What is appendix pain?
Appendix pain describes any significant discomfort and related uncomfortable sensation arising from the vermiform appendix. It is usually experienced in the lower right side of the abdomen. Appendix pain is just one symptom of diseases affecting the vermiform appendix. This is a small outpouching attached to the first part of the large intestine, known as the cecum, just before the it leads to the colon. There are various theories as to why the appendix exists but overall it does not appear to serve any definitive purpose in the human body. Nevertheless, as with any part of the body it is prone to injury, infection and various other diseases which may present with different symptoms, such as appendix pain.
How do I know if it is appendix pain?
The abdomen is the largest cavity in the human containing the most amount of organs from various systems. Therefore it is difficult to isolate pain in a certain area of the abdomen as originating from a specific organ. It is often assessed in conjunction with other symptoms that are typical of a disease of the specific organ. In this manner, the pain can be more specifically isolated to the organ in question. However, in this day and age of modern medicine it is the assistance of diagnostics investigations from a simple abdominal x-ray to the more invasive laparotomy that allows for a definitive diagnosis.
Appendix Pain Location
Firstly the appendix is located in the right lower quadrant (RLQ) of the abdomen in almost all people. The position of the appendix can vary to some degree, particularly in certain states like pregnancy and also very early in life. In some very rare cases, the appendix can be located on the lefts side of the abdomen.
A more definitive localization of lower abdominal pain that can be considered to be a sign of appendicitis is at McBurney’s point. To understand the location of the McBurney’s point, imagine a line between the belly button (navel) and the uppermost point of the pelvis at the front of the abdomen (anterior iliac spine). McBurney’s point is two-thirds the way along the line.
McBurney’s sign is tenderness that is experienced with deep pressure applied at McBurney’s point. This is considered definitive for acute appendicitis and is one of the only means to identify the location of appendix pain. However, it is only a clinical sign and prompts the doctor to investigate further based on this finding.
It is important to note that appendix pain initially starts towards the belly button (navel) and then localizes in the lower right region of the abdomen within hours.
Causes of Appendix Pain
Appendix pain refers to any pain originating from the vermiform appendix. However, given that the appendix is a portion of the lower gastrointestinal tract (and more specifically the cecum of the large intestine), surrounding irritation or inflammation may also present as appendix pain even if it does not directly involve the vermiform appendix. The main and most common cause of appendix pain specifically is acute appendicitis.
Acute and Chronic Appendicitis
Acute appendicitis is a condition where the appendix becomes severely inflamed, often developing over a short period of just a few hours to days. The exact cause is not always clear but it appears to be a combination of an acute infection of the vermiform appendix most likely as a consequence of an obstruction with feces. There is a risk that the appendix can burst (rupture) and it is therefore considered as a medical emergency.
Chronic appendicitis is not as well understood. It is sometimes debated whether it actually exists or should be considered as a portion of chronic diseases like inflammatory bowel disease (IBD), fecal impaction, scar tissue formation and other bowel conditions. Nevertheless it is considered as one possible cause of long term appendix pain, whether persistent or recurrent.
Injury to the Appendix
Trauma to the appendix can be due to any number of causes. Blunt force and even sharp penetrating injuries to the abdomen may be seen with motor vehicle accidents, assault, falls and related incidents. The vermiform appendix is a very small structure compared with other abdominal organs in the right lower quadrant (RLQ). Therefore the surrounding organs and tissue may also be involved.
Another possible case is iatrogenic. This means that there is injury to the appendix in the course of medical procedures for the diagnosis and treatment of conditions. The appendix can be injured during a laparotomy, surgery to the bowels or ovaries and fallopian tubes in women. It can in very rare instances be injured during a colonoscopy. However, a skilled physician and surgeon will ensure that this does not occur in most instances.
Blockage of the appendix tends to occur with a fecolith. This literally means a stone of feces. More correctly it occurs with hardened feces which lodges in the appendix. Normally the intestinal contents passing through the cecum are still in a mushy liquid stage. It only becomes firmer as it travels through the colon.
However, in people who have very slow bowel motility, are dehydrated or do not eat sufficient fiber, the intestinal substances can be of a more firmer or solid consistency as it passes through the cecum. Fecal impaction at the point of the rectum and lower parts of the colon causes a backing up on intestinal contents which can then become firmer at the site.
Blockage of the appendix or cecum as a whole can arise with tumors and in rare instances even polyps may be responsible.
A burst appendix (rupture) needs immediate medical treatment. Intestinal contents, primarily digested food and wastes, leaks into the abdomen. A ruptured appendix leads to peritonitis as the peritoneum (inner lining of the abdomen) becomes inflamed. The formation of an abscess at the site requires drainage.
Type of Pain
The nature of appendix pain can vary depending on the cause. However, since most cases of appendix pain are associated with acute appendicitis, it is worthwhile to assess appendicitis pain specifically.
- Starts as aching pain
- Sharp pain may be present with deep pressure (tenderness)
- Develops into sharp pain after a few hours
- Pain worsens with coughing or sudden movement
- Becomes excruciating pain if left untreated
The pain can be so severe in acute appendicitis that a patient may feel dizzy, experience intense nausea and possibly even faint.
Other Signs and Symptoms
Appendix pain is a symptom of some underlying disease involving the vermiform appendix or surrounding cecum. It is not a disease and other signs and symptoms that are present need to be noted in order to reach a diagnosis. Acute appendicitis being the main cause of appendix pain may also present with :
- Intense nausea and vomiting
- Constipation and sometimes even diarrhea
- Abdominal distension (sometimes)
- Lack of flatulence and the patient may be unable to pass gas despite having the urge to do so
- Mild fever (low-grade)
- Lack of appetite (not wanting to eat)
However, it is important to note that these symptoms are not specific for appendix pain. This means that other diseases can present with similar symptoms. It is usually the location of the pain at McBurney’s point that is considered to be definitive. Further diagnostic investigations are therefore necessary for a final diagnosis of the cause of appendix pain.
Treatment of Appendix Pain
The treatment of appendix pain depends on the cause of the pain. Anti-inflammatory drugs and analgesics can be prescribed for pain control. Narcotic painkillers are reserved for very severe cases. However, with appendictis, surgery is the main mode of treatment.
With appendicitis, the appendix needs to be surgically removed. This surgical procedure is known as an appendectomy or appendicectomy. It can be performed as open surgery or an endoscopic procedure (laparoscopic surgery).
Abscess formation at the site of the rupture appendix needs to be surgically drained. Antibiotics are prescribed and once the infection resolves, the appendix needs to be surgically removed (appendectomy) thereafter.