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After century of removing appendixes, doctors find antibiotics can be enough (arstechnica.com)
481 points by YeGoblynQueenne 5 months ago | hide | past | web | favorite | 205 comments

I found this conversation unnerving at 13 years old:

Doctor: "Does all this make sense? We need to remove your appendix.. now."

Me: "Doctor, ok, so you need to remove my appendix cause if you don't I could get really sick. "

Doctor: "Yes."

Me: "What does the appendix do?"

Doctor: "We don't know."

Doctor: in your case, kills you in about 24-48 hours.

I had mine out as well. I was 19. My dad drove me to the hospital. Doc slipped his finger up my bum, said, “you have appendicitis. You need surgery. Now.” I was being operated on quickly after that. It had ruptured. So it goes.

A ruptured appendix would not likely be resolved with antibiotics, I'd think. But catching appendicitis before it ruptures would be a less critical issue.

It definitely can, mine fully ruptured and I didn't find out till 4 days later. It requires very strong antibiotics, but did work good. My appendix came out 3 months later in a normal way.

Wow, I find that quite amazing.

Its not that surprising. You don't go removing your arm every time you get a cut.

Once the swelling that caused the rupture has stopped, it can heal. Assuming it wasn't too severe (you don't want to die of internal bleeding in the meantime)

Perhaps I was confusing "ruptured" with "exploding".

>Doc slipped his finger up my bum

Is this a standard way to diagnose appendicitis?

The appendix is a tricky organ, it's position varies a far bit so not all patients with appendicitis get the classical symptoms (pain that begins as dull around the belly button, then moves to the right lower quadrant add becomes sharp and worse on rebound).

Digital (as in finger) rectal examination is meant to help detect some of the atypical cases. It was part of my teaching, although I haven't read up much on it.

I'm a student doctor.

Yeah pressing on the area isn't so bad, but pull your fingers away quickly and oh Jesus! I had appendicitis when I was 8. It ruptured during the visit to my GP, literally shit blood, rushed off to the hospital for an emergency appendectomy. Fun times!

I was in there for a few days. The kid in the bed next to me was hard case. Nurse comes to check on him and he goes "yeah I managed to get all the grass out of my cut, and now it's heaps better"

He'd pulled all his stitches out.

Heh, yeah. It is traditional. And ineffective (of course). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071072/

I was kind of out of it. Maybe there was a lot of pain, but my memory of it was just so much discomfort, what is something minor like that?

That's an excellent article you link - to paraphrase the conclusion: digital rectal examination should not be performed routinely for abdominal pain, but should be considered an investigation to consider when diagnosis is unclear.

Thanks. I guess it isn’t fair to say it is ineffective, it can give some information.

Clinical history, some labs, and imaging are typically used to diagnose. In adults, CT scan has the highest sensitivity and specificity (0.96 and 0.96); better than ultrasound. The difference is not as pronounced in children (smaller abdomen-- easier to visualize using ultrasound), so that is commonly used to save exposure to radiation (though note that an abdominal CT scan is actually a very low dose).

Source: https://effectivehealthcare.ahrq.gov/topics/appendicitis/res...

"The estimated effective radiation dose of abdominopelvic CT is 8 to 10 mSv with standard dose and 2 to 4 mSv with low dose techniques [40]. To put these numbers into context, the effective dose from annual background radiation is 3.1 mSv and from plain abdominal radiography is 0.7 mSv." (from https://www.uptodate.com/contents/acute-appendicitis-in-adul...)

I was taught by a computer game that it's diagnosed by palpating the four quadrants of the abdomen and doing an ultrasound. A lot of the decoy cases were just gas; hold for observation until they fart it out.

This wasn't in the game, but I presume it may also be necessary to do a pregnancy test (ectopic?), urinalysis for urinary tract infection, swabs for genital tract infection, blood draw for white blood cell count, and maybe look for other bowel conditions, kidney stones, gallstones, clots, torsions, cysts, or diverticula with the ultrasound.

Was it "Life & Death"? That game was difficult as a kid. If surgery was involved, the patient always died.

That was it, I think. I could even do the aortal aneurysm surgery without killing the patient. And my boss hardly even yelled at me for mistakes.

It came in a bundle with Beyond the Black Hole, which came with 3D glasses that worked with CRT monitors. The feelies for L&D included a surgical mask. Maybe it came with Chessmaster, too?

There's videos of people doing the surgery, but I've never managed it either

I was 13 when I had it. I had a high fever and puking out an entire day. When I went to the doctor, i think he didnt even look at my face: just poked my abdomen. Even I understood immediately it was appendicitis.

I was taught first year of medical school (2017-2018) that it isn't. Some physicians probably still use it though.

"If you don't put your finger in it, you'll put your foot in it" is still a common aphorism. Enjoy your time on surgical assessment when you get to your clinical years!

Mine was blood test (checking infection), palpating (to see which parts of my gut hurt), and ultrasound. I now feel like I've missed out.

About 10 years ago, one study set forth an interesting hypothesis: The appendix is a place where "good" bacteria can safely hide during infection. I'm not sure if there's been any work since then to confirm the hypothesis, but it sure is an interesting idea.

Source: https://www.nytimes.com/2008/06/17/health/research/17appe.ht...

I think I remember reading at some point that another hypothesis is that it acts as a repository for bad bacteria, so that your immune system doesn't forget how to make antibodies for those bacteria. I think I remember the sinuses being posited as serving the same role.

What if the appendix is an attempt to "tame" bad bacteria into being good? Does giving bacteria access to nutrients from our food and mucus remove the selective pressure to evolve virulence factors?

Oh, yeah, I remember reading about that! I think that's seeped into my head as 'leading reason we think we have an appendix.'

This is the great thing about HN -- there's a very good change somebody will come along and update my intuition.

Papers please. Bacterial edition

Hands and feet are also very useful ... until they turn septic and need to be removed. Antibiotics can treat infections in the early stages if diagnosed well ahead of time. But once an organ is totally taken by infection it may be unrecoverable. Either you remove it or it becomes a lump of dead tissue spreading evil to the rest of the body. By the time someone is in the emergency room due to abdominal pain, by the time they are seen by a doctor and ultrasounded, it will need to come out.

Pretty sure the whole point of this article is that often enough patients arrive in the emergency room at a point where it's NOT too late to treat successfully with antibiotics.

Look at the people in the thread who ruptured. They certainly did not make it in time.

That’s correct. There’s a difference between “often” and “always”. There are also several people posting in this thread who had their appendicitis successfully treated with antibiotics.

Someone mentioned tonsils below, but in the past, we also had bloodletting, trepanation, and various other unnecessary excisions. Foreskin may one day join the list (who knows, though). This all raises the question of why medicine is practiced the way it is, with so much appeal to authority and memorization, rather than something more intrinsically scientific. Why do bad practices persist for so long?

> Why do bad practices persist for so long?

Define "bad". Appendicitis patients invariably survive surgery and go on to live their normal, healthy lives. Until an objectively better solution comes along, we have no reason to not go with what Just Works™. And that's why medicine dislikes change.

That's great to hear. However, keep in mind that appendicitis is still an extremely serious condition that will kill you if left untreated. The fact that you can avoid surgery in some cases doesn't mean that surgery is not an adequate treatment.

It's amazing how medicine has advanced: We can now cure illnesses with very minimal amount of invasiveness required in most cases. Even before this news, open surgery was already mostly supplanted by laparoscopy, which involves only a few tiny cuts.

