Study: Surgery Not Always Necessary for Appendicitis
There is a certain pleasure in having your prejudices overturned, at least when they are not essential to the whole of your mental economy. It reassures you that you are still a rational being, and not one who believes what he believes simply because has always believed it, and what he has always believed must be right.
Until the publication of the British Medical Journal of April 5, I strongly believed that the operation of appendectomy (known in Britain as appendicectomy) was essential for the condition of appendicitis. If the patient did not have the operation, he would suffer dangerous complications such as perforation and then peritonitis. True, I had not given a lot of thought to the question since I was a very young doctor, but it was what I had been taught in good faith by eminent men and so I continued to believe it.
The paper in the BMJ performs what is known as a meta-analysis of randomized controlled trials of initial treatment of uncomplicated appendicitis (that is to say, without evidence of rupture or peritonitis) with antibiotics compared with operation. There have been four such trials whose results were pooled in the meta-analysis, and I must say that I admire the courage of those who conducted these trials considering how strongly entrenched the necessity for operation is in most doctors’ minds (and, I suspect, in patients’ minds too).
The results favored initial treatment with antibiotics rather than immediate operation. The interpretation of those results was complicated slightly by the fact that if people with appendicitis did not improve within two days of antibiotic treatment, they went on to surgery regardless; nevertheless, at least two thirds of people with appendicitis were cured by antibiotics alone. Overall, they had a lower rate of complications than those who were operated upon straight away on diagnosis.
This finding is all the more significant because a high proportion of appendectomies prove to have been performed on appendices that were not inflamed and whose removal was not necessary. And while it is true that abdominal surgery these days carries far fewer risks than it once did, it is still not entirely without risk. No one would have his innards poked-about by a surgeon for the mere fun of it. In other words, if this meta-analysis is to be believed, the first-line treatment of appendicitis (without evidence of complication) ought to be antibiotics.
Yes, but…..what wa the rate of recurrence in those treated with antibiotics? What was the incidence of adverse reactions to the antiobitics? What additional morbidity was associated with delaying appendectomy two days versus immediate surgery? Meta analysis can be quite tricky, an d sometimes misleading.
I have a long experience with appendicitis, treated with antibiotics and not. The US Navy ballistic missile submarines used antibiotics and did not surface which would disclose their location. In my own practice, if a patient has a good reason to postpone (vacation trip, recent heart attack) I would try antibiotics for two days. About half of appendicitis is obstructive, caused by a hard bit of fecal matter. These cases tend to progress rapidly and may perforate in 24 hours. Thus a failure to resolve symptoms quickly is an indication for surgery. The incidence of negative appendix found at surgery is quite low these days with better diagnostic tests, however, the last 1,000 appendectomies I performed were via laparoscope. Here, the diagnosis is obvious and the procedure is quick and the recovery is very quick. If a you female, for example has a tubal infection, a common cause of right lower quadrant pain, it can be identified and even treated by irrigation of the pelvis.
In cases treated with antibiotics, I recommended an interval appendectomy when no symptoms are present. Recurrent appendicitis is common is cases where the surgery was deferred. Again, the patient after laparoscopic appendectomy can usually go home in the morning. The only risk in good hands is the anesthesia.
So I guess it’s not a question of surgeons greed??.. great. If the One develops right low quadrant pain, runs a fever, has a high white blood cell count, let’s sit back, light up and chill out. It works for me.
“If the One develops right low quadrant pain, runs a fever, has a high white blood cell count, let’s sit back, light up and chill out. It works for me.”
The incentives have always mentioned surgeons’ greed. Nobody talks about the payers’ incentives except surgeons. There was a study about ten years ago that showed the incidence of perforated appendicitis, as a share of all appendectomies in Chicago, went up substantially after HMOs became a major part of health care in Chicago. The other variable was the time before surgery from first symptoms. Delay, in other words. Antibiotic treatment was not part of the study. Perforated appendicitis is a near catastrophic complication of a simple disease. John B Murphy, of Chicago, was a pioneer in early diagnosis. THere is an irony in the reversal of his results.
Dr Daniels, I always enjoy your writings.
I’m sure you are aware of your countryman, Dennis Burkett’s contributions to the understanding of appendicitis and diverticulitis and their etiology, including their decline in recent years.
