Appendicitis

The appendix is referred to in anatomy as “vermiform”; latin for worm-like (think night-crawler). It comes off the first part of the colon called the cecum in the right lower quadrant, very near where the small intestine empties into the large intestine (colon). The appendix becomes inflamed often when the opening to it (medically referred to as the lumen) becomes blocked. The reason for blockage varies by age but in most adults can be secondary to little fecal stones called fecaliths or appendicoliths.

The most definitive treatment is surgery to remove it. Nowadays this can usually be done in a minimally invasive fashion with usually 3 small incisions. We use long instruments to disconnect the appendix from the colon, it’s blood supply (called the mesoappendix) and anything else it has gotten stuck to in the course of becoming inflamed.

What about non surgical management?

Many studies have looked at treating appendicitis with just antibiotics. The reality is the long term data from these studies has demonstrated a very high recurrence rate for patients who keep their appendix, and more importantly, there are subtle nuances that go into that decision based on patient factors, how the appendix appears on a CT scan, and the presence of fecaliths. The main takeaway here is that the decision to forego surgery on appendicitis should never be made without the involvement of a general surgeon.

Still, antibiotics and no surgery are sometimes still used to treat appendicitis. This can be based on patient factors where the risks of surgery for certain patients may be too great.

What about complex or unusual cases?

There are many ways appendicitis can be less than straightforward. First of all, the anatomy. The appendix can be short or very long and it can lie in a myriad of different ways off the colon. It can extend to the pelvis, it can flip backward and hide behind the colon (retrocecal). It can even be involved in a hernia. Add on inflammation where the tissues start sticking together and dissecting out a difficult appendix can be… more involved.

Perforation. The risk of an appendix perforating or rupturing (bursting) increases greatly with time. The mechanism is not what most people think. First the opening (lumen) to the appendix is blocked. This causes distension of the appendix (like a thin balloon, think balloon art, being blown up). The reality is that the wall of a healthy appendix is much stronger than the forces of distension, so it’s not that the appendix then just pops like a balloon. However, what then happens is that the pressure in the wall of the appendix now becomes higher than the blood pressure at which oxygen exchange happens. Areas of the appendix start to die (gangrene). And dead tissue has very little integrity. Now that pressure is too much and a hole develops through which stool and bacteria can leak.

Now what?

What happens after perforation can also be highly variable. The body is amazing in its ability to “wall off” contamination… most of the time. The goal here is now that the cat is out of the bag, can we at least limit the infection to a small area instead of a big area. The intestines as well as a long fatty sheet of tissue in our abdomen called the omentum will often actually move and surround the perforated appendix and stick to it to contain the infection.

What if the omentum and intestines can’t do all that?

Well, that sometimes happens, though rarely. In these cases a ruptured appendix can result in stool contaminating the entire abdomen on the inside. These cases can be more involved and require more surgery including a washout and leaving additional drains.

The other thing that can happen is that the inflammation from appendicitis can extend onto the colon. The problem with this is that when we remove the appendix we have to seal opening to the colon or you will have a hole in the colon. A major surgical principle is that inflamed tissues are more prone to complications with healing. So if the colon is very inflamed to where we might feel that it is unlikely to heal, we will then have to do a more extensive surgery where we remove the first part of the colon called the cecum. If you recall, that is also where the small intestine empties into the colon. So the surgery is actually an ileocecectomy, or removal of the cecum and last bit of small intestine (called the ileum). We then re-connect the ileum to the colon using healthy tissue to health tissue.

This is highly uncommon, I would say in my busy acute care practice this is something that is required only once or twice per year.

How will my body change without an appendix?

The overwhelming majority of patients will never know that they don’t have their appendix after they are healed from surgery. Something that can happen after any surgery is the formation of scar tissue which can be a risk factor in the future for bowel obstructions. However, this is incredibly rare.

What are the complications from appendicitis?

The overwhelming majority of patients have no complications after appendectomy. The most common complication is probably infection where the appendix used to be. This can take the form of just angry tissue that feels hard (called a phlegmon) and the treatment for this is usually just antibiotics. Or there can be an abscess or a walled off collection of pus. The treatment for this depends on its size and location, and can mean either antibiotics alone or antibiotics and a drain.