The People's Perspective on Medicine

Does Appendicitis Always Require Surgery?

Antibiotics may offer a less invasive way to treat uncomplicated appendicitis successfully.
Surgery, hospital, mistakes

A new study suggests that appendicitis doesn’t always need to be treated with surgery. This is a radical idea, given that most physicians and patients believe that acute appendicitis requires emergency appendectomy.

History of an Idea:

That idea got started back in 1886, when Dr. Reginald H. Fitz did autopsies at Massachusetts General Hospital. He was the first designated pathologist there. Dr. Fitz inferred from his autopsy findings that appendicitis progressed from mild mucosal inflammation to a condition affecting the wall of the appendix. He concluded that at some point thereafter the appendix would become gangrenous, burst and cause life-threatening infection.

Keep in mind that 1886 was prior to the advent of antibiotics, so no wonder Dr. Fitz’s colleagues concluded that appendicitis always required removal of the appendix. What was ignored was Dr. Fitz’s observation that many people showed signs of spontaneous recovery from appendicitis.

Antibiotics to Treat Appendicitis

Many decades later, in 1959, Dr. E. Coldrey treated a large number of people who had acute appendicitis. These patients were given antibiotics instead of surgery, and most did well. But this treatment went against the norms of American medicine and was soon forgotten.

The report on the current research is a bit confusing, but the results are fascinating. Finnish investigators recruited 530 patients with acute uncomplicated appendicitis. Their condition was confirmed with CT imaging, the gold standard for an appendicitis diagnosis. These people were randomly assigned to undergo immediate appendectomy or to receive a broad-spectrum antibiotic (injected ertapenem first, followed by oral levofloxacin) to knock out the infection underlying the inflammation. The follow-up period lasted a year.

The results were quite encouraging. Of 257 people assigned to get antibiotic treatment, only 70 required surgery for persistent or recurrent appendicitis. There was a worry that having delayed surgery would lead to complications of the procedure, but that didn’t happen with any of the folks who did need surgery following antibiotic treatment.

The scientists set up the study so that they would consider it a success if 24% or fewer of those who got antibiotics needed surgery later. Since 70 out of 257 is actually about 27%, they had to classify their study as a failure.

Nonetheless, for uncomplicated appendicitis confirmed by CT imaging, this still sounds like a good balance of benefit to risk for many people. It would require an in-depth conversation with the doctor or hospital to make sure everyone is on the same page. An editorial in JAMA that accompanied this research concluded that

“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.”

JAMA, June 16, 2015

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    This is irresponsible and life threatening. Okay some people may be okay with antibotic tx but the ones whose appendix ruptures they get peritinitis and die might take exception to this advise. Very disappointed in this article. Any idiot can write a article and find facts to support their claim doesn;t make it good advice

    We are merely the messengers. Please read the study to see what the science reveals.

    I had appendicitis about five years ago. I starting have pain Monday morning which continue to get worse as the day went on. Made a doctor’s appointment late in the day for Wednesday. Couldn’t get in for CT scan until Friday afternoon. By then I was feeling better and was no longer taking any medicine for the pain. The doctor called shortly after I returned home. Being hard of hearing I misunderstood her and thought she said go to the ER if things became worse not go to the ER right now. I continue to get better and have not had any more problems. Everyone here talks about the risks of taking antibiotics but are either forgetting or ignoring all the risks that surgery entails. I much rather take antibiotics than go through surgery.

    “The scientists set up the study so that they would consider it a success if 24% or fewer of those who got antibiotics needed surgery later. Since 70 out of 257 is actually about 27%, they had to classify their study as a failure.”
    My bet is that vitamin D and zinc levels were not addressed in this study, and if they were included in the treatment protocol, the results would have made the cutoff.

    The damage that antibiotics can do to the microbiome must be considered when making a choice between them and surgery. The longer the course, the more good bacteria die off and the whole balance is disturbed. Most people now know to eat yogurt during a course of antibiotics; but that is not the whole picture. Doctors know virtually nothing about this; unless they have read works by Dr. David Perlmutter and others. So you can have this damaged microbiome, leading to much inflammation in the body – leading to obesity, diabetes, cancer and beyond.

    I am concerned about this trend. While appendix cancer is rare compared to other cancers, the consequences of missing it can be devastating. My husband had complicated appendicitis, treated with IV antibiotics in hospital, then oral antibiotics for 3 weeks. He appeared healed. They only advised an appendectomy in case he was deployed (he is in the military) in the future and the appendicitis flared. 6 weeks after the appendicitis his appendix was removed. It was cancerous. He now has liver tumors, diseased lymph nodes and a very poor prognosis.

    In the 70’s, my sister was given antibiotics over 2 years for symptoms of flu or something. Xmas Eve her appendix burst but she waited until the day Afterward to be carried down 5 flights of stairs in a stretcher for a very serious burst appendix. They found something to indicate that it was her appendix all that time. She lost a year of work, 3 Very serious surgeries, ICU, and was extremely lucky to live. I sure wouldn’t want to wait- at 78, I’d still want the surgery.

    Incresed use of antibiotics increase resistance, which we already have too much of. The observation period of one year is short. Early surgery with a single dose of preoperative antibiotics is still probably the best option, recovery time if surgery is performed early in the course is short.

    * Be nice, and don't over share. View comment policy^