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Appendicitis

 

Inflammation of the Appendix

 

Where is the appendix located?


blinddarm lageThe appendix or vermiform appendix is a 10 to 12 cm long appendage of the tip of the large bowel with a diameter of about 1 cm. It was given its name because it ends without exit, and it is called "vermiform" because of its shape which is similar to a worm. The technical term in Latin is therefore "appendix veriformis". The location of the appendix varies a little from human being to human being, and it may be found, for example, before or behind the large intestine. It may also be pushed up against the liver or be stretched out into the small pelvis. With women, it may be placed quite near the female genitals.

 

 

 

 

Functions of the appendix

Up to the present, it has not quite been clarified what the importance of the appendix is. It is supposed that it plays a role in the defence mechanisms of the body, but it does not seem to be vital.

Acute inflammation as most common disease of the appendix

blinddarmentzuendung

When appendicitis is diagnosed, one usually talks about an "acute inflammation". In an acute inflammation, the tissue is affected by germs, which provoke a defence reaction. Specialised cells of the body attack the invading germs and try to destroy them. This reaction is called inflammation. If it starts all of a sudden, it is called acute.

In the case of an acute appendicitis, these defence reactions occur in the intestinal wall. Stool and pus collect in the interior of the appendix. When the whole wall is infiltrated with pus, the wall may break and cause a discharge of the contents of the appendix into the abdominal cavity. The "cracked" appendix presents a very dangerous situation as the inflammation may expand to the peritoneum and thus poison the body after some time. That is why doctors have learned from the history of the appendicitis that lasts for more than a century: the life-saving operation must be carried out as soon as possible.

Appendicitis is quite frequent and affects people of every age and sex. Often, young patients and children are attacked by an acute appendicitis. It is also a dangerous disease for elderly people or for patients with immunodeficiencies. It may also occur in old age and after preceding serious diseases. Anti-inflammatory medicaments or such medicaments, which are used to stall the endogenic defence mechanisms of the body after transplantations, may lead to an immunodeficiency.

The causes of an acute appendicitis are bacterial colonisations of the appendix, possibly evoked by a congestion of stool or faecal concretion in this organ without exit. But swallowed cherry stones with water most probably do not play any role. Even if doctors do not exactly know about the ultimate causes of the disease, they definitely know how it can be cured: by surgery. And to say it once again: the appendix is no vital organ.

How do I recognise appendicitis?

"I had planned to do some important work in my job this morning. But when getting up, I felt very unwell and could not have breakfast. Before I left, I suddenly started to feel strong nausea. So I stayed at home, then had to vomit and started to feel diffuse pains around the navel. Then, I developed a fever of some 38° C, and I felt pains in the right lower abdomen. I was able to point with my finger at the place in the right lower abdomen where I suffered from the strongest pain."

Patients are not always able to give such an exact description of their disease. However, only few indications are necessary today to raise the doctor's suspicion about appendicitis. An important and almost characteristic place of pain is the so-called McBurney’s point. It is located in the middle between the right pelvic bone in front and the navel. If the disease spreads, the appendix may crack for lack of an early-enough operation. In the process, the pains may even entirely disappear for a short time. But they return when the inflammation starts to affect the peritoneum and spreads into the whole lower abdomen. The pains become more intensive with the inflammation progressing and can be felt in the whole lower abdomen, even at the left side. Especially when walking or getting up, they may get very intensive. Patients often try to alleviate their pains by lying on their backs with the legs pulled up. It is also possible that pains as a symptom may be entirely absent with patients of advanced age, with patients of a weakened immune defence, or of patients with medicaments to suppress the immune defence. The pains may also be absent after the application of pain killers. Considering small children, one has to be aware of the fact that they point at the abdomen in the case of almost every indisposition. This is not necessarily an indication of an acute disease of the abdomen or of appendicitis, respectively.  

What clarifications have to be made?

