Appendicitis, the most common abdominal emergency
Appendicitis is the most common abdominal emergency, accounting for thousands of hospital admissions across South Africa annually. Every individual has a 7% to 8% lifetime chance of developing the condition1, the management and treatment of which remains surgery.
The appendix is a small, finger-shaped pouch of tissue that hangs from the lower right side of the large intestine.
An estimated one in 500 people a year develops an inflamed appendix. This is usually caused by an obstruction of the lumen of the appendix by, for example, a hard piece of stool known as a faecolith. Increased pressure in the lumen causes swelling and inflammation, resulting in pain, nausea, vomiting and fever. If not treated, an inflamed appendix can burst, spilling bacteria into the abdominal cavity and the bloodstream, putting the body at high risk of infection.
Prompt removal of the appendix before it has burst helps to avoid this situation.
Dr Vivian Simmons, specialist surgeon in private practice in Bloemfontein, estimates that 20% of appendix-related patients present with an already ruptured appendix.
Diagnosing appendicitis is not always easy, as symptoms can mirror other gastric or bowel-related conditions. Dr Simmons explains that abdominal ultrasound used to be the standard method to determine whether inflammation of the tissue was present, but this often led to misdiagnosis.
‘Most recent studies favour the use of diagnostic laparoscopy, particularly for women. A small incision is made at the umbilicus under general anaesthesia and a camera placed in the abdomen. The appendix is seen directly and, if inflamed, removed during a laparoscopic appendectomy,’ says Dr Simmons.
‘The traditional operation for appendicitis is the removal of the inflamed appendix through a 10cm incision to the right lower abdominal wall, opening the area by separating the muscles and entering the abdomen.
With laparoscopic surgery, smaller incisions of about 1cm are made on various sites of the abdomen, improving the cosmetic result. Patients undergoing a laparoscopic appendectomy have less post-operative pain, a smaller risk of wound infection, shorter hospital stay, and shorter time before resuming normal daily activities. The procedure is more costly than open surgery, and conversion to open surgery in difficult cases is a risk, but laparoscopic surgery remains the superior option.’
Various studies have shown the highest incidence of appendicitis is amongst children and adolescents, peaking at about 15 to 18 years of age, and again at about 50 to 60 years of age.
There has been some debate about the use of antibiotics in the treatment of appendicitis, with some people advocating an antibiotics-first approach over surgery. Dr Simmons disagrees, saying studies have not been able to prove conclusively that antibiotic treatment alone is superior to laparoscopic surgery.
‘Surgery, and specifically the laparoscopic appendectomy, remains the standard of choice for the condition. Appendicitis remains a surgical condition requiring excision of the appendix. The role of antibiotics is to prevent wound infection or continued abdominal infection from the appendicitis,’ says Dr Simmons.