Anyone interested in more about this subject might be interested in my book.
http://www.amazon.com/Brief-History-Disease-Science-Medicine/dp/0974946656
Thanx, Mike….to sum up there is no substitute for clinical judgement and experience (and a thorough reading of Zachary Cope). Unfortunately, many of these meta-analyses become the algorithm for the insurance panels, government payers and various regulators who possess none of the above qualities, but have been granted cookie cutters when they obtained their mail order MBA to use with their unpracticed MD.
I’m afraid this study gives credence to the old saw, “too smart for our own good”.
This is news?
I had an acute attack of appendicitis in 1952 when I was 10 years old. My mom took me to the doctor’s office (Chicago suburbs). He said, “Let’s try this new “wonder drug”, penicillin. I still have my appendix and never experienced another problem with it.
You probably didn’t have appendicitis in the first place.
With logic like that we’ll never change our minds about anything.
A major limitation of the study is how the diagnosis was arrived at in the first place. Only one of the series included required a diagnosis by CT, the gold standard for preoperative diagnosis of acute appendicitis. Contrast CT has a diagnostic accuracy of around 95% and can seperate those patients requiring emergency surgery from those who can undergo an intitial course of antibiotics prior to the decision for surgery.
The difference is important because not all patients admitted with right lower quadrant abdominal pain and clinical signs have appendicitis and often have another condition (diverticulitis, epiploic appendigitis, irritable bowel, inflammatory bowel disease, kidney stone etc) which may mimic appendicitis and will respond to non-operative treatment. These patients will be counted as a “success” for non-operative treatment which is a false positive.
Certainly there are cases of appendicitis which will resolve without surgery. It is now standard practice to give a course of antibiotics for 24-48 hours in uncomplicated cases which decreases the incidence of complications. The study, however, claims an somewhat unimpressive success rate of 63% on one year follow up for medical therapy alone.
The diagnostic issue also explains Dr. Dairymple’s question about declining incidence. The use of CT for diagnosis in the past 30 years greatly improves specificity. In the past if you had clinical signs you went to OR and the appendix came out, whatever it looked like (“see a little pink at the tip”) the final diagnosis was going to be appendicitis and you were “cured”. So it is likely that the number of actual cases has not changed but the number of false-positive diagnosis has decreased.
You definitely don’t have to be a doctor to understand a tendency incorrectly to label an appendix as diseased once you’ve gone to the trouble of taking it out. But I also remember reading several decades ago that medical boards would come down on doctors who removed too few healthy appendices, claiming that they were taking chances with patients’ lives by delaying appendectomies until they were really sure it was appendicitis.
As a medical student recently on my surgery clerkship–they still do teach residents that you should have a significant number of healthy appendices to come out. Perforation is very possible leading to intraabdominal abscesses and perhaps diffuse peritonitis. You might lead to requiring another procedure such as drainage of an abscess by an interventional radiologist or worse yet a reoperative washout to clean the area. This study may perhaps lead to more opening the minds of people to study it further but it is dangerous at this point to say that you have a choice between antibiotics and surgery. Appendicitis is all too often a surgical disease, which, if waited upon will develop into profound infection that could have been prevented. The difficult part is in distinguishing what is likely to be a complicated case–where the lumen of the appendix is cut off and antibiotics will not penetrate the area. There is no way to predict that reliably. So at this point we do need to operate a portion of those unknowns to prevent preventable complications. It’s definitely a cost benefit analysis and should be considered for each patient’s case on its own as different people have different tendencies to develop complications and abilities to clear infections.
A significant factor in considering whether to do appendectomy is the age and sex of the patient. A perforated appendix in a young woman of child bearing years is a disaster as infertility is a frequent sequela. There might even be a medical malpractice suit considered, though not in England, of course.
If you hear hoofbeats think horses, not zebras”
And remember Sutton’s law. The diagnosis is the key and CT imaging is the best tool. So all appendicitis is not equal. There are unequivocal cases. There are some with minimal appendiceal thickening with no secondary signs, those are equivocal and need close follow up. Symptoms may vary. A patient who has perforated gets temporary relief from pain but goes on to a much more complicated picture. Some of those need drains, antibiotics and intensive care before they go to surgery. Some do have an acute case which resolves. Always a surgeon needs to be on board to make the choice.
We accept a certain number of normals but the goal is to trim that without increasing morbidity. In the case of appendicitis medicine has done well in the past few decades. We still have issues about diagnostic tests ( please get contrast CT for undiagnosed RLQ pain whenever we can ).
