Ep 160 Appendicitis: Don’t know what you’ve got til it’s gone?

of a few hours, the pain got progressively worse. At around six pm on the evening of March sixteenth, I decided I would take a bath to see if warm water would help, and once I got out, I could barely walk, and I then decided that this was definitely not gas pain. When I got to the hospital, because I was thirty six weeks pregnant, they really just focused on me being in pre term labor, but the biggest issue being that the pain I was having was getting

progressively worse and was constant, which contractions aren't. At about two hours in, a doctor mentioned that what I was experiencing might be round ligaman pain and they were probably going to send me home with some exercises. Thank god they didn't. To the span of a few hours, I

had an ultrasound done as well as an MRI. Is a doctor's thought I could possibly have appendicitis, but when you're pregnant, the appendix is often hidden because of your baby, so standard tests don't allow you to see the appendix. Prior to going into the MRI machine. They gave me morphine, which still didn't touch the pain, and having to lay in the MRI machine for over forty minutes not being able to move was one of the worst things I've

ever experienced. Unsurprisingly, the MRI and ultrasound didn't show anything. Finally, after six hours, around midnight on the seventeenth of March, they decided to admit me to the hospital, still not knowing what was going on. As the hours went on, my white blood cell count continued to rise, I developed a fever, and I was losing amniotic fluid. So finally, after sixteen hours of being an excruciating pain, they decided that they had to do an emergency C section to

figure out what was going on. I remember getting the epidural and it being the greatest thing. Ever, because I could no longer feel the pain in my stomach as they cut me open. The one thing I can remember is that I'm saying, there's puss and her stomach called the other surgical team. Minutes later, they delivered my daughter, Madeline,

at twelve thirty four on Saint Patrick's Day. After they delivered my daughter, the ob team swapped out with a general surgical team, and for a brief moment, they considered keeping me awake since I had an epidural, but thankfully my husband stepped in and said, put her under now. Once they put me under, it was found that my appendix had ruptured and I had peratinitis in my intestines. For the next three days, I was on ivy antibiotics, but my white blood cell count was continuing to rise

and I was still running a fever and it looked awful. Thankfully, after three days, my white blood cell count finally dropped. At this point, my doctors confessed to me how concerned they were getting about me. I stayed almost a week in the hospital recovering from appendicitis in my c section, and I was very popular on the floor because most of the doctors had never seen a case like this. It took me weeks to fully recover, and I was seeing a doctor twice a week for over a month

because of constant issues I was having. My daughter spent two days in the special care unit receiving IVY antibiotics, but overall was really healthy considering what she had been through. While this was all going on, I was so focused on my pain, recovering and my daughter that I really didn't think about the implications of what had happened to me until I started your research and realized how dangerous the situation was and how it could have ended so

differently for both me and my daughter. Thankfully, we were both okay afterwards and having discussions with my doctor, they think that my appendix started to be inflamed when I went to labor and delivery in February of twenty fifteen. They also had a theory that my daughter was kicking my appendix and that may have caused it to become

inflamed in rupture. Lastly, during those agonizing sixteen hours prior to having my daughter, we had an amazing nurse who knew what I was experiencing wasn't labor pain or around ligament pain. And advocated for me and stay with us the entire time, even when she was off her shift, to make sure that we were okay. I will never forget her and the other nurses he took care of me.

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hungry because my stomach doesn't feel good. I don't want to eat anything, and then it might press to feeling actually nauseous, like feeling like you're gonna throw up, and then maybe some vomiting, and then that pain will start to move and it moves from around the belly button down into the right lower quadrant kind of mirror your right hip bone, like the part that sticks out, and

then you'll get a fever. And this tends to kind of progress usually over about like a twenty four hour period, Like it's not a super sudden onset, but it's not like prolonged. That's the classic description. And this classic description is not the only way that appendicitis can present by any means, but it is the classic description because it does happen, and it happens pretty frequently. It's very common that this kind of series of events is how appendicitis

starts and presents. I can very vividly remember having a patient describe their like course of symptoms that brought them to the emergency room exactly liked this, and I looked at them and I was like, well, you described the textbook description of a pendicitis.

