Appendicitis Treatment and Medications

Appendicitis is swelling of the appendix, a small tube-like pouch attached to the lower right side of the colon. Nearly all cases of appendicitis are acute appendicitis, in which an infection causes the swelling. The symptoms of acute appendicitis come on suddenly and progress rapidly in the first 48 hours.

Acute appendicitis is a medical emergency. The appendix has a high risk of rupturing, and the risk rapidly increases as time passes. The rupture of an inflamed appendix threatens to spread the infection and can result in sepsis, a potentially life-threatening condition where swelling occurs throughout the body.

In almost all cases, acute appendicitis requires an appendectomy (surgical removal of the appendix).

Acute appendicitis is one of the most common causes of abdominal pain. Around 7 in 100 people will experience acute appendicitis at some point in their lives. There are no particular risk factors, but appendicitis occurs most commonly in people between the ages of 10 and 30, and the incidence is higher in men than women.

Because the condition progresses rapidly, getting emergency medical treatment is urgent. Knowing what appendicitis is, identifying its symptoms, and understanding its treatment options can help someone with appendicitis avoid life-threatening complications.

What is the appendix, and where is it located?

The appendix is a thin, worm-shaped tube about four inches long attached to the bottom of the lower right side of the colon. Called the cecum, this part of the colon looks like a sink or bowl sunk below the opening where the small intestine feeds into the large intestine. The rest of the large intestine rises upwards toward the chest. The appendix lies at the bottom of that bowl.

Scientists don’t fully understand what the appendix does. For a long time, it was considered a useless vestige. Researchers now think it does have a function but aren’t sure what it is. One theory is that the appendix serves an immune purpose by harboring the white blood cells to handle possible colon infections. Another is that the appendix is an emergency “safe house” for beneficial gut bacteria.

What causes appendicitis?

Whatever its function, the appendix secretes mucus into the cecum. Mucus production is largely what that whole area of the colon does. The mucus produced by the cecum lubricates the intestinal walls. The appendix, though, is very thin. It can be easily blocked, usually by a stone formed of fecal material (a fecalith), foods such as unchewed fruit seeds, or tumors, parasites, or an overgrowth of white blood cells. Stones, though, are the usual culprit.

Once blocked, mucus builds up in the appendix. As the appendix swells, blood flow gets cut off (ischemia), and appendiceal tissues die, which triggers an infection. Bacteria multiply inside the appendix, swelling it even more and resulting in the classic symptoms of appendicitis.

This is the stage health professionals call uncomplicated appendicitis. The infection is limited to the appendix and can be quickly resolved by surgically removing the appendix.

If unchecked, eventually, the swelling will tear a hole somewhere in the appendix wall. The infection will seep out as an abscess or break out and infect the rest of the abdominal cavity surrounding the intestines, called the peritoneum.

A peritoneal infection, or peritonitis, is a serious and potentially life-threatening condition requiring aggressive emergency medical treatment. Even worse, the ruptured appendix may fill the bloodstream with the inflammatory substances the immune system uses to fight off infections, a condition called sepsis. Swelling happens throughout the body, threatening vital organs. Sepsis can rapidly progress to organ failure, anaphylaxis (a hazardous drop in blood pressure), and death.

How is appendicitis diagnosed?

Knowing the symptoms of appendicitis can save a life. The symptoms of appendicitis usually come on quite suddenly and progress rapidly. The first symptoms start developing in the first 12 to 24 hours, and appendix ruptures become a significant risk after 48 hours.

On a physical examination, a healthcare professional is looking for the definitive symptoms of appendicitis:

• Abrupt onset of Abdominal pain that starts around the belly button and localizes to the right lower quadrant of the abdomen,

• Rebound pain in that same area,

• Nausea,

• Loss of appetite

To test for rebound pain, the healthcare provider will apply pressure to the appendix. Rebound pain is the jolt of pain felt when the pressure is removed. It is a unique sign of appendicitis or peritonitis.

Other symptoms might include a dry tongue, bad breath, constipation, diarrhea, and flushing.

The definitive symptoms, though, are the five listed above. Doctors often use a scale called the Alvarado score to diagnose appendicitis. The five warning signs listed above add up to a score high enough on the Alvarado scale to move straight to surgery without any other tests or imaging.

Other tests will be done, though. Not all the definitive symptoms will be present. The emergency physician will ask for imaging tests, blood tests, and urine tests to confirm a diagnosis.

A CT scan provides the clearest picture of an inflamed appendix. However, time constraints and the patient’s medical condition may call for an ultrasound, MRI, or X-rays. For instance, the physician will use ultrasound on pregnant women and children.