At the end of the day it is a clinical judgement. I encourage you to review the meta analysis yourself which is available online without subscription ( thank you BMJ ).
That was before ultrasound and contrast CT which have improved pre op diagnosis greatly.
We’ll need to see a large, prospective, randomized study (or two. Or three). Each of the four individual studies Varadhan looks at found substantial long term recurrence rates. Since this forum is PMJ, I’ll point out that meta-analyzing is a game that governmental agencies can and will play to justify cutting services (see under “Health Policy Implications” in this British study). I’m not saying the appendicitis treatment paradigm won’t change eventually, just that the case for non-surgical primary treatment remains dubitable at this juncture.
Fear and common sense are the two choices we are faced with everyday. Common sense is rational: fear is an emotion, and often involves irrational decisions.
Intelligence offers no defense for fear. In some cases, intelligence only increases the fearful reaction, and we are left with doubt concerning the intellect of the affected.
Many angioplasties and coronary artery bypass operations are also unwarranted. Studies have shown they do not increase longevity over medical treatment with drugs. Medical treatment, dietary changes, and increased exercise regimens are often quite sufficient.
The problem lies in our society’s almost religious belief that technology and intervention always resolve problems, be they on the operating table with the use of a surgeon’s knife or in foreign policy arenas with the use of remotely controlled drones.
In moist cases, angioplasties and surgeries are for symptom alleviation and quality of life, not longevity. The exceptions are interventions during the course of a threatened infarction. If an MI can be prevented or reduced in size by an intervention, the risk of reduced cardiac output and eventual shortened life span related to reduced cardiac output is reduced.
4 and 5, spindok and hamilcarb are right. When I practiced pathology, in several California hospitals, up to 20% false positive (no appendicitis) was acceptible, indicating that the surgeon did not wait around for perforation. This was before extensive CT availability in small hospitals. Without CT the difficulty in diagnosis of “acute abdomen” is significant and suggests to me (with admitted bias)that the the major risk is to Government Health Service expense, rather than patient health.
I have not read the BMJ piece, but without imaging confirmation of appendicitis, the conclusions of the meta analysis are worth considerably less.
It does raise a larger issue, however.
Without imaging confirmation of the diagnosis, the piece would just be another in a long long of meta analyses trying to create ‘evidence based’ rationales for cheaper (and often less optimal, or less individualized) treatment. The agenda is to rationalize cost savings at the expense of individuals. The UK is a champion in this medical intellectual dishonesty.
‘Evidence based’ medicine is a Trojan horse. It seeks to negate the role of individual patient uniqueness on medical decision making, forcing a one size fits all approach, precisely at a time when science suggests that individual differences, including on a genetic level, may make all the difference in outcomes, and treatments need to therefore be tailored.
Obama wants to take us in the opposite direction. It’s about money and control. It is actually the democrats, who, by denial of care that does not meet their inappropriate definition of being ‘evidence based’, plan to push granny off the cliff.
The UK has been pushing its elderly off the cliff for years, through the rationalization of denial of care. The UK has become a horrible place from the perspective of individual rights.
Michael,
I am just a remote area paramedic, generally working in area’s that are inaccessible to hospitals, such as Papau New Guinea, Iraq, Afghanistan, East Timor etcetera, usually if your lucky you might get a chopper (Helicopter) within 12 to 48 hours… what does one do in such situations where all the bells and whistles are not available… I mean other than a field diagnosis and experience and if your damn’d lucky comms with Medical Direction and Consultation… Not trying to be a pain, but I’m not a physician and just curious..
Thanks..
Dave
Nothing new here! Treat the patient with antibiotics and very ofter cured. But treat with antibiotics and perforate, the doc gets sued for negligence.
Thanks for posting this!
This issue comes up every so often in settings where surgery is difficult (e.g., a sailor in a US Navy submarine).
Here’s a related article I read a few years ago supporting this approach:
“Medical Management of Acute Appendicitis: A Case Report”
http://www.jabfm.com/content/14/3/225.full.pdf
Next: liver stones (called by Western Medicine “gallstones”) can be expelled using the epsom salt-lemon juice – olive oil method – no surgery necessary in many cases.