bone than your belly button. Along this like diagonal line between your belly button and that hip bone, you can put your finger there, and that tends to be the most tender spot. It hurts really bad if you smush down there. There's a few other signs that you can see. Maybe someone doesn't have pain exactly right there, but they might If you smush down on the left side of

their belly, it might hurt on that right side. That's a sign that there might be appendicitis, and then there are a lot of other things, like the way that you move somebody's hip or leg that might tell you how far down into the pelvis, how extensive that infection might be. So when somebody comes into the hospital, to the emergency room or even an urgent care reading that textbook description, almost certainly, like over ninety percent of the

time people get diagnosed correctly with appendicitis. And it's possible based on those textbook descriptions that diagnosis can happen with just that story alone. But today, because it's available at least in most of the high income countries in the world,

we have access to technology to confirm this diagnosis. So most of the time when people come in with symptoms like this, there's going to be some kind of imaging that's either a CT scan or an ultrasound if you need to avoid radiation, to make totally sure that what we see is actually appendicitis. And that becomes even more important when people don't read the textbooks, aka, when your bodies present with appendicitis differently than what that classic description is, right.

Someone might think, and this is where things get very subjective, and we'll talk more about this later, but people might think, well, your pain doesn't seem that severe. So there's a lot of different ways you may or may not have that nausea or vomiting. You might have a lot of vomiting, you might have no vomiting. So like, there is a

huge range. But so when those symptoms might not exactly match what we think of as appendicitis, maybe the point where you have pain seems to be a little off from what I expect for appendicitis, whatever it is, then these kinds of imaging studies become even more important. And the truth is that there's also a lot of other pathologies that can mimic appendicitis, even if it seems like a textbook description right, something like an ovary intrsion, a

cyst rupture, an ectopic pregnancy. There's something called mesenteric lymphatinitis that looks almost identical to appendicitis clinically, but then on imaging is going to look really different, So there's other stuff that it could be. So imaging and then blood work are going to kind of help the overall picture of making sure that we're correctly diagnosing somebody with appendicitis.

So that's the kinds of things that you're looking for in blood work. There's not anything that's like, ooh, this blood work means appendicitis. There's no like specific blood work and Arin, I think you'll talk. I'm sure about how people used to deal with appendicitis back in the day. I can't wait, but a little spoiler for most people, because it wasn't that long ago that the standard of care was to cut somebody open with a big old incision and then cut that appendix out and then stitch

you back up. And that is called an open appendectomy. And that is what Madeline had. Ah, that's why she had a big old scar, and everyone was like, I want my appendix out too.

take the appendix out through these teeny tiny holes. And this is a lot better because it's a faster recovery, there's less trauma to the muscles of the abdominal wall, there's less pain, postoperatively. It's like, everything is better if you can do a laparoscopic procedure. But it's still surgery, right, It's still cut this thing out because it's causing problems. Today, in the year twenty twenty four, people are starting to

come around to this wild idea. And I say start because the literature goes back quite a ways.

or your large intestine. It has a lot of names. And I don't remember, Aaron, which episode it was relatively recently that you were like, can you tell me all the parts of your intestines? Do you remember that?

That is where this little extra bit sticks out that looks like an anemone tentacle. It's very small. It's like one to three millimeters in internal diameter, so really small, smaller than your pinky finger, and it sticks off of the bottom of your large intestine. Your poop is going to go through your small intestine and then swoosh up your large intestine and then eventually all the way out until you poop it out. Okay, So this little finger of an appendix can get clogged, and there's a few

different ways that it can get clogged. Sometimes it gets clogged with poop, and when it gets clogged with a chunk of poop, that chunk is called an appendico lith or a FeCO lith, a little hard poopball. But sometimes it can get clogged with other stuff. It could get clogged with a tumor, either a benign two or a cancerous tumor. It can get clogged with an overgrowth of lymphoid tissue that is like our immune tissue, which there's a lot of in our appendix, that can kind of overgrow.