At the beginning of every examination, the doctor asks the patient several questions. In the case of an assumed appendicitis, he will ask about type, duration, and appearance of pains as well as about the passing of urine and stools. Women are additionally asked about menstruation, bleedings, and vaginal discharge. Furthermore, temperatures are taken in the anus and under the armpit. Altogether, the five following series of examinations allow the doctor to make a normally correct diagnosis of appendicitis:

Examination of the abdomen with the hands: the doctor looks for the typical point of pain (McBurney’s point) and for an involuntary muscular defence when pressing the abdominal wall. He further looks for the pain when pressing the hand on the abdomen and suddenly releasing the hand (rebound tenderness). Besides, he looks for pains when tapping at the abdomen (pain on percussion) and for vibratory pains by shaking the patient.

Rectal examination: the examination of the rectum is best done with the patient lying on his back and the doctor using his forefinger. The examination is a bit uncomfortable, but it provides decisive indications for the correct diagnosis. The doctor inserts his forefinger, which is covered with a glove and a fingerstall, through the constrictor into the anus. Of course, he uses a lubricant to avoid pains. With men, the prostate is examined at the same time, with women, the neck of the womb, and whether the uterus is sensitive to pain. This examination is absolutely necessary. A doctor can be made liable if he does not carry out this rectal examination in case of a suspected appendicitis.

Laboratory examinations: blood taken from the patient provides indications of an inflammation. An additional examination of the urine has the purpose to rule out infections of the kidneys and the urinary tract.

Imaging methods: with the ultrasound examination, the appendix is shown, but also the whole abdomen with the draining of the urethrae, the bladder, the kidneys, the gall bladder, and the liver. With women, ovaries and fallopian tubes are additionally shown. Sometimes, an ultrasound examination through the vagina is necessary in order to exclude a gynaecologic disease. If the findings remain uncertain, an X-ray has to be made in a lying and standing position or a CT (computer tomography) with the application of a contrast medium. 

It is often very difficult to recognise a case of acute appendicitis. In spite of the disease being very common, diagnosis is difficult. Doctors therefore sometimes casually talk about "monkeys in the belly" because appendicitis is able “to ape” or simulate so many other diseases. Therefore, the examinations mentioned above are very important. Together, they constitute an integrated whole, which makes a correct diagnosis of appendicitis in most cases possible. In the rare borderline cases, the experience of the attending surgeon is most important. Available is also another imaging method, the laparoscopy, with which he can inspect the abdomen through a small opening (cf. under "The laparoscopic operation").


How can acute appendicitis be treated?

At its beginning, an acute inflammation of the appendix is very difficult to be diagnosed. Therefore, antibiotics and pain killers are often administered on a trial basis, but they cannot heal appendicitis. If it becomes obvious by further and repeated examinations and by the course of the disease that a case of appendicitis is at hand, an operation is inescapable. Today, there are two kinds of surgery, both of which have to be carried out under general anaesthesia.

The open operation

By an incision in the right lower abdomen of about 6 cm, the skin, the subcutaneous tissue, the muscular skin, and the muscles of the abdominal wall are severed. The peritoneum is opened, and unobstructed visibility is provided with the help of small retractors. The large intestine is seized with the hand, pulled in the opening, until the tip of the appendix can be grasped. The small suspensory ligament of the appendix is severed between two sutures. On the large intestine around the base of the appendix, a so-called tobacco bag suture is laid. Afterwards, the appendix is tied off and removed. The small stump of the base of the appendix is then laid under the tobacco bag suture and stitched on top of it. The abdominal wall is then closed layer by layer. If an abscess had been found around the appendix, a drain is installed in the purulent cavity.

