There are organs and appendages in our body we don’t think about much until they announce themselves with pain. The appendix is one such tiny finger-like appendage attached to the colon (large intestine). The space inside the appendix, called the lumen, is quite small and can sometimes get blocked by hardened feces, bacteria, viruses, parasites, or foreign bodies such as vegetable or fruit seeds. The lumen distends with time and affects blood flow to and from the appendix. If the blockage causes an inflammation along with a bacterial infection, you have appendicitis. Left untreated, the pressure exerted by the inflammation can make the appendix rupture.
Appendicitis can affect anyone, but it most often occurs in people between the ages of 10 and 30 years. Appendicitis is less common in infants and older adults although it is not unheard of. But appendicitis in these two age groups usually involves a longer period of illness because of delayed treatment, which again is because the symptoms are not reported correctly or in time. Even otherwise, gastroenteritis and gynecological disorders are usually the main reasons appendicitis is misdiagnosed across all ages.1
The Need For Early Diagnosis
Although appendicitis is quite a common condition, it is important to spot the symptoms early and reduce the chances of rupture. In most cases, the primary cause of rupture is delay in seeking medical attention once the pain begins.2
Studies show that after the first 36 hours of pain, the risk of a rupture increases by 5 percent every 12 hours. If surgery is delayed beyond 36 hours from the time the symptoms begin, if fever is more than 102 degrees Fahrenheit, and if heart rate is greater than 100 beats per minute, the chances of rupture progressively increases.3
When the appendix ruptures, it can lead to a potentially dangerous condition called peritonitis, in which the lining of the abdominal cavity is infected. The condition can lead to sepsis or a serious infection of the bloodstream. A ruptured appendix may initially mean less pain, but the pain soon worsens. In most cases of peritonitis, the appendix is removed immediately through a laparotomy (a single incision). When the infection and inflammation are under control – usually after about six to eight weeks – surgeons remove what is left of the burst appendix.
Appendicitis In Women: Why It Is Difficult To Diagnose
Appendicitis in women can be very confusing and a cause for much more worry. In spite of the distinct pain path usually associated with appendicitis, a study comprising earlier case studies found that in women, appendicitis pain is often confused with gynecological pains and menstrual cramps. On the other side, gynecological diseases can also easily masquerade as appendicitis owing to the proximity of the right ovary, the fallopian tube, and the uterus to the appendix.4
Misdiagnosis In Women
Appendicitis can become potentially dangerous for women if not diagnosed early. In fact, appendicitis is misdiagnosed in 33 percent of non-pregnant women of childbearing age. The wrong diagnosis can increase the incidence of perforation, cause abscess formation, and lead to a longer hospital stay. The most frequent misdiagnoses are pelvic inflammatory diseases (PID), followed by gastroenteritis and urinary tract infection.5 It can also be confused with abnormalities of the pelvic organs, including ruptured ovarian cysts, twisting of the right ovary, or bowel conditions such as colitis.6 Misdiagnosis, however, need not be the norm.
Before the advent of imaging, as many as 45 percent of women with symptoms suggestive of appendicitis had a normal appendix at surgery, and as many as one-third of women with true appendicitis were initially misdiagnosed.7 But today, in order to rule out other gynecological disorders and to confirm that the symptoms are indeed those of appendicitis, laboratory tests and imaging studies such as ultrasound or CT scans are available for use in cases where diagnosis is difficult.8
Appendicitis: Symptoms To Watch Out For
Appendicitis is often difficult to diagnose because the early signs and symptoms are mild and non-specific. Symptoms may include loss of appetite, nausea, and a general sense of being unwell – symptoms that could point at many other health issues. The symptoms become more pronounced only when appendicitis progresses.
1. Abdominal Pain
This is the most well-known symptom of appendicitis. In fact, if you ever experience pain on the right side of the abdomen, the possibility of appendicitis is sure to cross your mind. The pain is because of the pressure exerted by the inflamed appendix and is usually a generalized pain around the belly button. As the pressure increases and inflammation progresses, the pain typically moves to the right lower quarter (RLQ) of the abdomen, where the appendix is located. The pain shifts to the RLQ within a period of 24 hours and becomes worse when walking or coughing. If the tip of the appendix extends down into the pelvis or toward the middle of the lower abdomen, pain can occur in these less typical areas too.
2. Loss Of Appetite
This may begin in the early stages of appendicitis and is a common symptom. As the obstruction and inflammation worsen, you may experience nausea and loss of appetite. Nausea may also be accompanied with vomiting. Constipation is quite common at this stage although, on the other side, diarrhea can occur too.
