Appendicitis: symptoms, left or right, which side?

Appendicitis is a sudden and acute inflammation of the appendix, colon diverticulum right. This inflammation occurs as a result of obstruction of this organmost of the time by feces. It is common in the young subject under the age of 20 and requires a emergency appendectomy. What are the warning symptoms appendicitis? What is the precise location of the pain? Left or right ? What causes appendicitis? What are the most effective treatments? Explanations by Prof. Philippe Wind, visceral and digestive surgeon at Avicenne Hospital in Bobigny.

“The appendix is ​​a atrophied part of the beginning of the large intestineexplains Professor Philippe Wind from the outset. It is a lymphoid organ. This means that, like the lymph nodes, the appendix is ​​part of the body’s immune defences. Indeed, there are many lymphoid organs thus located around the digestive tract.” So the appendix looks like a kind of “dead end” between the small and the large intestine, from 6 to 12 cm in length for 5 mm in diameter on average and is hollow. We are talking about appendicitis attack when there is sudden inflammation of the appendix. This inflammation affects one in fifteen people, mainly between the ages of 10 and 30. It is a rare disease before the age of 5, and exceptional before the age of 3. Acute appendicitis is distinguished from chronic appendicitis:

► Acute appendicitis

Acute appendicitis can affect people of all ages, but occurs especially before the age of 30, with a prevalence peak usually between 10 and 14 years and another between 25 and 34 years. Acute appendicitis is a sudden inflammation of the ileocecal appendix, a natural diverticulum extending the first segment of the large intestine called the cecum. This inflammation is sudden and is accompanied by severe abdominal pain and sometimes other symptoms.

►Chronic appendicitis

Chronic appendicitis is a long-standing inflammation or fibrosis of theappendix. It manifests itself by a prolonged and intermittent abdominal pain. Unlike acute appendicitis, chronic appendicitis is relatively rare: its diagnosis is more difficult to establish because the clinical signs are much less visible and the progression of the infection is slower.

A typical attack of appendicitis begins with abdominal pain, most often located in the right iliac fossai.e. just above the groin crease. This is where the appendix is ​​located in most people. Note that in about a third of cases, the appendix is ​​not located in the right iliac fossa. It may for example be lodged under the liver, this is called the subhepatic appendix. Other times she finds herself in the middle of the abdomen, under the large intestine, and it is then a retro-caecal appendicitis. Hidden by these other organs, they are therefore more difficult to detect.

Appendicitis is characterized by:

• Of the sharp and persistent abdominal pain at the bottom of the abdomen, near the navel or a little more to the right,
• A moderate fever, 38.5°C
• Nausea
• Vomitings
• Headaches
• A constipation.

On the x-ray, the inflamed appendix is more puffy and more opaque. In the event of the appearance of these symptoms, it is advisable not to give food or drink and to telephone the doctor urgently or call 15. Above all, do not take laxatives which could increase the risk of the appendix bursting.

This inflammation can occur for various and, most often, undetermined reasons. “The original mechanism is not well known. We only know that sometimes germs or parasites are the cause of the onset of the attack“, continues the doctor. Impossible, therefore, to predict if and when the crisis will occur, or even to try to escape it. On the other hand, the only certain fact, it concerns much more often children and young adults. “Again, we don’t have a definitive explanation, but it may have something to do with the fact that children’s immune systems are often more active than adults’.“.

Several tools are now available to doctors to confirm or rule out a suspicion of appendicitis:

► Complete blood count (NFS): it is the quantity of leukocytes (a category of white blood cells) that will be measured. Leukocytes are produced by the lymphoid organs (of which the appendix is ​​a part) to fight against infections. Generally, in the event of appendicitis, the leukocyte count is much higher than normal. That said, CBC is not enough to diagnose appendicitis, since leukocytes can be elevated for countless reasons.

► THE CRP, or C-reactive proteins are other markers of inflammation. A bit like white blood cells, they have above all a negative predictive value: if the CRPs are high, it is consistent with an attack of appendicitis. If they are low during two measurements more than 24 hours apart: it is not appendicitis.

