The appendix is a mostly unnecessary part of the bowel. It serves no discernable purpose. It is, however, a major cause of illness, with over 35,000 patients being treated for appendicitis in the UK every year. Appendicitis is an important problem with its own complications should delay, misdiagnosis or failure to diagnose it at all occur.
What is the appendix?
The small bowel joins the large bowel at the ileo-caecal junction. Food is broken down and nutrients absorbed in he small bowel. In the large bowel, water is absorbed and stool made. Just beyond the junction between the small and large intestine lies the appendix. It is has a cul-de-sac opening into the bowel.
In appendicitis the appendix becomes inflamed. This is usually caused by a blockage to the outlet of the appendix. Inflammation develops in the surrounding tissues. The lymph glands enlarge and the blood flow to the appendix increases. The wall of the appendix becomes swollen and may become thinned and can rupture.
The classic signs of appendicitis are a low-grade temperature with non-specific features of abdominal pain. This tends to start about the umbilicus and runs down to the right lower part of the abdomen, called the right iliac fossa.
If the appendix bursts, pus may disperse throughout the abdomen causing inflammation of the lining of the abdomen. This is known as peritonitis and is a life threatening condition.
Alternatively, a burst appendix may be contained by the omentum (the apron of fatty tissue over the abdomen). This can envelop the appendix, stopping the escape of pus and is known as an appendicular abscess. This requires intravenous antibiotics and eventual removal.
Acute appendicitis is treated by surgical removal of the appendix.
The suspected diagnosis is made by a combination of clinical judgement, ultrasound and blood tests to look for a raised white cell count. The ultimate diagnosis is made by histological confirmation showing the presence of infection in the tissues of the appendix.
Because of the risks associated with rupture, acute appendicitis has to be considered a cause of abdominal pain in all young people coming to their doctor. The features may not be those as classically described but if it is not considered then the risk of morbidity and mortality increases significantly.
Laparascopic (key-hole) techniques are employed in most cases, decreasing the risk of wound breakdown and lessening intra-abdominal infection. In complicated cases, including those resulting from delay, there may have to be an opening of the abdominal wall, a laparotomy, to gain access to the appendix and deal with the infection associated with perforation.
Delay in making the diagnosis with progress of the appendicitis to rupture is the main basis for litigation. What should have been a simple laparoscopic procedure to remove the inflamed appendix can become a complex open abdominal surgery through delay.
It is estimated that in North America between 30-50% of cases are mis-diagnosed. It is not surprising, therefore, that appendicitis is the 5th most common cause of medico-legal litigation in the USA.
Ruptured appendix has a high morbidity in the young, especially in the very young. Delay in making the diagnosis can lead to peritonitis and eventually death. It is for this reason that appendicitis must be excluded for any child presenting with abdominal pain.
At Davies and Partners we have seen numerous cases of delayed diagnosis. We have considerable experience of successfully pursuing these claims on behalf of the children affected and their families.