Old name typhilitis or perityphilitis, referring to inflammation of right iliac fossa area rather than specifically the appendix itself. It was only at the beginning of the 19th century that cases of typhilitis were attributed to appendicitis.
Shortly before his coronation in 1902, King Edward VII developed appendicitis. He was later operated on by Sir Frederick Treves, who performed an appendicectomy or strictly speaking, a drainage of an appendiceal abscess.
Thought to be due to luminal obstruction, leading to increased luminal pressure, ischaemia and bacterial superinfection. Most cases are regarded as idiopathic, though enlargement of appendiceal lymphoid follicles may explain its preponderance in the younger age group. Various causes are recognised (although some may be open to debate):
Within the lumen
- Worms (Enterobius vermicularis, Strongyloides stercoralis, Ascaris lumbricoides), oesophagostomiasis, foreign material
In the wall
- Infection: Viral (CMV, adenovirus), bacterial (tuberculosis, Yersinia, Actinomycetes), Parasitic (amoebiasis, schistosomiasis)
- Inflammation: Crohn's disease, ulcerative colitis, pseudomembranous colitis
- Vascular abnormalities: Angioma, angiodysplasia, systemic lupus erythematosus, poylarteritis nodosa
- Hamartoma:Peutz-Jeghers syndrome
- Neoplasia: Of the appendix (Pseudomyxoma, adenocarcinoma, carcinoid), Caecal carcinoma, lymphoma
Outside the wall
- Familial tendencies
- Abdominal pain, clasically initially central (caused by more vaguely felt visceral pain), but settling into the right iliac fossa (as localised peritonitis causes somatic pain).
- Nausea and vomiting, usually associated with pain, rather than preceding it.
The inflamed appendix can irritate surrounding organs, leading to other symptoms that can sometimes be misleading, e.g.
- pelvic appendix can irritate bladder, causing urinary frequency.
- retro-ileal appendix can irritate small bowel causing diarrhoea.
- Right iliac fossa tenderness, classically over McBurney's point with rebound tenderness.
- Rovsing's sign is unreliable. In one series in 1956, only 5 cases out of 303, were positive for this.
The classic textbook description generally occurs when the tip of the appendix points forwards. There is considerable variation in the position of the appendix with the minority in the position to cause the classical symptoms.
A Medical algorithm, the Alvarado score, exists to assist diagnosis. The apparent success of algorithm-assisted diagnosis may be a consequence of the necessity of taking a detailed history in in order to complete the score rather than an inherent superiority over the traditional method of a thorough history and examination. Many surgeons consider appendicitis a clinical diagnosis and while investigations can aid diagnosis, they should not be the main determinant of a diagnosis.
- Exclude other diagnoses
- Intravenous access and fluids (patients often have anorexia, nausea and vomiting)
An episode of acute appendicitis can be successfully treated with broad spectrum antibiotics, commonly a combination of a second generation cefalosporin and metronidazole. About 80-85% of cases will respond to antibiotics, but most cases are treated surgically as the relapse rate within a year of antibiotic treatment is 14-35%. Furthermore, there is still possibility of progression and perforation despite treatment with antibiotics.
Appendicitis in distant and difficult situations, such as at sea in small vessels, or in the wild country or mountains may require this management.
An appendicectomy is indicated when history, examination and investigations strongly support a diagnosis of appendicitis. If the diagnosis is equivocal, patients can be observed for several hours and re-assessed. If, after observation, symptoms persist or worsen, it is often prudent to proceed to surgery.
Up to 10% of appendicectomies reveal normal appendices, nick-named Lily Whites due to their appearence. However, an exact figure is difficult to obtain as there is no universally agreed histopathological criteria.
- Sepsis due to perforation
- Appendiceal abscess (contained perforation)
- Abdominal collections
- ↑ Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Annals of surgery 1983;197(5):495-506. (Direct link – via PubMed central.)
- ↑ General Pathology Vivas, Lowe D.Cambridge University Press 2005, ISBN 1-84110-059-5
- ↑ Lu CL, Liu CC, Fuh JL, Liu PY, Wu CW, Chang FY, et al. Irritable bowel syndrome and negative appendectomy: a prospective multivariable investigation. Gut 2007;56(5):655-60. (Direct link – subscription may be required.)
- ↑ DAVEY WW. Rovsing's sign. British medical journal. 1956 Jul 7; 2(4983):28-30.
- ↑ Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007 Feb; 14(2):124-9.(Link to article – subscription may be required.)
- ↑ Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis? JAMA : the journal of the American Medical Association. 2007 Jul 25; 298(4):438-51.(Link to article – subscription may be required.)
- ↑ Alvarado A. A practical score for the early diagnosis of acute appendicitis. Annals of emergency medicine. 1986;15:557-64.
- ↑ Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. The British journal of surgery. 1995;82:166-9.
- ↑ Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, et al. Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial. World journal of surgery. 2006;30:1033-7. (Direct link – subscription may be required.)
- ↑ Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. The British journal of surgery. 2009 May; 96(5):473-81.(Link to article – subscription may be required.)