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

This is exactly right.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life.

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Not all group chats are the same, just like not all Adams are the same.

Adam Brody, for example, uses WhatsApp to plan his grandma's birthday using video calls, polls to choose a gift, and HD photos to document a family moment to remember.

All in one group chat.

Makes grandma's birthday her best one yet.

But Adam Scott group messages with an app that isn't WhatsApp.

And so, the photo invite came through so blurry, he never even knew about the party and grandma still won't talk to me it's time for whatsapp message privately with everyone hi my name is molly and in march of 2015 i was 36 weeks pregnant with my first child for the most part my pregnancy had been uneventful except for a visit to labor and delivery in mid-february with some pain that they determined at the time to be just gas so on the afternoon of march 16th when i started to feel similar pain again i just put it off as being gas and did all the recommended things to treat the pain But over the course of a few hours, the pain got progressively worse.

At around 6 p.m.

on the evening of March 16th, 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 36 weeks pregnant, they really just focused on me being in preterm 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 ligament pain, and they were probably going to send me home with some exercises.

Thank God they didn't.

In the span of a few hours, I had an ultrasound done as well as an MRI as a doctor 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 40 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 17th 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 16 hours of being in 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 them saying, there's pus in her stomach, call the other surgical team.

Minutes later, they delivered my daughter Madeline at 1234 on St.

Patrick's Day.

After they delivered my daughter, the OB team swapped out with the 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 put me under, it was found that my appendix had ruptured and I had peritonitis in my intestines.

For the next three days, I was on IV antibiotics, but my white blood cell count was continuing to rise and I was still running a fever and I 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 IV 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 to do 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 2015.

They also had a theory that my daughter was kicking my appendix and that may have caused it to become inflamed and rupture.

Lastly, during those agonizing 16 hours prior to having my daughter, we had an amazing nurse who knew what I was experiencing wasn't labor pain or round 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 who took care of me.

Thank you.

Oh

my gosh, that sounds terrifying.

Absolutely awful.

I can't, oh, I can't imagine.

Yeah.

Thank you so much for being willing to relive that experience and share that with all of us that, oh, I can't.

Yeah, I don't have words.

No, yeah.

Thank you.

Thank you.

It must have been really terrifying.

So thank you for sharing.

Hi, I'm Erin Welsh.

And I'm Erin Allman Updike.

And this is this podcast will kill you.

And today we're talking appendicitis.

Yeah.

Yeah.

This is kind of an oddball one for us, I feel like.

It is and it isn't, I feel.

Yeah, you're right.

I don't know.

I feel like that about a lot of our episodes recently, where I'm like, are there rules anymore?

I don't think so.

No, we make the rules, Erin.

This is our podcast.

It's so true.

But appendicitis, I think there's, I'm excited to learn history things.

Don't know it.

And

there's.

pathology there for sure.

So

I mean, one of my biggest touch points is Madeline, I think.

I talk about Madeline.

Yeah, good.

I was always drawn to that for some reason.

Probably I was a spooky little kid.

But

doesn't everyone love Madeline?

Like, it's a classic.

Yeah, I know.

But okay, were there multiple Madeline books or just Madeline?

I only know Madeline, but I don't know.

Oh, my gosh.

Okay.

For the longest time, I thought it was all.

I don't know.

I thought that was just like story number one in a Madeline series.

I don't know.

I've only read that that one.

Madeline.

Oh, me too.

Yeah.

Okay.

So I guess it feels like there must be, we are going to have to Google it after this.

Someone is going to reach out and be like, wow, wow, your Madeline knowledge is really poor.

Very poor.

One out of five stars.

Thank you, dear.

You know what?

It's good, though.

It is.

It's going to be a great episode.

But before we get into any of it, it's quarantining time.

It is.

Erin, what are we drinking this week?

We're drinking Waiting for the Rupture.

The Rapture.

Gosh, I'm pleased with myself on this one.

You should be.

It's a good one.

I would hope that we don't ever actually wait for the rupture, but it's a good quarantini name.

No,

it's a great name, if I do say so myself.

And it's a great quarantini as well.

It's got some delicious ingredients.

Essentially, what you've got here is a French 75, which is gin and champagne.

Subtract the champagne, add some sparkling cider for a a little bit of a fall, winter vibes.

Yes, some lemon spices, you know.

Delish.

Delish.

We'll post the full recipe if you need it on our website, thispodcastwithkati.com, and our social media for both the quarantini and the non-alcoholic placebarita.

They're there.

They're there.

Website.

We've got some great stuff on that website.

We just revamped it.

