinpoint the area of the abdomen where the pain originates when determining the cause of abdominal pain. This is done by combining questions such as - "When you first had the pain, where did you feel it?" - with examination of the abdomen. Softly pressing on certain areas to elicit the pain and perhaps palpating other areas to examine the size and exact location of an organ are other parts of the physical examination.

When this is combined with general questions about the pain such as "Is the pain dull or sharp?" "How long have you had the pain?" and questions about your state of health - "Did you have to vomit?" - the health care practitioner can narrow down the possible causes of the pain.

Once the questions and physical exam are completed, the health care practitioner will either give the patient a diagnosis and advise on follow-up recommendations or order blood tests, and possibly X-rays andimaging studiesto further help identify why the patient is in pain.

Abdominal Pain in Adults Causes

Many acute (short-term) and chronic (long-term) diseases cause abdominal pain.

Diseases people worry about most areappendicitis, gallbladder disease, duodenal andgastric ulcers, infections, andpregnancy-associated problems. Doctors also worry about the following conditions: ruptured blood vessels,heart attack, liver andpancreas inflammation, kidney stones, problems with the blood circulation to the intestine,diverticulitis, and other diseases.

Abdominal pain may not arise from the abdomen.

Some heart attacks andpneumoniascan cause abdominal pain. Diseases of the pelvis or groin can also cause a pateint's abdomen to hurt. Certainskin rashes, such asshingles, can feel like abdominal pain, even though the person has nothing wrong inside their body.

Even somepoisonings, such as ablack widow spider bite, can cause severe abdominal pain.

From the above it is apparent that abdominal pain can have many causes, some linked directly to the abdomen and others caused by non-abdominal disease. Sometime the cause of abdominal pain is not found by the patient's health care practitioner during the initial evaluation. In some cases, no specific cause is determined, and the pain gets better in hours or days.

Abdominal Pain in Adults Symptoms

Abdominal pain is a symptom. It may mean that the person has a medical problem that needs treatment.

Abdominal pain may go along with other symptoms. Try to keep track of the symptoms, because this will help the health care practitioner's find the cause of the person's painPediatric Appendicitis

Abdominal Pain in Adults Symptoms

Abdominal pain is a symptom. It may mean that the person has a medical problem that needs treatment.

Abdominal pain may go along with other symptoms. Try to keep track of the symptoms, because this will help the health care practitioner's find the cause of the person's pain.

Anatomy

The vermiform appendix is generally 5-10 cm in length. It arises from the cecum, which in most children is located in the right lower quadrant of the abdomen.

Although the base of the appendix is fixed to the cecum, the tip can be located in the pelvis, retrocecum, or extraperitoneum. Note that the anatomic position of the appendix determines the symptoms and the site of tenderness when the appendix becomes inflamed.

The appendix is lined by typical colonic epithelium. The submucosa contains lymphoid follicles, which are very few at birth. This number gradually increases to a peak of about 200 follicles at age 10-20 years and then subsequently declines. In persons older than 30 years, less than half that number is present, and the number continues to decrease throughout adulthood.

Pathophysiology

Once the appendix becomes obstructed, bacteria trapped within the appendiceal lumen begin to multiply, and the appendix becomes distended. The increased intraluminal pressure obstructs venous drainage, and the appendix becomes congested and ischemic.

The combination of bacterial infection and ischemia produce inflammation, which progresses to necrosis and gangrene. When the appendix becomes gangrenous, it may perforate. The progression from obstruction to perforation usually takes place over 72 hours.

One study noted that appendiceal perforation is more common in children, specifically younger children, than in adults. A substantial risk of perforation within 24 hours of onset was noted (7.7%) and was found to increase with duration of symptoms. While perforation was directly related to the duration of symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital delay.[1]During the initial stage of appendicitis, the patient feels only periumbilical pain due to the T10 innervation of the appendix. As the inflammation worsens, an exudate forms on the appendiceal serosal surface. When the exudate touches the parietal peritoneum, a more intense and localized pain develops.

Perforation results in the release of inflammatory fluid and bacteria into the abdominal cavity. This further inflames the peritoneal surface, and peritonitis develops. The location and extent of peritonitis (diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can contain the spillage of luminal contents.

If the contents become walled off and form an abscess, the pain and tenderness may be localized to the abscess site. If the contents are not walled off and the fluid is able to travel throughout the peritoneum, the pain and tenderness become generalized.