And that can happen just on its own because you just have immune tissue growing, or it can happen because that tissue is responding to an infection, or sometimes it can get clogged with other things like just a little chunk of calcium, whatever it is. Anytime in our bodies, a small tube that's connected to a bigger tube gets clogged, you have stagnation of stuff, and that is a perfect medium for bacteria to grow and.

up cutting off the blood supply. To the walls of that appendix, like to the tissue, and then eventually, because the blood supply is cut off, the tissue of the walls of the appendix starts to die and then it's weak because it's dead tissue, so then it can perforate, and that's what causes a perforated appendix. And then all that infected stuff, the bacteria, the inflammation, the white blood cells, the pus, it explodes out of your appendix, and a

couple of things can happen. If that happens, If just a little part of the wall gets a hole in it, like a small hole, then the fluid might come out and get trapped, and that is what forms an absce Okay, or sometimes the whole appendix can rupture and then it's not contained and then all of that infected fluid can kind of go throughout your whole abdomen. And that's what's called peritonitis, which is very serious. That's definitely an emergency.

Does that make sense, I mean, that's essentially appendicitis. That's that is what causes it.

answer this question. I am going to answer this question based on my knowledge of our anatomy, and I could be wrong about this, But in your guts in general, you don't have direct nervous sensory nerves that go to your guts, like to your small and large intestine, there's

no sensory innervation there. So a lot of times what can happen in your guts when you're having pain is that your brain doesn't actually know exactly how to interpret the signals of where that pain is coming from, because all of the sensory nerves are in like the wall of your abdomen. So if there's pain in one spot, sometimes your brain is like, ah, there's pain here, and so then you're like, this is where the pain is.

Because your brain doesn't quite know exactly where that sensory input's coming from.

And that's because our nerves travel together. So the nerves that innervate certain parts of say your diaphragm and some of your abdomen, also innervate places like your shoulder, and so sometimes when you have pain in certain parts of your abdomen, you might actually feel it in your shoulder. And so that's what referred pain is. It's essentially like

nerves that travel together. Your brain doesn't know how to interpret that signal, and so it goes to the place that it thinks that the pain is and it's like, hey, your shoulder hurts when actually it's your spleen or something like that.

Before an appendix ruptures, it's called uncomplicated appendicitis. So if you have these symptoms, if you have this imaging where we look at a CT scanner, we're like, yep, your appendix is inflamed, the walls are thick, it's angry. We can see inflammation, all these things, but it's not ruptured.

That's uncomplicated appendicitis. Once it's ruptured, it's considered complicated. Most of the studies that look at whether or not you can use antibiotics only to treat appendicitie or for uncomplicated appendicitis, So uncomplicated unruptured appendicitis in a lot of cases can be safely treated without surgery, just with the use of antibiotics.

So in this uncomplicated case, a lot of a lot of different studies have looked at whether or not you can safely cure somebody's appendicitis without using surgery, and you can in a lot of cases. In fact, some people even treat complicated infections if there's an abscess, like one pocket of fluid outside of the appendix where it's ruptured,

but it's not all over your whole belly. Sometimes you can then drain that fluid, like stick a tube in it, drain out all that gunk, and then do antibiotics on top of that, and you can cure the infection without needing to do surgery right away. There's some downsides to this, though. First you have to use pretty broad spectrum antibiotics, because this is usually an infection that's not just one bacteria.

It's a bunch of different types of bacteria, and there's not really a way for us to know which bacteria because there's so many that live in your guts. Which is the one that's causing yours versus your friends appendicitis.

in your guts. So yeah, they're mostly opportunistic infection, right, They're just able to multiply because of that clog. But what we see is that if people have appendicitis caused by a fecal lith caused by a chunk of pooh that's stuck there, they are less likely to do well with antibiotics alone.

to treat that infection. But it also means that that fecalth is still going to be there, right, So then even if you can get that infection under control, it's still going to be there and you're not going to be able to get rid of it unless you take it out. If you have appendicitis where there's no fecal lith and there's just a hypertrophy of tissue that's caused by an infection, you treat that infection, you fix that problem, and the appendix is no longer clogged.

