Appendix Pain? Appendicitis, Surgery, and More
By Steven ReinbergHealthDay Reporter
TUESDAY, Sept. 25, 2018 (HealthDay News) -- If you're suffering from acute appendicitis, you might be successfully treated with antibiotics and never need an operation to remove your appendix, Finnish researchers report.
Most appendicitis cases are uncomplicated, which simply means the organ hasn't ruptured, so they can be treated with antibiotics. Only when the appendix looks like it may burst immediately is an operation necessary. And the difference is easily seen on a CT scan, said lead researcher Dr. Paulina Salminen, a surgeon at Turku University Hospital.
"There are no severe complications associated with the antibiotic therapy, so it's a safe option," she said.
About 20 to 30 percent of patients with appendicitis have a perforated appendix that needs to be removed, but 70 to 80 percent of patients may only need antibiotics, Salminen added.
A perforation is a small tear in the appendix, which lets its contents leak out into the stomach. This can cause a potentially fatal blood infection.
In a trial that compared 273 patients who had an appendectomy with 257 treated with antibiotics, researchers found that about 60 percent of those treated with antibiotics didn't need to have their appendix removed in the five years after treatment.
In all, 100 of 257 patients treated with antibiotics had to have an appendectomy over the five years of the study, including 15 patients operated on during the initial hospitalization, the researchers found.
The report was published Sept. 25 in the Journal of the American Medical Association.
One U.S. expert brought up the pros and cons of antibiotics instead of surgery.
"I think the big issue is this -- can physicians and patients accept the fact that there could be close to a 40 percent chance of recurrence in five years?" said Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York City.
This might not be acceptable for many people, he said.
"It's a question of how risk-averse you truly want to be, given that once your appendix is removed with uncomplicated appendicitis, your risk of complications is quite minimal," Glatter said.
Patients need to understand that while antibiotics may effectively treat acute appendicitis 60 to 70 percent of the time, the treatment may also fail and require an operation, he said.
Although the antibiotics-only approach has been gaining increased attention and popularity, it requires further study in specific subgroups of patients who may be at higher risk, including patients with appendicolith, in which the appendix is obstructed with calcified deposits. These patients were excluded from this latest study, Glatter noted.
In addition, the study only looked at open appendectomy, not the less invasive laparoscopic appendectomy. The laparoscopic approach is associated with a shorter hospital stay and a lower risk of complications than open surgery, Glatter explained.
Antibiotic therapy required three days of intravenous antibiotics given in the hospital, plus seven days of oral antibiotics. The hospital stay after laparoscopic surgery was only one day, he noted.
"The decision to initiate antibiotics-only as opposed to pursuing an operative approach to treating acute appendicitis should incorporate shared decision-making between physicians, patients and their families," Glatter said.
In fact, a recent survey from the University of North Dakota School of Medicine found that even though appendicitis often resolves with the use of antibiotics, the overwhelming majority of Americans would choose surgery instead. Only about 1 in every 10 adults said they'd use antibiotics to ease an inflamed appendix, according to survey results.
Copyright © 2018 HealthDay. All rights reserved.
SOURCES: Paulina Salminen, M.D., Ph.D., Turku University Hospital, Turku, Finland; Robert Glatter, M.D., emergency physician, Lenox Hill Hospital, New York City; Sept. 25, 2018, Journal of the American Medical Association
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Appendix Pain? Appendicitis, Surgery, and More
What is the appendix?
The appendix is a small, pouch-like sac of tissue that is located in the first part of the colon (cecum) in the lower- right abdomen. Lymphatic tissue in the appendix aids in immune function. The official name of the appendix is veriform appendix, which means "worm-like appendage." The appendix harbors bacteria.
What is appendicitis?
The suffix "-itis" means inflammation, so appendicitis is inflammation of the appendix. Appendicitis occurs when mucus, stool, or a combination of the two blocks the opening of the appendix that leads to the cecum. Bacteria proliferate in the trapped space and infect the lining of the appendix. If the inflammation and blockage are severe enough, the tissue of the appendix can die and even rupture or burst, leading to a medical emergency.
Who is affected by appendicitis?
