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AUSTRALIAN doctors have reacted cautiously to suggestions that a new, conservative approach to treating non-perforating appendicitis with antibiotics be considered rather than surgery, after a US study suggested the treatment of acute appendicitis should be revisited. (1)
The study, published in Archives of Surgery, presented data suggesting that non-perforating appendicitis in children behaves similarly to non-perforating diverticulitis in adults.
The study authors said a growing body of literature suggested that the relationship between non-perforating and perforating appendicitis was not as clear as previously thought. “Given the vastly improved abilities to establish these disease diagnoses and detect complications coupled with more effective antibiotic therapies, the treatment of acute appendicitis should be revisited,” they said.
They said it was assumed, but had never been proved, that appendicitis always perforated unless appendectomy was performed early in its course.
There had been randomised controlled trials comparing antibiotic treatment of appendicitis with surgery, and a non-randomised study demonstrating that acute appendicitis could be safely treated with antibiotics alone, they said.
Professor Danny Cass, professor of paediatric surgery at the University of Sydney and the Children’s Hospital at Westmead, said the study should certainly challenge assumptions and prompt a rethink of current treatment of non-perforating appendicitis.
“My first impression is that we should consider trials using antibiotics in the mild cases, that is, no fever, normal white blood count and only deep tenderness — clearly non-perforated,” he said.
“In this mild group, there need not be admission to hospital but there must be meticulous follow-up and enrolment in a prospective review.”
But Professor Cass said that for children under 10 years with clear signs and symptoms of appendicitis, it could be difficult to be certain that the appendicitis was truly “non-perforated”, so he would be reluctant to change the current approach.
Dr Naeem Samnakay, paediatric surgeon at Princess Margaret Hospital in Perth, said the results were interesting and food for thought but for now, appendectomy remained the gold standard treatment for appendicitis in children.
“To vary management from this would require clear evidence that antibiotic management alone provides a better outcome for children with appendicitis,” he said. “It would also require clear evidence of the natural history and pathogenesis of acute appendicitis and of a difference in pathogenesis, if there is one, between non-perforating and perforating appendicitis. This definitive evidence is currently unavailable.”
Dr Samnakay said his experience was that very young infants and toddlers often present with perforating appendicitis even with short presenting histories. “Our experience also is that children with delayed presentations are more likely to have perforating appendicitis.”
The study authors analysed data from the US National Hospital Discharge Survey to investigate the incidence of admissions for appendicitis in children under 20 years of age and diverticulitis in adults over age 40, between 1979 and 2006.
They found that perforating appendicitis and diverticulitis behaved differently from their non-perforating counterparts.
“These findings seem incompatible with the long-held view that perforating appendicitis is merely the progression of non-perforating disease where surgical intervention was delayed too long,” the authors said.
“If appendicitis represents the same pathophysiologic process as diverticulitis, it may be amenable to antibiotic rather than surgical treatment.”
However, Dr Samnakay said there was much more to acute appendicitis than “perforating” or “non-perforating”. “There is a range of intra-operative appearances of the inflamed appendix, from mild oedema, to suppurative inflammation, to fibrinous inflammation, to gangrenous inflammation.”
An invited critique in Archives of Surgery said more information was required before the approach to non-perforating appendicitis and diverticulitis was altered. (2)
Although the argument put forward by the study authors was well formulated and supported with extensive statistical analysis, the pathogenesis of acute perforating appendicitis was unclear if not originating from its non-perforating predecessor.
“Is it then safe to assume that any two diseases that are equated through cointegration [analysis] are, in fact, the same disease?” the critique said.
The study authors said appendicitis and diverticulitis shared many similarities and some differences. Both were rare where hygiene was poor and diets were high in fibre, there was an increased incidence of both as cleanliness in the Western world had improved, and they were more common in populations with a higher socioeconomic status.
