Appendicitis

What is the purpose of the appendix?

The role of the appendix is not yet fully understood. The appendix contains lymphoid tissue, which is involved in immunity. The lumen of the appendix also contains a number of bacteria that may be involved in the intestinal flora (the microbiota). Removal of the appendix is a common procedure and has been carried out for many years. To date, no functional consequences have been demonstrated following appendix removal.

Appendicitis is inflammation and infection of the appendix.

The causes of appendicitis are probably multiple and still only partially understood.
Obstruction of the appendix by faeces may lead to bacterial proliferation and infection of the appendix. Bacterial proliferation secondary to a change in the appendicular microbiota may also be to blame

The consequences of appendicitis

Whatever the cause, infection of the appendix will lead to inflammation of the appendix, thickening of the appendix wall and potentially rupture.

At the first stage of appendicitis, the infection will be localised to the appendix wall only. Appendicitis may progress to an abscessed form, where a collection of pus may form in the appendix and sometimes around the appendix.
Appendicitis may also progress to perforation of the appendix. In this case, the lumen of the appendix communicates with the cavity of the abdomen, which is lined with a layer known as the peritoneum. The perforation may be contained by the organs surrounding the appendix and lead to the formation of a localised abscess around the appendix.
If the perforation of the appendix is not contained by the surrounding organs, pus or even faeces may leak into the abdominal cavity, causing generalised inflammation or infection of the abdomen (generalised peritonitis).

The symptoms of appendicitis depend on the location of the appendix and its stage.
In its early stages, the pain may be poorly localised and patients may feel as though they have pain close to the umbilicus. These pains generally occur gradually and their evolution may vary from one patient to another. In most cases, the pain will gradually increase in intensity, but in some patients the pain may fluctuate at first.
Pain often tends to localise quickly where the inflammation of the appendix is at its worst. If the tip of the appendix is mainly inflamed (which is often the case), then the pain will be located where the tip of the appendix is. Most of the time, the tip of the appendix is located in the right iliac fossa. However, if the appendix is very long, the pain may also occur in the left iliac fossa.
In more advanced stages of the infection, particularly if the appendix ruptures and pus or faeces spills into the abdominal cavity, the pain spreads to the whole abdomen, causing generalised peritonitis.

Who is prone to appendicitis?

Appendicitis is a condition that can affect the whole population, regardless of age or sex. Although infections occur more frequently in children and young adults, it is not uncommon to see appendicitis in older patients, and even in the very elderly. 

Appendicitis must be diagnosed by an experienced doctor.
The diagnosis of appendicitis is based partly on clinical factors (the history of symptoms and their evolution, as well as the patient's physical examination) and partly on laboratory and imaging tests.
Blood is usually taken to look for signs of infection.
Imaging is based mainly on ultrasound and CT scans. These two radiological examinations are complementary, and the choice of one or the other, or of both sequentially, must be decided on a case-by-case basis by an experienced doctor. The choice of radiological modality is based on a number of criteria, such as the patient's age, the symptoms of the disease and any alternative diagnoses.
At the end of the medical evaluation, if appendicitis is strongly suspected or confirmed, a consultation with a surgeon is necessary.

Surgery

The standard treatment for appendicitis is surgical removal of the appendix. This surgery can be performed in several ways, but the most common method today is laparoscopy (or laparoscopy). Laparoscopy involves making small incisions in the skin of the abdomen in order to insert a camera and long instruments. After dilating the abdominal cavity with carbon dioxide (CO2), the appendix can be visualised using this technique and removed using long instruments.
When the appendix is surgically removed, it is important to remove the entire appendix. Depending on the position of the appendix on the cecum, partial removal of the cecum may be necessary.

Laparoscopy

Depending on the stage of the appendicitis, additional procedures may be necessary. If there are pockets of pus (abscesses), plastic drains may need to be inserted at the end of the operation to remove any residual bacteria. In the case of extremely severe infection involving the appendix and neighbouring organs (cecum, small intestine, for example), excision of part of the colon or intestine may be necessary.
Depending on the extent of the surgery to be performed, a change in the type of surgery may be indicated during the operation, such as the need to perform open surgery by incising the abdomen on the midline or on the side.

Key point: The extent and difficulty of the surgery depends on the stage of the appendicitis. In the event of delayed diagnosis or management, a more extensive procedure may be required.

What about antibiotics?

Although some studies have shown that infection of the appendix can, in certain cases, be treated with antibiotics, the rate of recurrence of appendicitis when treatment is stopped is significant. At present, surgery to remove the appendix is still the recommended treatment for acute appendicitis.
Inadequately treated with antibiotics, appendicitis may continue to evolve in an asymptomatic form, but give rise to purulent collections and involve several neighbouring organs.

Key point: In the event of acute abdominal pain, antibiotic treatment should never be initiated without medical advice.

What happens after appendicitis surgery depends on the stage of the infection. In the case of mild appendicitis, a very short stay in hospital will be required, with a full and rapid recovery.
For more advanced forms of appendicitis, prolonged hospitalisation will be necessary, particularly if drains are used (for forms with abscesses), or even if surgery requires more extensive resections.

Key point: Progression and recovery from appendicitis depend on the stage of the appendicitis, and will be much faster in milder forms.

In the event of new onset abdominal pain that increases in intensity or does not subside quickly, it is essential to consult a doctor or the emergency department.
Because of the variety of symptoms that can accompany appendicitis, it should be included in any differential diagnosis (possible diagnosis) of new-onset abdominal pain.
Because of the potential complications of untreated or inadequately treated acute appendicitis, it is imperative that a competent medical team be consulted as soon as possible.

Hôpital de la Tour has specialists in digestive and visceral surgery, as well as a La Tour Centre for Digestive Pathology, and offers a 24/7 emergency service with all the specialities and equipment needed to treat all stages of appendicitis

• Appendicitis is a common condition that can affect all age groups, and the diagnosis cannot be ruled out solely on the basis of the patient's age.
• The diagnosis of appendicitis requires specialist advice and often access to laboratory and radiology tests.
• If there is a strong or established suspicion of appendicitis, surgical advice is required.
• The severity of appendicitis often depends on the time between diagnosis and treatment.
• The need for surgery and the ease of recovery depend on the severity of the appendicitis.

Any acute abdominal pain should raise the suspicion of appendicitis and requires consultation with a specialist team.