You're working in the emergency department, and a 24-year-old male comes in complaining of right lower quadrant abdominal pain that he has been experiencing for the past 4 hours. He is in obvious discomfort and complains of associated nausea and vomiting. Upon exam, you palpate the man's abdomen and find that he has exquisite tenderness with rebound to his right lower quadrant. As a good clinician, you run some labs and order a CT-abdomen. You think to yourself, "slam-dunk appendicitis." As you predicted, the radiology read confirms your diagnosis of acute appendicitis. As trained, you get a general surgery consult, who agrees to admit your patient for an appendectomy the following morning. You congratulate yourself and wish that all your cases were this straightforward. You did everything correct, right?
Appendicitis Can Often Be Treated With Antibiotics. (n.d.). WebMD. Retrieved September 19, 2020, from https://www.webmd.com/digestive-disorders/news/20150616/appendicitis-can-often-be-treated-with-antibiotics
Bettina, K. (2017). Clinical Value of Postoperative C-reactive Protein in the Detection of Complications After Open and Laparoscopic Appendectomy (Clinical Trial Registration No. NCT03119740). clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT03119740
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278–1287. https://doi.org/10.1016/S0140-6736(15)00275-5
Salminen, P., Paajanen, H., Rautio, T., Nordström, P., Aarnio, M., Rantanen, T., Tuominen, R., Hurme, S., Virtanen, J., Mecklin, J.-P., Sand, J., Jartti, A., Rinta-Kiikka, I., & Grönroos, J. M. (2015). Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA, 313(23), 2340–2348. https://doi.org/10.1001/jama.2015.6154
I think it is very important to reference cross-cultural studies like you incorporated here. It is easy to forget that there are one hundred and one ways to solve a problem, but as medical professionals we should remember to collaborate with others as to provide our patients with the best possible care.
ReplyDeleteI feel the antibiotic and surgical treatment option should be provided to patients rather than the typical push for surgery given the ethical principle of autonomy. Financial stress keeps people in need out of the emergency room, so promoting the non surgical antibiotic treatment for a potentially inevitable case of appendicitis would likely save lives in the long-term.
Austin, I found your blog post very interesting! I have previously taken care of pediatric patients with appendicitis and have always wondered if an appendectomy is the most effective form of treatment in children. Many of the patients I took care of had an increased length of stay due to post-operative complications such as nausea and vomiting. After researching a bit more about pediatric appendicitis, I found that the non-operative approach for appendicitis has shown some effectiveness in uncomplicated (without the tendency for perforation) pediatric cases. One study conducted by Knaapen et al., 2018, evaluated 45 patients with appendicitis. 42 of those patients were able to discharge from the hospital without an operation. Additionally, about 93% of the patients evaluated in this study responded well to antibiotic treatment and showed rapid recovery (Knaapen et al., 2018).
ReplyDeleteAlthough non-operative treatment seems to be effective, it would be interesting to see whether these patients developed ongoing symptoms of appendicitis or even perforated appendicitis. It would certainly be beneficial to take the less invasive approach and decrease length of hospital stay, but you also run the risk for readmission due to reoccurring symptoms or perforation.
Knaapen, M., Lee, J. H., Heij, H. A., Heurn, E. L., Bakx, R., & Gorter, R. R. (2018). Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: Secondary analysis of a prospective cohort study. European Journal of Pediatrics, 178(2), 235-242. doi:10.1007/s00431-018-3277-9
Hi Austin!
ReplyDeleteI think this is an excellent topic. I worked on a general surgery and trauma floor as a patient care technician for a year; many of my patients had appendectomies! I can only think of one circumstance where one of my patients was treated with antibiotics for appendicitis instead of surgery. This was due to the patient's past medical history of abdominal surgeries and her Crohn's disease; the general surgery team decided there was likely too much scar tissue and did not want to risk postoperative complications. The patient was in her young twenties.
