What are the causes and preceding symptoms of acute appendicitis (inflammation of the appendix) prior to severe presentation requiring immediate hospitalization?

From the Guidelines

Acute appendicitis is primarily caused by obstruction of the appendix lumen, typically by a fecalith (hardened stool), lymphoid hyperplasia (swollen lymph tissue), or occasionally by foreign bodies, tumors, or parasites, as stated in the most recent guidelines 1. The causes of acute appendicitis can be attributed to various factors, including obstruction of the appendix lumen, which leads to increased pressure, reduced blood flow, bacterial overgrowth, and inflammation. Some key points to consider include:

• The "classic" clinical presentation of patients with appendicitis consists of periumbilical abdominal pain migrating to the right lower quadrant (RLQ), loss of appetite, nausea or vomiting, with fever, and leukocytosis is present in approximately 50% of patients 1.
• Early symptoms that may appear before requiring immediate hospitalization include periumbilical pain that migrates to the right lower quadrant (McBurney's point), loss of appetite, mild nausea, and low-grade fever.
• As the condition progresses, symptoms worsen to include vomiting, fever above 101°F, rebound tenderness (pain when pressure is released), and severe abdominal pain.
• If you experience persistent abdominal pain, especially if it moves to the right lower abdomen and is accompanied by fever, nausea, or vomiting, seek medical attention promptly, as delaying treatment can lead to appendix rupture, causing peritonitis, a life-threatening infection of the abdominal cavity.
• The standard treatment for acute appendicitis is surgical removal (appendectomy), though some cases may be managed with antibiotics under close medical supervision, as suggested by recent guidelines 1. Some important considerations in the management of acute appendicitis include:
• The use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy 1.
• The role of diagnostic imaging, such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI), in the diagnosis of acute appendicitis 1. It is essential to prioritize the most recent and highest-quality studies when making decisions about the management of acute appendicitis, as the guidelines and recommendations are continually evolving 1.

From the Research

Causes and Preceding Symptoms of Acute Appendicitis

The causes of acute appendicitis are not fully understood, but it is one of the most common abdominal emergencies worldwide 2. The preceding symptoms of acute appendicitis can vary, but classic symptoms include:

• Vague periumbilical pain
• Anorexia/nausea/intermittent vomiting
• Migration of pain to the right lower quadrant
• Low-grade fever 3
• Abdominal pain that localizes in the right lower quadrant, more typical in men than in women of childbearing age 4

Diagnosis and Management

The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging 3. The management of acute appendicitis can be divided into uncomplicated and complicated disease, with antibiotics and timely appendectomy being the standard treatment 4. However, recent studies have demonstrated that nonoperative management of uncomplicated appendicitis without fecalith can be managed with antibiotics alone 4, 3, 5, 6.

Risk of Complications

The risk of complications, such as perforation and peritonitis, is higher in patients with certain imaging findings, such as appendicolith, mass effect, and a dilated appendix greater than 13 mm 3. In these cases, surgical management is recommended 3. The overall incidence of complications of appendicitis is lower in patients treated with antibiotics compared to those who undergo immediate appendectomy, but the frequency of perforations and peritonitis does not differ between the groups 5.

Treatment Outcomes

The outcome of treatment for acute appendicitis varies, with 73% of patients treated with antibiotics alone being asymptomatic and having no complications or recurrences after one year, compared to 97% of patients who undergo immediate appendectomy 5, 6. However, the quality of the studies is low to moderate, and the results should be interpreted with caution 6.