Appendicitis will kill you! And the surgery in most cases will save you. :) At least in my case.

I technically died from a ruptured appendix and spent 9 days in ICU. The doctors delayed surgery to see if the antibiotics would work. This was ~10 or so years ago.

Can you give more details of "technically died"? Any after-life experience?

Technically died likely means cardiopulmonary arrest aka a heartrate of zero. Medical personnel refer to this as "a code" or "code blue"

I drowned as a kid in a friend's pool when I was 7 or 8. I was "technically dead" as well. No afterlife experience, but as I was thrashing underwater, my entire body felt like you feel when your leg goes to sleep, and before I went "to sleep" I got really calm and everything was peaceful. The only thing I could feel other than whole body numbness was a strong warmth. I took one last look up at the sun sparkling on the ripples of water above and closed my eyes.

A few minutes later, I awoke puking water and choking with my best friend shrieking hysterically as her mother frantically performed CPR on me. For some reason, my parents never ever let me swim in her pool again or go to her house unsupervised.

You're crazy lucky, CPR isn't supposed to bring you back from anything or flush water out of your lungs, it's supposed to keep your blood flowing to your brain until paramedics can get to you.

Lucky indeed! I was terrified of water until I was about 12 and only then learned to swim.

The doctor told me that there was no heartbeat and no breathing for approximately 3 minutes. Since I'm still here... :) I called it technically dead.

As for afterlife... I don't remember anything from surgery until I woke up 9 days later in the ICU.

Any permanent damage? Or did you make a full recovery?

I had/have a few issues now. My kidneys were damaged and there have been slight memory issues. Both eased over time.

The weirdest thing was, I started craving BBQ ribs. I was indifferent to them before.

Glad you are feeling better...but after reading your comment I too am craving bbq ribs. I was indifferent to them before.

After his comment I was curious, but still indifferent to bbq ribs. After yours, I too am craving bbq ribs. Some sort of ripple effect?

I read all three of these comments and I still dislike bbq ribs.

Funny guys :)

It was almost an obsession for several months to the point the family got sick of them... I'm glad that's over with.

I've asked a bunch of doctors about it and none of them had answers.

Not a doctor but supposedly a brain can be without oxygen for about 6 minutes without permanent damage.

That's not a phrase a physician would typically use. Laypeople sometimes use it to describe respiratory and/or cardiac arrest.

Thanks. I have no medical training, so that helps. So the brain can still function for a while during cardiac arrest?

Yes. In fact you can be "dead" for rather a while and still get better under very specific circumstances, typically involving hypothermia.

I think the saying is, “Nobody is dead until warm and dead.”

Example: https://www.pennlive.com/midstate/index.ssf/2015/03/union_co...

Another example: http://time.com/3897897/how-an-italian-boy-survived-42-minut...

They delayed surgery before or after the rupture? Was it already ruptured when you arrived?

Before :) -- They were looking for the antibiotics to possibly save me from the surgery, which was my request when I was told what the treatment approaches could be.

The thinking there is likely part of what saved my life. They put a thing in the huge vein in my neck at the point I opted to attempt to avoid surgery that was used to directly deliver the antibiotics to the brain.

In this case, would they keep you in hospital for a while to see if the antibiotics work, while being on standby to do emergency surgery?

do we know how non 'modern' cultures deal with that ? different diet/lifestyle makes the condition rare if not more ?

This reminds me of when tonsils were removed at the first sign of trouble.

When I was in my early 20s, in the 1970s, I went to my doctor about a bad sore throat. He advised me to see an ENT who barely bothered to look down my throat for more than a second and automatically declared I needed mine removed. That bothered me but I very much respected my personal doctor who said he respected this ENT. When I mention this to doctors nowadays, most nod their heads that, today, it's not likely mine would have been removed.

Growing up, I felt like getting tonsils removed was as common as changing teeth, it must've happened to a third or so of my classmates at the time.

It seemed harmless enough from a distance, they pull out some stuff from your throat and you get ice cream.

They tell you you can have all the ice cream you want to eat, but neglect to mention that you'll be in too much pain and too nauseous to actually want to eat any. :P

Believe me, all the ice cream in the world isn't worth that experience. You're not missing anything.

I had mine out as an adult and it was a pretty painful week of recovery.

Yes but Allison visited me in the hospital! TIL: Alisson liked me!!

Another example of this is how frequently ENTs will combine septoplasty to fix a deviated septum with turbinectomy. This has resulted in a lot of people suffering from Empty Nose Syndrome which is so distressing that some kill themselves over it [1]. My wife recently consulted with an ENT, and he said that he rarely does turbinectomies, since enlarged turbinates are often just a result of a deviated septum and will revert to a normal size months or years after septoplasty alone. He said with some dismay that lots of other ENTs haven’t changed their approach.

[1] https://www.buzzfeed.com/joeloliphint/is-empty-nose-syndrome...

That's horrifying. At least wikipedia says it can be fixed in many cases by a surgery that replaces the missing turbinate parts with artificial structures that serve the same function.

It depends on lots of factors. Under age of six they have decent chance to grow it out, but doc should check for other conditions like missing some breathing while asleep etc. Also depends on risk avoidance of your doc in general.

Are there hypotheses now for the purpose of the tonsils the way they've developed some for the purpose of the appendix?

From the Wiki page on tonsils, it seems they have an immunological function.

I had my tonsils removed when I was 4. They were so infected, that they basically fell apart shortly after removal.

Somewhat OT but interesting: "When [Kurt] Semm introduced laparoscopic surgery at the University of Kiel, he had to undergo a brain scan at the request of coworkers as 'only a person with brain damage would perform such laparoscopic surgery.' On September 13, 1980, Semm performed the first laparoscopic appendectomy, opening up the path for a much wider application of minimally invasive surgery. At first, his operation was severely criticized. Initial attempts to publish it were rejected, and the American Journal of Obstetrics and Gynecology stated that his technique was 'unethical.' The president of the German Surgical Society demanded that Semm be suspended from medical practice."—Wikipedia

You’d be surprised to learn what happened to the person who suggested it is better if the surgeons wash their hands between patients (Ignaz Semmelweis)

I just looked this up and oh wow, and I don't perceive that this situation could have only happened back then.

In the modern day, a lot of people with a lot of education will scoff at anything that hasn't been produced by science, or even anything that simply wasn't taught to them in medical school. Meanwhile, the medical system is full of inefficiencies and outdated practices because of politics and resistance to accepting or learning newer scientific findings. Worthwhile questions about simple ways to improve things often go unanswered, because nobody has been able or willing to do a large, randomized trial about it.

A recent example: Drs. Barry Marshall and Robin Warren, who discovered that gastritis, gastric ulcers, and stomach cancer are caused by the bacteria H. pylori. "In 1983 they submitted their findings so far to the Gastroenterological Society of Australia, but the reviewers turned their paper down, rating it in the bottom 10% of those they received in 1983."—Wikipedia. Marshall and Warren were awarded the Nobel Prize in Physiology or Medicine in 2005 for their discovery.

Hey! We must read similar things.


Looking back I could have talked about Zika here. How many childhood viruses are we sure don't cause down-the-road issues like cancer? Most of the time when you get a random virus, the doctor has no clue which one it is and doesn't test to find out. I can remember being told by nurses at the school "there's a virus going around," and that's all we knew: there was some virus, and everyone was getting it. We just assume that these things are harmless and irrelevant once you recover from them.

