When it comes to abdominal pain, one condition that often sparks concern is appendicitis. The appendix can quickly turn into a source of intense discomfort and potential danger. Often striking suddenly and without warning, appendicitis affects thousands of people and accounts for about 280,000 appendectomies each year in the U.S. Knowing more about this common but enigmatic ailment is key.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
For this installment, physicians took time to discuss what patients need to know about appendicitis. These AMA members are:
- Jacob Altholz, MD, an emergency physician in Denver and an AMA Resident and Fellow Section delegate representing the Colorado Medical Society in the AMA House of Delegates.
- Hilary E. Fairbrother, MD, MPH, a pediatric and adult emergency physician in Houston, and chair-elect of the AMA Specialty and Service Society Governing Council. She is also a member of the AMA Council on Legislation.
- Alfred P. Kennedy, Jr., MD, a pediatric surgeon in Danville, Pennsylvania, and head of the surgery department at Geisinger.
- Jordan M. Warchol, MD, MPH, an emergency physician, educator and health policy scientist in Omaha, Nebraska.
Geisinger is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
The appendix is on the right side of the abdomen
“The appendix is a vestigial organ that is like a little outpouching of the first part of the colon called the cecum,” said Dr. Kennedy, noting the location of the appendix is not the same in everyone, which “can present a diagnostic dilemma depending on where it is.”
“It’s not always out in front of the cecum. Sometimes it is tucked behind. But the appendix is typically on the lower right side of the abdomen,” he said. “For those patients where it’s in a different spot than the lower right side of the abdomen, it can become a little bit more of a diagnostic dilemma.”
It is inflammation of the appendix
“Appendicitis is when part of the intestine gets inflamed, infected, irritated or blocked—something causes it to be abnormally swollen,” Dr. Fairbrother said. “When part of our intestine gets inflamed or swollen, we start seeing a high risk for bacterial infection.”
“In reality, it happens almost always the same way, which is that it gets clogged. And if it gets clogged, then the backside of it where all that bacteria was just stews and eventually just gets meaty and gross and infected and then sometimes it pops,” Dr. Altholz said. “What clogs it is more often than not referred to as fecalith. It’s a stone that is made out of your poop.”
Pain is the first symptom of appendicitis
“Classically, what we learn in the textbooks is pain is first—everybody has some element of pain from the inflammation,” Dr. Kennedy said. “But usually, the patient will develop nausea at some point, maybe even vomit.”
“Some of the unusual symptoms are diarrhea. Sometimes if the appendix is down in the pelvis and causing inflammation there, the patient may experience some urge to pee a lot or poop a lot,” he explained. “That can confound things because people may think it’s a viral issue, when it is not.”
“Then with anorexia, they generally lose their appetite, although that’s much less common in children who will eat through anything it seems, but then a late finding is a fever,” Dr. Kennedy said. “People may think that if their child doesn’t have a fever, they don’t have appendicitis, but it’s actually a late finding and usually signifies the appendix burst or is about to burst.”
“One of the classic things I always look for is migration of pain. So, it started in one spot and then it moved and then it became sharper or more unbearable. That’s really a hallmark symptom of appendicitis,” he said, adding that “it usually begins as a dull tummy ache that may be around your belly button that’ll last a few hours and then the person suffering from it will notice the pain migrates or moves and it becomes more intense, sharp and obvious in the lower right side.”
There are four stages of appendicitis
Appendicitis “we don’t really talk about the stages as much as the minute-to-minute basis of taking care of appendicitis, but what they are is that the first stage is just that it gets clogged,” Dr. Altholz said. “If it gets clogged, you’re not going to feel it necessarily at that point.”
“The second stage is when it starts to get irritated and what it does is—like much of the colon—it starts getting backed up,” he said. “So, it starts getting distended and then you start feeling that. But what you feel isn’t specific. … You just feel like something is wrong.
“Next is when it starts irritating things around the appendix … and that’s when you start feeling it in the right lower quadrant,” Dr. Altholz said. “What we often say is that the pain localizes, so you start off with this vague, awful, something’s wrong and you don’t know if you’re going to poop yourself or if you’re not going to poop for three days.”
“You can’t really tell what’s happening to your body, but then all of a sudden the pain is in the right lower quadrant, which is what we think of as most classically appendicitis,” he added. “That’s exactly what happened to me when I had appendicitis.”
