The appendix is a small, tube-like structureattached to the �rst part of the large intes-tine, also called the colon. The appendixis located in the lower right portion ofthe abdomen. It has no known function.Removal of the appendix appears to causeno change in digestive function.

Appendicitis is an in�ammation of theappendix. Once it starts, there is no e�ec-tive medical therapy, so appendicitis isconsidered a medical emergency. Whentreated promptly, most patients recoverwithout di�culty. If treatment is delayed,the appendix can burst, causing infectionand even death. Appendicitis is the mostcommon acute surgical emergency of the

abdomen. Anyone can get appendicitis,but it occurs most often between the agesof 10 and 30.

CausesThe cause of appendicitis relates to block-age of the inside of the appendix, knownas the lumen. The blockage leads toincreased pressure, impaired blood �ow,and in�ammation. If the blockage is nottreated, gangrene and rupture (breakingor tearing) of the appendix can result.

Most commonly, feces blocks the insideof the appendix. Also, bacterial or viralinfections in the digestive tract can lead to

The appendix is a small, tube-like structure attached to the �rst part of the large intestine, also called the colon. Theappendix is located in the lower right portion of the abdomen, near where the small intestine attaches to the largeintestine.

Small intestine

Appendix Large intestine

Inflamedappendix

swelling of lymph nodes, which squeezethe appendix and cause obstruction. Thisswelling of lymph nodes is known as lym-phoid hyperplasia. Traumatic injury tothe abdomen may lead to appendicitis in asmall number of people. Genetics may be afactor in others. For example, appendicitisthat runs in families may result from agenetic variant that predisposes a personto obstruction of the appendiceal lumen.

SymptomsSymptoms of appendicitis may include

• pain in the abdomen, first aroundthe belly button, then moving to thelower right area

• loss of appetite

• nausea

• vomiting

• constipation or diarrhea

• inability to pass gas

• low fever that begins after othersymptoms

• abdominal swelling

Not everyone with appendicitis has allthe symptoms. The pain intensifies andworsens when moving, taking deep breaths,coughing, or sneezing. The area becomesvery tender. People may have a sensationcalled “downward urge,” also known as“tenesmus,” which is the feeling that abowel movement will relieve their discom-fort. Laxatives and pain medicationsshould not be taken in this situation.Anyone with these symptoms needs to see a qualified physician immediately.

People With Special ConcernsPatients with special conditions may nothave the set of symptoms above and maysimply experience a general feeling of beingunwell. Patients with these conditionsinclude

• people who use immunosuppressivetherapy such as steroids

• people who have received a trans-planted organ

• people infected with the HIV virus

• people with diabetes

• people who have cancer or who arereceiving chemotherapy

• obese people

Pregnant women, infants and young chil-dren, and the elderly have particular issues.

Abdominal pain, nausea, and vomiting aremore common during pregnancy and mayor may not be the signs of appendicitis.Many women who develop appendicitisduring pregnancy do not experience theclassic symptoms. Pregnant women whoexperience pain on the right side of theabdomen need to contact a doctor. Womenin their third trimester are most at risk.

Infants and young children cannot commu-nicate their pain history to parents or doc-tors. Without a clear history, doctors mustrely on a physical exam and less specificsymptoms, such as vomiting and fatigue.Toddlers with appendicitis sometimes havetrouble eating and may seem unusuallysleepy. Children may have constipation,but may also have small stools that containmucus. Symptoms vary widely among chil-dren. If you think your child has appen-dicitis, contact a doctor immediately.

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Older patients tend to have more medicalproblems than young patients. The elderlyoften experience less fever and less severeabdominal pain than other patients do.Many older adults do not know that theyhave a serious problem until the appendixis close to rupturing. A slight fever andabdominal pain on one’s right side arereasons to call a doctor right away.

All patients with special concerns and theirfamilies need to be particularly alert to achange in normal functioning and patientsshould see their doctors sooner, rather thanlater, when a change occurs.

DiagnosisMedical History and PhysicalExaminationAsking questions to learn the history ofsymptoms and a careful physical examina-tion are key in the diagnosis of appendicitis.The doctor will ask many questions—muchlike a reporter—trying to understand thenature, timing, location, pattern, and sever-ity of pain and symptoms. Any previousmedical conditions and surgeries, familyhistory, medications, and allergies areimportant information to the doctor. Useof alcohol, tobacco, and any other drugsshould also be mentioned. This informa-tion is considered confidential and cannotbe shared without the permission of thepatient.

Before beginning a physical examination,a nurse or doctor will usually measure vitalsigns: temperature, pulse rate, breathingrate, and blood pressure. Usually the phys-ical examination proceeds from head totoe. Many conditions such as pneumoniaor heart disease can cause abdominal pain.Generalized symptoms such as fever, rash,or swelling of the lymph nodes may point todiseases that wouldn’t require surgery.

Examination of the abdomen helps narrowthe diagnosis. Location of the pain andtenderness is important. Pain is a symptomdescribed by a patient; tenderness is theresponse to being touched. Two signs,called peritoneal signs, suggest that thelining of the abdomen is inflamed and sur-gery may be needed: rebound tendernessand guarding. Rebound tenderness iswhen the doctor presses on a part of theabdomen and the patient feels more ten-derness when the pressure is released thanwhen it is applied. Guarding refers to thetensing of muscles in response to touch.The doctor may also move the patient’s legsto test for pain on flexion of the hip (psoassign), pain on internal rotation of the hip(obturator sign), or pain on the right sidewhen pressing on the left (Rovsing’s sign).These are valuable indicators of inflamma-tion but not all patients have them.

