Post-Appendectomy Pain After 3 Months: 5 Causes, Gastroenterologist Explains.

Many conditions lead to abdominal pain at the site of your appendectomy operation. However, in most cases, non-specific abdominal pain is predominant.

Don’t overthink the mild or dull pain that comes and goes. Dull pain in the right lower abdomen is common in patients after appendicitis. It is often caused by non-specific causes such as gas, food intolerance, or irritable bowel syndrome.

However, you may have more significant causes, such as stump appendicitis and incisional hernia.

Wound infections or abscesses are unlikely to occur three months after appendectomy.

1. Gastrointestinal conditions (Very common).

The most common cause of pain months after appendectomy is probably your gastrointestinal tract. Too many conditions can lead to abdominal pain in the lower right abdomen, such as:

• Gas inside the colon (at the lower right of your abdomen).
• Irritable Bowel syndrome.
• Inflammatory bowel disease (Crohn’s disease and ulcerative colitis).
• Food intolerances.
• Acute or chronic intestinal infections.
• Diverticular disease (Diverticulitis).
• Colorectal cancer.

Non-specific abdominal pain from gas and indigestion can localize in the lower abdomen. In addition, dull pain can develop in the lower right abdomen, often related to eating.

The characteristics of gastrointestinal pain:

• Often in the form of colics that comes and goes.
• Associated with bloating, passing gas.
• Related to changes in your bowel movements (diarrhea or constipation).
• Relieved by pooping or passing flatus.
• Triggered by eating certain foods (as with lactose intolerance and FODMAP foods in irritable bowel syndrome).
• NOT associated with fever.
• DOES NOT increase by pressing your abdomen or walking.
• It can occur in attacks (flare-ups and remissions) like Irritable bowel syndrome.

More: Dull pain in the left lower abdomen that comes and goes.

2. Hernia (incisional and right inguinal hernia).

A. Incisional Hernia

An incisional hernia can lead to vague pain at the site of the appendectomy operation. With an incisional hernia, the Abdominal wall muscle disrupts, and parts of your intestine are felt as a soft swelling directly under the skin.

The bulging intestine causes stitching or shearing pain at the appendectomy site. Moreover, you may notice a swelling (often lemon size) at the incision site.

An incisional hernia occurs at the site of the appendectomy wound. It is rare; the incidence of incisional hernia at the appendectomy site is about 0.4% of all cases (reference).

Pain from an incisional hernia can present months or years later after the appendectomy operation. Consult your doctor if you notice a localized swelling at the operation site.

B. Right inguinal hernia.

Hernia can naturally occur through weak points in your abdominal wall.

The inguinal canal is one of these weak points. The right inguinal canal lies just under the site of the appendectomy operation.

You will often feel pain at the site where the appendix was removed. Pain is associated with a bulge or swelling in the lower right part under the appendectomy scar.

The bulge is very soft and compressible (a part of the intestine lies directly under the skin). The swelling can proceed below toward the genitals (it can reach the scrotum in males).

Inguinal and incisional hernias at the lower right of the abdomen often present with swelling and pain. However, pain without noticeable swelling is common in the early stages of the hernia (during its development).

Typically, you will need a hernia repair surgery to close the defect in the abdominal wall.

3. Stump Appendicitis.

Stump appendicitis occurs when your surgeon leaves a part of the appendix during the appendectomy operation (incomplete excision) (reference). As a result, the left stump can get inflamed and cause typical appendicitis.

It is a rare complication. One study estimated that stump appendicitis occurs in one of every 50,000 appendectomy cases (reference).

The type of appendectomy operation doesn’t matter. However, stump appendicitis can complicate open and laparoscopic appendectomy (reference).

Stump appendicitis can occur anytime from 2 weeks after the operation to many months or years later.

If you have typical appendicitis pain three months after an appendectomy, call your doctor immediately.

Stump appendicitis symptoms:

• Location: starts around the umbilicus and can shift to the lower right abdomen (at the site of the previous appendectomy).
• Character: the pain starts mild but increases markedly within hours and becomes more localized.
• Low-grade fever can develop. However, if perforation occurs, the fever may become high-grade.
• Changes in bowel habits (mainly diarrhea and sometimes constipation).
• Nausea and vomiting.
• The pain dramatically increases when you move or press the abdomen.
• Generalized fatigue and body aches.

Your doctor diagnoses appendicitis on a clinical basis. Ultrasonography or CT of the abdomen helps with the diagnosis.
Treatment of stump appendicitis is via operation (re-appendectomy). Also, Your doctor can perform the surgery by a laparoscope or open technique.

In severe cases, stump appendicitis may lead to complications such as perforation and intestinal obstruction. Unfortunately, these complications are expected with stump appendicitis due to a late and challenging diagnosis (reference).

MORE: What Causes Appendix to Burst?

4. Female-related causes.

The females’ reproductive organs (the uterus, fallopian tube, and right ovary can be the source of such pain.

• Right ovarian cyst. It may become ruptured or infected.
• Abscess in the right ovary or the right fallopian tube.
• Ovulation pain (Mittelschmerz): mid-cycle pain that occurs every month.
• A right ovarian tumor (benign or malignant).
• Ectopic pregnancy: maybe in the right fallopian tube, ovary, or pelvis.
• Pelvic inflammatory disease: affecting the right tube and ovary.
• Ovarian vein thrombosis.

5. post-appendectomy adhesions:

Operations inside your abdomen can lead to scar formation (adhesions). The scar tissues lead to the sticking of your intra-abdominal organs together (mainly the intestine).

Intra-abdominal post-appendectomy adhesions are more likely to occur if you had complicated appendicitis before the operation. In addition, appendicular abscess or perforation is a risk factor for abdominal adhesions.

Most abdominal adhesions have no symptoms. However, They can cause pain at the site of the appendectomy operation three months later. The pain due to adhesion may arise from the intestine (which cannot move properly) or other organs.

Moreover, adhesions can lead to severe complications such as intestinal obstruction and infertility.

Unfortunately, the diagnosis of adhesions is difficult. Imaging teachings such as abdominal ultrasonography, CT, and MRI cannot detect adhesions.

Adhesions can be seen only if a subsequent abdominal operation is needed. The pain from intestinal adhesion is often chronic or recurrent over long periods.

Intestinal adhesion leads to intestinal obstruction, presenting abdominal pain, distension, vomiting, and constipation.

6. Others (Infrequent).

• Right ureter pain (stone in the right ureter): The pain is severe and policy with the more prevalent symptom. Ureteric pain often drives you to the ER. It is uncommon for ureteric pain to be dull or mild.
• Pain from the right lower abdominal wall muscles (muscle strain).
• Decreased blood supply to the colon or intestine (mesenteric ischemia).
• Enlarged lower right abdominal lymph nodes (mesenteric lymphadenitis).
• Familial Mediterranean Fever.
• Pseudoappendicitis.
• Psychological diseases.
• Acute intermittent porphyria.
• Abdominal migraine.
• Perforated ileum or ascending colon.
• Intestinal obstruction.
• Pelvic congestion syndrome.
• Right hip bone disease or fractures.

When to see a doctor:

Pain at the location of the previous appendectomy can be due to simple causes (such as colics and gas) or more significant causes.

See a doctor if the pain is:

• Severe or intolerable.
• Extreme tenderness when you press at the site of pain.
• Associated with nausea or vomiting.
• Fever (low or high-grade.
• Blood or mucus in the stool.
• Recurrent pain that affects your daily life without apparent cause.