Ask the Doctors: Antibiotics may be option for patients with acute appendicitis

Dear Doctor: My older brother was experiencing abdominal pain and nausea, and when he went to his doctor, he was told he had a “hot” appendix. But instead of surgery, he was treated with antibiotics. Is this safe? Shouldn’t his appendix have been removed?

Dear Reader: You’re correct that surgery has long been the go-to method of dealing with appendicitis. The first successful appendectomy was actually performed in London in 1735, to remove the perforated appendix of a young boy who had swallowed a pin. (And this was pre-anesthesia, so you can imagine what a grueling procedure that must have been.)

Since that time, surgical techniques have advanced to the point where, by the late 1990s, traditional open surgery had given way to the less invasive laparoscopic approach. Now, medicine is revisiting the idea of treating the existing infection in the appendix — that’s where the antibiotics come in — rather than pre-emptively removing the organ.

The appendix is a thin, tubular pouch, about 2 to 4 inches long in adults, which descends from the colon on the lower right side of the abdomen. Since it has no obvious purpose, it has been the subject of scientific speculation pretty much from the moment it was first identified. However, according to the most recent findings, the appendix is more complex and more important than was previously thought. Research shows that it’s the site of vital cellular activity during fetal development. In adults, it appears to have a role in immune function.

An inflamed or infected appendix is a medical emergency. That’s because, if left untreated, the buildup of infectious materials inside of it can cause it to become perforated or even burst. If that happens, the contents of the appendix will spill into the abdominal cavity, which can lead to serious complications, like peritonitis. In cases of a burst or perforated appendix, surgery is always the primary treatment. Not only does the appendix need to be removed, the abdominal cavity must be cleansed to prevent infection.

When the appendix is merely inflamed, though, and when CT scans confirm that the organ is not in danger of bursting, treating the existing infection with antibiotics becomes an option. Patients say they opt for this treatment because they want to avoid the risks of surgery and the resulting time spent recovering from the procedure. They are also drawn to the lower cost of the antibiotics option. And while studies support the use of antibiotics in treating uncomplicated acute appendicitis, the approach has its drawbacks.

A study published in the Journal of the American Medical Association in 2015 compared the outcomes patients who underwent appendectomies with those who underwent treatment with antibiotics. In the group that had the surgery, all but one of the 273 surgical patients had successful outcomes. Among the non-surgical group, 70 of the 256 patients — that’s 27 percent — had a recurrence and required surgery within the next 12 months. Still, for the other 186 patients, antibiotic therapy spared them the risks and costs of surgery.

Of course, every person’s circumstance is unique. We’re assuming your brother had a conversation with his doctor about the best treatment for him, and we would encourage others to do so as well.

Eve Glazier, M.D., MBA, is an internist and assistant professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and primary care physician at UCLA Health.