Here again, laparoscopy has changed the practice and the economics, as well. Patients are routinely discharged the same day or the next morning after lap chole. There was a lot of interest and investment in stone shattering machines for gall stones 25 years ago. Lap chole ended that interest pretty quickly. Lemon juice cures and considerably more dubious. I remember a patient who treated his rectal cancer with celery juice. As he was dying, he was convinced he had not used enough celery juice. Odd health beliefs can be very stubborn.
I must second #3 drifter’s comment. On Dec 31, 1956 I was diagnosed with appendicitis. I was in fourth grade (soon to have my 10th birthday). We were living at a US Army base in Japan and I went to Army hospital supporting Camp Zama and other nearby Army bases. Since the hospital was minimally manned, surgery was postponed I, also, went on a penicillin regime. Every few hours a shot in my rear end. I got over it quickly. A very few days later I went home none the worse. Today I still have my appendix. As an aside I just read a recent article (Scientific American?) that indicates that the appendix is not a vestigial part of the digestive system but has a real role in human health.
You more than likely had mesenteric adenitis (q.v.) and required no surgery.
So the British Medical Journal says every case of appendicitis should first be treated with antibiotics, eh?
I wonder how many times previously the BMC has played Cassandra about the growing inefficacy of antibiotics due to overuse by doctors making across-the-board use of them.
When I started my medical internship in the pre-CT days, an old-school surgeon gave us a lecture on appendicitis. This consisted of advice on what to say to the family after a normal appendix had been removed. Apparently all would be well if you told them “…that appendix REALLY needed to come out…”. In those days it was accepted that about 25% of appendices would be lily white but having seen various complications during my brief surgical rotation I think I prefer the old adage of “…when in doubt, take it out…”.
One other point to make on this issue is that it is not new. The British approach to the treatment of uncomplicated “appendicitis” was similar to this more than 20 years ago. I remember discussing it back when I was in residency training.
Meta-analysis is to medical science what derivative securities were to the financial crisis: a lot of fancy numbers one step removed from their corresponding reality. That seems to make a difference. We need a controlled study with CT and path confirmation to answer this question.
Statistics in medical studies are seldom done by statisticians, so you have to be wary of the results. Also remember, this is just one study. Can these statistics be confirmed in other studies?
Medicine is practiced on one patient at a time. Any approach recommended by a study may or may not be suited to the patient at hand. The circumstances in which a study takes place may not be comparable to every other physician/patient’s circumstance. “Best practices” are sometimes WRONG!! Unfortunately the MPHs, MPPs, and bureaucrats can only think in one-size-fits-all terms. That will be the ruin of health care in this country.
Was this particular study was done in The UK? Families there are increasingly complaining about not even getting antibiotics for their elderly or disabled loved ones, because, as one judge put during a court battle to get treatment, the life of the disabled patient wasn’t worth it!
And greed! Are you out of your mind?! If a surgeon did one appendectomy after another, all day long, she couldn’t make enough to keep a practice open!!
Somebody must have listened to Obama talk about $40,000 amputations. He lied! There is no such thing.
The average cost of appendectomy is $15,000. I dare say someone’s making money.
FOLLOW-UP STUDY NEEDED ON ANTIBIOTIC-TAKING GROUP
–What change in diet resulted? Any new food intolerance?
–Any change in bowel habits?
–What is the degree of intolerance to fats and oils, especially to healthy vegetable oils?
–Have any allergies appeared?
A year or so after the incident would be a good time to gather answers.
In my case, my abscessed appendix went acute. A week of IV antibiotics did nothing. Out it came, described by my surgeon as a “humongous mess.”
In poring over my past, appendix went bad about at age 9 when I became more intolerant to fats & oils. I had to trim fat from meat or it would kill appetite or make me queasy. I could never eat cheese or pizza. I gathered more food allergies through the years. My slowly increasing intolerance to sodium became acute, though not a salt-usoing person or a drunk, and I had to go on meds. About 6 years after that, the giant goose egg appeared in the lower right quadrant and the liking for solid food disappeared.
Once the humongous mess was gone, the acquired food allergies remained, leading the immune system to attack the joints and skin, and the onset of asthma. As some allergies were occult, it took years to sort it out and get free of joint pains, and the asthma disappeared.
After age 9, I would have rare occasions of right lower quadrant discomfort and tenderness; one goes to the doctor for serious things, not for that. I also had episodes of oral and injected antibiotics, including daily while hospitalized. It made no difference or change. Nothing ever showed up on a white count.
My vote is for laparascopic extraction.