if that's it. But this is also really important because you said Aaron earlier, like what about recurrence and things like that, and that is the biggest if there is a sort of downside to this antibiotics only or antibiotics first approach, is that failure rates tend to be relatively low, like eight to twelve percent of people if you try and treat them with only antibiotics end up getting sicker

during that time period and needing surgery. And usually if that happens, they are sicker and that appendix is ruptured or closer to rupture. And it's like a more serious infection than maybe if you had treated it before by doing surgery rather than antibiotics. In many cases, that's when there was actually a fecalith there, right, So a lot of that initial failure rate is when there was a poop ball that was causing the initial appendicitis.

risk for having appendicitis again? If we don't take that appendix out And the answer is that yes, recurrence can happen, and depending on the study, depending on the timeframe that they looked at. Most studies are short and only look at like one year rates of recurrence. A couple studies have looked up to like five years out, and if you look up to like five years out, the recurrence rates can be as high as forty percent. So what this means is that there really is a choice that

people can make. And by people, I mean everyone who is involved in this decision. The person who's stick with appendicitis, that person's family, the physician who is treating them in the emergency room, the surgeon who may or may not be needed to do a surgery. Everyone is involved in the decision. Do we do surgery right now or do we not do surgery right now? If we don't do surgery now, do we do it later because we want to prevent this recurrence? But do we wait until we've

treated the infection? Right? And so that is kind of like what it stands right now in terms of what is the kind of standard of care. There's not a perfect answer. Can you treat appendicitis with antibiotics alone, yes? Can you treat it with first line surgery? Yes? Is

there a perfect answer, No, there is not. There are significantly higher rates of complications in almost all cases, and that means things like reoperations, wound infections, incisional hernias, small bowel obstructions, like major complications by doing surgery compared to antibiotics alone in a lot of the studies, And the only studies that seem to show more complications for antibiotics only in uncomplicated appendicitis is if people had one of

those Pooh chunks, then they were more likely to get more sick, including maybe have deeper infection or sepsis, by not doing surgery right away.

there any complications other than surgical complications? Not that like we know of no, okay, and so there Really it used to be the case that, like I remember working with an obgui n right, So she did like pelvic surgeries on uteruses, and I remember being in a surgery with her where she showed me she was like, hey, look this is this person's appendix. Back in my day when I trained, we would take this out almost every time. If you see an appendix, just take it out because

then they are never going to get appendicitis. And that was like standard of care way back when.

already ruptured. Fortunately he made a full recovery. NASA strongly recommends that astronauts have their appendix and gallbladder removed before venturing into the stars, and many have done so, and people who moved to VLS Astraeas, which is a long term settlement in Antarctica, they have to have their appendix out before moving in. Kids.

noted were weakness, general malaise, later nausea. Within a few hours, pain arose in the upper portion of the abdomen, which soon shifted to the right lower quadrant. Body temperature rose to thirty seven point four degrees celsius. It was clearly a case of appendicitis end quote. Over the next day, things got worse and worse. Vomiting became more frequent, his fever got worse, the pain grew more intense, and with a blizzard, moving in help from another station became impossible. Quote.

The only solution was to operate on myself. End quote. Can you imagine now, Rogazov injected a zero point five percent novacane solution into his abdomen, and while his co workers held a mirror and retractors, he made an incision and cut out his appendix. Quote. Sometimes I had to work entirely by feel end quote. Just by feel, I would be a disaster at that. I don't know what things feel like in my abdomen. I'm not a doctor, but.