I really look forward when the premise of Theranos becomes technically viable. Cheap continuous medical tests.

So much in medical diagnosis is just a very coarse decision tree and it is uneconomical to investigate every sickness.

Imagine doctors having more time per patient. Imagine many diseases detected before there are symptoms.

I got carried away here, but medicine looks so much more promising then CS sometimes.

There is huge room for medicine to be improved, but actually the reason for that is there is a lot of resistance to changing things in major ways despite all the things that could be done. A lot of software companies know that their key to staying on top is to improve things fast enough that a group of founders in a co-working space won't put them out of business. Hospitals don't have this pressure at all; they just have to keep providing the acceptable services that they always have, and people will still go there. I've been pressured into unnecessary procedures and even given (multiple!) sales pitches for surgeries that I haven't needed or wanted, because the hospital makes huge amounts of money from it, and consumers aren't savvy enough to know when their doctor is just trying to pad his profitability figures.

Plus, when you write software that disrupts an industry, your employees are still software developers who work and function like software developers. If you want to change healthcare, you need to change how the doctors operate.

> I've been pressured into unnecessary procedures and even given (multiple!) sales pitches for surgeries that I haven't needed or wanted, because the hospital makes huge amounts of money from it, and consumers aren't savvy enough to know when their doctor is just trying to pad his profitability figures.

That's called Fee-For-Service (FFS) and is there is active effort to replace it with quality-based schemes. Providers still get paid for individual services but the rate depends on quality metrics of their overall population. (Source: worked in software for Population Health)

The inefficiencies you describe are less from the clinical side and more from the administrative side. Many of these admin-level people are doing what they can in an incredibly complex maze of processes, most of which started for a good reason. But they are process bees, and unable to make any changes: there's a huge barrier to change as of course nobody wants to be responsible for worse outcomes / deaths due to failure to respect process—yet they are immune from repercussions if poor outcomes are cause by said process.

More to the point, clinicians live in a constant grey zone: everything is a risk tradeoff and they do what they can to get the best outcome. The adminstrative folk see things in black and white. Here's a real example: outpatient office has slightly expired meds that are life-saving if a procedure goes bad, but new meds are not available because factory got damaged by hurricane. Common-sense is that a med does go from perfect to useless overnight and a few weeks is no big deal, especially when there is no alternative. Administrative view is the meds can't be used and must immediately be discarded because having them around the office will expose them to liability during audits... yet of course doesn't understand why that means all procedures of that type would get cancelled.

I'm a retired neurosurgical anesthesiologist with 37 years of experience. Medications one day after their so-called expiration dates are just as effective as they were 24 hours earlier. Loss of potency and therapeutic efficacy over time varies tremendously depending on storage conditions: drugs kept refrigerated and in the dark will likely work just fine for YEARS after their expiration date. Pharmaceutical companies have noted that they are extremely conservative when it comes to expiration dates, much preferring to err on the side of caution. Dept. of eating your own dogfood: I had an anaphylactic/allergic reaction of unknown etiology in late 2015, my first ever; I had to go to the ER for IV steroids and Benadryl for treatment. No recurrence since. I immediately bought two Epi-Pens, one for my house and one for my car. Their expiration date was March 2017. I am completely comfortable not having purchased new ones, especially considering their now inflated prices even after all the bad publicity that focused on their markup. So I have bet my life on my belief that these "expired" epinephrine injectors will save my life should I ever have another anaphylactic/allergic reaction. However — if someone asked me for advice, I would tell them to get up-to-date ones; as a former practicing physician, this is one of those cases where what you advise is quite different from what you yourself would do.

We also assume that we only get a virus when we notice it.

The reality is probably more like: You're exposed to millions of different viral antigens over the course of your lifetime; Many of them don't have a mechanism to really hurt you, and nearly all of them are dealt with efficiently by your immune system.

Not only do they not cause symptoms, we don't even have a mechanism to identify them unless we already know what we're looking for.

"Ancient Viruses Are Buried in Your DNA":https://www.nytimes.com/2017/10/04/science/ancient-viruses-d...

Side note, my daughter was born at Semmelweis hospital in Vienna. My wife was studying in Vienna at the time. That's when I heard of Semmelweis and read up all about him.

It's weird in retrospect.

When my grandfather had his gall bladder removed (late 1960s, I think), he spent about 4-6 weeks in hospital and another couple of weeks at home recovering; last year, I had my gall bladder removed, they sent me home after three days. Now that's progress!

My GF had a laparoscopy a few years ago where they removed a 10cm cyst. She was home the next day, and that was only because they had a slight concern. She had another one a few weeks ago, first one under the knife, home the same day.

Still 4-6 weeks of recovery, but that's mostly due to them having to inflate the abdominal cavity to be able to see / work and a bit of bruising and shifting of stuff.

My gallbladder removal 5 years ago was outpatient surgery. I went in around 7am and was home on the couch by mid afternoon. Gave up the serious pain meds the next day since the side effects (zero attention span) were more annoying than the bit of pain. It's amazing how far we've come for some medical treatments.

>> Gave up the serious pain meds the next day since the side effects (zero attention span) were more annoying than the bit of pain.

Next time you can try Ibuprofen + Tylenol, to avoid mentioned side effects.

Ibuprofen Plus Acetaminophen Equals Opioid Plus Acetaminophen for Acute Severe Extremity Pain: https://www.aafp.org/afp/2018/0301/p348.html

I was a little disappointed I did not get any opioid analgesics after the procedure, but on the plus side, I did not need it. I got Metamizole (https://en.wikipedia.org/wiki/Metamizole) on the first day and was told I could ask for more on the second day, but the pain was negligible, so I did not ask for more.

I had my gallbladder out in 2010, three day stay as well, and while I took a few days to get back to being able to walk comfortably (this was pre-lifting so I was a scrawny weak guy generally so took longer to recover) it was still amazing how quickly you could bounce back from having an organ removed.

But also - how much of that is medical progress, and how much of that is ballooning costs coupled with insurance companies refusing to cover more than the absolute minimum (and in some cases much less than what really should be the minimum for the sake of safe recovery)?

Good question. I think the medical progress is tremendous. My grandfather needed weeks before he could sit up again without serious pain, and he had a scar that went all across his abdomen. I had four small incisions (the largest was about 2cm long) and was on my legs and walking around without trouble the next day. I did not even need or get serious pain medication. As long as I stayed in the hospital, the doctor looked at the incisions every day to see if there was any sign of inflammation or infection. About the only serious discomfort I had was from the gas they used to inflate my abdominal cavity; but that was not so much painful as uncomfortable.

As far as I can tell, gall bladder removal is a fairly routine procedure by now, and the risks and possible complications are well enough understood that a competent surgeon can tell after three days if the procedure went well or if there are any problems. (Also, they told me to come back immediately if I experienced any pain or fever, or the incisions appeared not to heal properly.)

I Germany, hospitals usually get flat fee per case depending on the diagnosis, so there is an incentive to release patients as soon as possible. But all the doctors and nurses I have met so far take the health of their patients very seriously, and I do not believe they would release somebody who was still in need of medical care. Plus, ethical considerations aside, that might incur legal repercussions for the hospital and the doctor ordering the release, even in Germany.

I was home the next day after having mine out. It sucked for a couple of days as my body absorbed the gases they pumped my body up with, but then it was fine.