Etiology

Acute appendicitis is due to obstruction of the blind ending appendix, resulting in a closed loop. In children, obstruction usually results from lymphoid hyperplasia of the submucosal follicles. The cause of this hyperplasia is controversial, but dehydration and viral infection have been proposed. Another common cause of obstruction of the appendix is a fecalith.

Rare causes include foreign bodies, parasitic infections (eg, nematodes), and inflammatory strictures.

Epidemiology

Appendicitis has an incidence of 70,000 pediatric cases per year in the United States. The incidence between birth and age 4 years is 1-2 cases per 10,000 children per year. The incidence increases to 25 cases per 10,000 children per year between 10 and 17 years of age. Overall, 7% of people in the United States have their appendix removed during their lifetime. The male-to-female ratio is approximately 2:1.

Appendicitis is much more common in developed countries. Although the reason for this discrepancy is unknown, potential risk factors include a diet low in fiber and high in sugar, family history, and infection.

Appendicitis occurs in all age groups but is rare in infants. Appendicitis is most common in the second decade of life (age 10-19 y), occurring at a rate of 23.3 cases per 10,000 per year. Thereafter, the incidence continues to decline, although appendicitis occurs in adulthood and into old age.

Prognosis

Generally, the prognosis is excellent. At the time of diagnosis, the rate of appendiceal perforation is 20-35%. The rate of perforation is 80-100% for children younger than 3 years, compared with 10-20% in children 10-17 years old. Children with ruptured appendicitis are at risk for intra-abdominal abscess formation and small bowel obstruction, and they can have a prolonged hospital stay (several weeks or more). The mortality rate for children with appendicitis is 0.1-1%.

Death from appendicitis is most common in neonates and infants for the following 2 reasons:

Appendicitis is rare in this age group; thus, unless the physicians index of suspicion is high, appendicitis is often low on the list of suspected differential diagnoses.

Very young patients are unable to communicate the location and nature of their pain. Some neonates may not even become febrile. Often, the patients only symptom is irritability or inconsolability.

History

The classic history of anorexia and vague periumbilical pain, followed by migration of pain to the right lower quadrant (RLQ) and onset of fever and vomiting, is observed in fewer than 60% of patients.[2]If the appendix perforates, an interval of pain relief is followed by development of generalized abdominal pain and peritonitis. Although some patients progress in the classical fashion, some patients deviate from the classic model. Atypical presentations are common in neurologically impaired and immunocompromised patients, as well as in children who are already on antibiotics for another illness.

In patients with a retrocecal appendix, who constitute 15% of cases, signs and symptoms may not localize to the RLQ but instead to the psoas muscle. In other patients, the tip of the appendix is deep in the pelvis, and the signs and symptoms localize to the rectum or bladder.

Certain features of a child's presentation may suggest a perforated appendix. A child younger than 6 years with symptoms for more than 48 hours is much more likely to have a perforated appendix. The child may have generalized abdominal pain and may have a temperature higher than 38C.

A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study and was found to increase with duration of symptoms. While perforation was directly related to the duration of symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital delay.[1]Pain

All patients with appendicitis have abdominal pain, and many have anorexia; absence of both of these findings should place the diagnosis of appendicitis in question. A child who states that the ride to the hospital is painful when the vehicle hits bumps in the road may have peritoneal irritation.

Acute onset of severe pain is not typical of acute appendicitis but is seen with acute ischemic conditions such as volvulus,testicular torsion, ovarian torsion, orintussusception. If the pain is initially located in the right lower quadrant, severe constipation should be considered.

After a few hours, the pain migrates to the RLQ due to inflammation of the parietal peritoneum. This pain is more intense, continuous, and localized than the initial pain. This shift of pain rarely occurs in other abdominal conditions.

Atypical pain is common and occurs in 40-45% of patients. This includes children who initially have localized pain and those with no visceral symptoms. Pain on urination can be seen with pelvic appendicitis.

Nausea and vomiting

A unique feature of appendicitis is gradual onset of pain followed by vomiting. Vomiting first is more typical ofgastroenteritis.

Generally, vomiting that occurs prior to pain is unusual. However, in patients with retrocecal appendices, particularly those that extend cephalad along the posterior surface of the right colon, inflammation of the appendix irritates the nearby duodenum, resulting in nausea and vomiting prior to the onset of RLQ pain.

Diarrhea

Significant diarrhea is atypical in appendicitis, and the physician should consider other diagnoses, while not ruling out appendicitis. In patients with an appendix in a pelvic location, inflammation of the appendix occasionally results in an irritative stimulation of the rectum. These patients often report diarrhea. However, upon closer questioning, such patients usually describe frequent, small-volume, soft stools rather than true diarrhea.

