Appendicitis: Not so fast with the scalpel

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A new study in The Lancet led by Dr. Corinne Vons of the Assistance Publique-Hopitaux de Paris and Université Paris XI finds that assessing the need for surgery in appendicitis patients using radiological tests (such as CT scans) is not sufficiently reliable to avoid surgery by treating with antibiotics. Currently, uncomplicated appendicitis is treated solely with antibiotics, while complicated appendicitis requires surgery because the appendix is perforated. Though a CT scan is used to discern between the two, it is not always easy to accurately diagnose complicated appendicitis.

Dr. Vons and her team of researchers randomly assigned 239 patients with what they found to be probable uncomplicated acute appendicitis, as diagnosed using a CT scan, to receive either an appendectomy or amoxicillin plus clavulanic acid antibiotic treatment for eight to 15 days. When they assessed the results at 30 days, they found that the incidence of peritonitis — a serious abdominal cavity infection resulting from perforation of the appendix — was four times higher in the antibiotic versus the surgery group (8 and 2 percent, respectively).

Moreover, it was later found that 18 percent of the patients in the surgery group had complicated appendicitis with peritonitis, despite the negative initial CT scans. And 12 percent of antibiotic recipients needed an appendectomy within a month after treatment.

Not everyone agrees with the study results, however. Dr. Rodney J. Mason, associate professor of surgery at the University of Southern California’s Keck School of Medicine, writes in an accompanying editorial that there were many biases in the study. First, he points out that the wrong antibiotic drug combination was used; next, he highlights that, at the end of the study, two-thirds of the patient population did not need surgery.

“Given that the false negative rate was so small, while also taking into account the wrong choice of antibiotic therapy, patients should still be given the option of antibiotic therapy, which, as Dr. Mason points out, is not something doctors usually tell their patients,” says ACSH's Dr. Gilbert Ross. “Also, you can’t ignore the risks associated with an appendectomy, which can be potentially dangerous. Then again, antibiotics have their own risk profile as well, and may sometimes be associated with adverse effects.”