Tells you a thing or two about the social nature of applied sciences.

It is indeed progress, all that time spend among the sick and not moving around is very hurtful to the human body. It is mainly that realization that causes the difference, and not better surgical techniques I think.

Mmmh, one large scar across your abdomen (~20cm, I think in case of my grandfather) vs. four incisions about 1cm each makes a huge difference.

Being able to get up and move around on the next day vs. having to lie in bed for weeks certainly makes a difference psychologically, but the laparoscopic procedure does put a much smaller burden on the body, too.

An aspect of this that is seldom remembered is that Semmelweiss was a HUGE jerk, which didn't help adoption. Instead of telling or showing other doctors how things could be better, he called them barbarian murderers for not washing their hands. It was a decade before he'd even have a civil conversation about it, or publish for peer review.

There's a lesson in that...sometimes being right isn't enough on it's own.

Semmelweis also couldn’t explain why his procedure supposedly worked. Again that’s hugely problematic: a sound theory requires an explanatory framework. Otherwise it’s just not convincing.

That the laparascopic pioneer's name is Semm is unreal. You couldn't make it up.

Wow, given the context, I just immediately assumed it was coined because of the story OP detailed. An incredible coincidence!

to paraphrase randall munroe, what are the odds that we would have two unrelated US presidents whose names both started with T-R-U-M ?

I found this definition very strange, from its choice of words and mentioning “undeveloped planets”?!

"Mob behavior found among primates and larval hominids on undeveloped planets, in which a discovery of important scientific fact is punished"

The article concedes that it is a "polemical definition" -- it may still be the first documented usage.

It was irony.

Are there examples of other fields being so staunchly/abusively conservative? I'm struggling to imagine a physicist, engineer, or attorney being forced to undergo a mental examination for suggesting a radical new theory or procedure.

"I hold that space cannot be curved, for the simple reason that it can have no properties. It might as well be said that God has properties. He has not, but only attributes and these are of our own making. Of properties we can only speak when dealing with matter filling the space. To say that in the presence of large bodies space becomes curved, is equivalent to stating that something can act upon nothing. I for one, refuse to subscribe to such a view."—Nikola Tesla

Perhaps he will be validated when we develop/discover a deeper theory.

After all, we have physicists going around now (e.g. Nima) saying 'spacetime is doomed'

Presumably they had a brain scan machine (scanner?) nearby, ready to go. Everyone likes a joke with a prop.

I'm so confused. From Wikipedia:

> Appendicitis is caused by a blockage of the hollow portion of the appendix. This is most commonly due to a calcified "stone" made of feces. Inflamed lymphoid tissue from a viral infection, parasites, gallstone, or tumors may also cause the blockage... The combination of inflammation, reduced blood flow to the appendix and distention of the appendix causes tissue injury and tissue death. If this process is left untreated, the appendix may burst, releasing bacteria into the abdominal cavity, leading to increased complications... Acute appendicitis is typically managed by surgery. While antibiotics are safe and effective for treating uncomplicated appendicitis, 26% of people had a recurrence within a year and required an eventual appendectomy.

Given that bacteria are not even listed as a cause of appendicitis above, how do antibiotics help at all? Is there anything they can do to prevent "tissue death" in the appendix itself, and how? What about that "stone"?

Or are the antibiotics for dealing with an actual ruptured appendix (to kill leaking bacteria from the gut into the rest of the body), while the appendix presumably eventually resolves its blockage and heals itself on its own? Which sounds... scary, but of course I'm no MD.

Would love if anyone here knows how to explain what the article doesn't.

> Or are the antibiotics for dealing with an actual ruptured appendix

If your appendix ruptures, it is life threatening and has to come out.

Most appendix removals happen before the appendix ruptures. The conclusion of the study is that high doses of antibiotics is an effective way to prevent the appendix from rupturing without surgery.

> The conclusion of the study is that high doses of antibiotics is an effective way to prevent the appendix from rupturing without surgery.

I've been through a few million dollar surgeries and I had my appendix out as well. When you get a blocked appendix (appendicitis induced), you create scar tissue from the inevitably distended bile duct. Now you have an increased chance of it occurring again, and a weaker duct (scar tissue is generally weaker). This snowballs. Removal is the safe course after the first onset. This study assumes 2 things. First, that no major damage is done over the course of appendicitis attack(s). Second, the patient is compliant with a dietary restriction and an antibiotic course. Yes, you don't NEED to have your appendix out after the first attack if you eat right. The chances that a patient is compliant is less than 50% This is just a medical reality. People who take blood thinners have to be monitored, more for compliance than anything else, and there's a whole industry to the more dangerous conditions than appendicitis.

No, it's not a medical reality. It's a perception in the American system. Europe currently follows the high dosage antibiotic approach.

I would agree that it's "not a medical reality", in that it does apply only to the USA.

I still have the question: what about the 'stone'? Do antibiotics cure that somehow? Or is that the reason that 30% of those treated with antibiotics ultimately have the surgery?

One of my kids had his appendix out last year, and I asked a similar question. My recollection was: Blockages can form and resolve on their own -- it's possible he'd had blockages before, felt pain, but they resolved before an infection could occur. You could be having this happen right now, but it could resolve later in the day and you never notice anything. Or the blockage could be too severe and never resolve on its own.

the actual study states that presence of a stone was an exclusion criteria

Just a guess, but maybe they can do the same thing they do with kidney stones with shock-wave therapy, though I feel like they would mention that somewhere in wiki or the article.

I thing it is the second one. I don't see antibiotic helping with that.

I think what he is saying is that "viral infection, parasites, gallstone, or tumors" doesn't include bacteria.

> If your appendix ruptures, it is life threatening and has to come out.

It is life-threatening, but it most certainly doesn't have to come out for full recovery. In some cases, it's impossible to remove due to the infection (inflammation, abscess) obfuscating its location. The treatment is aggressive intravenous antibiotics for a period of time, then oral antibiotics. The statics for recurrence after recovery I've had quoted as between 1/4 and 1/3 lifetime chance, and patients are advised on proactive surgery to remove what remains of the appendix.

Yes, this is exactly what happened to me. The only exception is that the nurse told me if they don't find pill antibiotics strong enough then I'd require daily intervenous antibiotics. However, I was glad they did find some.

I think the antibiotics probably tone down the inflammation (not sure why) which resolves the appendicitis.

It's also possible our previous understanding of appendicitis (as documented on Wikipedia) needs to be updated in light of this study.

I thought the stuff in your gut wasn't feces until it'd been through at least the small intestine?

The appendix is right after the transition between the small and large intestines.

in general the presence a stone (appendicolith) would no longer qualify as uncomplicated acute appendicitis. I did not see if that was specifically mentioned in this trial, but I have seen similar trials enrolling in the US where this was the case

I recall reading sometime in the past that appendectomies are the perfect cash crop at hospitals. Most are not needed but it's not worth the risk so everyone gets them, they are a low risk easy surgery, and they can charge a lot for them. I also recall that the cost for the surgery varies widely across hospitals.

What's interesting is that you'd think the switch over to a laparoscopic technique would save money, but it actually costs more.


Article says sick leave on antibiotics was 11 days compared to 22 with the invasive surgery.

The non invasive surgery only has you taking it easy for 7 days with no lifting anything over 10 pounds for a bit after that. They send you home from the hospital after 2 days. Most people resume work during the initial week.