The laparascopic operation

blinddarm op

Today, the so-called keyhole surgery is used more and more for the operation of the appendix. For this purpose, the abdominal cavity is filled with warmed gas through a small trocar inserted at the navel. At the navel, also a 1 cm incision is made, and through the opening, a sterile miniature video camera is pushed into the abdominal cavity. Thus, the surgeon can inspect the abdominal cavity on a screen. Through two more small incisions of about 5mm to the left and right of the lower abdomen, instruments like small scissors and clamps can be introduced. These instruments are used to grip the appendix and to cut its suspensory ligament with a special device. The appendix is severed at its base near the wall of the large intestine with a special linear stapling device. The sick organ is pulled out through one of the incisions which then are stitched. Sometimes, only an open operation is possible for the resection of the appendix, especially for patients with certain anterior operations and adhesions.

 


What happens after the treatment?

"When I awoke from the narcosis, I still had slight pains in my lower abdomen, but I was surprised how fast I felt much better. That same day, I was allowed to drink some tea and water, and I was told to get up a little. On the second day, I already had a light meal and I was feeling well again."

In the case of open surgery as well as in the case of a laparoscopic operation, the patient can normally get up that same day for a short while and already drink a little. On the second day, he is allowed to eat again. In the case of a cracked appendix, an antibiotic usually has to be administered, and the small pipes of the drainage can be pulled out of the wound 4 - 6 days after the operation. As in every other operation, complications cannot be ruled out with the appendix operation, but they are fortunately quite rare. Besides, they are well-known to the doctors and their treatment is not difficult. Most common are harmless infections of the wound, but complications in the abdominal cavity occur quite rarely.

What has to be paid attention to in future everyday life?

After the operation, the disease is definitely healed. There is a very low risk that adhesions may form years or decades after the operation, causing an intestinal obstruction, which would have to be operated in any case.

 History

The disease of appendicitis has been known since the Middle Ages. Already in the 16th century, it was discovered and described when autopsies were carried out. In the 18th century, the disease could be diagnosed in a living patient for the first time. James Parkinson described in1812 a peritonitis which followed after appendicitis. The disease was recognised as being dangerous, but the treatment followed traditional methods: blood-letting, leeches, and clysters. It was only in 1886 that the American anatomist Reginald Heber Fitz from Boston described the inflammation of the appendix as cause of the disease. He created the word inflammation of the appendix ("appendicitis") and demanded the complete surgical removal of the diseased organ - which was extremely radical for the standards of that time. Who was the first surgeon to carry out the first operation of the appendix (appendectomy) is not quite clear. Robert Lawson Tait in 1880 in England, Rudolf Ulrich Krin in 1886 in Germany, or George Thomas Morton in 1887 in the USA– all carried out operations of the appendix. The first interventions were undertaken late in the course of the disease after the acute inflammation had subsided. The surgeons only drained the pus or removed just part of the appendix. Then, it was the surgeon John Benjamin Murphy from Chicago who introduced early surgical intervention, which is still common today. He demanded that the appendix should be completely removed before pus of the inflammation could enter the abdominal cavity through the wall of the appendix. There were few people that believed him at that time. Still too common was the belief in a treatment with medicaments and still quite immature were the technique and knowledge of the few courageous surgeons in the USA and Europe. European doctors smiled anyhow at the "wild" Americans, and they felt that surgeons were annoying rivals.

The breakthrough of appendix surgery came on 24June, 1902, when the English Prince of Wales fell ill with appendicitis shortly before his solemn coronation as King Edward VII, which meant a political and social disaster for the superpower of Great Britain. After dramatic symptoms and vain medicinal treatment by the royal physician, Frederick Treves was the one who carried out the life-saving operation. He was assisted by the already very old Joseph Lister, the discoverer of antisepsis, which was indispensable for all kinds of operations. The pus was drained and King Edward VII recovered. He thanked Treves for saving his life by awarding him the hereditary title of a baron.

Today, the operation of the appendix (appendectomy), which has been in use for over 100 years now, is carried out as early as possible after the disease has been diagnosed. The inflammation of the appendix is the most common disease of the gastrointestinal tract, and the appendectomy belongs to one of those abdominal operations with which doctors or surgeons, respectively, have the profoundest experience.

 

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