Appendicitis

What is appendicitis?

Appendicitis is swelling and infection in your appendix, a small pouch attached to your large intestine. It usually causes pain that starts near your belly button and moves to the lower right of your abdomen, and will require urgent treatment in hospital.

What are the symptoms of appendicitis?

It typically starts with pain in the middle of your abdomen, which may come and go at first.

After a few hours, the pain usually moves to the lower right of your abdomen and becomes constant and more severe. It often feels worse when you move, cough or press on the area, and slightly better when you pull your knees up towards your chest.

Other symptoms can include:

• feeling or being sick, or loss of appetite
• a high temperature or a fever
• constipation or diarrhoea
• needing to pass urine more than usual
• a swollen or bloated tummy
• sudden confusion.

Only about half of people with appendicitis have this classic pattern of symptoms. Pregnant women, young children and the eldery are less likely to have typical symptoms: children may develop symptoms faster with more pronounced vomiting and fever, older people may have milder or fewer symptoms, and in pregnancy the appendix shifts upwards, so pain may be felt higher up, nearer the ribs.

The pain may fluctuate, and any apparent improvement in symptoms can be misleading, so if you suspect you have appendicitis, seek urgent medical immediately.

What causes appendicitis and who's at risk?

Appendicitis usually happens when the appendix becomes blocked, allowing bacteria that are already there to multiply and cause infection and swelling. Common causes of blockage include:

• a build-up of hardened stool
• swollen lymphoid tissue, sometimes as a reaction to an infection elsewhere in the body
• rarely, parasites, a tumour or a foreign body.

Appendicitis can happen at any age but is most common between the ages of 10 and 30, and is more common in males than females. A family history of appendicitis raises your risk, though it isn't clear why, and a diet higher in fibre appears to lower the risk.

Around 1% of the population will get appendicitis and around 5% of people will have acute appendicitis at some point in their life.

Are there different types of appendicitis?

Most appendicitis is acute, meaning it starts suddenly and gets worse quickly, usually over a matter of hours. This is the type that needs urgent treatment.

Chronic appendicitis is much rarer and less well understood. It causes milder, intermittent symptoms that can persist for weeks, months or even years, which makes it harder to recognise, and it's sometimes only diagnosed after it changes into an acute episode.

How is appendicitis diagnosed?

A doctor will ask about your symptoms and examine your abdomen. They’ll check for tenderness, swelling and rigidity and they may seewhether pressing on the area and suddenly releasing it, or coughing, makes the pain worse.

There's no single test that always confirms appendicitis, partly because the symptoms can look like several other conditions, including urinary tract infections, kidney stones or gallstones, gynaecological conditions, or bowel conditions such as IBS or Crohn's disease.

You'll usually need hospital tests, which may include blood tests (to check for signs of infection), a urine test (to rule out a urine infection, kidney stones or pregnancy), and a scan such as an ultrasound or CT scan to look for swelling in the appendix.

In pregnancy, an MRI scan may be used instead, to avoid radiation exposure. Sometimes doctors will monitor you in hospital for a few hours to see how your symptoms develop before deciding on treatment.

How is appendicitis treated?

Appendicitis is usually treated with surgery to remove the appendix, called an appendectomy or appendicectomy. You don't need your appendix, so removing it doesn't cause any long-term problems.

Surgery

If surgery is needed, it's normally carried out within 24 hours of diagnosis, since the appendix can rupture within around 36 hours of your first symptoms. The operation usually takes about an hour and follows these main steps:

1. You're given a general anaesthetic, so you'll be asleep and feel no pain
2. The surgeon makes a few small cuts and uses a thin tube with a camera to remove the appendix (keyhole surgery), or, less often, a single larger cut (open surgery)
3. The appendix is removed – if it has already burst, the surrounding area is also cleaned
4. Your wounds are closed with stitches, clips or glue.

If you have keyhole surgery, you may be able to go home the following day. Open surgery or complications usually mean a longer hospital stay. Most people recover within 1 to 2 weeks, though full recovery, including regaining normal strength, can take up to around 6 weeks, especially after a burst appendix or open surgery.

Antibiotics

Almost everyone with appendicitis is given antibiotics, both to treat infection and to help prevent it around the time of surgery.

In a small number of very early, mild cases, antibiotics alone may be tried instead of surgery, but this isn't usually recommended, since appendicitis often returns afterwards; around 4 in 10 people treated with antibiotics alone have a recurrence.

Occasionally, appendicitis causes a lump (an appendix mass), where nearby tissue sticks to the inflamed appendix. In this case, you'll usually be treated with antibiotics first, with surgery only considered later if symptoms continue.

Left completely untreated, appendicitis carries a high risk of life-threatening infection, which is why prompt treatment is so important; with early treatment, the outlook is very good and most people recover completely.

When should you see a doctor?

Get an urgent GP appointment or call 111 if you or your child have abdominal pain that's gradually getting worse, doesn't go away, or moves to the lower right of the abdomen.

Call 999 or go to A&E immediately if you or your child have any of the following as these can be signs of sepsis:

• severe abdominal pain
• confusion
• skin that looks blotchy or paler than usual (on black or brown skin, this may be easier to see on the palms or soles)
• difficulty breathing.

Don't drive yourself to A&E – ask someone to drive you or call 999 for an ambulance.

After surgery, contact your GP or 111 urgently if your wound becomes increasingly red or sore, leaks blood or pus, or you develop a high temperature, as these can be signs of infection.