“The fourth stage is when it perforates. So, you can have this right lower quadrant pain, and it can be really angry and then your appendix just pops and if it does that, sometimes people actually feel relief,” Dr. Altholz said. “But then the goop just goes everywhere in your abdomen and then it gets bad because then that infection spreads everywhere. That has a lot more complications behind it.”
Appendicitis pain is on the lower right side
“If you split your stomach into four quadrants using your belly button as the center, your appendix is generally on the right lower side,” Dr. Warchol said. “That said, though, people can have pain in a lot of different areas.”
But “the classic one is the right lower quadrant,” she emphasized, noting “I have had people with back pain before or maybe their appendix moved around because your bowels are more or less free-floating in your belly.
“There are some tether points, so it can move around and based on your personal anatomy,” Dr. Warchol added.
Appendicitis can happen to anyone
“It’s in your 20s that appendicitis typically happens. That’s not to say that it will happen, but if you have an appendix, you’re at risk for it,” Dr. Altholz said. “People are most worried about it in their kids. It almost never happens under the age of 1.”
“But between the ages of 5 and 45 is when most cases of appendicitis happen. And then there’s another age when you’re past 60 where it bumps up again,” he said. “I have seen patients who are 4 and who are 40 who have appendicitis, so it’s not uncommon.”
“If you think about what your chance is of getting appendicitis in your entire lifetime, in women it’s about 7% and in men it’s about 8.5%,” Dr. Fairbrother said.
Other conditions are ruled out
There are a number of conditions that can be mistaken for appendicitis. For example, “the right lower quadrant in women ... the structures that are down there are the ovaries,” Dr. Fairbrother said. “And the No. 1 thing that I am ruling out when I have someone who I'm working them up for appendicitis is ovarian torsion or in general just pathology or a problem with the ovary.”
“Men have something similar called testicular torsion, which is the same thing where the testicle spins on itself and then the pain can actually go from the testicle up into the right lower quadrant,” Dr. Altholz said.
Additionally, “you can have enteritis, which is inflammation of your bowels. Sometimes people have diverticulitis, which is more classically on the left side, and think it’s appendicitis,” Dr. Warchol said. “On the right side of your abdomen is your gallbladder and your liver, so you can have gallbladder problems that—for whatever reason—you’re having pain in that right lower side or a little further down.”
“Then, anybody who has a kidney stone will tell you that it can start in the back, come to the front, radiate down into the groin,” Dr. Altholz said. “That difference between the groin and the right lower quadrant can be a little difficult sometimes because people say they have some pain right towards that front area, but it’s actually the lower part of the ureter—the part where the kidney connects to the bladder.”
Seek medical help within 24 hours
“If your pain is uncontrolled at home, that’s always a good reason to go in,” Dr. Warchol said. “If you just feel like you can’t take it anymore, that’s totally a reasonable reason to go in.”
Additionally, “if you have belly pain and a fever, that’s a good reason to go in or if it’s been there pretty persistently for 12 hours to a day,” she said.
“If it’s something that’s just a virus or some gas pain, a lot of those things will feel better within 12 to 24 hours,” Dr. Fairbrother said. “Appendicitis isn’t going to go away. It doesn’t get better or worse as you eat. It’s just constantly getting worse and worse and worse. So, if you are having something like that, that is the time to get evaluated.”
Appendicitis is different in pregnancy
“It presents an urgency not only to the mom, but also to the unborn baby,” said Dr. Kennedy. “As the uterus grows during pregnancy, it actually pushes the cecum in the appendix higher in the abdomen.”
“Pregnancy pushes all of the internal organs up and back. Because of that, a pregnant woman might have pain in a different place,” Dr. Fairbrother said. “A pregnant woman might have pain in the flank, back or right upper part of the abdomen as opposed to the right lower part of the abdomen because everything is getting shifted around.”
Additionally, an appendix “rupture occurs more frequently in pregnant women,” she said, noting “it is suspected in about one in every 600 pregnancies and confirmed in one out of every 800 pregnancies.”
CT scans help with diagnosis
“We use a lot of different tests, but most specifically, we look into the human body to visualize the appendix and around where the appendix should be to see if we see secondary signs of inflammation,” Dr. Fairbrother said, noting “there are all sorts of other secondary tests that we can use.
“Blood tests would go along with if you have elevated white blood cells or an elevated inflammatory marker. All those things may go along with appendicitis, but they’re not diagnostic of appendicitis,” she added. “The traditional test is really a CT scan. Once CT scans were ubiquitously available across the United States, that is how everyone was diagnosed with appendicitis.”