3. Fever
Fever may not be the first symptom you would associate with the condition but a low-grade fever of around 100 degrees Fahrenheit is actually quite common. A ruptured appendix is suspected when fever is accompanied by bouts of shivering.9
How Do I Differentiate Between An Appendicitis Pain And Other Abdominal Pains?
To differentiate appendicitis pain from other more common abdominal pains, watch out for pain that is persistent and comes on rather suddenly over several hours or lasts throughout the day. In appendicitis, there is often a path that the pain follows. The sharp pain might move from your navel to the area directly over your appendix 12 to 24 hours after you start experiencing symptoms. This distinct progression is a red flag you should watch out for.10
Appendicitis In Pregnancy
Appendicitis in women can become even more confusing when it occurs during pregnancy. Incidence rates of appendicitis in the first trimester range from 19 percent to as high as 36 percent. There is a higher incidence of appendicitis in the second trimester, ranging from 27 percent to 60 percent. Although incidence moves between 15 percent to 33 percent in the third trimester, some studies have reported a 59 percent incidence in the third trimester.11
Challenges During Pregnancy
Most of the classic signs of appendicitis are not always evident or clear during pregnancy. Diagnosis becomes challenging since the appendix is displaced by the enlarged uterus, and the pain may not be localized to the right lower abdomen. Instead, it may be anywhere on the right side of the abdomen. Appendicitis pain may also be misinterpreted as early labor. The other symptoms such as nausea, vomiting, and lack of appetite are also not appendicitis-specific and quite common in pregnancy too.
Adding to the challenge is the appendix’s a tendency to move around. It migrates in a counterclockwise direction toward the right kidney. Pain and tenderness in the RLQ of the abdomen dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant or right flank pain is a possible sign of inflammation and is a symptom to watch out for.12 Being aware of the possibility and reaching out for immediate help are your best course of action.
Management Of Appendicitis During Pregnancy
If diagnosed correctly, and in time, appendicitis alone poses little risk during pregnancy but a ruptured appendix can be very serious for both the mother and baby. Delays of more than 24 hours have been associated with appendiceal perforation and high chances of not only a miscarriage, but also of maternal mortality.
Most of the complications and risk during pregnancy are a result of the reluctance to operate on pregnant women. There has long been a myth that an appendectomy in women can result in infertility. In fact, appendectomy was thought to be the cause of Tubal factor Infertility (TFI). The pelvic inflammations and scar tissues caused by appendicitis were believed to block the fallopian tubes resulting in infertility. In truth, any kind of invasive surgery can become a risk for pregnancy later. However, to put the entire blame on appendectomy is rather unfair. Nowadays, with laparoscopic surgery, the fallopian tubes can be restored even if they do have scar tissues.13 In fact, recent research shows that there’s no conclusive evidence to prove that a perforated appendix may mean infertility! Even for women who need to undergo an appendectomy during pregnancy, there is no long-term effect and subsequent pregnancies need not be affected.14
Treatment For Appendicitis
Appendicitis almost always requires surgery (appendectomy). Although some alternate treatments do exist for appendicitis, these should only be used in a supportive capacity to help alleviate the pain and swelling and never in lieu of medical treatment.
1. Chinese Medicine
In traditional Chinese medicine certain herbs are believed to be capable of treating appendicitis. Acupuncture and electroacupuncture have also been used in Chinese medicine to treat appendicitis. Chinese medicine believes that combining acupuncture with conventional post-operative care improves patient recovery after an appendectomy. Although no clinical trials have been conducted to test the efficacy of these treatments, researchers state that acupuncture improves surgical recovery rates including a more rapid recovery of intestinal function.15
2. Naturopathy
Naturopathy is not just an alternative treatment but rather a philosophy that believes in the healing power of nature. In naturopathy, the treatment for acute appendicitis is the same as the treatment for any acute inflammatory feverish disease. The essentials are plenty of air, fasting, and hydrotherapy. According to some claims, initial treatment involving massage and water compresses followed by later treatment with milk and fruit juice whenever the patient is hungry has also helped cure cases radically.16
3. Ayurveda
According to Ayurveda, appendicitis is a vrana-shotha or an inflammatory condition that causes swelling. Some of the natural home remedies that are part of Ayurveda can help ease the symptoms of appendicitis, especially at the early stages. These include a tablespoon a day of an infusion of green gram for the pain associated with acute appendicitis; and tea made from fenugreek seeds to prevent the appendix from becoming a dumping ground for excess mucus and intestinal waste.17
All of these options however, are ways of management and are in no way a cure for appendicitis. When surgery is required, it is wise not to avoid it. Surgery does not necessarily mean complications. And today, because of the common use of antibiotics before surgery, pain management has become even more effective.18
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