Appendicitis

Appendicitis is one of the most common acute medical conditions in Singapore, which affects approximately 5 – 7% of the general population, across all age groups. A delay in treatment can lead to rupture and  life-threatening complications such as peritonitis or abscess formation. This makes appendicitis a medical emergency that requires immediate treatment, typically through surgical removal of the appendix through an appendicectomy.

What is Appendicitis?

The appendix is a small, tube-like structure located in the lower right abdomen, attached to the large intestine (caecum). While its exact function remains unclear, it is believed to play a negligible role in gut health. 

Appendicitis occurs when the appendix becomes spontaneously inflamed, leading to bacterial overgrowth, swelling, and infection. This can cause severe abdominal pain, nausea, vomiting, and fever. As the condition worsens, the appendix may rupture, spreading infection throughout the abdomen.

Types of Appendicitis

There are different forms of appendicitis, which are classified based on severity, and progression:

• Acute Appendicitis – acute appendicitis is a sudden, and severe inflammation of the appendix, often requiring emergency surgery. It typically presents with intense pain in the lower right abdomen, fever, and digestive symptoms. If it is not treated promptly, the appendix can rupture, leading to life-threatening complications.

• Chronic Appendicitis – chronic appendicitis is a less common condition, where mild inflammation persists over time, causing recurrent episodes of abdominal discomfort. As such, symptoms may be intermittent, and less severe, making diagnosis more challenging. However, it can still lead to acute appendicitis if left unmanaged.

Four Stages of Appendicitis

Appendicitis progresses through distinct stages, with each requiring timely intervention to prevent complications:

• Early inflammation – in the initial stage, inflammation begins within the appendix, leading to mild, diffuse abdominal discomfort, often starting around the belly button before localising to the lower right abdomen. Patients may experience nausea, mild pain, and a general sense of unease, but symptoms may not yet be severe. 

• Suppurative appendicitis – as inflammation worsens, the appendix fills with pus, triggering more intense, and persistent pain in the lower right abdomen. Fever may develop, and nausea or vomiting can worsen. At this stage, the risk of complications increases, making medical attention crucial to prevent further progression.

• Gangrenous appendicitis – without treatment, the appendix begins to lose its blood supply, leading to tissue death (gangrene). The pain intensifies, fever spikes, and the risk of systemic infection increases. At this stage, patients may feel increasingly unwell, and urgent surgery is necessary to prevent rupture.

• Perforated appendicitis –  if the inflamed appendix bursts, its contents spill into the abdominal cavity, causing peritonitis. This stage is a medical emergency, leading to severe pain, high fever, rapid heart rate, and signs of sepsis. Immediate surgical intervention is required to remove the infected tissue, and prevent life-threatening complications.

What causes Appendicitis?

Appendicitis occurs when the appendix becomes inflamed, and swollen. The inflammation  leads to a build-up of mucus, and bacteria, resulting in infection, and inflammation.

As the appendix swells, its blood supply may become compromised, causing tissue damage or even tissue death. If left untreated, the appendix can rupture, spreading infection into the abdominal cavity, leading to a serious condition known as peritonitis. In some cases, an abscess may form around the appendix, acting as a protective barrier to prevent the infection from spreading further.

What are the symptoms of Appendicitis?

While symptoms can vary, the most common include:

• Abdominal pain – typically starting as a dull ache near the navel or gastric region, and progressing to a sharp pain in the lower right abdomen.

• Changes in bowel habits – some individuals experience constipation or diarrhoea.

• Fever and chills – usually mild at first but can worsen if infection spreads.

• Loss of appetite – a common early symptom that may be accompanied by nausea.

• Nausea and vomiting – may occur shortly after the onset of pain.

• Pain worsening with movement – coughing, sneezing or sudden movements can exacerbate discomfort.

• Swelling or tenderness – the abdomen may feel bloated or sensitive to touch.

Who is at risk of Appendicitis in Singapore?

Although appendicitis can occur in anyone, there are certain factors that may increase the likelihood of developing the condition. In Singapore, these risk factors include:

• Age – appendicitis can affect anyone at any age, however it is most common in individuals between 10, and 30 years old.

• Gender – while both men, and women can develop appendicitis, it appears slightly more common in males.

• Infections – gastrointestinal infections, particularly those causing inflammation of the lymphoid tissue in the appendix, may increase susceptibility to appendicitis.

Appendiceal cancer treatment singapore 

Can Appendicitis lead to Appendiceal Cancer?

While appendicitis is commonly associated with acute inflammation, and infection, in some cases, there has been no link to  appendiceal cancer, a rare condition.. This rare but serious condition arises from abnormal cell growth in the appendix, sometimes presenting symptoms like appendicitis. 

Appendiceal cancer is rare, and can be difficult to diagnose early because of its symptoms, which often mimic that of appendicitis. 

