Can appendicitis pain come and go for months: Chronic Appendicitis: Symptoms, Causes, and More
Chronic Appendicitis: Symptoms, Causes, and More
Overview
Chronic appendicitis is a rare medical condition. It can be difficult to diagnose because the symptoms may come and go, and they can also be mild. The most common symptom is abdominal pain. The likely cause is inflammation or an obstruction in your appendix.
It’s important to get the correct diagnosis because chronic appendicitis can be life-threatening in some cases.
Read on to learn more about this condition.
The symptoms of chronic appendicitis may be mild. In some cases, abdominal pain is the only symptom with chronic appendicitis. The pain is usually in the lower right side of the abdomen. It may also appear near the belly button and move to the lower right side of the stomach in some cases. The pain can vary from sharp to dull, but it’s more common for it to be dull.
Other symptoms of chronic appendicitis include:
- abdominal pain
- fever
- abdominal swelling and tenderness
- fatigue or lethargy, which is a lack of energy
- malaise, which is a general feeling of discomfort or illness
Some people might also experience nausea or diarrhea.
Symptoms may come and go, which can make the condition more difficult to diagnosis.
If you have any of these symptoms and they continue to become more severe, consider going to the doctor. They may be a sign of a serious medical problem.
Chronic appendicitis and acute appendicitis are sometimes confused. In some cases, chronic appendicitis isn’t diagnosed until it becomes acute appendicitis.
Chronic appendicitis can have milder symptoms that last for a long time, and that disappear and reappear. It can go undiagnosed for several weeks, months, or years.
Acute appendicitis has more severe symptoms that appear suddenly within 24 to 48 hours. Acute appendicitis requires immediate treatment.
The cause of chronic appendicitis is often unknown. Inflammation and obstruction of the appendix are sometimes the cause.
Other possible causes of chronic appendicitis include:
- accumulation of fecal matter
- calcified fecal deposits
- tumors
- enlarged lymphoid follicles
- worms
- trauma
- accumulation of foreign objects, like stones, marbles, or pins
When you have an obstruction or inflammation in your appendix, it can allow bacteria to grow and multiply.
In chronic appendicitis, the obstruction may be partial.
It’s not clear if you can do anything to prevent chronic appendicitis. Eating a diet rich in fiber may lower the risk of appendicitis, but research on diet, nutrition, and eating patterns for the prevention of chronic appendicitis is inconclusive. High-fiber foods include whole grains, vegetables, and fruits.
Diagnosis of chronic appendicitis can be difficult. To diagnose your condition, your doctor will begin by doing a physical exam, and discussing your symptoms and medical history. Symptoms of chronic appendicitis are similar to symptoms of other medical conditions, so your doctor will likely run tests to rule out other conditions. These may include:
- blood tests
- pelvic exam
- pregnancy test
- urinalysis
- CT exam
- abdominal ultrasound
- MRI scan
- X-ray
Some conditions that share similar symptoms with chronic appendicitis, and which your doctor may be trying to rule out, include:
- gastrointestinal disorders
- Crohn’s disease
- ulcerative colitis
- urinary tract infection
- kidney infection
- irritable bowel syndrome (IBS)
- ovarian cysts
- pelvic inflammatory disease (PID)
Your doctor will provide you with a specific treatment plan.
It’s important to follow all the instructions and take any medication as recommended. Sometimes antibiotics are used to treat chronic appendicitis. Your doctor may also drain the pus that forms in your appendix.
The most common treatment for chronic appendicitis is an appendectomy, which is surgery to remove the appendix. That can be done using laparoscopic surgery or laparotomy. Laparoscopic surgery has fewer complications and uses smaller incisions. A laparotomy is abdominal surgery through one incision.
Discuss surgery options with your doctor, and ask them which type they recommend and why.
Several complications can develop because of chronic appendicitis. It’s important to get immediate treatment and follow all of your doctor’s recommendations to reduce their risk.
The most common complications of chronic appendicitis include:
- acute appendicitis
- ruptured appendix
- abscess, which is a pocket of infection
- sepsis, which is your body’s serious response to infection
- peritonitis, which is inflammation of the abdomen’s lining
It’s important not to ignore your symptoms and to get medical help.
The complications of appendicitis can be life-threatening. A ruptured appendix can spread an infection throughout your body. If this isn’t treated immediately, it can be very dangerous.