all just get our appendixes out? That was the leading vibe, like you said, Erin about the organ for much of the twentieth century, just cut it out until the tune began to change as researchers realized that what had for so long been labeled a vestigial organ might actually perform some very important functions. So let's trace how our understanding of this weird little organ evolved over the centuries. It begins,

of course, in ancient Egypt. Technically speaking, it begins when humans first evolved in appendix and developed appendicitis, which we undoubtedly have had for millennia. But an early piece of physical evidence of appendicitis comes from an Egyptian mummy from the first few centuries see who had right lower quadrant adhesions,

suggesting a past episode of appendicitis. And while the appendix doesn't seem to get a mention in ancient anatomical texts, appendicitis does make an appearance, with Galen in the second century describing lower right quadrant pain that at the time was treated with either draining the abscess that formed or letting the patient die quote unquote a peaceful death, oh dear,

from the sepsis that ultimately developed. Okay, peaceful as I think in the eye of the beholder, probably in that instance, yep. Over the next thousand years, or so, no doubt, people continued to get ill and die from appendicitis, but the labeling of human dissection as sacrilegious kept people from identifying where exactly the trouble was coming from. Like, you have this pain, but what's causing it? We don't know because

we can't cut into your body. Yeah, And if people did perform dissections, it was on animal and most animals outside of primates and the wombat, don't have the same looking appendix in humans, they don't have the vermiform appendix.

didn't get published until a couple hundred years later. Andreas Vesalius also drew the appendix, but called it the secum, which led to decades of confusion over terminology and the link between the organ and the condition, like is this actually what is this condition caused? By?

he's like, no, it's not. So it's great. Anyway. In seventeen thirty five, Claudius Amiand treated an eleven year old boy for his hernia, and in the process he found a fecal fistula to the scrotum, caused by a pin that the boy had ingested that had perforated his appendix.

appendix was not the initial target. These continued throughout the seventeen hundreds and into the eighteen hundreds, but people still weren't really making the connection between this organ which was occasionally described as black or swollen or gangrenous, and the abdominal pain associated interesting.

white dude names and most of the nineteenth century. More surgeries meant more opportunities to observe the appendix in its natural habitat inflamed, uninflamed, ruptured, gangrenous, perforated, just all the different flavors, like the spectrum of what the appendix can look like, right, and so getting more of that information would allow them to kind of make more classifications on when is it what is a healthy looking appendix versus

what is not a healthy looking appendix, And eventually physicians and surgeons began to see the appendix as a surgical target in itself, not taken out just because you happened to be elbow deep in someone's intestines and you think, may as well kill two birds with one stone. Kind of a thing, but a reason to cut to begin with.

In eighteen eighty six, Reginald Herbert Fitz, a pathologist, first introduced the term appendicitis and proposed that at any sign of lower right quadrant pain, that appendix has got to go. Just a year later, Thomas Morton performed the first appendectomy solely for appendectomy's sake, and the patient recovered. Another of his patients, however, did not dying from stepsis soon after surgery, which made Morton go is this really the right call? Like,

do we really need to be doing this? In response to Morton's hesitancy, one doctor Chapman replied, quote, A true vermiform appendix is found only in six animals man, gorilla, chimpanzee, orange gibbon, and wombat. There can be no doubt therefore, that the sekl appendix is one of those parts of the human body having no particular function of significance, being of use only in animals. In the human being, it

ought to be removed with no bad effect whatsoever. So that I thoroughly agree with doctor Morton and what he has to say regarding the opening of the abdomen and taking out the appendix. It seems to me that the human being is better off without the appendix than with it, for it is nothing but a trap to catch cherry stones and other foreign bodies.

End quote. And so okay, I can see in some regard if you are when people get appendicitis and it's not treated or it's not removed, which would have been the case in much of the eighteen hundreds, you think, what is this thing that exists that kills us? If it gets bad? And if we take it out and someone survives the surgery, they survive it's not like your heart. It's not like your liver, right, like you can recover with no Effecteah.

to fruits, it was no longer necessary. This was again furthered by or like underlined by the fact that people who had their APPENICX taken out seemed to recover fine, and then that pattern encouraged further appendectomy because it was like might as well, no big deal.