Study was in Finland. How much time people take off presumably depends heavily on national laws and norms around sick leave. Some countries have very generous laws around paid sick leave; others, like the US, don’t have mandatory paid sick leave at all.

Finland seems to be a special case; 10 days paid sick leave for a given incident, but in practice this is improved on by collective bargaining agreements in many trades.

I had the surgery via laparoscopy ~10 years ago; go to the ER at 8AM, surgery at Noon, and home by 9PM the same day.

I had the non-invasive version a year or so ago. That matches my experience pretty much exactly.

It's interesting, an acquaintance of mine had this happen. Hospitalized, with antibiotics, but just fine, no knife.

Definitely surprising to hear about, but I'm glad we're still learning about these kinds of things. Imagine all the things we take for granted that are simply superstition when examined closely.

In Australia, where public hospitals provide a free service, antibiotics are first line for uncomplicated appendicitis. Most people recover just fine.

It's amazing how things are different when a surgeon doesn't want to do a procedure since it means more work for them, compared to where a surgeon wants to do a procedure since that's how they get paid.

Obviously, it's much better for the patients if they avoid unnecessary surgery.

Even in socialized medicine systems, doctors who do more stuff get paid more. 'Single Payer' usually means the government runs insurance not the doctors office. So the doctor bills more in both cases.

Both of those inscentives are maligned though - the doctor should do 'what's right'.

What's also nutbars is that there isn't a standard playbook for this stuff.

There should be specific procedural research on all of this stuff with the 'best practices' updated all the time.

There should be ongoing debate and churn around the practice, but once it's published, the doctors should all be in sync.

Doctors, like judges, have too much leeway. I think they feel that 'every case is special' and they are to some extent, however, I feel that they are playing against a statistical game and that their 'gut' is not right.

Just like airline pilots go through massive 'checklists' ... so should doctors.

I've been misdiagnosed for heart burn (doc thought it was heart palpitation) and for wound infection (was not infected, just a little red) - which is tragic because those are very common things.

Actually, at least in the medicine systems I know (France and Belgium) doctors can either be independent or employed. It's about 50% each in both countries.

Independents are paid more when they do more stuff, but employed doctors are usually paid a fixed salary depending on fixed work hours. Depending on the system, the practice either bills patients directly per consultation, or the social security organization, or gets a fixed income from social security or from the ministry of health that does not directly depend from how many patients they see. All three systems exist.

Best practices and procedures are usually handled at the hospital or... "medical house" (maison médicale or wijkgezondheidscentrum, the place where several non-independent doctors work as a team) level. It is indeed not something that really gets standardised at a higher level, although doctors also have a number of mandatory meetings that get conducted with attendees from different practices and that help with diffusing procedures, best practices and knowledge.

They don't all get in sync at the same time, but knowledges and best practices do diffuse through all doctors. Although independents usually try to attend the bare minimum because meetings directly translate to missed income for them.

I don't think the current model is wrong, although I think independent doctors are ill equipped to stay up to date, and not enough incentivised to do so.

These standards of care do exist for a lot of things. (see NCCN treatment guidelines for ones related to oncology). Oftentimes a doctor will not be reimbursed by insurance if they give treatments that are outside of approved standards. There is leeway given, though, because its just damn hard in many cases. Patients can present with 4/7 key symptoms and may report other unrelated issues. Or ailments can act differently in different people. Or maybe you have never been able to sleep well and don't even notice that, and it's a key issue related for a diagnosis.

1 really interesting point about it, though: They vary WILDLY by nation. You wouldn't think it would make a difference, but because of the varied regulatory bodies, and even culture, it does. (This was an issue that Watson for Oncology ran into after being trained by US doctors. In Japan, even on the occasion is gave a reasonable answer - it was watson after all - it often was not how the Japanese doctors would act in that circumstance).

Depends on the system. Most hospital doctors here (Ireland) are just employees of public hospitals; beyond overtime (and they tend to be right on the legal limits provided by the working time directive for that; the system is understaffed at the moment) they don’t get paid more for doing more procedures. Similar in the UK.

I had my appendix removed in January and the doctors told me back then that it's sometimes treated with antibiotics but you risk having appendicitis again. I'm pretty sure I had chronic appendicitis so I was really glad to be rid of it.

> Imagine all the things we take for granted that are simply superstition when examined closely.

I see it more as a refinement of knowledge, just like Newtonian mechanics -> relativity. Or perhaps this is a bad example which should be the other way around because surgery works in all cases whereas the antibiotics work in most but not all cases. Ok, never mind :)

A friend (in UK) had a similar condition called diverticulitis wherein the intestine makes a new pouch and it gets infected.

They were treated only with IV antibiotics (and pain killers) but spent almost a week in hospital vs people attending for surgeries who were out again in a couple of days.

I imagine _if_ it requires a longer hospital stay that will override the medical necessity.

Perhaps samples could be taken, eg of stool, in order to select bacteria with which to reseed the intestine? I suppose that's quite labour intensive.

There's also some evidence that the bacteria in your stool is even less well-correlated to the bacteria further up your intestines than we thought (and we already thought it wasn't great). [1]

[1] - https://www.theguardian.com/science/2018/sep/06/probiotics-n...

There is currently a very similar study being conducted in the US. I am a subject in this study after I got appendicitis last summer. I chose to be treated with antibiotics and have been symptom free for the last ~14 months. I could also have opted to participate in the randomized controlled trial (where a treatment would have been randomly assigned to me) but surgery isn't really something I'm comfortable leaving up to chance.

I had a cousin who delayed being seen for their stomach ache and the appendix burst. They ended up hospitalized for like 6 weeks with one end of the surgical opening left open so the wound could be drained or repeatedly cleaned out or something.

I'm glad they are doing studies here. Please note the phrasing in the article concerning "uncomplicated" cases. I have plenty of criticisms of modern medicine, but let's not throw the baby out with the bathwater here.

This is no new news. When I was 17, I had all the signs of an appendicitis. But I really feared to go to the hospital. I read through some medical books where they mentioned that after 72 hours of pain things can get real dangerous. I found some old antibiotics in the house (well beyond their date), took them and after 48 hours the apendicitis was gone.

When I was 34, appendicitid struck again. I new instantly that I had it, and this time I did not fear the hospital. This time, I wanted to avoid hospital because we were just a few weeks from moving to a new house. So I took antibiotics again, measured the fever, noted every measurement point in Excel but after 36 hours I found that it was not getting any better. So finally I took advantage of my wonderful German health insurance and got the appendix brilliantly removed...

Just want to state: there are times when antibiotics work and times when they do not.

Is this really news ? I've gotten it removed, and before had antibiotics to cure an infection. They misread the echo and though it was too infected to start antibiotics. It hurt like hell. After the operation, he said they removed it but could have been fixed by antibiotics earlier. They decided during the operation is was safer in the future to remove it (as I had more problems with it). They really don't want to remove it here, so I'm surprised this is news ...

I had an appendectomy a few years ago (in my late 20s) and I really wish the doctors had given me the option of just antibiotics. I was in severe pain and had spent the entire day vomiting, but from the CT scan my appendix wasn't at risk of rupturing at that point. They basically told me they were going to take it out as it was faster for them to manage it that way.

It's anecdotal, but ever since I had my appendix out I've struggled with digestion issues. I've tried so many things: elimination diets to discover food allergies, probiotics, a switch to vegetarianism, tons of fiber supplements, no fiber supplements, intermittent fasting, acupuncture, traditional Chinese medicine. I tried out uBiome to see if I could discover anything with that. Nothing really has worked.

