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When in doubt, cut it out -- especially if its your appendix. Some doctors believe the days are numbered for that particular surgical maxim. A new research study raises the possibility that many cases of appendicitis have viral roots, making surgical removal of the organ unnecessary. This would represent a major shift in thinking in that most appendectomies may prove unnecessary. But there are some practical concerns being raised that may make this quite a controversial topic in the coming months, with a lot of back and forth likely to ensue.
Appendicitis Goes Viral?
Appendicitis is a surprisingly complex condition. When the appendix is infected, the result is often pain in the lower right abdomen, a condition known as acute appendicitis. While the vast majority (75% to 80%) of inflamed appendixes are not ruptured (or perforated -- the terms are used interchangeably), the danger for those that are is that fluid will leak into the abdominal cavity, causing widespread infection and -- if not treated -- possibly even death. Until now, doctors have operated on the assumption that, left in place, an infected appendix will almost certainly rupture. But this new research shows thats not actually true.
The study, published in Archives of Surgery, analyzed data from US government statistics on hospital patients between 1970 and 2005. Its leader, Edward Harry Livingston, MD, professor and Hudson-Penn Chair in Surgery at The University of Texas Southwestern Medical Center at Dallas, went through the dramatic findings with me, explaining why the study may upend treatment of appendicitis in the near future. The researchers learned...
Appendicitis has various causes. The studys main finding contradicts the conventional wisdom about appendicitis, which was that its root cause is obstruction (typically by hardened fecal matter). Instead, said Dr. Livingston, about half of people with appendicitis have no signs of obstruction whatsoever -- and similarly, about half of all people who have such obstructions never get appendicitis. This finding led to the conclusion that a high percentage of cases are associated with a viral infection that leaves the appendix vulnerable to the bacterial infection that becomes appendicitis.
CT scan results should dictate treatment. The appendix is perforated in only about 20% to 30% of cases of appendicitis. These can be identified with CT scan -- and perforated appendixes often can be effectively treated nonsurgically, with drainage procedures and/or antibiotics.
Most inflamed appendixes wont rupture. If a patient arrives at the hospital with symptoms of appendicitis and the CT scan shows the appendix is not perforated, Dr. Livingstons research suggests it is unlikely to perforate -- therefore it, too, may be treatable with antibiotics alone. "If theres no acute secondary bacterial involvement, the appendix may not need to be removed -- and it is safe to wait a few days to see whether symptoms worsen while waiting to decide," Dr. Livingston said.
Is It Really an Emergency?
Dr. Livingston described his research as "hypothesis-generating" and told me that he believes it merits considering a change in how appendicitis should be treated. He proposes that the new standard of care should be that patients who have "nonperforated appendicitis that may be caused by viruses should get treated with antibiotics (to combat bacterial infection), followed by an appendectomy only if theres no improvement in 12 to 24 hours."
New studies are now underway to determine how effective antibiotics are in treating such cases of appendicitis, with results expected near the end of this year. Dr. Livingston told me that he anticipates that the data will back up his proposal, and that he is already getting very positive reactions from physicians around the country. "I had expected that surgeons would not really receive this very well, but the response has been positive," Dr. Livingston said. "Every surgeon has a story to tell me about a patient treated nonsurgically who got better."
Not So Fast...
Despite the interest in avoiding appendectomies and the obvious benefits of nonsurgical treatment, many surgeons are cautious about making changes, including George Sarosi, MD, associate professor of surgery at the University of Florida, who is also on the research team. He told me that one concern with such an approach is cost-effectiveness. "An appendectomy is a 24-hour admission," he pointed out, "while treatment with antibiotics could be a two- or three-day hospitalization and then a week or 10 days of oral or IV antibiotics." Dr. Sarosi said that another problem is that some patients with nonperforating appendicitis suffer a recurrence after having been treated successfully with antibiotics. And the third -- most important -- worry, he said, is whether this is really safe for patients, since a severe infection can quickly become lethal.
What To Do?
You may recall our article from just a few months ago in which the wisdom of appendix removal was questioned in light of evidence that the appendix plays a role in digestion as well as immunity (Daily Health News, "Think Twice Before Organ Removal," April 1, 2010). That adds yet another layer to the issue. So now, when the pain in your lower right abdomen is diagnosed as appendicitis, the treatment decision might not be quite so black and white. If you find yourself in this position, Dr. Sarosi suggests asking your doctor for a full and frank discussion of your options. If it happens anytime soon, he guesses that your doctor will strongly recommend an appendectomy. But in the not-so-distant future, the standard recommendation might change to antibiotics first... and appendectomy only if the symptoms persist. Ill be curious to see -- and report on -- how this plays out.
Source(s):
Edward Harry Livingston, MD, professor and Hudson-Penn Chair in Surgery, The University of Texas Southwestern Medical Center at Dallas.
