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Drawing of colon seen from front (the appendix is colored red). Credit: Wikipedia.

For more than 100 years, the standard treatment for appendicitis has been surgery. Now a large Finnish study provides the best evidence to date that most patients can be treated with antibiotics alone.

How did the usual treatment of doing an appendectomy (appendix removal) arise? In 1886 Dr. Reginald Fitz, while investigating pelvic infections (which resulted in many deaths in those days), decided that an inflamed appendix progresses from a mild inflammation, to gangrene, then perforation, which would result in pelvic abscess.

This reason for an appendectomy (that it would prevent serious infection) became established in medical thought and still guides appendicitis management today. But nowadays we have antibiotics! And the researchers noted that some cases resolved on their own without any treatment.

And instead of the prevailing view for many years that the appendix is a "vestigial organ with no purpose",  it turns out that the appendix has a great reason for existence. It seems to provide a safe haven for good bacteria when gastrointestinal illness flushes those bacteria from the rest of the intestines. This reservoir of gut microbes then repopulates the digestive system following the illness.

It makes me wonder why some people get appendicitis and others don't - do they have inflammation for some reason so that their bacterial communities are out of whack (dysbiosis)? Would dietary changes help prevent recurrences?

From the NY Times: Antibiotics Are Effective in Appendicitis, Study Says

For more than 100 years, the standard treatment for appendicitis has been surgery. Now a large Finnish study provides the best evidence to date that most patients can be treated with antibiotics alone. The study, published Tuesday in JAMA, involved 530 patients aged 18 to 60 who agreed to have their treatment — antibiotics or surgery — decided at random. Three out of four who took antibiotics recovered easily, the researchers found. And none who had surgery after taking antibiotics were worse off for having waited.

The new study comes amid growing questions about the routine use of surgery to treat appendicitis, which strikes about 300,000 Americans a year, afflicting one out of 10 adults at some point in their lives.

The results only apply to uncomplicated appendicitis, stressed Dr. Paulina Salminen, a surgeon at Turku University Hospital in Finland and lead author of the new study. She and her colleagues excluded from their trial the 20 percent of patients with complicated cases — people with perforated appendices or abdominal abscesses, and those with a little, rock like blockage of the appendix called an appendicolith.

In the 1950s, soon after antibiotics were discovered, some doctors reported success using them to treat patients with appendicitis. But, Dr. Livingston wrote in his editorial, “So powerful is the perceived benefit of appendectomy for appendicitis that surgical treatment for appendicitis remains unquestioned, with seemingly little interest in studying the problem.”

Dr. Livingston also found that most appendices that perforate have already done so by the time the patient shows up at an emergency room. Those that have not perforated when the patient seeks medical help almost never do so. People with so-called uncomplicated appendicitis, he concluded, seem to have a different disease — one that can be treated with antibiotics.

“The reason we take the appendix out and do it as an emergency is the belief, dating back to 1886, that the appendix will eventually become gangrenous and cause a pelvic abscess,” Dr. Livingston said.

Even with the results of the Finnish study, many questions remain. A person who has had one episode of appendicitis is at higher than usual risk for another....Accumulating data has led other experts to raise an even more controversial idea: Perhaps antibiotics aren’t always necessary, either. It is possible, some researchers say, that most people with appendicitis would get better on their own if doctors did nothing. The Finnish team is now planning a clinical trial to test that theory.