On top of that, the surgery cost $25k.

Certainly there are instances where the surgery is absolutely needed, as a rupture will kill you. I'd really like to see more research on the theory that the appendix holds a backup copy of good bacteria, because at this point I'm willing to believe the appendix isn't just vestigial and actually plays a role in intestinal health that we just don't understand.

So no need to have appendixes removed prior to being stationed in Antarctica anymore?

i think this is for the scenario where you have uncomplicated acute appendicitis that can be treated in time.

there can still be scenarios where you developed acute appendicitis, it isn't treated in time (by either surgery or antibiotics), it perforates, possibly causing "infection of the lining of the abdominal cavity"

so i'd guess that removing the thing before there are any symptoms would still reduce risk, although maybe the cost-benefit tradeoff is a bit less clear.

Wait is that a requirement?

From the Australian Government - Department of the Environment and Energy, Australian Antarctic Division:

The answer is no, however doctors who are wintering at Australian Antarctic stations are required to have their appendix removed. This is because there is usually only one doctor on station during winter, and evacuation back to medical care in Australia is impossible for at least part of the year. The requirement dates from the 1950s, when an Australian Antarctic doctor developed appendicitis on Heard Island and required a very challenging evacuation back to Australia.

In 1961 a Russian doctor successfully removed his own appendix at Novolazarevskaya station in Antarctica. With no outside help possible, he used local anaesthetic and had two expeditioners assist with surgical retractors and a mirror so that he could see what he was doing. The operation was a success and the doctor was back on duty within two weeks. It's not a situation that Australian Antarctic doctors would like to find themselves in!

As part of their overall medical review, all expeditioners are required to have a dental check before they depart for Antarctica within six months of their departure date. There is no requirement for expeditioners to have their wisdom teeth removed unless the dentist identifies that they may cause a problem over winter. The station doctor has eight days of training in emergency dentistry as part of their preparation, but this does not include wisdom teeth extraction.


The self-surgery bit is definitely incredible. The doctor was Leonid Rogozov (https://en.wikipedia.org/wiki/Leonid_Rogozov). More info with photos here: https://rarehistoricalphotos.com/leonid-rogozov-appendix-196...

That perfectly aligns with my personal stereotypes of Australians and Russians.

The Americans, of course, would just attempt surgery on site using remote assistance from stateside surgeons, do the horrendously expensive evacuation when it goes wrong, try to bill the patient for the entire multi-million dollar amount, and then base a screenplay or teleplay on the story.

Evacuation in winter is possible, the Americans do it if there is a real emergency - it's just that it's very very expensive (even for the US). Because it's possible but expensive, all the non-US bases treat it as prohibitive and effectively not to be counted on.

It's only possible in some places, for example Kerguelen island has no airstrip, the closest airstrip being on Réunion island 3000km away (Davis station on the Antarctic continent is closer, 2000km, but does not have a permanent airstrip).

No helicopter in the world has such a range, so the only means of evacuating is by ship, with the fastest ships in the area taking minimum 3 days to make the trip. If a navy ship is around, it could probably treat the emergency on board but most others will have to get back to Réunion first.

In the likely event that no ship from the French navy is around, the fastest means of evacuating will be requisitioning a nearby fishing ship but those will probably not make it to Réunion until at least one week.

Fortunately, the relative emergencies (but not life threatening) I have witnessed have always happened when a ship was already on its way for other reasons, but US or not there are real technical impossibilities in these places.

Could you parachute fuel down for helicopter refuelings along the way?

Edit: it seems that aetial refueling for helicopters is a thing as well.

There is only the ocean along the way though, I don't think it would be possible to drop resupply fuel that way.

Aerial refueling though I guess could work, although I suspect that no suitable tanker airplane is to be found within range anyway most of the time (and no suitable helicopter either) as the military base on Réunion is not a major air force base and there is no other country than France with decent forces in the area. Australia has tankers but they're on the wrong side of their country, nowhere near Perth.

I think we're getting beyond very, very expensive here and into the territory of things no country would do outside of extraordinary circumstances, the kind of circumstances in which the country operating the base would not matter anyway as most others would cooperate in any way they could.

I wonder if this implies the incidence of appendicitis is higher when living in the Antarctica. Perhaps something about the living conditions is more likely to trigger appendicitis.


Apologies for the source, but I remember reading the same thing in a better source too.

Of course not, that's utter nonsense.

Only the madman is absolutely sure.

So what is the biological mechanism at work here? Take boatloads of antibiotics and kill most of your intestinal flora, so that inflammation on the appendix is reduced? (If I'm completely of the mark please correct me, it's been years since I had any biology related coursework)

With all the recent studies of the evolving antibiotic-resistant properties of bacteria and the importance of mantaining a healthy intestinal flora and how much the gut influences the brain, I am not sure that this treatment is necessarily preferable to modern appendix removal surgery. That said, if given the option, I'd probably prefer this than getting cut open (even if the incision with modern techniques is very very small).

I'm guessing you still have to take antibiotics when you have any surgery to reduce chance of getting an infection.

The whole point of the appendix is maintaining a healthy gut flora, so removing it for the sake of avoiding antibiotics that impact the gut flora doesn't seem that wise.


A few notes of interest:

1) Europe has been doing abx before surgery for a while now. Unfortunately, their data has largely been lacking (thus the need for this trial), creating the impression that this was pushed by their national health services as a cost-saving measure rather than a patient-oriented one. The culture among surgeons in the US, regarding abx for appendicitis, is largely "we don't kill patients just to save a few bucks." The irony that the bucks being saved go directly into their pockets usually goes un-mentioned, but they are in earnest. It's just a win/win that their earnest desire to do the best for patients also pays their bills. It feels nice to get paid for doing the right thing. However, that creates a cultural bulwark against a change in expectations on appendicitis management.

2) There is often a feeling that "if we have to end up doing surgery anyway, we should just do the surgery. There's no value in making the patient go through two such episodes when we have definitive treatment." It's going to be highly subjective whether you think a 1/3 chance of two appendicitis episodes and inevitable surgery vs. a 2/3 chance of avoiding surgery means "it's obvious you should get abx" vs. "it's obvious you should get surgery." I think this study doesn't make anything obvious, but does pave the way to giving patients a reasonable alternative course of action.

3) This is not tantamount to saying "well, we've just been rash all these years in just going straight to appendectomy." Previous trials on this have been, methodologically, poor. Even this trial is a five-year follow-up to what was initially a one-year trial that wasn't adequately persuasive. The initial trial showed a 27% rate of return appendicitis. You can imagine that if the five-year results showed "80%" vs. "36/39%" we'd be having a different discussion. If it showed that having an appendicitis pop up a few years later had more adverse effects, we'd be having a different discussion. So this data was needed, and the fact that docs didn't jump on previously heavily flawed data is... well, docs doing what they're supposed to. You don't want your doc jumping after every poorly-supported shadow.

4) Appendicitis isn't diverticulitis. There's often a layman's shorthand that diverticulitis is just left-sided appendicitis, but it's not. The pathogenesis and appropriate treatments vary quite a bit: conservative treatment of a piece of normal anatomy is quite different from conservative treatment of a piece of herniated, pathologic anatomy. Don't confuse this study for meaning anything regarding the appropriate management of diverticulitis. That's not to say that abx management for diverticulitis is inappropriate, per se, but just saying these are different diseases and not to be confused here.