Anyone can get appendicitis, but it occurs most often in people between the ages of 10 and 30. About 7% of people in the U.S. experience appendicitis during their lifetime. Very young children and elderly people are at higher risk of complications due to appendicitis. Early recognition and prompt treatment of the condition are necessary, especially in vulnerable populations.
What are the most frequent complications of appendicitis?
Delaying the diagnosis and treatment of appendicitis increases the risk of complications. One potential complication -- perforation -- can lead to an accumulation of pus (abscess) around the appendix or an infection that spreads throughout the abdominal lining and that of the pelvis (peritonitis). Surgery should occur as soon as possible after the diagnosis of appendicitis. Longer delays between diagnosis and treatment (surgery) increase the risk of perforation. For example, the risk of perforation 36 hours after appendicitis symptoms first appear is 15% or more.
What is another complication of appendicitis?
Sometimes the inflammation associated with appendicitis interferes with the action of the intestinal muscle and prevents bowel contents from moving. Nausea, vomiting, and abdominal distention can occur when liquid and gas build up in the part of the intestine above the blockage. In these cases, the insertion of a nasogastric tube -- a tube that is inserted into the nose and advanced down the esophagus into the stomach and intestines -- may be necessary to drain the contents that cannot pass.
What are the symptoms of appendicitis?
One of the first symptoms of appendicitis is abdominal pain that is hard to localize. People with appendicitis typically experience pain in the central part of the abdomen that eventually moves over to the right lower quadrant. Loss of appetite is another early symptom of appendicitis. Nausea and vomiting may occur early in the course of the illness or even later as the result of an intestinal obstruction.
How is appendicitis diagnosed?
Doctors diagnose appendicitis based on the patient's symptoms and findings during physical examination. A person with appendicitis usually experiences moderate-to-severe pain when the doctor gently pushes down on the lower right abdomen. A potential indication of peritonitis is "rebound tenderness," which is a worsening of pain when the doctor removes his hand after pressing down on a tender area of the abdomen.
How is appendicitis treated?
Surgical removal of the appendix is called an appendectomy. Antibiotics are given to a patient with suspected or confirmed appendicitis both before and after surgery. Appendectomies can be performed laparoscopically, where special surgical tools are advanced into the abdomen via several small incisions. The following is a step-by-step account of an appendectomy.
Appendectomy: Step 1 of 8.
This image shows a normal appendix in a female patient undergoing surgery for an infection in her reproductive system. Since there is no known function of the appendix and to prevent diagnostic confusion in the future, the surgeon removes it to prevent potential appendicitis in the future.
Appendectomy: Step 2 of 8.
To remove the appendix, the surgeon separates it from the mesentery, which is the tissue that delivers blood to the area. Electric current delivered by an instrument called a bipolar forceps is used to seal (cauterize) the blood vessels and prevent bleeding.
Appendectomy: Step 3 of 8.
In the next step, the surgeon uses scissors to snip the appendix free from the mesentery. He alternates between electrocautery (to seal blood vessels) and cutting to completely separate the appendix from the surrounding tissues until the only remaining connection is to the colon.
Appendectomy: Step 4 of 8.
In the next step, the surgeon crushes the base of the appendix with a clamp and then moves the clamp slightly towards the end of the appendix, positioning a pre-tied suture at the base of the appendix to tie it off.
Appendectomy: Step 5 of 8.
The surgeon tightens and secures the suture using a fisherman'’s knot, which can be tightened but is incapable of loosening by itself.
Appendectomy: Step 6 of 8.
The surgeon then uses the scissors to cut the suture above the knot.
Appendectomy: Step 7 of 8.
The surgeon cuts the appendix with the same scissors above the knot but below the clamp to prevent contamination.
Appendectomy: Step 8 of 8.
The surgeon and his surgical team complete one final inspection of the area to ensure there is no bleeding.
Are there complications and/or long-term consequences of appendectomy?
Infection at the surgical sites is the most common complication associated with an appendectomy. Redness and pain may be present with a mild infection. Moderate infections may have more severe symptoms. Antibiotics are used to treat mild-to-moderate postsurgical infections. If an abscess develops, drainage may be necessary.
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