Laboratory TestsBlood tests are used to check for signs ofinfection, such as a high white blood cellcount. Blood chemistries may also showdehydration or fluid and electrolyte disor-ders. Urinalysis is used to rule out a urinarytract infection. Doctors may also order apregnancy test for women of childbearingage (those who have regular periods).

Imaging TestsX rays, ultrasound, and computed tomogra-phy (CT) scans can produce images of theabdomen. Plain x rays can show signs ofobstruction, perforation (a hole), foreignbodies, and in rare cases, an appendicolith,which is hardened stool in the appendix.Ultrasound may show appendiceal inflam-mation and can diagnose gall bladderdisease and pregnancy. By far the mostcommon test used, however, is the CT scan.This test provides a series of cross-sectionalimages of the body and can identify many

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abdominal conditions and facilitate diagno-sis when the clinical impression is in doubt.All women of childbearing age should havea pregnancy test before undergoing anytesting with x rays.

In selected cases, particularly in womenwhen the cause of the symptoms may beeither the appendix or an inflamed ovary orfallopian tube, laparoscopy may be neces-sary. This procedure avoids radiation, butrequires general anesthesia. A laparoscopeis a thin tube with a camera attached that isinserted into the body through a small cut,allowing doctors to see the internal organs.Surgery can then be performed laparoscop-ically if the condition present requires it.

TreatmentSurgeryAcute appendicitis is treated by surgery toremove the appendix. The operation maybe performed through a standard smallincision in the right lower part of theabdomen, or it may be performed using alaparoscope, which requires three to foursmaller incisions. If other conditions aresuspected in addition to appendicitis, theymay be identified using laparoscopy. Insome patients, laparoscopy is preferable toopen surgery because the incision is small-er, recovery time is quicker, and less painmedication is required. The appendix isalmost always removed, even if it is foundto be normal. With complete removal, anylater episodes of pain will not be attributedto appendicitis.

Recovery from appendectomy takes a fewweeks. Doctors usually prescribe painmedication and ask patients to limit physi-cal activity. Recovery from laparoscopicappendectomy is generally faster, but limit-ing strenuous activity may still be necessary

for 4 to 6 weeks after surgery. Most peopletreated for appendicitis recover excellentlyand rarely need to make any changes intheir diet, exercise, or lifestyle.

Antibiotics and OtherTreatmentsIf the diagnosis is uncertain, people maybe watched and sometimes treated withantibiotics. This approach is taken whenthe doctor suspects that the patient’s symp-toms may have a nonsurgical or medicallytreatable cause. If the cause of the pain isinfectious, symptoms resolve with intra-venous antibiotics and intravenous fluids.In general, however, appendicitis cannotbe treated with antibiotics alone and willrequire surgery.

Occasionally the body is able to controlan appendiceal perforation by forming anabscess. An abscess occurs when an infec-tion is walled off in one part of the body.The doctor may choose to drain the abscessand leave the drain in the abscess cavity forseveral weeks. An appendectomy may bescheduled after the abscess is drained.

ComplicationsThe most serious complication of appen-dicitis is rupture. The appendix burstsor tears if appendicitis is not diagnosedquickly and goes untreated. Infants, youngchildren, and older adults are at highestrisk. A ruptured appendix can lead toperitonitis and abscess. Peritonitis is adangerous infection that happens whenbacteria and other contents of the tornappendix leak into the abdomen. In peoplewith appendicitis, an abscess usually takesthe form of a swollen mass filled with fluidand bacteria. In a few patients, compli-cations of appendicitis can lead to organfailure and death.

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Hope Through ResearchThe National Institute of Diabetes andDigestive and Kidney Diseases (NIDDK)conducts and supports research into manykinds of digestive disorders, including somerelated to appendicitis.

For More InformationAmerican Academy of Family Physicians P.O. Box 11210 Shawnee Mission, KS 66207–1210Phone: 1–800–274–2237Email: fp@aafp.orgInternet: www.aafp.org

American College of Surgeons633 North Saint Clair StreetChicago, IL 60611–3211Phone: (312) 202–5000Fax: (312) 202–5001Email: postmaster@facs.orgInternet: www.facs.org

American Society of Colon and RectalSurgeons (ASCRS) 85 West Algonquin RoadSuite 550Arlington Heights, IL 60005Phone: (847) 290–9184Fax: (847) 290–9203Email: ascrs@fascrs.orgInternet: www.fascrs.org

National Library of Medicine—MEDLINEplusInternet: www.nlm.nih.gov/medlineplus

Points to Remember• The appendix is a small, tube-like

structure attached to the first part ofthe colon. Appendicitis is an inflam-mation of the appendix.

• Appendicitis is considered a medicalemergency.

• Symptoms of appendicitis includepain in the abdomen, loss ofappetite, nausea, vomiting, consti-pation or diarrhea, inability to passgas, low-grade fever, and abdominalswelling. Not everyone with appen-dicitis has all the symptoms.

• Physical examination, laboratorytests, and imaging tests are usedto diagnose appendicitis.

• Acute appendicitis is treated bysurgery to remove the appendix.

• The most serious complication ofappendicitis is rupture, which canlead to peritonitis and abscess.