Blood tests will count white blood cells. A urine test can help determine if the pain has another cause, such as a urinary tract infection (UTI) or an ectopic pregnancy, which are sometimes confused with appendicitis.

All this time, however, the clock is ticking. The physician will analyze the images and tests in the context of the symptoms to determine the risk of appendicitis. If this risk is low, the patient will probably be admitted for observation and put on antibiotics.

If the risk is high, things will move pretty fast.

Appendicitis treatment options

The surgical removal of the appendix is the primary treatment for acute appendicitis. This surgery is called an appendectomy or appendicectomy.

A laparoscopy—surgery using a small tube inserted into the abdomen through a small hole called a laparotomy—can treat uncomplicated appendicitis. Complicated appendicitis involving an abdominal abscess or advanced infection may require an open appendectomy.

Laparoscopic appendectomy has fewer complications than an open appendectomy. It involves less pain, fewer complications, and faster recovery time than open surgery.

Survival rates for uncomplicated appendicitis after surgery are excellent. However, mortality increases more than seven-fold for patients who go into surgery with complicated appendicitis.

Sometimes, however, patients are misdiagnosed. In the middle of the appendectomy, the surgeon will discover the appendix is perfectly healthy. Although the procedure is then unnecessary, the surgeon may still remove the healthy appendix as a preventative measure. The removal of a healthy appendix based on a misdiagnosis is called a negative appendectomy. It happens quite frequently. Up to 1 in 7 appendectomies are unnecessary.

Increasingly, however, patients at lower risk may be treated only with antibiotics and pain relievers. The patient will be observed for one or two days and released if the symptoms improve. Most low-risk patients fully recover on antibiotic therapy alone. However, they are at high risk for another appendiceal infection in the future.

Appendicitis medications

The last two decades have seen dramatic rethinking of the role medications play in treating acute appendicitis. Pain relievers and antibiotics were once used sparingly, but now may be used to treat appendicitis alone without surgery.

Pain relief medications

At one time, healthcare professionals believed that pain medications made diagnosing appendicitis difficult, delaying a definitive diagnosis when every hour matters. The primary symptoms, after all, are pain symptoms. Some health sites still warn about taking pain relief medications before going to the emergency room. However, we now know that pain relievers do not influence diagnosis, so there’s no reason to suffer while waiting for the doctor or surgery.

It is now standard practice to immediately administer pain medications such as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetaminophen upon admission to an emergency room.

Antibiotics

The use of antibiotics was and still is controversial. Until recently, the only treatment option was an appendectomy, and antibiotics were used to prevent infection of surgical wounds. However, the high rates of negative appendectomies, which have hovered around 20% to 25% over the last few decades, are cause for concern. So intravenous antibiotics are now administered almost immediately and may be the only treatment necessary to treat the infection in some patients.

Most patients receive intravenous antibiotics as soon as they get an appendicitis diagnosis to prevent infection of surgical wounds. Intravenous antibiotics are usually continued for 24 hours after surgery to prevent complications.

Increasingly, healthcare professionals are relying on antibiotic treatment alone for lower-risk patients. Research has shown that antibiotic therapy for lower-risk patients is highly successful and doesn’t involve surgical complications.

The downside, however, is that the patient is at risk for appendiceal infection in the future. About 40% of patients with uncomplicated appendicitis who receive only antibiotics need surgery within the next year. Compare this to 8.5% of appendectomy patients who require a second surgical procedure in a year.

A whole menagerie of bacteria, including Escherichia, Pseudomonas, Peptostreptococcus, Bilophila, and Bacteroides, cause appendicitis. Therefore, a variety of wide-spectrum antibiotics can fight off the infection, including:

• Penicillin-type drugs with a beta-lactamase inhibitor: Zosyn (piperacillin and tazobactam), Unasyn (ampicillin-sulbactam)

• Cephalosporins: Rocephin (ceftriaxone), Cefotan (cefotetan)

• Carbapenems: Merrem (meropenem), Invanz (ertapenem)

• Aminoglycosides: Gentak (gentamicin)

• Nitroimidazoles: Flagyl (metronidazole)

• Lincomycins: Cleocin (clindamycin)

Healthcare providers follow a well-established protocol and their own experience when prescribing antibiotics, so the use of any of these medications will depend on several factors.

Choosing the best medication

Drug treatment for appendicitis, both before and after surgery, focuses on eliminating the infection or relieving pain. Because appendicitis infection involves several different types of bacteria, healthcare providers will prescribe broad-spectrum antibiotics. There is, however, no “best” antibiotic for appendicitis. Physicians follow a protocol when prescribing antibiotics for appendix infections. They will also tailor the prescription to the patient’s history of antibiotic sensitivity. Prescription NSAIDs can adequately manage pain both before and after surgery.

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Best medications for appendicitis