Well, just, I guess now it's been months because this two and a half months ago, we revamped it

by the time this comes out, but it's great.

Check it out.

It is great.

It's got things like transcripts.

It's got links to our bookshop.org affiliate account, our Goodreads list.

It's got links to merch.

Some pretty sweet stuff going on there.

It's got links to our Patreon.

It's got links to...

Oh, music by Blood Mobile.

It has got sources for each and every one of our episodes, a little section about the errands.

There's a submit your first-hand account form.

There's areas where you can contact us.

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You can find them.

Go to our website, click extras and savings.

You can find it there.

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If you like the show, please rate, review, subscribe.

Make sure that you're subscribed on whatever podcatcher you use.

It really helps us out a lot.

So it does.

Yeah.

Thank you.

Thanks.

Well, should we get started?

Let's do it.

Let's take a quick break and then begin.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life.

There was the six-foot cartoon otter who came out from behind a curtain.

It actually really matters that driverless cars are going to mess up in ways that humans wouldn't.

Should I be telling this thing all about my love life?

I think we will see a Twitch stream or a president maybe within our lifetimes.

You can find Close All tabs wherever you listen to podcasts.

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There is this kind of very textbook description of appendicitis, and I'm going to tell you how it goes.

It starts with usually kind of a vague pain, an abdominal pain, around the belly button, kind of like in the center of the belly, around your belly button.

And it tends to go along with like i'm not really feeling hungry because my stomach doesn't feel good i don't want to eat anything and then it might progress to feeling actually nauseous like feeling like you're going to 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 near 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 24-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 and presents.

I can very vividly remember having a patient describe their like course of symptoms that brought them to the emergency room exactly like this.

And I looked at them and I was like, well, you described the textbook description of appendicitis.

Are you an actor right here?

Like,

is this a real patient encounter?

And then when you're in the emergency room and the person examining you starts to do their exam and they touch your stomach, sure enough, very often people have pain in this kind of textbook area.

And that point, there's a point, it's called McBurney's point.

It's like two-thirds of the way between your belly button and that sticky outy part of your hip bone, which is called your anterior superior iliac crest.

So it's like a little bit closer to your hip bone than your belly button along this like diagonal line between your belly button and that hip bone.

You can put like your finger there and that tends to be the most tender spot.

It hurts really bad if you smoosh 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 smoosh 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 like textbook description, almost certainly, like over 90% 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?

And what are some of the ways that it doesn't present with that classic description?

One of the ways that it gets missed the most is when somebody is having constipation.

And so they're maybe not having, because sometimes you get diarrhea with appendicitis.

When people are having constipation and appendicitis, it's more likely to get missed for one reason or another.

You might not have a fever.

You might not have a fever yet.

You might have pain, but it's a little bit more nonspecific.

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 ovarian torsion, 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.

What do you see in the blood?

You might see an elevated white blood cell count because you have an infection going on.

And then you would expect usually not to see other things like your liver being out of whack because that might make you think it's something else that's going on.

You always have to check if somebody has a uterus to make sure that there's not a pregnancy because A, then it could be an ectopic pregnancy.

And B, then you might change the type of imaging that you're going to do to avoid radiation.

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 Erin, 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 wanted my appendix out too yep i did as well um before i knew more about

appendixes so open appendectomy was the standard of care for a long time until the advent of what's called laparoscopic appendectomy which is instead of one giant cut they use really a couple of really really really small cuts and then these instruments on long sticks and a camera that they can put inside of your belly to look at your appendix and all of your other organs.

And then, if needed, 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 it's causing problems today in the year 2024 people are starting to come around to this wild idea and i say starting because the literature goes back quite a ways yeah to like the 50s at least i think oh that's even further than i realized i knew of it like to the early 2000s

but like it's been an accepted practice i think since like the mid 2000s but still is not that common that you maybe don't have to cut it out and maybe can just use antibiotics to treat it.

But is there, there's like a higher relapse rate or whatever it would be called, like a higher recurrence rate of appendicitis, right?

Or is there?

A lot.

Let's talk about it.

Okay, okay.

So let's talk first about what is actually going on in your appendix.

What is appendicitis really?

Like now we know what it looks like.

And most of the time, you're going to need surgery to get it out.

So what's going on?

And that might tell us when it might be a good idea to not not do surgery or do surgery based on what's going on.

Oh,

good, good.

So your appendix in humans, Aaron, I remember you asking me this while we were before we recorded and I was like, had to look all this up because

there's so many different names for the appendix.

Yeah.

In humans, it's called the vermiform appendix because it looks like a little worm, vermis, like a worm.