► The scanner East “undoubtedly the best reviewcomments Professor Wind. It makes it much easier to spot a thickening of the appendix and fatty infiltration all around, a typical sign of an appendicitis attack..” If the result is not 100% guaranteed, it is still, and by far, the most reliable diagnostic tool.

► Ultrasound has the same properties as the scanner, but it is less reliable: depending on where the appendix is ​​placed, the amount of abdominal fat, etc. it can be difficult to spot. it is all the same the examination recommended for pregnant women and children, who cannot be too exposed to the rays of the scanner.

Today, it is very rare to operate without having performed a scanner or an ultrasound. This is especially true for men over 40.”because appendicitis is rare at this age“) and in women, to eliminate any gynecological affections.”Thanks to this examination, today there are almost no more unnecessary appendectomies“, rejoices Philippe Wind.

In a few rare cases, the crisis resolves on its own. But most of the time, to treat an attack of appendicitis, it is necessary to carry out a appendectomy, in other words, removal of the appendix. But bewaresurgical intervention is no longer systematic And we now favor withdrawal by laparoscopy (versus laparotmia which involved an incision in the right iliac fossa). The laparoscope consists of practicing three small holes in the abdomen under general anesthesia, to introduce a mini-camera to incise and remove the appendix with the least possible damage. Of carbon dioxide is introduced into the abdomen to lift the abdomen, so that the viscera are easily accessible. Thanks to large needles (trocars), the surgeon can introduce the surgical instruments into the abdomen and perform the ablation. After the operation, in the case of a “simple” attack of appendicitis, the patient receives antibiotic therapy for about two days, in order to ensure that the infection is properly controlled.

In the case of an operation by laparoscopy, the three small holes become almost invisible a few weeks later. For a classic operation, the incision of a few centimeters, very fine, becomes barely perceptible over time.

If appendicitis is not treated, there is a strong risk that it degenerates into peritonitis

If appendicitis, treated in time, is benign, peritonitis on the other hand can leave sequelae. “We speak of peritonitis as soon as there is inflammation of the peritoneumexplains Professor Wind. Peritonitis is not necessarily consecutive to an attack of appendicitis. On the other hand, if appendicitis is not treated, there is a strong risk that it degenerates into peritonitis.“The peritoneum is the membrane that covers the inner walls of the abdomen. In 10% to 15% of cases, infection of the appendix will contaminate it.”In fact, it’s the scenario feared by doctorswhich is why they tend to be overly cautious with abdominal pain.” The signs are much more telling. They are about the same as for appendicitis but express themselves with much more intensity. This time, both doctor and patient generally have much less hesitation.”. Once started, the procedure is more complicated and more painful for the patient. But, “in industrialized countries, for healthy people, cases of appendicitis with peritonitis are treated perfectly well“, emphasizes Philippe Wind. However, the postoperative course can be a little more complicated and painful.

In addition, for very fragile people or in countries where appendicitis is less well taken care of, peritonitis can be fatal. Indeed, if it is not spotted in time, it induces sepsis, that is to say a generalized infection, from which it is almost impossible to get out alive. Apart from the time factor between the start of the appendicitis attack and the moment of diagnosis, we do not know how to explain why about 1 in 10 people will have peritonitis and not the others.

On the health forum: discussions about appendicitis

To remember

► The appendix measures 6 to 12 cm in length for 5 mm in diameter on average.

► Acute appendicitis occurs mainly before the age of 30 with 2 peaks: between 10 and 14 years old and between 25 and 34 years old.

► Sharp and persistent abdominal pain in the lower abdomen, near the navel or a little more to the right may suggest appendicitis,

► In the event of an operation, the technique of laparoscopy is preferred in 90% of cases.

► We speak of peritonitis as soon as there is an inflammation of the peritoneum.

Thanks to Professor Philippe Wind, visceral and digestive surgery specialist at the Avicenne Hospital (AP-HP) in Bobigny.