Start with an ultrasound for kids
“The issue with a CT scan is the relatively large amount of radiation. This is a common problem in people, period, but it’s pretty common in children,” Dr. Fairbrother said. “We are very sensitive to exposing children to radiation. We know that their growing and developing bodies have worse side effects when we expose them to radiation. It’s for life.”
“If I get exposed to radiation as a woman who’s already had my children and I’m not having any more kids and we’re really only thinking that I don’t want to be exposed to so much that I get cancer, I have a very different risk profile than a 6-month-old,” she said. “And I have a very different profile than a 22-year-old who hasn’t had children yet but has all of the eggs in their body that they are going to ever have.”
“We are particularly cognizant of children being sensitive to radiation and we don’t want to irradiate them,” Dr. Fairbrother said, noting “many pediatric centers of excellence—whether it’s a pediatric standalone hospital or just a hospital that sees a lot of children—will start with an ultrasound and then move to an MRI of the appendix for diagnosis.”
Surgery is done laparoscopically
“The majority of cases are done laparoscopically, meaning there’s no large incision. There are teeny tiny little incisions,” Dr. Fairbrother said, noting “the recovery is very quick. It’s only a matter of days because there is no large incision with tons of sutures to be taken out and work to be missed.”
“So, the majority of people get some IV [intravenous] antibiotics and get a laparoscopic surgical removal of their appendix and are back at doing their normal life activities within about 1-2 weeks,” she said.
If the appendix bursts, surgery is more complicated
“For an appendix that bursts, surgery is still done laparoscopically, but there may be a collection of fluid or an abscess that needs to be drained,” Dr. Kennedy said. “At the same time, it’s a little more complicated and difficult.”
“It may even be a little bloodier, but it’s best just to get in there as soon as possible and remove the appendix,” he said. “Most of our kids spend about four to five days in the hospital after an appendectomy if it’s associated with a rupture.”
Antibiotics may be an option
“You can be offered antibiotics and that is not somebody trying to say that they don’t want to do surgery on you, but it’s a discussion that you should have,” Dr. Altholz said, emphasizing that “every health care choice should obviously be a discussion, especially major things like surgery.”
“If there wasn’t, in theory, something clogging the appendix and we just have an infection that we think will get better, then antibiotics might be a good choice,” he said.
“The problem is about 20% of those patients will have a recurrence of their appendicitis sometime because whatever set them up for appendicitis to begin with is going to happen again,” Dr. Fairbrother said, noting “there’s not a high tolerance in the United States for that knowing how simple, easy and uncomplicated the procedure for removing the appendix has become.”
Don’t ignore constipation
“There isn't a lot of prevention for appendicitis. The one thing I tell patients is to not delay preventative care for constipation for them or their children,” Dr. Fairbrother said. “Not every constipated kid will get appendicitis and same with adults. That's not how it works. But it is associated.”
“Even if the child or the adult has figured out a way to live with it, we really do like patients to come in for intestinal and gut health. We really would like everyone not to be constipated,” she said.
Sudden pain is a concern
“We call appendicitis the great masquerader because it can present in many different ways,” Dr. Kennedy said. When at home, “parents should be mindful of pain that comes out of the blue.”
“If no one else is sick at home and it’s pain that just comes out of the blue and is continual, that would be a concern,” he said. “That requires an ED visit because if we get to the appendix before it ruptures, it’s a very different scenario than if we don’t.”
Returning to normal activities varies
When it comes to returning to normal activities after an appendectomy, “there are two different paths. For a patient whose appendix is not ruptured, they’re probably back on their feet and back to school within a few days,” Dr. Kennedy said, adding that kids can go “back to sports within a few weeks.”
“Patients who had a ruptured appendix, it may languish much, much longer,” he said. “Our general instruction is, we like kids to get back to some form of school within a week, but heavy lifting or strenuous activity we usually have them take at least three weeks off.”
There’s no change to your everyday life
“You can have your appendix removed and there’s essentially no lasting complications to not having an appendix,” Dr. Warchol said. “Compared to a gallbladder, which you have to do some dietary modifications, there’s really no change to your everyday life if you don’t have an appendix.”
“For the recovery, generally, your surgeon will have specific things they want you to do or don't want you to do. But in the long term there are really no changes,” she said.