Fanatastic Article,
For one, I work in the ‘Remote’ field. for example Papau New Guinea, Antartica, Africa, Iraq and Afghanistan… former SOF-IDC, now a remote area paramedic, where evac is not always available, so after the initial/differential diagnosis which basically excludes what it isn’t or possibly can’t be we are left with what is it likely to be and then it boils down to experience and if your lucky and I mean damn’d lucky and have (Godly in my opinon) Medical Direction and Consultation with a switched on Doc by phone or sat phone or radio…
My own experience… Oman, Middle East, Jebel Al Akari I think, (Give me a break it was 1985, Op Saif Sera) I… yes myself the team medic had what used to be called ‘Grumbling Appendicitis, OMG, Horrendous, as bad as Kidney Stones (Unfortunately had them too… not fun = Childbirth (14 hours+) without anathesia) sorry digressing… suffice to say like the good Doc said… I initially set myself up on a Antibiotic drip and oral, guess what I used Doc… suffice to say it resolved itself… unfortunately it reoccured 6 months later in the jungles of Belize, Central America, this time it was evac to the local 3rd world hospital, I have beautiful 3 inch scar, no problems since… well except the damn kidney stones and that too was in the middle east, Iraq 2007.. dehydration apparently was a major component… no sh*t, 140%F, 30lbs plus of body armor, too much caffenine and other diruetics (Coffee, Tea, Red Bull), high protein diet… I know I know I should know better…. Anyway back to the Doc… your right, I have used Anti-biotics in remote locations with excellent results, in my experience about 1 out of 7 need surgery, amazing when I think back, have treated a total of 32 people for appendicitis… yeah I’m an old fart, don’t even ask me about remote child birth or gall bladder and kidney stones…
Great Article..
Thanks
Doc
Just a couple of comments: at Med school in the 80′s our Prof. of surgery told us that most cases of appendicitis resolved without surgery; so no news here. I also love the attacks on the ‘UK’! There is some confusion between socialised healthcare and British-sourced scientific papers. I do not believe British/European authors are deliberately trying to force any style of healthcare on their readers – that sounds like isolationist paranoia. I also note that those against socialised healthcare are increasingly resorting to the need for ‘individualised’ care as though socialised systems don’t routinely do this (they do). The defence of ‘individual care’ seems to revoke the need to look at large studies and potentially better evidence thus derived. In a many ways this is the defence of the homoeopath – every patient is absolutely unique and any trial where n>1 can be ignored.
I’ve had two bouts of appendicitis. The first I didn’t know what it was and just rode it out. The second time it happened, I realized what it was. The list of symptoms found on the Internet confirmed my diagnosis. I had the typical pain around my belly button that later focused in my lower-right abdomen. My body expelled everything in my digestive tract out both ends. Pain on day one was excruciating. I had a 102 degree fever with chills for a day that dropped every few hours. I fasted from solids and drank bone broths and Vernor’s that a friend brought over. The pain lessened each day.
Now before some closed-minded wit comes along to say, “You must not have had appendicitis,” I waited until day three to go to the hospital (to ensure I had the strength to escape if necessary) to confirm my diagnosis. My fever had subsided by this time, I was much more coherent, and the pain had halved. CT scan revealed inflamed and thickened appendicitis with no abscess or perforation. My white cell count was normal. I was on the mend. Gotta love that immune system!
But the doctor kept insisting on surgery, which I declined. Then they wanted to at least admit me for antibiotics, which I also declined. With no fever and normal white blood count, why administer antibiotics and destroy my flora? Paradigms are harder to leave than the hospital.
Why have I had two episodes? I suspect food allergies. This last bout occurred about three months after I learned to cook Thai food. I insisted on a food allergy test (RAST), and it confirmed allergy to peanuts, soy, dairy and gluten. I was eating a lot of soy and peanuts. I already knew I was allergic to gluten and had been using-gluten free soy sauce thinking I was safe.
I have read that the appendix is so situated that in the event of a rupture, it will typically rupture its contents into the colon. (Nature is very intelligent.) Unless, of course, you have a doctor poking you and putting pressure on the appendix, forcing an unnatural rupture.
I dare say that fasting and bed rest is the best remedy for appendicitis. And avoiding doctors who love to poke. And cut. And drug.
In your wisdom, you reverted to prehistoric appendicitis management.
It works well, for 1 out of 10 cases.