5) One shouldn't expect this to result in cultural change too quickly. There remains the fact that the primary protection against a malpractice suit is "local standard" - if all the local docs are doing the same thing, it's not malpractice to follow suit. The first doc to go out on a ledge with this is going to be minced meat the moment there's a bad outcome and someone sues. A study is beside the point - if you point to a new study during a suit, the plaintiff's attorney says, "Oh? You have a PhD in study design? No? Then what qualifies you to analyze this study better than every other doctor in your community?" This really won't go anywhere until an entire medical department agrees to go in on this simultaneously - most likely an emergency medicine department. Politically, though, they'd probably have to go to war with their hospital's surgery department to push it through, or otherwise have the surg folk on-side. It'll happen eventually, but it's not going to happen overnight.

Do we need more reasons to soak ourselves in antibiotics? Appendectomies on otherwise healthy people are extraordinarily safe procedures. And while some research has indeed shown the appendix as a useful organ, having it out doesn't have lasting side effects. Given the coming tide of antibiotic resistance, perhaps this is an area where physical intervention via surgery can reduce the need for antibiotics.

(I know antibiotics are normally prescribed after an appendectomy anyway, but I presume that would be less than the dose needed to kill the primary infection outright.)

It would be interesting if someone were to compile a list of surgical procedures that have been performed too proactively throughout history. Uteruses, molars, tonsils, breasts, I think some cases of prostate cancer, now appendixes. My list might contain huge errors - I am not a medical professional, but even as a medical layperson, it's really remarkable how common this general type of situation occurs.

For myself appendicitis was a condition that recurred - I didn't realize what I was having at the time until one night when I put the symptoms together and went "uh oh", when I'd probably experienced those symptoms a half dozen time in my adult life. I wonder what antibiotics mean for re-occurrence, do you end up treating it like an ear infection, and take em when you get a flare up?

I wonder if this would eventually be extended to wisdom teeth, something dentists are too trigger happy to remove.

Not quite sure I understand - give antibiotics instead of pulling wisdom teeth? They pull them because wisdom teeth often grow in at an angle to a mouth of fully developed and settled adult teeth. Sort of a "why mess with a good thing" (the teeth there already) approach. I certainly see an issue with the rampant pulling of wisdom teeth for cosmetic reasons, but don't see how it's relevant to a new treatment method for a life threatening illness.

I meant the overall principle of maintain rather than remove.

So... braces? It's cheaper just to pull them. You really have to if you're someone like me whose mouth was too small for them to even come in.

My wisdom tooth extraction was a shit show for that reason, but I've had all my 12 year molars removed since then, the last one a couple of weeks ago, and the recovery is pretty easy. (They wanted to root canal it and crown it... I was like bro just pull it because otherwise we're just gonna have this same conversation again in 10 years.)

Fillings. For people who have reasonably well aligned wisdom teeth (not impacted, functional teeth), some dentists are inclined to remove them anyway; others to treat any decay which shows up but otherwise leave them alone. Again, this is something where norms differ by country.

Edit: Wait, you’ve had all your _second_ molars removed? That seems very unusual. I’m a little surprised the dentis was willing to do it, unless there was a big problem that couldn’t be dealt with otherwise.

Probably not unless people start losing more teeth to make room. They are a chronic source of some nasty problems unlike appendicitis which can just go away with antibiotics.

This is a tangent but... Medical Science is an interesting institution. It's a huge, formalized truth-values finding process...

A half sibling of Law (the other formal truth finding institution) and Science (the abstract unformalized institution).

Yeah, so unfortunately regarding medical science "formalized truth-values finding process" is actually about as far from reality as you could be. "Politicized agenda-propelled random search" would be closer. However, we still slowly are making progress thanks to new technologies, so all is not lost...

I understand that, looking at individual scientific problems, it's easy to get cynical. It's even fashionable to be so.

Deaths attributable to heart disease in 1970 were just shy of 800k per annum. As of 2010, it was about 600k. A 25% drop in the leading cause of death, in less than a generation. Life expectancy was 70.8 years in 1970, and 78.7 in 2010 - an increase of more than 10% in a single generation.

Science isn't a process that moves along by weeks, months, or even years. It's something that moves generationally, and our society has made impressive strides.

You're welcome to be skeptical - science would die without that. But be the "loyal opposition," not a casual cynic: help the process improve, don't discard it as some political shell-game. Lives are in the balance.

I have both feet in the game, being a clinical researcher. So, cynic but not casual.

"Politicized agenda-propelled random search" Lol!

I think you and arkades both have it right. It's a "politicized agenda-propelled random search" on a large enough scale and over a rich enough search space that it "has made impressive strides" despite its flaws and inefficiencies.

I have a friend who works as a Healer. People come to him and pay him good money and he gets results. He doesn't advertise, he gets referrals by word-of-mouth alone. My point is he gets results.[1] He can do things that are totally off the map of conventional medicine. However, he's uninterested in science and scientists (in general) are uninterested in him. "It's something that moves generationally" indeed, if paradigm shifts really require the dying out of the old guard.

If we think of inefficiencies in the search due to e.g. politics and superstition as a kind of malady, then it seems we are witnessing a phase of "Physician heal thyself", what with the advent of mass medical monitoring and big data correlation, eh?

[1] Have you heard the joke, "If alternative medicine works it's just called medicine."? Well, yes and no. Some things that work are too far outside the belief structures and will be ignored or ridiculed.

That's mostly because smoking has been stigmatized.

And nothing to do with the pile of research that’s been done in the past few decades identifying exactly which medications actually provide mortality benefit in cardiac disease and which don’t, of course.

Well, that's precisely my point. Yes, new drugs help, but often less so than the "dogma of the year" lets you hope at first. The point is that MDs are usually identified as scientists because many people think they actually had an important part to play in the development of new useful technology, and don't see that most of the time those new things come directly from the lab and clinicians just test drive them to find the optimal use case. It's true that test driving is essential, but I have a hard time calling it science when you see what people from hard science can do. Additionally, the proportion of MD researchers who understand nothing about what they do, or who even deliberately cook up results is absolutely alarming.

To follow up on your cardiology example, I'd say that pills certainly helped, but the game changers really are the new toys of the interventional cardiologist.

And I would also add one of my favourite pseudo quotes: "science advances one funeral at a time." -- Max Planck

> To follow up on your cardiology example, I'd say that pills certainly helped, but the game changers really are the new toys of the interventional cardiologist.

Balloon caths re-stenosed 30% of the time. Balloon caths with bare metal stents re-stenosed about 15% of the time. Balloon caths with stents and dual-platelet drugs re-stenose about 3% of the time. I think this is one of those "drugs help ... but less so" situations where drugs get less credit than they're worth, and the physician scientists that did the endless slogging to figure out how to optimize interventional cardio's toys deserve real credit.

But, yes, I agree: most MD's aren't scientists. Quite a lot of MDs are only barely science-literate. They're engineers: they're taught a body of science and its application, with the expectation that they apply it usefully.