Fever

Most children with appendicitis are afebrile or have a low-grade fever and characteristic flushing of their cheeks. Severe fever is not a common presenting feature unless perforation has occurred, and even then it may still be rare. According to one study, vomiting and fever are more frequent findings in children with appendicitis than in children with other causes of abdominal pain.

Physical Examination

The physical examination findings in children may vary depending on age. Irritability may be the only sign of appendicitis in a neonate. Older children often seem uncomfortable or withdrawn. They may prefer to lie still because of peritoneal irritation. Teenaged patients often present in a classic or near-classic fashion.

Examination of the child requires skill, patience, and warm hands. Initial and continued observation of the child is of critical importance. An ill-appearing quiet child who is lying very still in bed, perhaps with the legs flexed, is much more a cause for concern than a child who is laughing, playing, and walking around the room.

The examination should be thorough and start with areas other than the abdomen. Because lower lobe pneumonias can cause abdominal findings, a history of such should be elicited and a thorough chest examination performed. It is also important to excludeurinary tract infection(UTI) as a cause of abdominal pain.

Children vary in their ability to cooperate with the physical examination. It is important to tailor the physical examination to the child's age and developmental stage.

General examination

Patients general state and gait should be observed before interacting with them. The patients state of activity or withdrawal may lend information into their condition. A patient in obvious distress with abdominal pain gives the impression of an infectious process; however, other causes must be ruled out.

Cardiac and pulmonary examination

The findings on evaluation of the heart and lungs typically reflect the patients overall state more than they may suggest appendicitis. Patients are often dehydrated or in pain and may be tachycardic or tachypneic. Pediatric patients have great physiological reserves and may not show any general symptoms until they are very ill.

Abdominal examination

Full exposure of the abdomen is key. Before examining the abdomen, ask the child to point with one finger to the site of maximal pain. Begin palpation of the abdomen at a site distant to this, with the most tender area examined last. If the child is particularly anxious, palpation may be performed with a stethoscope.

Distracting questions concerning school and family members may be helpful to relieve anxiety during the examination. Observing the child's facial expressions during this questioning and palpating is critical.

Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary guarding of the rectus or oblique muscles. In early appendicitis, children may not have significant guarding or peritoneal signs. Younger children are much more likely to present with diffuse abdominal pain and peritonitis, perhaps because their omentum is not well developed and cannot contain the perforation.

Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass may be palpable in the RLQ if the appendix is perforated.

However, the appendix may lie in many positions. Patients with a medially positioned appendix may present with suprapubic tenderness. Patients with a laterally positioned appendix often have flank tenderness. Patients with a retrocecal appendix may not have any tenderness until appendicitis is advanced or the appendix perforates.

Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or percussion) strongly suggests peritoneal irritation.

To assess for the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A positive response suggests an inflammatory mass overlying the psoas muscle (retrocecal appendicitis).

Check for the obturator sign by internally rotating the flexed right thigh. A positive response suggests an inflammatory mass overlying the obturator space (pelvic appendicitis).

During the abdominal examination, try to avoid eliciting rebound tenderness. This is a painful practice and certainly destroys any trust that has been garnered during the examination. Peritonitis can be confirmed with gentle percussion over the right lower quadrant. Involuntary contraction of the abdominal wall musculature (involuntary guarding) and tenderness can be elicited with minimal stress or discomfort to the child.

Other methods can be used to establish that the patient has peritoneal irritation. Asking the patient to sit up in bed, cough, jump up and down, or bounce his or her pelvis off the bed while in the supine position may elicit pain in the presence of peritoneal irritation. Alternatively, other acceptable maneuvers are tapping the patient's soles and shaking the stretcher. A child with advanced appendicitis typically prefers to lie still due to peritoneal irritation.

Rectal examination

The digital rectal examination is often deferred but can be helpful in establishing the correct diagnosis, especially in sexually active adolescent girls. The patient should be told that the examination is uncomfortable but should not cause sharp pain. The caliber of the patient's anus should be taken into consideration, and smaller digits should be used for examining younger patients.

The rectal examination is particularly important in the child with a pelvic appendix, in whom the findings on the abdominal examination for appendicitis may be equivocal and indicative of peritoneal irritation.

Objective information to ascertain includes impacted stool or an inflammatory mass. Right-sided tenderness of the rectum is the classic finding in patients with pelvic appendicitis or in those with pus that pools in the pelvis from an inflamed appendix elsewhere in the abdomen.