Learn more: Emergency signs and symptoms of appendicitis »
Chronic appendicitis is different from acute appendicitis. The symptoms of chronic appendicitis tend to be milder. Abdominal pain is the most common symptom of this condition.
It’s easy to confuse chronic appendicitis with other medical problems. However, it’s important to get the right diagnosis. Serious complications can develop from chronic appendicitis if it’s left untreated.
Chronic Appendicitis: Symptoms and Causes
Your appendix is a finger-shaped pouch that’s connected to your large intestine. It can become inflamed and infected, resulting in a painful condition known as appendicitis.
Chronic appendicitis is an inflammation of the appendix that lasts for weeks, months, or even years. Appendicitis symptoms that arise — particularly pain in the lower right abdomen, where the appendix is located — can subside on their own only to return at a later time.
Chronic appendicitis is estimated to account for just 1.5 percent of all appendicitis cases. (1)
Acute Appendicitis vs. Chronic Appendicitis
When people talk about appendicitis, they’re usually referring to acute appendicitis, which generally begins with abdominal pain around the belly button that then migrates to the lower right abdomen and intensifies.
Numerous other symptoms can follow, including:
- Nausea
- Low-grade fever
- Vomiting
- Constipation
- Diarrhea
- Loss of appetite
- Inability to pass gas or stool
Acute appendicitis is typically caused by an abdominal infection that has spread to the appendix, or an obstruction — such as hardened stool, a foreign object, or an ulcer — that has blocked up the appendiceal lumen (the inner cavity of the appendix). (2)
If the appendix is not removed promptly, pressure within the organ will increase until the appendix ruptures, releasing its contents into the abdomen and potentially causing other serious infections.
Sometimes, however, the appendiceal lumen will be only partially obstructed, resulting in chronic appendicitis. Sources of the partial blockage include:
- Calcified fecal deposits called fecaliths
- Enlarged lymph tissue on the wall of the appendix
- Tumors
- Foreign objects such as pins, stones, and bullets
Over time, the inflammation of the appendix will worsen, and its internal pressure will build. But instead of bursting the appendix, the pressure will overcome the partial obstruction, allowing the contents of the appendix to move out of the pouch.
When this happens, appendicitis symptoms will partially or fully subside — until, that is, the obstruction causes the appendix to become inflamed again.
Like acute appendicitis, chronic appendicitis most often results in pain located in the lower right side of the abdomen. The pain may be as sharp and severe as it is with acute appendicitis, but it’s often more like a dull ache. Sometimes, abdominal pain is the only symptom that people with chronic appendicitis experience.
In other cases, people may suffer from some of the other typical symptoms of acute appendicitis, including nausea, fever, and diarrhea.
Some clinicians make a distinction between recurrent appendicitis and chronic appendicitis. A case report from 2015 described the difference between recurrent and chronic appendicitis. (3) One or more episodes of acute appendicitis, lasting one to two days, is considered recurrent appendicitis. Chronic appendicitis, on the other hand, usually occurs as a less severe, nearly continuous abdominal pain lasting longer than a 48-hour period, sometimes extending to weeks, months, or even years.
Once chronic appendicitis is properly diagnosed, removal of the appendix usually resolves the symptoms for most patients. (4)
When and Why Chronic Appendicitis Is Misdiagnosed
In the early 1900s, the diagnosis of chronic appendicitis was made relatively often. But because abdominal pain can be caused by many different diseases, including ovarian cysts, (5) indigestion, and food allergies, doctors often misdiagnosed chronic appendicitis and performed unnecessary appendectomies — the surgical procedure in which the appendix is removed.
Chronic appendicitis became controversial, with some experts questioning whether the condition existed at all. (6) Today, chronic appendicitis is well documented in the medical literature, but physicians sometimes diagnose patients with some other disease when they in fact have chronic appendicitis.
Most often, chronic appendicitis is confused with other conditions because the patient doesn’t have typical appendicitis symptoms (7) or the symptoms are thought to be the result of another condition that can cause recurrent abdominal pain or chronic inflammation, including:
- Crohn’s disease
- Ulcerative colitis
- Irritable bowel syndrome
- Pelvic inflammatory disease, which is an infection of a woman’s reproductive organs
The use of imaging techniques — including ultrasounds, magnetic resonance imaging (MRI), and, in particular, computer tomography (CT) scans — can help distinguish between these health conditions and chronic inflammation, but they’re not foolproof.