diagnosed with likely appendicitis. He tried to delay the surgery and be like, we gotta do the coronation first, but then ended up having to delay the coronation to have the surgery. For the first few decades of the twentieth century, appendectomies were like ton selectomies, right, like we said, just get them out, it's fine, no need, no need. But unlike ton selectomies, people started to ring the alarm bell or like pump the brakes a bit earlier for the appendix,

like let's just take a pause. Maybe we could use the appendix From a nineteen thirty one paper quote the diagnosis of chronic appendicitis must be made only after the history has been very carefully taken and thorough exclusion has been made of the numerous conditions simulating appendicitis. The day of indiscriminate appendectomy has passed and quote, but has it Some researchers think perhaps not. The introduction of antibiotics in the nineteen forties and the use of laparoscopic surgery in

the nineteen eighties further lowered the threshold for appendectomy. But in the last few decades some people have questioned whether some cases of appendicitis could be instead treated with antibiotics rather than with the knife, like we talked about, And part of that questioning springs from the mystery of the appendix itself. What causes appendicitis? Does the appendix serve a purpose? If so, what is that purpose? And is it important enough to try to preserve the appendix when we can.

Darwin's dismissal of the appendix in the eighteen seventies stuck around like a bad habit for about one hundred years or so, although a few people had their doubts for much longer, like a researcher named Barry, who reported in nineteen hundred that the human appendix contains lots of lymphoid tissue Gault Gault.

tonsils are removed. This is followed by the removal of the pharyngial tonsil a few years later. The appendix becomes an ever increasing terror, which is only a laid when that organ has been placed in a glass jar. The majority of mankind seems to do very well with the appendix. It gives rise to no annoyance in them, for it is, after all a small percentage of the community that becomes the victims of appendicitis? Is the appendix really a useless organ?

taking over and helping with digestion of nutrients. But what happens when you get food poisoning or something just kind of like cleans out your entire gut, taking all the good bacteria in these biofilms along with it. That's where the appendix comes into play.

our seadiff episode from a million years ago. People who have like a seadiff infection, the bacteria just like colonize the entire intestinal tract and make it really difficult for any other commensal or like your your good bacteria to recolonize in your gut, and it's just like it's bad news, right, And so there have been studies that show that people who have had their appendix taken out have higher rates of sea diff infection, Okay, And so it's thought that

the appendix helps to initiate an immune response after exposure to seed diff as like one of these things, Yeah, got bacteria that we'll just take all over.

So early I mentioned that alongside humans, we have just a few other species that have these worm like vermiform appendixes, But as it turns out, many other animal species have what is functionally classified as an appendix, even if it doesn't have the same worm look to it. Marsupials, primates,

and gliers, which is a new word for me. It means rodents and lagomorphs like rabbits, compires all have species within those groups that have an appendix, and researchers estimate that the appendix has evolved independently at least twenty nine times in mammals.

other aspects of ecology, by life history characteristics. We don't yet know. There's even variation within a species. So in certain primate species, some individuals have an appendix and others don't.

all these animal species. But that being said, until recently, most research has focused on human appendixes, and other animals have largely been ignored. And so it might be that we get more clarity on that in the years to come, as we hopefully will for the causes of appendicitis and being able to better manage like treatment and weighing the scales in the favor of antibiotics or surgery. But speaking of the years to come, what else this might be

on the horizon for appendix research? Can you hit me with some global appendicitis numbers?

thousand adult Okay, which is pretty high. So this is like thousands, hundreds of thousands of people in the US, millions of people across the globe that get appendicitis every year. The incidence, at least in the US tends to be the highest in teens, so like age ten to nineteen is tends to be the highest incidents, but plenty of young adults and older adults also get appendicitis. You can get it at any age. It is pretty rare to get it under age ten, and I don't have a

good answer as to why that is. My best guess is like less lymphoid tissue in there. Maybe it hasn't grown enough. I have no idea.

those assigned female at birth. But it's also the case. And what I want to focus on a little bit in terms of our statistics is that accurate diagnosis is really important, right because this is something that can very easily go from treatable to emergency, to sepsis to life threatening.