Types of Appendiceal Cancer

• Epithelial Appendiceal Cancer (Adenocarcinoma) – develops from the glandular cells lining the appendix, and can spread similarly to colorectal cancer. A rare subtype, mucinous neoplasm, produces excess mucus, potentially leading to pseudomyxoma peritonei (PMP) if it spreads into the abdominal cavity.

• Neuroendocrine Tumours (NETs) – arise from enterochromaffin cells (ECs) within the appendix, and are typically slow-growing but can sometimes behave aggressively.

• Goblet Cell Carcinoma (GCC) – a hybrid tumour with features of both adenocarcinoma, and neuroendocrine tumours, but with a more aggressive progression like adenocarcinoma.

• Signet-Ring Cell Adenocarcinoma – a rare and aggressive subtype of adenocarcinoma, characterised by distinctive signet-ring-shaped cells and a higher likelihood of early spread.

Additionally, appendiceal cancer is often diagnosed in two main scenarios:

Incidental Discovery After Appendicitis Surgery

• In some cases, an appendix that was removed due to suspected acute appendicitis is later found to contain cancerous cells upon further histopathological examination.
• These cancers are typically in their initial stages, and if they are localised with no spread, additional surgery may not be necessary.

Chronic or Atypical Symptoms Suggesting Advanced Cancer

• Unlike typical appendicitis, some patients experience chronic lower right abdominal pain lasting for weeks or months.
• Other warning signs include unexplained weight loss, anaemia-related symptoms, such as fatigue, breathlessness, reduced exercise tolerance, on top of persistent bloating or abdominal distension due to fluid buildup.
• In such cases, appendiceal cancer may already be at an advanced stage, requiring further intervention.

Treatment for Appendiceal Cancer

The treatment approach depends on the stage, and type of cancer:

Surgical Removal of the Right Colon (Right Hemicolectomy)	If cancer is detected beyond the appendix, removing part of the colon ensures complete clearance of cancerous tissue. This procedure is often performed using a minimally invasive laparoscopic approach for faster recovery.
Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC)	For cases where the cancer has spread widely within the abdomen, a more extensive procedure known as CRS with HIPEC may be required. This involves removing visible tumours, and applying heated chemotherapy directly into the abdominal cavity to eliminate residual cancer cells.

How is Appendicitis diagnosed in Singapore?

At Alpine Surgical Practice, Dr. Aaron Poh adopts a meticulous, and patient-centred approach to diagnosing appendicitis. As this condition can sometimes mimic other abdominal issues, an accurate diagnosis is crucial to ensure timely, and appropriate treatment. Generally, the diagnostic methods entail:

Consultation

• Clinical examination – a detailed physical assessment is conducted, including palpation of the abdomen to check for tenderness, especially in the lower right quadrant, which may indicate appendicitis.
• Medical history review – Dr. Poh then evaluates the patient’s symptoms, including the nature, and duration of abdominal pain, nausea, vomiting, fever, and changes in bowel habits.

Diagnostic Tests

• Blood tests – a complete blood count (CBC) may be performed to detect elevated white blood cell levels, which indicate infection or inflammation.
• Urine tests – since appendicitis symptoms can resemble those of urinary tract infections (UTIs) or kidney stones, a urine test may be conducted to rule out these conditions.

Imaging Tests

• CT Scan – a more detailed imaging test that helps visualise an inflamed or ruptured appendix, ensuring an accurate diagnosis, especially in cases with atypical symptoms.
• MRI Scan – used in selected cases, such as pregnant patients, to provide high-resolution images without radiation exposure.
• Ultrasound imaging – a non-invasive scan that provides real-time images of the appendix, particularly useful in younger patients, and pregnant women. 

How is Appendicitis treated in Singapore?

Once Dr. Aaron Poh confirms a diagnosis, he then tailors treatment based on the severity of appendicitis, and the patient’s overall condition. While some mild cases may be managed conservatively, surgical removal of the appendix is often necessary to prevent complications. Treatment options include:

• Antibiotic therapy – in select cases of uncomplicated appendicitis, a course of antibiotics may be used as an initial treatment. However, surgery remains the definitive option for most patients.

• Laparoscopic appendectomy – a minimally invasive keyhole surgery where small incisions are made to remove the appendix using specialised instruments. This approach offers faster recovery, reduced post-operative pain, and minimal scarring.

• Open appendectomy – in cases of ruptured appendix or severe infection, an open surgery may be necessary to ensure thorough removal, and drainage of infected fluids.

• Management of complicated appendicitis – if the appendix has ruptured, leading to an abscess or peritonitis, additional drainage procedures, and extended antibiotic therapy may be required.

Conclusion

If you are experiencing persistent abdominal pain, nausea or symptoms suggestive of appendicitis, seeking prompt medical attention is crucial. Early diagnosis, and timely treatment can prevent complications, and ensure a smooth recovery. Additionally, it improves your odds of detecting, and treating appendiceal cancer in its early stages.

At Alpine Surgical Practice, we are committed to patient-centric and compassionate care. No issue is too small. Schedule a consultation with us today for a comprehensive diagnosis and personalised treatment plan. 

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