For example, in at least one case, doctors used CT scans to diagnose a young woman with pelvic inflammatory disease when she actually had chronic appendicitis, according to a 2004 case report. (5) And a similar case occurred in a person with Crohn’s disease, according to a 2005 report. (8)
Regarding acute appendicitis, its symptoms are also similar to many other conditions, so it’s sometimes misdiagnosed as well, resulting in unnecessary appendectomies. A 2011 study found that almost 12 percent of all appendectomies performed in the United States between 1998 and 2007 occurred in people who did not have appendicitis, but rather some other condition. (9)
But if appendicitis is missed, it can lead to serious complications. Misdiagnosis can result in the formation of abscesses as well as infertility, according to research. (7)
Additional reporting by Deborah Shapiro.
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Question to the doctor: how not to miss an attack of appendicitis
It would seem that everyone knows everything about appendicitis (or, in any case, they are sure that they do). However, this well-understood disease can be tricky in terms of diagnosis, and many patients have no idea “how exactly it hurts with appendicitis.” How to understand that you need to see a doctor urgently? How not to miss an attack?
About this – Head of the Department of Abdominal Surgery of the National Medical Research Center of Surgery. A.V. Vishnevsky, Doctor of Medical Sciences, Professor Andrey Germanovich Krieger.
What increases the risk of appendicitis?
Nobody knows. Medicine is an imprecise science.
Lifestyle, stress, nutrition?..
Neither physical activity, nor psychological troubles, nor a person’s dietary preferences affect.
In men and women, the incidence of the disease is almost the same (another thing is that women are more likely to suspect appendicitis, but then gynecological problems are detected).
That is, the disease has long been described and it has long been clear what to do with it, but the risk factors are still unknown?
Unknown.
Does it make sense to remove the appendix prophylactically?
No way. Any surgical intervention carries the risk of complications, and appendectomy – removal of the appendix – is far from an indifferent operation. And not as simple as it might seem. After it, always, naturally, inevitably, adhesive adhesions occur, which can lead to intestinal obstruction, the occurrence of adhesions.
In America in the 1950s and 1960s there was a wave of prophylactic appendectomy for newborns. Refused, fortunately. The practice didn’t pay off.
Does the appendix also perform certain immunological functions?
Yes, and it is also called the intestinal tonsil, because here is the lymphoid tissue, which has a certain significance in the general immunological status of a person.
What are the symptoms of acute appendicitis?
Pain in the right iliac region (on the right lower abdomen) – not intense, constant, aching, dull, not giving anywhere. It hurts and – aching, aching, aching … And it gets worse with movement.
And many people think that appendicitis is when “it hurts in the side, it hurts”…
That’s when it hurts – it’s not appendicitis. If a person feels unbearable pain in the abdomen, it is most often colic (renal, biliary) or perforation of a hollow organ (perforated ulcer). Then there are the so-called dagger pains.
It turns out that the widespread opinion that appendicitis is a sharp pain that a person cannot endure is wrong?
Completely wrong. This pain can be tolerated, so quite often people do not go to the doctor in a timely manner.
What does constant pain mean? A day, two, three, a week?
One, two, three.
Or maybe appendicitis pain behave like this: it hurt for an hour or two and passed, the next day it hurt again for an hour or two and passed?
No, it can’t.
If it started, then it aches, aches and intensifies with movement.
So call an ambulance?
Of course.
But not everyone will call an ambulance if they experience pain that can be endured for a couple of hours.
That’s the problem. I already said – quite often people do not do it on time. But we must understand that acute appendicitis is a risk of peritonitis, a life-threatening condition.
How does it all start with appendicitis?
Pain occurs in the epigastrium (upper abdomen) or throughout the abdomen. Then nausea appears (vomiting may not be there or it is one or two times). After 3-5 hours, the pain moves to the right iliac region (lower abdomen on the right). And if everything develops in this way, we can talk about inflammation of the appendix (in medicine this is called pathognomonicity – a symptom characteristic of a particular disease). The usual story of the patient goes something like this: “It hurt, something twisted in the stomach, I couldn’t understand what was the matter 2-3 hours ago, but now I got up, walked and felt that now it hurts in the right lower abdomen.