Accurate diagnosis is very tightly linked to outcomes. So having a delay in your diagnosis or the incorrect diagnosis the first time that you present to care results in worse outcomes perforation, more severe infection, potentially death, and unfortunately and unsurprisingly, it is very predictable what the risk factors are that contribute to delayed diagnosis. Things like race and ethnicity are

significant contributors to delays in diagnosis. So studies have found that especially in kids, Black children are less likely to get opioid pain medication compared to white children who present with appendicitis. Black children and Asian children in some studies are more likely to have appendicial rupture compared to white children, which could be a contribution of difficulties and access to care as well as delays in diagnosis. Uh huh, And

there wasn't a lot of data that I found. At least it might be out there on populations like the Hispanic or Latino populations, but I would guess that, especially in this country, there are huge racial and ethnic discrepancies

there as well in terms of access to care. In terms of delayed diagnosis, sex also plays a role people as on female at birth both adults and children are more likely to have a delayed or misdiagnosis of appendicitis and socioeconomic status itself, at least as measured by insurance type. So in the US, people with private insurance tend to be of higher income to those on public insurance, and people on public insurance are more likely to have a

pendicial rupture than people on private insurance. So this is a huge issue of equity and discrepancies in access to care. In social determines of health, it's multifactorial. It's not just not being believed and not being diagnosed correctly or taken seriously in the emergency room, but that is part of it. It's also not having access to an emergency room close to where you live or whatever. Like, there's a lot

of different things that play into it layers. Yeah, I think that in terms of one of the like where does the research go? There's like there's so much erin But I think one of the things that is going to be really interesting to watch in real time, like we are living this right now, is like, are these tides really shifting fully towards a non operative approach? And if so, how do we accomplish that? What more data do we need to know? Who is going to do

really well with antibiotics alone? What are the criteria that we're using to come up with the best antibiotic regimen, because right now, there's not like a standard like, well, if you're going to do only antibiotics, here's your standard of care, right, And where do we go from here? Because the incidence of reoccurrence of appendicitis is not trivial, right, It's like fifteen to forty percent depending on the study.

So then my question is does the appendix go the way of the gallbladder where ideally, if you have cholisistitis, which is infection because your gallboughder gets clogged, the same way that your appendic gets clogged. Ideally you treat it with antibiotics first and then do surgery later when there's

not an active, really bad infection. Because the thing that's not kind of mentioned in a lot of this is doing surgery on an abdomen that's actively infected is a lot harder than doing surgery on an abdomen that's not infected, because infection comes with a lot of other stuff. It comes with a lot of inflammation, which means that you have a more likely risk of things like adhesions and complications later on. So if you can do a surgery

when things are not angry and infected, that's better. But is it necessary in the case of appendicitis or is it not? I don't know, Aaron.

the right answer right now? There isn't one right And so we've talked a lot on this podcast about how medicine moves slowly, and I think that this is something like the treatment of appendicitis with antibiotics is something that has been picking up more and more steam, but there's still a lot of open questions as to what the safest and best way is to do that. And so it's going to vary a lot where you are, which er you show up to, who's working, what your particular

case looks like. To know, like what is the best possible outcome, and sometimes we can't possibly know that. But the more data that we have, the better of a prediction that we can have on what the quote unquote best option is, which is it's really interesting. I think that part of that will also have to go along with more information on what the heck does this appendix do right? And how bad is it to take it out? I mean, we take out gallblotters all the time. We

take out appendixes all the time. We take out You can take out a spleen. You can take out so many your whole colon. You can do it all and live without these organs. But should we?

Like there's so many, oh, so many. I could keep going, but if you want to just learn more instead of hearing us blatd on, We've got sources for you.

bit old, but kind of fun. And then for the paper that discussed the function of the appendix, there's a paper from two thousand and seven titled biofilms in the large bowel suggests an apparent function of the human vermiform appendix Bolinger at all, give it, give it all to us.

the connection between the appendix and alsative colitis. That was from a Nature Reviews in gastra Entrology paper from twenty twenty three titled the appendix and alsative colitis an Unsolved Connection. So there's a bunch there. You can find the list of sources from this episode and all of our episodes on our website This Podcast will Kill You dot Com under the episodes tab.