Dear Doctors: One of my roommates went to the ER because of abdominal pain and nausea. It turned out to be appendicitis, and we all thought he would need to have surgery. But the doctors did something they called nonoperative management, and he got better. What is that? Is it safe?
Dear Reader: Let’s start with the appendix. It’s a small, thin pouch that extends from the juncture where the small and large intestines meet. In adults, it ranges from 2 to 4 inches long.
The appendix has long been categorized as a vestigial organ with no known function. However, newer research suggests it may play an important role in safeguarding populations of good bacteria during periods of intestinal illness.
When someone has appendicitis, it means that their appendix has become inflamed. Symptoms often begin with the abdominal pain that your roommate experienced. The classic presentation is pain in the center of the abdomen which, as it worsens, migrates to the lower right quadrant of the abdomen. This may be accompanied by loss of appetite, nausea, fever and something known as rebound tenderness -- pain that occurs when pressure that has been applied to the abdomen is suddenly released. Coughing, walking or raising the right leg may also trigger pain during appendicitis.
Because of the variable position of each person’s appendix, and the general nature of the symptoms, an accurate diagnosis of appendicitis can be challenging. Statistics show that one-fifth of cases are misdiagnosed. However, if an infected appendix ruptures, it will spill its toxic contents into the abdominal cavity. This is extremely dangerous. A burst appendix can lead to widespread, and often life-threatening, infection. But surgery also carries risk.
For that reason, and under certain circumstances, a medical team will opt for what is known as nonoperative management of appendicitis. This is an approach that does not include the removal of the appendix. It is used only in cases where scans and tests show that the appendix is not perforated, does not contain an abscess and is not at risk of rupture.
Instead of surgery, patients are treated with antibiotics to manage infection. This typically begins with several days of intravenous antibiotics, followed by up to a week or more of oral antibiotics. Some studies have found that managing the symptoms of inflammation without the use of antibiotics can be equally effective for certain patients.
While avoiding surgery is a plus, patients are left with a degree of uncertainty. The data show that some people with appendicitis who have nonoperative treatment go on to develop new symptoms. And the chance of a recurrence increases with time. A study that followed 257 of these patients found that, at the one-year mark, the incidence of recurrence was slightly more than 27%. By year five, it had risen to 40%. The return of symptoms meant additional emergency room visits, repeat hospitalization and, possibly, surgery. Your roommate’s doctors will have advised him of this and given him instructions about what symptoms to watch for and how to respond should they arise.
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