Remove or Not Remove The Inflamed Appendix?

That is the new public health dilemma.

I once worked as a Hospital Medical Director, and without exception, every patient who came to the hospital with a severe abdominal pain in the right lower abdomen was suspected of having appendicitis (an inflamed appendix).

Among those above, those who show elevated white blood cell counts in their blood work were admitted for urgent removal of that inflamed appendix. In more advanced medical centers, the surgeon usually requested an ultrasound of the abdomen to document that the patient had an inflamed appendix. If the patient were older than 40 years, the surgeon usually requested an CT scan of the abdomen to rule out any possibilities of cancer causing the pain.

In my whole career as a healthcare provider, I have only seen one or two cases of appendicitis who were treated with antibiotics without resorting to surgery. The last one of them was one of my colleagues who came to the hospital about a month ago with the same classic pain of an inflamed appendix, and was seen by an eminent surgeon, but was advised to take intravenous antibiotics. Luckily, he survived the incident!

All this ran through my mind as I read that recent paper that was published this month in JAMA. In that paper, the authors cited evidence that medical treatment in the form of antibiotics has the same effect on most cases of uncomplicated appendicitis as surgery. They even proposed that antibiotics should be routinely prescribed for such cases from now on.

According to the authors, it seems that in 70% of cases suffering from appendicitis, the profile fitting for antibiotics is that of an otherwise healthy individual who suffer from severe appendicitis, as confirmed by laboratory results or imaging studies, and who has no risk factors for the rupture of the inflamed appendix.

Otherwise, nearly 30% of cases with appendicitis are either diagnosed with complicated appendicitis, or are having risk factors favoring its rupture. In that case, surgery looks like the most appropriate option.

As much as the above research looks promising to many patients who don’t like or don’t afford surgery as a definitive treatment to acute inflammation of the appendix, I think the application of the paper’s recommendations will take some time to be taken in by the medical community for the following reasons:

1. More research is needed on the long term outcomes of patients who were treated with antibiotics for their inflamed appendix. Personally, I would like to know if they had other episodes of appendicitis, when those episodes took place, whether they were complicated or not, and whether they were treated with antibiotics or surgery in the following episodes. These pieces of information are of the utmost important for measuring the feasibility of adopting those new recommendations.
2. More research is needed to predict which treatment strategy (surgery vs antibiotics) is associated with the most favorable long term outcomes for patients with acute appendicitis. I will be most concerned about whether suggesting antibiotics for patients with appendicitis has led to more complications for these patients on the long run. In other words, if choosing antibiotics for patients with acute appendicitis was associated with more hospitalizations later on, or more complications later on, or even increased deaths from these complications, then surgery will be the safest alternative, may be not at the time of presentation, but on the long run.
3. Hospitals are always afraid of malpractice lawsuits. Sometimes the patient who initially preferred not to have surgery to treat his appendicitis may find it unacceptable to re-enter the hospital for the second time with the same diagnosis and may file a malpractice lawsuit against the hospital for that reason. So, if we are to implement using antibiotics to treat acute appendicitis at large, a good support from the scientific communities must be there to protect surgeons from losing their licenses.

In conclusion, I strongly invite public health researchers to run statistical models to predict the best cohort of patients to receive antibiotics, the best long term outcomes associated with the use of antibiotics in the treatment of acute appendicitis, and the economic outcomes of implementing such a novel strategy. Conservative treatment options are preferred by patients, but when the other alternative is surgery, healthcare systems need to be careful about how to conserve.