Surgery still prevails "first antibiotic" appendicitis approach

When appendicitis strikes, an operation to remove the appendix has long been the road to recovery. But a new strategy called "antibiotics first" could help some people avoid surgery for appendicitis.

In an article in clinical practice in the current New England Journal of Medicine, Dr. David Flum, a surgeon at the University of Washington in Seattle, explores the history of the first antibiotics for appendicitis, the way it is currently used who could benefit from this approach without Surgery and disadvantages.

Appendicitis 101

The appendix is ​​a small finger-shaped tube that hangs from the lower right portion of the large intestine. Exactly what kind of doctor is a mystery.

Approximately 300,000 Americans a year, the Annex becomes inflamed, usually due to infection or obstruction in the digestive tract. This inflammation, called appendicitis, can cause pain, nausea, vomiting and fever. If untreated, the inflamed appendix can burst and bacteria spill throughout the abdominal cavity and into the bloodstream, setting the stage for a potentially lethal infection complicated and requires emergency surgery.

Rapid removal of the annex before it bursts avoids this dangerous scenario. Once a person is diagnosed with appendicitis, or even a strong suspicion of having, he or she usually has an operation to remove the body, often within 24 hours. 

This surgery, known as appendectomy, once held a large incision in the lower abdomen. Today, however, it is done laparoscopically. This means that the projection is removed by several small incisions. Laparoscopic Appendectomy resulted in fewer complications and shorter recovery time.

Systematic removal of the appendix is made largely because the conventional wisdom (and doctor) is the inflammation of the appendix will burst if not removed, and the more time passes after symptoms begin, the greater the risk that it explode. Some evidence, however, this scenario is difficult. 

Antibiotics first?

All people with appendicitis, even those on the way to surgery, antibiotics sets. These medications treat the infection in the annex and to reduce the risk of generalized infection if splinters or has already broken out.

First antibiotics antibiotics means someone with appendicitis and then look to see what happens. If medications treat the infection and appendicitis fades, no surgery is required. If a course of antibiotics does not work, then follow appendectomy.

This idea was first tested involuntarily - and successfully - in the Navy personnel who developed appendicitis at sea, and out of reach of an operating theater.

The idea of ​​first-antibiotics has generated interest because some evidence suggests that appendicitis do not always lead to appendicitis. And a 2014 study Surgery JAMA showed no association between the number of adults with appendicitis time spent in the hospital before an appendectomy and the risk of a ruptured appendix. So while appendicitis remains a pressing problem, it can not be so urgent that we thought.

Randomized clinical trials comparing antibiotics raw appendectomy have not made the case for delaying surgery. On the positive side, the first non-antibiotic appears to increase complications, including appendicitis, compared to an immediate appendectomy. On the downside, as a third of those assigned to first antibiotics still get to have an appendectomy, or within 48 hours or the next year.

"It is fair to say that antibiotics just can delay the inevitable for some patients," said Dr. Joshua Kosowsky, Clinical Director of Emergency Medicine, Harvard-affiliated Brigham and Women's Hospital. 

Staying the course

The first antibiotic approach has the potential to help some people avoid appendicitis surgery. But it also has disadvantages. Keep appendix instead leaving open the possibility of repeated episodes of appendicitis, with appendectomy follow the path. It could also lead to persistent symptoms and a feeling of uncertainty which could affect the quality of life.

Appendectomy, on the other hand, when done laparoscopically, is safe, has a short recovery time, is responsible for appendicitis, and prevents recurrence.
Doctors are not a good way to know who might benefit most antibiotics forward facing immediate surgery.

In the NEJM article, Dr. Flum concluded that appendectomy should remain the first choice of treatment for most people with appendicitis, at least until larger trials directly comparing surgery and antibiotics were first made. The American College of Surgeons, the World Society of Emergency Surgery, and other professional groups agree.  

However, antibiotics, initially it may be appropriate for persons now

    1.   prefer not to undergo surgery
    2.   are not healthy enough for surgery
    3.   they are not near a medical center, which regularly laparoscopic appendectomy.

The diagnosis of appendicitis is not always easy. Conditions such as inflammatory bowel disease can mimic appendicitis. And young children are often unable to describe their symptoms enough to rule out other causes of stomach pain accurately. "Giving antibiotics to a patient with an uncertain diagnosis, then watch carefully is a reasonable plan of action in some cases," says Dr. Kosowsky. "But appendectomy remains the standard treatment for appendicitis."