Patients who are able to communicate should be asked if they have tenderness in different areas of the rectum. The rectal examination in a young child may have to be completely objective because they may not be able to communicate variations in tenderness or may have general discomfort from the examination.

Genitourinary examination

An external genitourinary (GU) examination is helpful to rule out testicular or scrotal tenderness in males and hematocolpos in pubertal girls.

Pelvic examination

A pelvic examination should be considered in sexually active adolescent girls to evaluate for tenderness (adnexal and/or cervical motion tenderness), masses, bleeding, or discharge.

Atypical findings

Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or more of the following atypical features[3]:

No fever

Absence of Rovsing sign

Normal or increased bowel sounds

No rebound pain

No migration of pain

No guarding

Abrupt onset of pain

No anorexia

Absence of maximal pain in the RLQ

Absence of percussive tenderness

Diagnostic Considerations

Do not diagnose gastroenteritis rather than appendicitis unless the patient has nausea, vomiting, and diarrhea. Even with the presence of vomiting and diarrhea, consider the unusual presentations of retrocecal or pelvic appendicitis. Additionally, appendicitis can develop as a sequela of gastroenteritis associated with lymphoid hyperplasia.

Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal symptoms. Instruct patients to be reevaluated in 8-12 hours by their primary care physician or to return to the emergency department. Patients with equivocal examination findings should be admitted for observation for serial abdominal examinations or to undergo imaging with ultrasonography or abdominal CT scanning.

If constipation is diagnosed and treated with enemas and/or stool softeners with resolution of the signs and symptoms, inform the patient and family that recurrence of the abdominal pain in the future could be recurrent constipation or acute appendicitis and to seek medical advice.

Appendicitis should be considered in special patient populations, such as the immunocompromised and developmentally delayed. Appendicitis is rare in infants. If an infant has appendicitis, the diagnosis ofHirschsprung diseaseshould also be considered.

Other problems to consider include the following:

Ovarian cyst

Ovarian torsion

Pelvic inflammatory disease (PID)

Pregnancy

Ectopic pregnancy

Renal calculi

Mesenteric lymphadenitis

Mittelschmerz

Pneumonia (right lower lobe)

Neutropenic typhilitis

Lymphoma

Epiploic appendagitis

Paratubal cysts

Volvulus

Typhlitis

The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and malignancy.

Differentials

Constipation Ectopic Pregnancy Hemolytic-Uremic Syndrome Henoch-Schoenlein Purpura Meckel Diverticulum Ovarian Cysts Ovarian Torsion Pancreatitis Pediatrics, Gastroenteritis Pediatrics, Intussusception Pediatrics, Urinary Tract Infections and Pyelonephritis Pelvic Inflammatory Disease Pregnancy Diagnosis Pregnancy, Ectopic Pyelonephritis Renal Calculi Testicular Torsion Urinary Tract Infectionhttp://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/National Digestive DiseasesInformation Clearinghouse (NDDIC)

A service of theNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),National Institutes of Health (NIHWhat is appendicitis?

Appendicitis is a painful swelling and infection of the appendix.

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What is the appendix?

The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen. Scientists are not sure what the appendix does, if anything, but removing it does not appear to affect a person's health. The inside of the appendix is called the appendiceal lumen. Mucus created by the appendix travels through the appendiceal lumen and empties into the large intestine.

The appendix is a fingerlike pouch attached to the large intestine in the lower right area of the abdomen.[Top]

What causes appendicitis?

Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include

feces, parasites, or growths that clog the appendiceal lumen

enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body

inflammatory bowel disease, including Crohn's disease and ulcerative colitis

trauma to the abdomen

An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomena potentially dangerous condition called peritonitis.

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Who gets appendicitis?

Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other cause.

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What are the symptoms of appendicitis?

Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain.

The abdominal pain usually

occurs suddenly, often causing a person to wake up at night

occurs before other symptoms

begins near the belly button and then moves lower and to the right

is new and unlike any pain felt before

gets worse in a matter of hours

gets worse when moving around, taking deep breaths, coughing, or sneezing

Other symptoms of appendicitis may include

loss of appetite

nausea

vomiting

constipation or diarrhea

inability to pass gas

a low-grade fever that follows other symptoms

abdominal swelling

the feeling that passing stool will relieve discomfort

Symptoms vary and can mimic other sources of abdominal pain, including

intestinal obstruction

inflammatory bowel disease

pelvic inflammatory disease and other gynecological disorders

intestinal adhesions

constipation

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How is appendicitis diagnosed?