” Oh my dear, it’s appendicitis!
Do characteristic symptoms make diagnosis easier?
In the vast majority of cases – yes, the diagnosis of acute appendicitis is made quite simply and confidently: epigastric pain after 2 hours shifted to the right iliac region, leukocytes are elevated, temperature is 37.2 (the so-called Kocher’s onset, Kocher’s symptom).
Why are diagnostic errors allowed in this case?
First, the clinical picture can be the same in a number of diseases. Secondly, we talked about the classic symptomatology, which, fortunately, happens in most people, when the appendix is located exactly where it is most often located. But there may be anatomical variations.
What, for example?
For example, in a woman, the caecum is elongated and shifted into the small pelvis: the fallopian tube lies, and next to it, right on top of it, is the appendix. And he got inflamed. So try it, conduct a differential diagnosis between salpingitis (inflammation of the fallopian tube) and appendicitis, when it is necessary to inflame one organ, immediately the contact inflammation passes to another.
Why did women in the past, when there was no laparoscopy, often undergo unnecessary appendectomies? Pain in the right lower abdomen. Hurts? Hurts. They take it to the table. They enter the abdomen, there is no appendicitis, but there is, for example, an ectopic pregnancy. But the shoot was removed in any case.
Why, if no appendicitis was found?
When there was no laparoscopy, surgical access for suspected appendicitis was made on the right lower abdomen. For any surgeon, such a characteristic scar was evidence that the patient had already had an appendectomy. And, if the next time a person was admitted to the hospital with complaints of abdominal pain, appendicitis was immediately ruled out and looked elsewhere. Otherwise (there is a scar, but the appendix is not removed), confusion could arise with serious consequences.
But does the person remember that they “removed his appendix”?
Not always.
With all the knowledge of the disease, the diagnosis is not so simple.
..
Of course, it is not easy. Another option: if the appendix is high, next to the gallbladder, then there will be a clinic, as in acute cholecystitis. Only acute cholecystitis does not need to be urgently operated on, because the gallbladder does not perforate a day after the onset of the disease, but acute appendicitis is necessary. But, unfortunately, there are situations when acute cholecystitis is diagnosed, dynamic observation is carried out, but it turns out to be purulent appendicitis, as a result – perforation, peritonitis …
How often does this happen?
It happens. It is no coincidence that mortality in appendicitis does not decrease. It is small (0.03 percent), but is not decreasing.
This is despite the fact that instrumental research methods today are not the same as 20-30 years ago?
Yes, and the main reason is late diagnosis. A late diagnosis is either a person did not go to the doctor in time, or a diagnostic error was made.
Has the operation itself changed?
Technically, the operation to remove the appendix has not undergone any changes – this is a classic example of the so-called amputation surgery. Only now it is carried out in a more gentle way – laparoscopically.
Acute appendicitis
Acute appendicitis is an acute inflammation of the appendix (vermiform appendix of the caecum), requiring urgent surgical treatment, one of the most common inflammatory diseases of the abdominal organs.
What is the “appendix” and why does it become inflamed?
The appendix arises from the lower end of the caecum (the beginning of the large intestine). It is believed that the appendix is one of the links of the immune system, since the mucous membrane of the appendix is rich in lymphoid tissue. It is generally accepted that inflammation of the appendix may occur due to blockage of the appendix lumen by enlarged lymphoid tissue, fecal stones (hard stools resulting from chronic constipation), a foreign body, and sometimes helminths.
Blockage leads to expansion of the appendix cavity, the rapid development of infection and inflammation. However, the exact cause of this common disease is not clear.
Symptoms of acute appendicitis
Manifestations of acute appendicitis depend on the location of the appendix, the time elapsed from the onset of the disease, the severity of the inflammatory process in the appendix and the involvement of nearby organs and peritoneum, as well as the age of the patient and the presence of concomitant diseases.
Since the appendix is a mobile organ, its inflammation can mimic almost any disease. In some cases, doctors have difficulty in making a diagnosis, since the main symptom of appendicitis – pain – can occur not only in the right lower abdomen, where it should be located according to the anatomy of the caecum, but also in the navel, in the groin, above the pubis , in the lower back, in the right hypochondrium and disguised as diseases of the liver, kidneys, female genital organs.
