Some People With Appendicitis Can Be Treated With Pills, Not Surgery

New research suggests antibiotics may be a better option for most appendicitis patients.

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Oct 11 2018, 5:51pm

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If you develop appendicitis and your appendix is not surgically removed, it will burst and you will die. You probably learned this as a kid, and so did your parents and grandparents.

“This narrative, which I call ‘appendiphobia,’ has been cemented in medical lore for over 100 years,” says David Talan, a professor of medicine at the David Geffen School of Medicine at UCLA. “But it’s a myth.”

Talan is part of a research team conducting a $12-million clinical trial into the effectiveness of antibiotic treatments for appendicitis. While his trial is ongoing, he says we know enough today to recommend antibiotics—not surgery—to many appendicitis patients. “What you and your parents and grandparents were taught was false,” he says.

The appendix is a small, finger-shaped pouch that dangles off the large intestine. It’s what doctors call a “blind-ended organ” because it only has one opening. If that opening becomes blocked or closed off—either by a piece of stool, a tumor, or by inflammation resulting from an infection—the bacteria and mucus that flow in and out of the appendix can’t escape. This can lead to swelling and, in some cases, a burst appendix, which can indeed be deadly.

Infections of the appendix are commonplace. About one in 10 people will develop appendicitis, and it usually strikes people in their teens and 20s—though rates among older adults have lately ticked upward. The name for the surgery to remove the appendix is an “appendectomy,” and it’s among the most common ER operations. An appendectomy requires general anesthesia, but it’s so simple that, in many cases, it’s performed by surgeons in their early years of training.

Until recently, the vast majority of appendicitis patients were treated with an appendectomy. Outcomes are usually good: The offending organ is cut out, and so the risk of a burst appendix or a recurrence of infection is removed. But recent clinical trials have found that, for many patients, a simple course of antibiotics may be just as effective as surgery for the treatment of appendicitis.

The best and most widely cited of these trials was performed in Finland, and the results were published in JAMA in 2015. Patients with uncomplicated acute appendicitis—meaning those who had an infection of the appendix that had not developed advanced complications like a perforation or an abscess—were split into two groups. One group received antibiotics, while the other underwent an appendectomy. Of the 250 or so patients treated with antibiotics, roughly 25 percent either didn’t respond to the drugs or had a recurrence of infection within the following year. The other 75 percent of these patients recovered fully.

When the results of this trial were published, Talan says many in the medical community argued the findings weren’t conclusive enough to abandon surgery in favor of antibiotics. “They said we don’t know enough, or one year of follow-up isn’t enough,” he says. But the Finnish team kept tabs on their study groups, and last month they published the results of their follow-up. They found that, within five years of receiving antibiotic treatment, roughly 60 percent of patients had no recurrence of appendicitis. Also, for those patients who had experienced a repeat infection, it was no more complicated than the initial bout of appendicitis.

Talan says many doctors looked at these follow-up results and declared “game over”—meaning antibiotics are clearly a viable alternative treatment for acute uncomplicated appendicitis, which is the type that strikes 80 percent of patients. “If the appendix bursts and there’s diffuse peritonitis”—something that occurs in a very small percentage of patients—“then you absolutely need to get immediate surgery,” he says. But for many appendicitis patients, he says antibiotics can be considered a safe alternative treatment option.


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He’s not alone in this opinion. “For the right patient, antibiotics are a completely reasonable option,” says Matthew Dong, an assistant professor of surgery at the Icahn School of Medicine at Mount Sinai. “The important thing is to have a conversation with your doctor so you understand the risks of each treatment modality.”

What are those risks? When it comes to surgery, Dong says complications could stem from undergoing general anesthesia. Those risks are uncommon and usually minor—stuff like nausea or short-term grogginess—but could be serious or even deadly, especially for older or infirmed patients. “There’s also a risk of damage to the structures near the appendix, as well as a risk of bleeding or infection,” he says.

On the plus side, “once the surgery is done, your appendix issues are over,” Dong says.

It’s worth noting that, until recently, the appendix was considered a useless “vestigial” organ—meaning it was something humans needed hundreds of thousands of years ago but don’t any longer. The thinking on that has shifted. Some new evidence suggests the appendix may be a repository of healthy gut bacteria, and so may help a person recover after a bad stomach bug or other types of microbiome trauma. In support of this theory, some research has found people who’ve had their appendixes removed are at increased risk for bacterial GI infections.

So, say the appendix turns out to play a role in the health of the gut’s microflora. The fact that antibiotic treatments allow you to keep yours would be one big benefit. Shorter recovery time is another. “If I give you antibiotics, you will be back to feeling normal in a few days,” Talan says. “If you get laparoscopic appendectomy”—the least invasive type of surgical appendix removal—“you won’t feel normal for about two weeks.”

Of course, opting for antibiotics also means you don’t have to go under the knife unless the infection recurs. “Some people are scared to death of surgery, or just don’t want it, and so antibiotics gives them another option, Talan says.

But antibiotic treatment does come with some caveats. “There is a risk that the primary episode of appendicitis was related to a cancer,” says Andrew Kirby, an associate clinical professor of microbiology at the University of Leeds in the UK.

While cancers of the appendix are uncommon—about 1 in 100,000 Americans develop this type of cancer each year—an appendectomy can help doctors identify the cancer while also removing any future risks that this disease will develop. Kirby says the side-effects of antibiotic treatment tend to be mild—stuff like short-term nausea or diarrhea. But some of his research has found an increased risk for appendix perforations or other complications among people treated with antibiotics compared to those who underwent surgery. He also raises the issue of antibiotic resistance, or the proliferation of drug-resistant infectious bacteria stemming from the overuse of antibiotics in medical settings (and elsewhere).

“Personally, I would not accept a treatment with a high failure rate,” Kirby says of antibiotics. “I would worry for the next few years that I might be about to get appendicitis again.”

Dong reiterates this concern, and says this may be a deciding factor for people who travel to parts of the world where an emergency appendectomy may be a riskier procedure. He adds that not all Americans have easy access to emergency care, and so the risk of developing complications from appendicitis treated with antibiotics may outweigh the benefits of avoiding surgery.

There are many other variables that come into play. Dong says appendicitis is a “highly variable” condition with many different categories of complication, and the risks or benefits of surgery and antibiotics will vary depending on a patient’s age, health status, or pregnancy status. “The studies on antibiotics haven’t addressed pediatric or geriatric populations,” he says. “So to summarize my thoughts, I don’t think there’s one right answer for everyone—it’s more about the right choice for you.”

Talan agrees, cautiously. “We don’t have a lot of experience treating the very old or very young with antibiotics, so we have a lot more to learn.” But based on what we know today, he says antibiotics are clearly a safe, effective option for adolescent and adult patients with the most common types of appendicitis.

“Appendectomy is still an effective treatment for appendicitis,” he adds. “But it appears that most people could be treated just with antibiotics.” The “myth” that surgery is the one and only way to treat appendicitis needs to be cut out and tossed away.

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