Appendicitis

Appendicitis is inflammation of the appendix, the small blind-ended pouch that hangs off the start of the large bowel in the lower right corner of the abdomen. It begins deceptively gently, with a vague ache near the navel that almost everyone blames on something they ate. After that the story moves in hours rather than weeks, and an inflamed appendix can burst. It can strike at any age, but teenagers and young adults are affected most often.

How the pain starts

In the first few hours the pain is dull and spread out, sitting around the navel or "all over the tummy", and impossible to pin down with a fingertip. Four to twelve hours later it shifts down and to the right, becomes sharper and much easier to locate. That migration is the most telling feature of appendicitis and it is worth more than any single test.

The pain grows worse on walking, coughing, going over bumps in a car and trying to straighten up; it eases a little when lying on one side with the knees drawn up. Alongside it there are usually:

• loss of appetite, to the point of turning down a favourite meal;
• nausea and one or two bouts of vomiting, always after the pain has begun, never before it;
• a modest temperature, around 37–38 °C;
• constipation, or less often loose stools.

The order counts: pain first, then nausea and the aversion to food, and only after that a temperature. If it all started with repeated vomiting and diarrhoea and the belly began hurting later, the picture fits a bowel infection better.

When it becomes a matter of hours

Call the emergency services (112 in Europe) if even one of these appears:

• the pain is severe and getting worse, and makes it impossible to stand upright or move about;
• the abdomen has gone board-hard and the lightest touch causes a stab of pain;
• a temperature above 38.5 °C with shivering, skin that is pale, grey or blotchy, a racing pulse;
• confusion, heavy drowsiness, fast breathing, bluish lips — that is what sepsis looks like;
• pain low on the right side of the abdomen during pregnancy;
• in a child or an older person, lethargy, refusal to drink or muddled thinking on top of the pain.

Nobody in that state should be driving, and it is best not to eat or drink before being examined: anaesthesia needs an empty stomach. Expect to be asked what medicines are being taken.

When the picture is misleading

The classic shift of pain down and to the right happens in only about half of people. In the rest things look different, and usually it comes down to where the appendix lies.

• Behind the caecum. The right flank or the lower back hurts, while the abdomen stays almost quiet when pressed.
• Down in the pelvis. Pain is felt towards the back passage and the bladder, with frequent urination and loose stools added in — easily mistaken for an infection.
• In pregnancy. The growing womb pushes the appendix upwards, so the pain ends up under the right ribs.

Age changes the picture too. A child under five will not show where it hurts: they go off their food, cry and pull their legs up, so the illness is spotted later while it moves faster. In older people the pain is mild, a temperature may be missing altogether, and weakness and confusion take its place. In anyone taking glucocorticoids or living with a weakened immune system the inflammation is muffled and the abdomen stays soft.

The most treacherous moment is the burst itself. Pressure inside the appendix drops and the pain fades for an hour or two. It feels like a turn for the better, and that is exactly when some people decide against the hospital after all. The pain then comes back across the whole abdomen, with fever, and the operation becomes a harder one. Pain that suddenly "lets go" after being severe is no reason to cancel the call.

What not to do before being examined

• do not warm the belly: a hot water bottle or a hot bath speeds up the rupture;
• do not take laxatives and do not use an enema;
• do not start antibiotics on your own — they blur the picture without solving anything;
• do not eat or drink until you have spoken to a doctor.

A painkiller is not forbidden; it is no longer thought to hide the diagnosis. But it is not treatment: if the pain has been dulled, you still have to go.

Telling it apart from the lookalikes

The doctor feels the abdomen, looking for tenderness low on the right, tensed muscle and a reaction to coughing. Then come a blood test with white cell count and C-reactive protein, a urine test and, for women of childbearing age, a pregnancy test. Children and pregnant women are scanned with ultrasound; in an adult whose ultrasound is unclear the next step is a CT scan.

No single test rules appendicitis in or out. White cells can be normal in the first hours of genuine inflammation and raised for a dozen other reasons. That is why it is sometimes wiser to keep someone in hospital for a few hours and examine them again than to operate blind. This kind of watching is part of making the diagnosis, not a way of doing nothing.

Similar pain comes from a urinary infection or a stone in the ureter, inflamed lymph nodes in the mesentery after a cold (a common cause in children), inflammation of the tubes and ovaries, a twisted or ruptured ovarian cyst, an ectopic pregnancy, diverticulitis, a flare of Crohn's disease, or pneumonia in the right lower lobe. In men, abdominal pain occasionally turns out to be a twisted testicle, which is an emergency operation in its own right.

What happens in hospital

The main answer is to take the appendix out. Usually that means laparoscopy: a few small cuts under general anaesthesia. Open surgery is needed when the inflammation has spread widely or there are adhesions. The appendix does no job you cannot live without, so losing it leaves nothing missing.

Antibiotics alone are an option in uncomplicated inflammation, and they are discussed when an operation would be risky for that particular person. It is worth knowing the catch: in some people appendicitis returns within the year and surgery is needed anyway.

If the inflammation has walled itself off and a firm mass or an abscess has formed around the appendix, rushing to theatre is more dangerous than waiting. Antibiotics come first, an abscess is drained, and the operation follows weeks later under calm conditions.

The rare find in a removed appendix

A removed appendix always goes for examination under the microscope, and that is not a formality. Now and then it turns out that the opening was blocked not by a hard plug of bowel content but by a tumour of the appendix itself: most often a small neuroendocrine one, less often a mucus-producing growth or a cancer. Such findings are rare, but they are the reason appendicitis after the age of 40 or 50 deserves separate thought — especially when months of vague discomfort, weight loss or a changed bowel habit came before it.

The practical conclusion is simple: wait for the tissue result and ask your doctor about it, even if you already feel perfectly well. The answer decides whether a colonoscopy and further follow-up are needed.

Getting better after the operation

After laparoscopy people usually go home the next day; after open surgery or a burst appendix, a few days later. Returning to ordinary life takes one or two weeks, longer if there were complications. Stitches most often dissolve on their own.

In the first days moderate pain in the abdomen and around the wounds, bloating and either constipation or looser stools are all normal. Keep the wounds dry and change the dressing if it gets wet. Sport and lifting come back later than everyday tasks, and driving waits until you can brake hard without pain. Any prescribed course of antibiotics is finished to the end.

Complications are uncommon but real: infection of the wound, bleeding, an abscess inside the abdomen, adhesions that years later may rarely cause bowel obstruction, and renewed inflammation in the stump left behind. Contact the hospital if after discharge a temperature rises, the wound turns red and weeps, the pain grows instead of fading, or vomiting appears together with a complete absence of stool and wind.

Online consultation

In an online appointment a doctor can go through how the pain changed and what came with it, say whether this looks like a case for emergency care, and explain what to take to hospital. After surgery it helps to read the discharge summary and the tissue result together and work out which restrictions still apply.

An online appointment is no substitute for a pair of hands on the abdomen: with any of the signs listed above the thing to do is call the emergency services, not book a consultation.

This material is for information only and does not replace medical advice.