Many patients who undergo laparoscopic appendectomies receive surgical drains to prevent build-up of intra-abdominal abscess formation for complicated acute appendicitis (Schlottmann, 2016). Current research demonstrates that inserting the surgical drain to drain abdominal fluid may cause more harm than good; it may lengthen hospital stay and there were no known benefits associated with inserting the drain (Schlottmann, 2016). After this research, I can understand why some clinicians are opting to use antibiotic treatment instead of surgical intervention. I believe it is important to base this decision case by case, instead of a "one size fits all" approach. Taking into account a patient's past medical history, their age, additional co-morbidities, etc. is important. For example, if a patient was 77 years old with a past surgical history of multiple abdominal surgeries, and Type 2 Diabetes, I think clinicians should heavily weigh the benefits and risks of prescribing antibiotics instead of surgery. I believe as healthcare professionals, it is our job to consider each patient as a whole person, cura personalis, to ensure each patient is receiving the best, most personalized, care for their specific health conditions. If it was my family member, I would want clinicians to base their decision regarding my family member’s treatment on a holistic perspective.
Schlottmann, Francisco, et al. “Could an Abdominal Drainage Be Avoided in Complicated Acute Appendicitis? Lessons Learned after 1300 Laparoscopic Appendectomies.” International Journal of Surgery, vol. 36, 2016, pp. 40–43., doi:10.1016/j.ijsu.2016.10.013.
I would likely choose antibiotics first, and if I continued to have issues then look at an appendectomy. It's often easy to disregard other possible solutions to a problem because our solution works well enough, but I think it's crucial to keep an open mind. And I think that's what the European study shows us. Do appendectomies work? Yes. But I think removing the recovery time due to surgery, risk of post-op complications, and the financial burden (as said in the original post) all associated with appendectomies makes antibiotic treatment a better option for those who it would be viable for. The main question I have would be: are there any risks and how severe are they if antibiotic treatment does not work?
ReplyDeleteFor me personally, I think I would just go ahead with surgery. I am biased with my opinion because I had appendicitis when I was 5 years old but mine ruptured fully so I didn’t get the option to choose. Despite having an option this time, I still think I would go ahead with full removal rather than antibiotics. Although the antibiotics show promising results, there’s no guarantee that appendicitis won’t happen in the future with a chance of it rupturing and causing fatal problems. I think I would rather sleep comfortably at night without having to worry about future complications. Antibiotics have always been cheaper than surgery, but there are people who paid for both antibiotics and surgery because the antibiotics didn’t work the first time.
ReplyDeleteTaking into consideration beneficence, I could see how antibiotics would be the immediate and right choice for someone with the luxury of early diagnosis of appendicitis. Additionally, I see how it can be cost effective, but without 100% guarantee that the antibiotics work, I don’t think I would choose them over surgery. Also, I had done some research on appendicitis and I think uncomplicated acute appendicitis which is appendicitis without neither perforation nor appendiceal abscess nor mass formation (Coccolini, 2018) would be okay to treat with antibiotics. However, as cases get more complicated and as many people could have future complications, I would just go with full removal.
References:
Coccolini, F., Fugazzola, P., Sartelli, M., Cicuttin, E., Sibilla, M. G., Leandro, G., De' Angelis, G. L., Gaiani, F., Di Mario, F., Tomasoni, M., Catena, F., & Ansaloni, L. (2018). Conservative treatment of acute appendicitis. Acta bio-medica : Atenei Parmensis, 89(9-S), 119–134. https://doi.org/10.23750/abm.v89i9-S.7905
I was trying to find the re-occurrence of appendicitis when treatment of antibiotics only is used and couldn't seem to find any information. I wonder if going forth with the surgery would be more beneficial due to the chances of appendicitis happening again. If this were the case, that I could potentially have appendicitis again, I would absolutely do the surgery. It's my understanding that appendicitis is very painful and I would not want to go through that type of pain again.
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