Dr. Kevin Most: Appendix- is it important? Appendicitis –Surgery or Antibiotics?

Dr. Kevin Most

Each week we try to take a few minutes to discuss a recent story in the news regarding healthcare. I try to not confuse people but share the information on a level that makes sense. Well this week may change that a little as I share some recent news about a body part that can cause discomfort and perhaps even more long term issues that won’t seem to make much sense at first. The body part is the appendix. This roughly 4 inch tube is a part of your gastrointestinal tract, it is a part of your large intestine and is located in the right lower portion of your abdomen.

Anyone in the studio have their appendix removed? In the United States each year close to 300,000 individuals have their appendix removed, almost all of them are removed urgently or emergently. The surgery is performed in every acute care hospital in the United States. We all probably know someone who has had this surgery. The appendix is a small outpouching in our intestines that can get infected and if not treated can rupture and cause bacteria into the abdominal cavity and may result in a fairly serious infection. The traditional treatment has always been to have surgery within a day or two of the diagnosis being made and have the appendix removed. The diagnosis of appendicitis is made with a good physical exam and history, often a CT scan may be done as well. We are trying to limit the CT scans in children as it is a lot of radiation. In many cases the surgeon will want to watch the symptoms instead of just rushing into surgery with any one with lower abdominal pain.

The classical history for appendicitis is a pain that starts around the belly button and moves down and to the right. The pain is reproduced when that area is pushed down by the physician and often hurts as well when the pushing is released. The patient often will complain about the ride to the hospital and hitting bumps along the way causes pain. The patient often will not have an appetite. I would always ask my young patients, “What is your favorite food?” and then I would ask them if I had that food right now would they eat it. If the answer is No, and they have pain it raised my suspicion of appendicitis.

Why are we talking about this? A study published last week reviewing treatment options in Finland shows that in some cases treating the patient with antibiotics for 10 days will have outcomes as good as surgery initially. The study was started in 2009, in that study they took over 500 patients with uncomplicated appendicitis and split them into two groups. One group received surgery, the other group received antibiotics. They looked at how long the individuals were in the hospital, how much lost time from work as well as complications. The study certainly has some limitations in analysis of the data. The doctor decided who would have surgery versus who would get antibiotics, so this would lead to those who are sicker to get surgery, while others who looked like they could wait got antibiotics. The complications from surgery were higher in these patients as the equipment and techniques used are not state of the art. That fact is helpful in areas of the world where the newer technology is not affordable.

The results essentially showed that of the two groups those who had the surgery had higher rates of complications from the treatment, and longer use of sick days. The two groups had similar lengths of stay in the hospital. The cost of the two treatments was not documented but one would surmise that those receiving antibiotics were probably treated at a lower initial cost.

The study also showed that 40% of those who received antibiotics as the treatment initially ended up having the surgery within the next five years, that does mean that 60% did not. The 10 year data from this study will be published in a few years

The idea of treating appendicitis with antibiotics only has not been widely accepted here in the United States and in fact it was not widely accepted in Finland when this study started. The results of this study will probably lead to larger better controlled studies in the future. A larger well run study may allow surgeons the data they need to decide which patient needs surgery urgently and which may be treated with antibiotics safely. That being said currently many surgeons will watch a patient overnight or for a period of time while they give them IV antibioitics as they watch for a response. Many patients or parents may want to have the surgeon take the patient to surgery right away, even if it is in the middle of the night. This study certainly shows that the patient with uncomplicated acute appendicitis can wait and in many cases should wait until the surgery can be performed in the most safe time frame.

Ok, so we discussed the importance of perhaps treating a patient with antibiotics in place of surgery and that the impact may save some from having surgery. Now comes the time to confuse you, last week a study came out that shared results of a study that showed that individuals who had their appendix removed at a young age were 20% less likely to have Parkinson’s as they aged.

So now the conundrum, as a parent do you ask to try to avoid surgery by giving antibiotics or do you have the appendix removed knowing you may have decreased the chance of your child from having Parkinson’s in the future. We know that there are risks with any surgery so how do we balance the risks with the benefits? Before we discuss that, I am sure many of you have a simple question in your mind.

Right now many of you are probably thinking how can the appendix impact my chances of having a movement disorder in my brain? How can a small portion of my intestines have anything to do with my chance of developing Parkinson’s decades later?

This study first looked at results from the Swedish Patient Registry. This registry has data from 1.7 million patients and has followed them for up to 52 years. The review showed that 550,000 of those patients had their appendix removed, they then looked at the incidence of patients with Parkinson’s. They then compared the Parkinson’s patients and looked to see which patients had their appendix removed at a young age. They found that individuals who had their appendix removed at an early age had a 20% lower chance of developing Parkinson’s later in life.

That information caught the attention of many and the logical next question was, Why does this occur? So they examined the appendix of a large group of healthy individuals and found that many had an abundance of clump forms of a protein called Alpha synuclein. This protein is not well understood but some studies suggest it helps regulate the release of dopamine which is the chemical responsible for controlling the start and stop of movements. This is important as this protein when it mutates has been attributed to Parkinson’s patients. Now this protein is found in everyone so the possible relationship is that the appendix is a seeding for this protein to migrate into the central nervous system and brain through a nerve called the vagal nerve. If the mutated proteins were to enter the brain it can an effect on the control of the release of dopamine and lead to Parkinson’s

As this is a new study just released last week more work needs to be done. It again shows the importance of looking at big data. It is a stretch to say people were already thinking that the appendix may be involved in Parkinson’s disease. The ability to note a trend and then look at a group of health appendix to find that this protein is present in clumps in the healthy appendix. This allowed them to look at individuals who had this protein removed as they removed their appendix resulted in a 20% decrease in their chance of developing Parkinson’s. Amazing when you put the pieces all together.