– Cathy Saunders
1. Arch Surg 2011; 146(3): 308-314
2. Arch Surg 2011; 146(3): 315
Posted 28 March 2011
Surely further study, long term study included, is needed before any valid conclusion can be published, bearing in mind varying skills and locations of practitioners, varying compliance of patients and in children of parents, varying attitudes of non-medical people about doctors, their knowledge base and what internet postings influence, also varying attitudes of judges, juries and lawyers to name a few cogent variables? Other variables include adhesion formation, tendency over long term to intestinal obstruction in operated and non-operated, as well as immediate morbidity, mortality etc.
In my view only after that, perhaps in some years will variation of present practice be safe?
Notwithstanding my conservatism, the new question is a good one to raise.
I was taught to regard the vermiform appendix from an evolutionary perspective: it is a vestigal structure that probably served an essential function in herbivorous animals as it apparently does presently, for example in the koala. There is evidence, however, that this vestigal structure may still serve potentially useful functions as an immunological or physiological regulator of gut microbiological flora. In the same way, literature as early as 1929 suggested that the lymphoid tissues comprising the human tonsils served no purpose and thus surgeons might reasonably have a low ‘threshold’ for managing tonsillitis by effecting their extirpation. There will at times be sound clinical grounds for elective or urgent tonsilectomy. Conversely, in (certain Australasian) populations at risk of rheumatic fever, there will be clinical circumstances where best practice would involve oral antibiotic treatment even of relatively mild, initial, tonsillitis associated with group A Steptococcus as well as others where a conservative (mouth gargles and analgesia) approach is reasonable. The challenge for scientific practitioners of medicine and surgery is in differentiating between the need for timely appendicectomy or a trial of either parenteral or oral antibiotic therapy. Further studies seem warranted.
I agree.
In my resident days at Sydney Hospital (late 1960s) I did a gynae term so was exposed to many cases of “blown fallopian tubes” with a past history of a complicated appendicitis.
In my general surgical (registrar) days in the UK any young female for whom I was responsible with symptoms and signs related to the RIF (esp. deep tenderness and rebound) parted company with their appendix. I had no regrets with this approach.
I have suspected something along the lines of this article for some time. Sure we must treat this possible alternative management with caution, but that is not hard in the stable GP population, by just arranging regular review with hand on the tummy, until ‘clearly out of the woods’. However, it never made sense to me that the appendix should behave so differently from the rest of the body, which the ‘all or nothing’ concept of appendicitis seems to suggest. And then there is the frequently experienced grumbling appendix to explain… Add to that the significantly lower incidence of acute appendicitis (certainly my experience after 40 years), possibly because we are seeing and treating kids with antibiotic more than in the ‘old days’ and thereby sometimes inadvertently saving them (probably) not only from rheumatic fever, scarlet fever and scarletina – terms one has almost forgotten these days they are so rare, not to mention acute post-strep glomerulonephritis, which has also diminished in frequency by a significant amount. It is quite possible the lower frequency of acute appendicits falls into the same camp, ie, in many early cases preventable or treatable by conservative means. That is by oral antibiotic, specifically or serendipitously administered….?
There are many situations where a perforated appendix might be obscured – retrocaecal, retroileal, pelvic. I agree that many patients with pain in the RIF may be mild appendicits or not appendicitis at all and these may be the ones that respond to antibiotics. Close monitoring is essentail as obstructive gangrenous appenditis progresses relentlessly to perforation and is best treated by early operation. By the way it is appendicitis, not appenditis and, so, appendicectomy not appendectomy – we are not the next state yet!
Before we go “inventing the wheel” again…it would surely be
good to consider where medicine, indeed where surgery has come
over the past 200 years and reconsider the diverse circumstances which we as practitioners find ourselves being called to treat common conditions such as acute appendicitis and acute diverticulitis. A tertiary referral centre in the middle of a capital city in Australia is a far cry from a rural or regional centre either in this country or any other…likewise ‘the resources’ available !
And surgical removal of the infected appendix……CURES 100%