Can the appendix be inflamed intermittently?

Intermittent Appendiceal Inflammation: Occurrence and Management

Yes, the appendix can become inflamed intermittently, a condition known as recurrent or chronic appendicitis, which occurs in approximately 10% of appendicitis cases and should be considered in patients with recurrent abdominal pain. 1, 2

Understanding Intermittent Appendiceal Inflammation

Recurrent appendicitis is characterized by:

• Episodes of right lower quadrant or lower abdominal pain that resolve spontaneously
• Multiple episodes over time (can span weeks to years)
• Periods of complete symptom resolution between attacks
• Pathologic evidence of chronic inflammation or fibrosis when the appendix is eventually removed 1

This condition is often misdiagnosed because many clinicians are unwilling to accept appendicitis as anything other than an acute condition requiring immediate intervention. However, evidence shows that acute appendicitis can resolve spontaneously and recur repeatedly in the same individual 1.

Clinical Presentation and Diagnosis

The clinical presentation of intermittent appendicitis differs from classic acute appendicitis:

• Less severe pain that may wax and wane
• Longer duration of symptoms (weeks to months)
• May have history of similar episodes that resolved without surgery
• Often lacks the progressive intensity typical of acute appendicitis

Diagnosis can be challenging because:

• Imaging may appear normal between episodes
• Laboratory markers may be normal or only mildly elevated
• Symptoms may mimic other gastrointestinal conditions

Management Approaches

For Uncomplicated Recurrent Appendicitis

The 2020 WSES Jerusalem guidelines suggest:

• Appendectomy is recommended for patients with recurrent symptoms, even if the appendix appears "normal" during surgery 3
• Laparoscopic approach is preferred when expertise is available
• Studies show that 90% of normal-looking appendices removed during laparoscopy for recurrent abdominal pain harbor inflammatory changes on pathological examination 3

For Complicated Appendicitis with Phlegmon or Abscess

If a patient presents with appendiceal abscess during an episode:

1. Initial non-operative management with antibiotics and percutaneous drainage (if available) is recommended 3, 4
2. Success rates of 76-97% have been reported with this approach 3
3. Interval appendectomy is not routinely recommended after successful non-operative management in young adults (<40 years) and children 3
4. Interval appendectomy should be performed for patients with recurrent symptoms 3

The reported rate of recurrence after non-surgical treatment for perforated appendicitis ranges from 12% to 24% 3.

Special Considerations

Age-Related Concerns

• For patients ≥40 years old with complicated appendicitis treated non-operatively:
  • Higher risk of underlying neoplasm (3-17%)
  • Both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended 3
  • Consider interval appendectomy due to the higher risk of malignancy

Differential Diagnosis

When evaluating recurrent right lower quadrant pain, consider:

• Inflammatory bowel disease (particularly Crohn's disease)
• Yersinia infection (accounts for approximately 25% of granulomatous appendicitis cases) 5
• Other infectious causes (mycobacteria, fungi, parasites)
• Foreign body reactions

Key Pitfalls to Avoid

1. Misdiagnosis: A history of prior similar episodes of pain should never dissuade clinicians from considering appendicitis 1
2. Delayed treatment: Recurrent episodes may eventually lead to complications including perforation or abscess formation
3. Overlooking underlying pathology: In older adults, recurrent appendicitis may mask appendiceal neoplasms
4. Unnecessary interval appendectomy: Routine interval appendectomy after successful non-operative management is not justified in young patients without recurrent symptoms 3

In conclusion, intermittent appendiceal inflammation is a real clinical entity that should be included in the differential diagnosis of recurrent abdominal pain. Appendectomy is curative and should be considered in patients with recurrent symptoms, even when the appendix appears normal during surgery.