George A. Sarosi, MD, associate professor of surgery, University of Florida, Gainesville, and staff surgeon, North Florida/South Georgia Veterans Health System.
Appendicitis Goes Viral?
Appendicitis is a surprisingly complex condition. When the appendix is infected, the result is often pain in the lower right abdomen, a condition known as acute appendicitis. While the vast majority (75% to 80%) of inflamed appendixes are not ruptured (or perforated -- the terms are used interchangeably), the danger for those that are is that fluid will leak into the abdominal cavity, causing widespread infection and -- if not treated -- possibly even death. Until now, doctors have operated on the assumption that, left in place, an infected appendix will almost certainly rupture. But this new research shows thats not actually true.
The study, published in Archives of Surgery, analyzed data from US government statistics on hospital patients between 1970 and 2005. Its leader, Edward Harry Livingston, MD, professor and Hudson-Penn Chair in Surgery at The University of Texas Southwestern Medical Center at Dallas, went through the dramatic findings with me, explaining why the study may upend treatment of appendicitis in the near future. The researchers learned...
Appendicitis has various causes. The studys main finding contradicts the conventional wisdom about appendicitis, which was that its root cause is obstruction (typically by hardened fecal matter). Instead, said Dr. Livingston, about half of people with appendicitis have no signs of obstruction whatsoever -- and similarly, about half of all people who have such obstructions never get appendicitis. This finding led to the conclusion that a high percentage of cases are associated with a viral infection that leaves the appendix vulnerable to the bacterial infection that becomes appendicitis.
CT scan results should dictate treatment. The appendix is perforated in only about 20% to 30% of cases of appendicitis. These can be identified with CT scan -- and perforated appendixes often can be effectively treated nonsurgically, with drainage procedures and/or antibiotics.
Most inflamed appendixes wont rupture. If a patient arrives at the hospital with symptoms of appendicitis and the CT scan shows the appendix is not perforated, Dr. Livingstons research suggests it is unlikely to perforate -- therefore it, too, may be treatable with antibiotics alone. "If theres no acute secondary bacterial involvement, the appendix may not need to be removed -- and it is safe to wait a few days to see whether symptoms worsen while waiting to decide," Dr. Livingston said.
Is It Really an Emergency?
Dr. Livingston described his research as "hypothesis-generating" and told me that he believes it merits considering a change in how appendicitis should be treated. He proposes that the new standard of care should be that patients who have "nonperforated appendicitis that may be caused by viruses should get treated with antibiotics (to combat bacterial infection), followed by an appendectomy only if theres no improvement in 12 to 24 hours."
New studies are now underway to determine how effective antibiotics are in treating such cases of appendicitis, with results expected near the end of this year. Dr. Livingston told me that he anticipates that the data will back up his proposal, and that he is already getting very positive reactions from physicians around the country. "I had expected that surgeons would not really receive this very well, but the response has been positive," Dr. Livingston said. "Every surgeon has a story to tell me about a patient treated nonsurgically who got better."
Not So Fast...
Despite the interest in avoiding appendectomies and the obvious benefits of nonsurgical treatment, many surgeons are cautious about making changes, including George Sarosi, MD, associate professor of surgery at the University of Florida, who is also on the research team. He told me that one concern with such an approach is cost-effectiveness. "An appendectomy is a 24-hour admission," he pointed out, "while treatment with antibiotics could be a two- or three-day hospitalization and then a week or 10 days of oral or IV antibiotics." Dr. Sarosi said that another problem is that some patients with nonperforating appendicitis suffer a recurrence after having been treated successfully with antibiotics. And the third -- most important -- worry, he said, is whether this is really safe for patients, since a severe infection can quickly become lethal.
What To Do?
You may recall our article from just a few months ago in which the wisdom of appendix removal was questioned in light of evidence that the appendix plays a role in digestion as well as immunity (Daily Health News, "Think Twice Before Organ Removal," April 1, 2010). That adds yet another layer to the issue. So now, when the pain in your lower right abdomen is diagnosed as appendicitis, the treatment decision might not be quite so black and white. If you find yourself in this position, Dr. Sarosi suggests asking your doctor for a full and frank discussion of your options. If it happens anytime soon, he guesses that your doctor will strongly recommend an appendectomy. But in the not-so-distant future, the standard recommendation might change to antibiotics first... and appendectomy only if the symptoms persist. Ill be curious to see -- and report on -- how this plays out.
Source(s):
Edward Harry Livingston, MD, professor and Hudson-Penn Chair in Surgery, The University of Texas Southwestern Medical Center at Dallas.
George A. Sarosi, MD, associate professor of surgery, University of Florida, Gainesville, and staff surgeon, North Florida/South Georgia Veterans Health System.