The coronavirus disease 2019 (COVID-19) pandemic presented numerous challenges to global healthcare, extending far beyond the primary respiratory symptoms. Acute appendicitis, an inflammation of the appendix, is a common surgical emergency. The co-occurrence of this condition with SARS-CoV-2 infection raised significant clinical questions. Researchers observed a potential link between the viral illness and appendicitis, prompting investigation into whether COVID-19 could serve as a trigger. This required a re-evaluation of diagnostic procedures and treatment strategies for patients presenting with acute abdominal pain during high viral transmission.
How COVID-19 May Trigger Appendicitis
The association between SARS-CoV-2 infection and appendicitis is thought to involve two main biological pathways.
Systemic Inflammation
One primary hypothesis centers on the profound systemic inflammation induced by the virus, sometimes referred to as a cytokine storm. This widespread inflammatory response can cause secondary inflammation in the appendix, often manifesting as lymphoid hyperplasia. The appendix contains significant lymphoid tissue, and its swelling can obstruct the narrow opening, leading to the classic symptoms of appendicitis.
Direct Viral Infection
A second mechanism suggests a more direct involvement of the virus itself in the gastrointestinal tract. SARS-CoV-2 uses the Angiotensin-Converting Enzyme 2 (ACE2) receptor to enter human cells, and these receptors are highly expressed on the cells lining the intestinal tract, including the appendix. Studies have confirmed the presence of SARS-CoV-2 RNA and viral proteins within the appendix tissue of some patients. This suggests that the virus may directly infect the appendix, initiating a localized inflammatory process. This direct viral entry can cause local tissue damage and endothelial injury. In children, this inflammatory response is particularly notable as part of the Multisystem Inflammatory Syndrome in Children (MIS-C), which frequently presents with severe gastrointestinal symptoms that can mimic or directly cause appendicitis.
Identifying Appendicitis During COVID-19 Infection
Diagnosing acute appendicitis became considerably more challenging when patients were also infected with SARS-CoV-2. Both conditions often present with overlapping symptoms, creating diagnostic confusion in the emergency setting. Fever, nausea, vomiting, and abdominal pain are common to both COVID-19’s gastrointestinal presentation and the early stages of appendicitis. This clinical overlap meant that a patient’s symptoms could be mistakenly attributed solely to the viral illness, delaying the recognition of a surgical emergency.
The pandemic itself introduced a public health dynamic that contributed to delayed diagnosis and treatment. Fear of contracting the virus in a hospital setting led many individuals to postpone seeking urgent medical attention for abdominal pain. This reluctance meant that patients often presented with a more advanced stage of appendicitis. Consequently, during periods of high viral transmission, many hospitals reported a higher rate of complicated appendicitis, such as those with perforation or gangrene, compared to pre-pandemic times.
When diagnosis was suspected, clinicians increasingly relied on cross-sectional imaging, such as computed tomography (CT) scans, to confirm the diagnosis and assess for complications. The use of imaging over clinical judgment helped differentiate true appendicitis from the inflammatory gastrointestinal symptoms of COVID-19. However, this necessity for more definitive imaging also added to the time and resources required for patient management in an already strained healthcare system.
Treatment Decisions in a Pandemic Setting
The pandemic necessitated a shift in the standard approach to managing acute appendicitis to conserve healthcare resources and minimize viral transmission risk. Traditionally, an appendectomy is the definitive treatment, but hospitals began to prioritize Non-Operative Management (NOM) with antibiotics for uncomplicated cases. This non-surgical approach helped to preserve operating room capacity, intensive care unit beds, and personal protective equipment (PPE) for the most severe cases.
The adoption rate of NOM for uncomplicated appendicitis rose significantly during the pandemic compared to previous years. For patients who required surgery, the presence of a COVID-19 infection introduced specific risks for both the patient and the surgical team. Laparoscopic surgery, the preferred method for many appendectomies, was viewed with caution due to concerns about aerosol generation, which could increase the risk of viral spread to staff. Some surgical teams opted to revert to an open appendectomy approach for COVID-19 positive patients to mitigate this risk. The choice of management involved a careful risk-benefit analysis, weighing the possibility of a recurrent infection with NOM against the risks of surgery, anesthesia, and viral exposure.