What is the appendix? All of us have an appendix located in the right lower abdomen. It is a narrow tube, usually the size of your little finger measuring from 4 to 12 cm in length and it arises from the caecum, which is the start of the large intestine. It is generally considered to have no important function. However, it is the commonest cause of emergency surgery whenever it becomes inflamed – acute appendicitis. How does appendicitis develop? Appendicitis is the term used to describe an infected appendix. Infection can occur when fecal matter gets caught within the appendix and causes infection to build up, much like a blocked sewer pipe. This causes it to swell and form pus. Sometimes intestinal worms may trigger the infection. Although it is normal for human beings to have bacteria residing in the large intestine, these germs rarely cause an infection in the colon or appendix under normal circumstances. Appendicitis occurs in all age groups but is more common in those below 40 years.

view of acid injury to the lining of the gullet during gastroscopy Laparoscopic Appendectomy in Progress

What are the symptoms of appendicitis? In the beginning, patients can feel unwell and nauseated, and abdominal pain is felt at the upper or central abdomen. When severe pain is present, vomiting can occur, especially in children. Fever, diarrhoea, and loss of appetite are common but not always present in every patient. Movement, cough or straining may cause the pain to worsen. As the infection progresses, the pain will usually shift to the right lower abdomen. This explains why in certain instances, if the patient were to see the doctor before the pain shifts to the right, acute appendicitis may be misdiagnosed as gastritis or gastroenteritis. Appendicitis will usually get worse if not diagnosed early, resulting in gangrene, perforation or abscess formation. Sometimes septicaemia (blood poisoning) can occur with disastrous consequences including death. Occasionally the intestines & omentum can wrap up the infected appendix causing a mass to develop. This can occur if the diagnosis has been delayed or if antibiotics have been used to treat the patient mistakenly for gastroenteritis. How is appendicitis diagnosed? A good history of your symptoms together with the doctor’s clinical examination will in most instances tell if appendicitis is likely. The doctor will take into consideration all the information given by you to arrive at a diagnosis. In teenage and adult females, the menstrual history is important as 30% with suspected appendicitis, have gynecological causes. In younger children, recent ‘flu’ and sore throat can cause lower abdominal pain mimicking appendicitis. Blood tests, CT or Ultrasound Scans of the abdomen are used in some instances to help diagnose appendicitis or other causes of abdominal pain. The decision to perform such tests should be made by the surgeon or the specialist concerned as these investigations are not always accurate, nor are they always necessary. Generally the accuracy of diagnosis of appendicitis by an experienced doctor is about 90% in males and 80% in females – diagnosing appendicitis before surgery is not an exact science. The reasons for this difficulty is that several other organs namely the large & small intestines, the ureter, the intestinal lymph nodes, and in the female, the gynecological organs, all share the same vicinity and the same pain nerves appreciated by the brain. This makes for overlapping symptoms and signs, and it is sometimes difficult for the patient and the doctor to ascertain the source of the pain. How is Appendicitis treated? Surgery is the main stay of treatment and it is combined with antibiotics. It is done under general anesthesia. Traditional open surgery (open appendectomy) involves making a 5 to 15 cm incision on the right lower abdomen to remove the appendix. This requires a 3-day stay in hospital and 2 to 4 weeks of recovery. The problem arises when the diagnosis of appendicitis is incorrect. Further evaluation may be required and this can result in a larger incision to deal with the new diagnosis (like colon cancer). The wound infection rate is also high in open appendectomy (20%). Laparoscopic Appendectomy is the modern technique, using “Minimal Access Surgery” to remove the appendix. Three small punctures (5mm to 10mm) are made into the abdominal wall and a telescope with attached camera is passed into the abdominal cavity, which has been inflated with carbon dioxide gas. It allows a thorough evaluation of the abdominal cavity and an accurate diagnosis to be made, followed by the surgical procedure. This is especially so in females where gynecological causes can be present, or, in those with possible intestinal infections, or, for the occasional cancer. Following laparoscopic appendectomy, the pain is less, recovery is faster and the cosmetic outcome is superior. The wound complications are also much lower (2%). This procedure can be done in all types of patients including children and pregnant ladies and should be carried out by surgeons trained in “Minimal Access Surgery.”