"Sulfonamide drugs were the first antibiotics to be used systemically, and paved the way for the antibiotic revolution in medicine."—Wikipedia. These drugs came into widespread use in the late 1930s.

this qualifier is interesting:

> researchers led by Paulina Salminen randomly assigned 530 patients that showed up in the hospital with an acute, uncomplicated appendicitis to get either a standard, open surgery to remove their inflamed organ or a course of antibiotics. (By “uncomplicated,” the authors mean there weren’t other issues like perforation, abscess, or suspicion of a tumor.)

although if your appendix is already perforated then it's a bit late to try to prevent it from perforating by cutting it out, so fair enough.

You've made the correct conclusion. Management of a perforated appendix is vastly different from management of the (much more common) uncomplicated appy. There isn't much controversy about the management of the perforated appy: it's going to be surgery and antibiotics. Removal at that point isn't in question, because the perforation is due to an increase in intra-appendiceal pressure compressing its vasculature, causing a focal necrosis. The perforation happens when a piece of the appendix dies, and thus loses its integrity. Dead tissue has to go.

And of course surgical clean-up of the abdomen must follow, along with a big pile of abx.

I also know 3 people that went to the doctor after some time of belly aches and the doctor telling them: "You probably had an inflamed appendix but it's ok now."

As a kid in the mid-80's I once woke up with a bit of a belly ache and thought "I can milk this for a day off school to play with Lego"

Ended up having an emergency appendectomy that night.

many people will die from this article because they wil not believe their doctor and go to another one with a broken appendix that kills you in a few days from septic shock.

The removed mine while I had another surgery just in case.

Just in case of ...? I do not usually think of surgeons having the mentality of 'I was in the neighborhood... so.... yeah, why not!'.

Well, they were fiddling around with my intestines, moving them around (I have / had intestinal malrotation) and they told me that it could be an issue if they didn't remove it.

Although they told me afterwards, but the surgeons were extremely competent so I don't question their judgement.

Finally a thread where I can contribute!

I was part in the Finnish APPAC trial (published on JAMA/2015).

In April 2012 I was in an out of the hospital for four or five times with intensive stomach pains, but as they weren't localised in the mcburney area and my white cell counts weren't elevated, I just got sent home with painkillers.

The last time my white cell counts were slightly elevated (around 36 when under 14 is considered to be normal) and the stomach pains were worsening while jumping and the pain localising in the lower right of my stomach I was personally sure about what I had. Doctors still disagreed.

I was then told that there's an experimental trial and if I sign up for it, they'll do a CT scan (I had begged for this the previous visits). Lo and behold, the scan showed inflammation not caused by a stone.

I got ertapenem intravenously for three days and 7 days of metronidazole and levofloxacin. For about a year everything was fine, but I started to get occasional localised pains again, but they came and went and never really worsened. I think between 2013 and 2017 I've been to the hospital about 6 or 7 times because of the pains but they've always resolved by itself.

Two months ago it came back again and it was worse than the first time I got diagnosed. Spent two nights in the ER waiting for surgery. Again, ct scanned and blood levels show inflammation. I get sent home with pain killers and metronidazole and floxacin. ER nurses and surgery doctors were baffled by the case, said they've never seen an inflammated appendix been put on the non-urgent surgery waiting list.

Got told today that it's going to be removed this year, lol. After six years and asking every time to have it removed.

Approximately 80% of the appendicitis cases are not at risk of bursting anytime soon so an immediate surgery is not necessary. The rest are complicated and need urgent surgery.

I've been told that about 74% are fine after the antibiotics for the first year but a majority in the trial have ended up with it removed within a 5 year window. So, while having an appendix would be ideal and it's cheaper to throw a ct and some medicine at the patient, a surgery is still almost always needed.

In my personal experience, I have a strong gut feeling that a low carb diet might've affected how many times my appendix has shown slight signs of inflammation. Up until 2016 I was in ketosis for a four years and that was when I had issues most often (although the latest has been the worst overall). The sample size of this idea is just n=1 so take it with a grain of salt.

Oh, a sidenote, latest hospital ordeal put me in bed rest for almost a month because metronidazole did not play nicely with my ankles and I lost my job during that time so I'm also going through talks with my lawyer about a suit for unlawful termination. Fun times.

Please do ask questions if I can clarify anything or you want to hear about something specific!

I'm surprised to hear you lost your job because of health issues in ... Finland?

That kind of wrongful termination sounds like something that would happen in the States not Europe. Correct me if I'm wrong.


I'm glad it worked for you but usually appendicitis is caused by an infection which will cause sepsis if the appendix ruptures, and fasting won't fix that. If you think you have appendicitis at least talk to a doctor, because if it ruptures there is a high probability you will get sepsis and die.

Waiting cures a wide range of problems, that don't end up killing you.

It's really hard to separate 'doing a rain dance' and 'just waiting' when you have a sample size of 1.

And the ones who do die, don't post here to let us know how it turned out.

I hate that the healthcare situation actually forced you to flip a coin for your life. :(

(I'm assuming you're in the US or somewhere like it where an appendix removal isn't free)

You're literally playing with your life.

a little too late perhaps?

Got confused there for a moment, thought it was about PDF files...

Great news! Seems like I (not a doctor but probably the most medically-qualified person in any group of random people that doesn't include anybody with actual medical education) probably won't end up doing an appendectomy on anybody after I move to a deep rural area...

An appendectomy might be easier than procuring the necessary antibiotics in a deep rural area, depending on how rural....

Being a person fairly interested in medical science and lacking insurance I always take care to have some antibiotics for just a case (I ask friends from Russia to get them for me, you can buy antibiotics without prescriptions there) although I hardly ever use any actually. Needless to say, I'm going to take quite a selection with me when I travel to some place where they're hard to get and there are no doctors around. By the way one should better have antibiotics ready when performing this kind of surgery or chances are their patient is going to die of sepsis.

> I ask friends from Russia to get them for me


Would you mind telling what's there? It says "Unfortunately, our website is currently unavailable in most European countries..." as I open it directly and shows no article body as I open it through us.ixquick-proxy.com.

A tl;dr summary...

> A US Special Forces soldier bought fish antibiotics at a pet store to treat his sinusitis. It did not work out.


I grew up in an area with 6 to 8 different military bases and it is fairly common knowledge in military areas that you can sometimes get away with using fish antibiotics to treat human infections. And in a lot of cases the pills are exactly the same. But sometimes not.

Article also states that aquarium antibiotics are more expensive than prescription antibiotics, while conveniently omitting the copay and time cost required for the doctor's office visit, which was needed to obtain the prescription.

As such, it is also an uncommon practice to lie about symptoms during an office visit that was required for some other reason, to get a prescription for antibiotics that is not immediately needed. I don't actually know anyone who has done this, so it may be just rumor. I do know people who have used aquarium antibiotics, because their copay for a $150 office visit is $150 until their $8000 annual deductible is met. US health care is bananas.

> As such, it is also an uncommon practice to lie about symptoms during an office visit that was required for some other reason, to get a prescription for antibiotics that is not immediately needed.

Wait, do doctors actually prescribe antibiotics given just invisible symptoms and no actual flora analysis? What's the point of the prescription system them? Isn't a doctor meant to find out what specific bacteria causes the problem and choose the right antibiotic to target these?

Thanks. A nice-to-know lifehack, I just really hope I'm not going to need it but who knows... BTW I've actually bought pure butyric acid in a fish food store to produce sodium butyrate in my kitchen and take it instead of the human-approved supplement which is available on Amazon but is fairly expensive by the east-European income standards (and, according to the scientific papers I've found so far, hardly does anything if taken in the doses it is usually packed in).

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