As a rule, the disease begins with the appearance of pain in the upper abdomen, which gradually increases, moves to the right iliac region (right lower quadrant of the abdomen). The pain is aggravated by coughing and movement. Usually there is a subfebrile body temperature of 37.2-37.5 ° C. Examination of the abdomen reveals involuntary tension of the muscles of the anterior abdominal wall and pain in the right iliac region. The pain is constant and may be accompanied by nausea and sometimes vomiting. There is often loss of appetite and refusal to eat, as well as stool retention caused by restriction of intestinal motility due to inflammation spreading through the peritoneum.
Unfortunately, these classic signs of appendicitis occur in just over half of patients with acute appendicitis. The pain may not have a clear localization, especially in children under 3 years of age. In elderly and senile patients, reduced reactivity of the body, connective tissue replacement of all layers of the appendix wall and its blood vessels contribute to poor symptoms of acute appendicitis and a large number of complicated forms.
In pregnant women in the second and third trimesters, a uterine appendix may cause an atypical clinical picture. Therefore, so often patients with acute appendicitis come to the emergency surgery department already with complications (perforation of the appendix, peritonitis).
What is “phlegmonous” and “gangrenous” appendicitis?
If the patient’s symptoms of appendicitis are mild, but, nevertheless, the inflammatory process develops (the pain is not very strong, there is no nausea and vomiting), he is in no hurry to seek medical help, and then catarrhal appendicitis turns into a phlegmonous form. The appendix fills with pus and ulcerates. Inflammation begins to spread to the surrounding tissues: the walls of the intestine, the peritoneum. The pain becomes more pronounced, aggravated by the tension of the abdominal muscles; in thin people, the inflamed process can be felt as a dense roller.
Phlegmonous appendicitis can turn into a gangrenous form, when the inflammatory process develops already in the abdominal cavity.
With gangrenous appendicitis, there is a decrease or complete absence of pain associated with the death of the nerve endings of the appendix, but signs of general intoxication, deterioration of the general condition: weakness , pallor, bloating. If at this stage the patient is not helped, the patient’s life is at risk due to the development of peritonitis.
How is appendicitis diagnosed?
If acute appendicitis is suspected, the patient must be urgently admitted to a surgical hospital. In the EMC Surgical Clinic, emergency operations are performed around the clock for acute appendicitis and its complications.
At the stage before hospitalization, even in the presence of a pronounced pain syndrome, painkillers should not be taken, as this may complicate the diagnosis of the disease. You should also not use antibiotics, as this can blur the picture with the further development of complications (perforation of the process, diffuse peritonitis).
Diagnosis begins with a thorough questioning and examination, as well as taking a blood test (a complete blood count usually reflects inflammation – an increase in the number of leukocytes, leukocytosis occurs).
In the classic course of acute appendicitis (high temperature and pain in the right iliac region from tolerable to very strong), the diagnosis is not difficult. For patients with questionable or unclear symptoms, doctors may order an abdominal and pelvic ultrasound and/or computed tomography when admitted to the hospital.
In some cases, a diagnostic Laparoscopy can be performed, a diagnostic procedure in which a thin fiber optic tube with a camera is inserted into the abdominal cavity through a small opening in the abdominal wall. Laparoscopy allows you to see the appendix and other organs of the abdominal cavity and pelvis and assess their condition.
Acute Appendicitis Emergency
Surgery to remove an appendix (inflamed appendix) is called an “appendectomy” in which the inflamed appendix is removed.
In the presence of perforation (rupture) of the appendix, the surgical intervention becomes technically more difficult to perform. There is a need for a thorough “washing” of the abdominal cavity from pus.
Consequently, both the operation itself and recovery can be delayed.
Removal of the appendix is preceded by intravenous antibiotics to prevent complications. If there is a perforation of the appendix, antibiotic treatment continues until the blood tests normalize (approximately 5-7 days). The question of the abolition of antibiotics is decided by the attending physician.
Laparoscopic Appendectomy
As a general rule, in EMC most of the surgical interventions for acute appendicitis, even in the case of severe forms of the disease, are performed laparoscopically, which guarantees a minimum of pain and a shorter recovery period. In uncomplicated appendicitis, if the appendix has not been perforated, the patient is usually discharged the next day. Patients with a perforated appendix may stay in the clinic longer (up to 7 days), especially if peritonitis has developed.