He was a star quarterback for a high school team. The final game of the season was a chance for the state tournament at large. And he was seeing me for a peculiar right lower quadrant pain.
Tell-tale signs were his loss of appetite and how the pain began earlier in the day around his navel but now migrated to the right lower side of his abdomen. As a part of my physical exam, I slowly pressed into his abdomen. While that caused an ache, he yelped in pain when I snapped my hand back, a textbook response to “rebound” tenderness. Adding information from his exam and some blood tests, the diagnosis was nearly certain: acute appendicitis. Our hometown pride-and-joy needed surgery today and was out for the season-ending thriller.
The appendix is a tube of tissue coming off the intestine. It ends in a blind pouch, dangling there inside our bellies. We don’t have a good answer for any purpose it serves. The appendix only gets attention when it unpredictably becomes inflamed, swells up and begins to hurt. If we don’t get it fixed, the appendix can rupture, filling the abdomen with infection. So we’re quick to do surgery if we find a “hot” appendix.
The characteristic symptoms of right lower quadrant pain and rebound tenderness do not always classically appear, so we look for other tests to confirm if the appendix is inflamed, called appendicitis. Appendicitis is typically triggered by a bacterial infection caused by either a related inflammation of the GI tract or from a blockage of the appendix opening from food waste or stool.
Blood tests can help point the right direction, but ultrasounds, CT scans, and sometimes an MRI often can give more definitive proof. Despite the best — and often expensive — tests, it still can be difficult to be sure the right lower quadrant pain really means an appendix needs to come out.
That year, the team lost the season closer and the chance at state championship vanished. I kept in touch with the parents for a few years. Their joy in their son’s journey was forever shrouded by the “bout with the appy” and wondering what might have been.
The surgery can be by laparoscopy, requiring just a few incisions covered by Bandaids, but it still sets anybody back at least 10 days. Surgeons usually agree that when all signs point to appendicitis, we better cut it out because the risks are too great. That means we’ll accept having a few normal appendices turn up because it’s better than missing a true appendicitis until too late (some estimate 15-30 percent of appendectomies have normal appendices).
Now there is evidence that maybe, just maybe, we don’t have to run to the surgeon so fast.
A variety of recent research studies have examined using antibiotics to treat the inflamed appendix and show promising levels of success. A cornerstone study just released in the Annals of Surgery reported on 159 patients who had confirmed appendicitis by physical exam, blood tests, ultrasound, and CT if needed. After following the patients for two years, 86 percent were cured without surgery.
For the right person, antibiotics may be the new answer for appendicitis. Keep in mind that surgery remains the standard, standing the test of time.
But for some, this is a game-changer.