A doctor or other health care provider can diagnose most cases of appendicitis by taking a person's medical history and performing a physical examination. If a person shows classic symptoms, a doctor may suggest surgery right away to remove the appendix before it bursts. Doctors may use laboratory and imaging tests to confirm appendicitis if a person does not have classic symptoms. Tests may also help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or the mentally impaired.

Medical History

The doctor will ask specific questions about symptoms and health history. Answers to these questions will help rule out other conditions. The doctor will want to know when the pain began and its exact location and severity. Knowing when other symptoms appeared relative to the pain is also helpful. The doctor will ask questions about other medical conditions, previous illnesses and surgeries, and use of medications, alcohol, or illegal drugs.

Physical Examination

Details about the abdominal pain are key to diagnosing appendicitis. The doctor will assess pain by touching or applying pressure to specific areas of the abdomen.

Responses that may indicate appendicitis include

Guarding.Guarding occurs when a person subconsciously tenses the abdominal muscles during an examination. Voluntary guarding occurs the moment the doctor's hand touches the abdomen. Involuntary guarding occurs before the doctor actually makes contact.

Rebound tenderness.A doctor tests for rebound tenderness by applying hand pressure to a patient's abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness. A person may also experience rebound tenderness as pain when the abdomen is jarredfor example, when a person bumps into something or goes over a bump in a car.

Rovsing's sign.A doctor tests for Rovsing's sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing's sign.

Psoas sign.The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed. A doctor can check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down.

Obturator sign.The right obturator muscle also runs near the appendix. A doctor tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.

Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis.

The doctor may also examine the rectum, which can be tender from appendicitis.

Laboratory Tests

Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests may also show dehydration or fluid and electrolyte imbalances. Urinalysis is used to rule out a urinary tract infection. Doctors may also order a pregnancy test for women.

Imaging Tests

Computerized tomography (CT) scans, which create cross-sectional images of the body, can help diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.

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How is appendicitis treated?

Surgery

Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the likelihood the appendix will burst.

Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.

Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery.

Sometimes an abscess forms around a burst appendixcalled an appendiceal abscess. An abscess is a pus-filled mass that results from the body's attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.

Nonsurgical Treatment

Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.

Recovery

With adequate care, most people recover from appendicitis and do not need to make changes to diet, exercise, or lifestyle. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity during this time allows tissues to heal.

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What should people do if they think they have appendicitis?

Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a doctor or go to the emergency room right away. Swift diagnosis and treatment reduce the chances the appendix will burst and improve recovery time.

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Points to Remember

Appendicitis is a painful swelling and infection of the appendix.

The appendix is a fingerlike pouch attached to the large intestine and located in the lower right area of the abdomen.

Symptoms of appendicitis may include abdominal pain, loss of appetite, nausea, vomiting, constipation or diarrhea, inability to pass gas, low-grade fever, and abdominal swelling.

A doctor can diagnose most cases of appendicitis by taking a person's medical history and performing a physical examination. Sometimes laboratory and imaging tests are needed to confirm the diagnosis.

Appendicitis is typically treated by removing the appendix.

Appendicitis is a medical emergency that requires immediate care.

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Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports basic and clinical research into many digestive disorders.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visitwww.ClinicalTrials.gov.

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For More Information

American Academy of Family PhysiciansP.O. Box 11210Shawnee Mission, KS 662071210Phone: 18002742237 or 9139066000Email:fp@aafp.orgInternet:www.aafp.org

American College of Surgeons633 North Saint Clair StreetChicago, IL 606113211Phone: 18006214111 or 3122025000Fax: 3122025001Email:postmaster@facs.orgInternet:www.facs.org

American Society of Colon and Rectal Surgeons85 West Algonquin Road, Suite 550Arlington Heights, IL 60005Phone: 8472909184Fax: 8472909203Email:ascrs@fascrs.orgInternet:www.fascrs.org

http://www.nlm.nih.gov/medlineplus/appendicitis.html

The appendix is a small, tube-like organ attached to the first part of the large intestine, also called the colon. It is located in the lower right area of the abdomen. It has no known function. A blockage inside of the appendix causes appendicitis. The blockage leads to increased pressure, problems with blood flow and inflammation. If the blockage is not treated, the appendix can break open and leak infection into the body.

Symptoms may include

Pain and/or swelling in the abdomen

Loss of appetite

Nausea and vomiting

Constipation or diarrhea

Inability to pass gas

Low fever

Not everyone with appendicitis has all these symptoms.Appendicitis is a medical emergency. Treatment almost always involves removing the appendix. Anyone can get appendicitis. It happens most often to people between the ages of 10 and 30.

National Institute of Diabetes and Digestive and Kidney Diseases