Yeah.

It's a little out pouching.

Basically, your appendix is this little like outpouching, this little like finger of tissue that comes off of the very first part of your colum or your cecum or your large intestine.

It has a lot of names.

And I don't remember, Erin, which episode it was relatively recently that you were like, can you tell me all the parts of your intestines?

Do you remember that?

I think it was norovirus.

Norovirus.

Okay.

So.

As a refresher, your small intestine is what's connected to your stomach.

And that is what wriggles its way back and forth in the center of your abdomen.

And it ends in the right lower quadrant of your belly.

And there's a valve that connects your small intestine to your large intestine.

And right next to, just kind of right underneath, like

down south, closer to your feet, I guess, of where your small intestine connects to your large intestine, 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 appendicolith or a fecolith, a little hard poop ball.

But sometimes it can get clogged with other stuff.

It could get clogged with a tumor, either a benign tumor 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 thrive.

Like a stagnant pond, yeah.

Exactly like a stagnant pond.

And so that is what happens in our appendix when you get appendicitis.

You have something that causes this tube that should be like open to communicate with your large intestine to get clogged and blocked off.

And then bacteria start to grow and multiply.

As that happens, it triggers inflammation because that's what a bacterial infection does.

It triggers inflammation.

And that inflammation causes swelling.

And when you have swelling in a really small space, that ends 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 hole in it, like a small hole, then the fluid might come out and get trapped.

And that is what forms an abscess.

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 is what causes it.

Be honest.

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Okay, so at what point,

like what's happening when your belly button hurts versus when that pain moves to the lower right quadrant?

And then like when does surgery, when is surgery indicated?

When is it not indicated?

You know, like what, what's going on?

Oh, such a good question.

These are fun questions.

Okay, so what's happening when it's going from your belly button pain down to your right lower quadrant?

I don't 100% know the answer to this question.

I don't know if the answer to this question has been like, I don't know.

I didn't read any papers that directly 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.

Why does it move?

The thought is that once that inflammation, as it starts to get more severe, then your brain can localize it more because there's more of that inflammation just touching in that one area.

Okay.

That's my best explanation.

I don't know if it's a perfect one.

What's going on with referred pain?

Ooh.

I love referred pain.

I mean, I don't love referred pain, but I love.

So referred pain means that you have inflammation or something that's going on that should be causing pain, that's triggering pain in one area, but the pain that you feel is coming in a different area.

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.

Got it.

Yeah.

I've always been curious why that works.

However, our brain is so interesting and weird.

So, yeah, so that's why we kind of get pain, where it might start more generalized and then move as that infection gets more severe.

The second question that you asked is like, then when would you need to surgerize versus not surgerize and how all of that.

So, let's talk a little more about that.

So, appendicitis starts well before an appendix ruptures.

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 appendicitis are 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 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 friend's appendicitis.

And so, this appendicitis, if it's caused by an infection, not a fecalith, it's like, is it opportunistic bacteria that like normally reside in your gut?

Arian, I love your question.

So

all appendicitis is an infection.

Okay.

All appendicitis is an infection, but you said, is it a fecalith or is it not?

The first trigger to that appendix getting clogged could be a chunk of something

or it could be some other reason, whether it's an infection or non-infection that causes your tissue to hypertrophy, right?

And what we see in all of these cases, the bacteria that are growing are just the kind that live in your gut so yeah they're mostly uh 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 fecolith caused by a chunk of poo that's stuck there they are less likely to do well with antibiotics alone ah why

Well, because that chunk isn't going anywhere.

Okay.

And so that chunk not only is causing like a constant blockage, it's also causing a blockage that's reducing blood flow, we think maybe.

And that's part of why the antibiotics are not able to get in as well to the appendix 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 fecolith 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.

Are there risk factors for appendicitis broadly or fecolith appendicitis?

Like, what are the risk factors?

Not, yeah, great question.

I don't know.

I don't think we know like who is likely to get it versus not get it, you mean?

I don't know.

Yeah, we don't know.

People who are assigned male at birth are more likely to get appendicitis than people who are assigned female, but opposite of gallbladder stuff.

Right.

But we don't know like why.

Why is that?

And it's not like a very significant, I think it's like an 8% lifetime risk versus 6% lifetime risk.

So it's not like huge.

Super meaningful.

Yeah.

Yeah.

But yeah.

And like, and it's older people who tend to get appendicitis from fecoliths, younger people who tend to get it not from a fecolith, which kind of just makes sense.

I think of it at least as like, you've had more time for poop to get hard.

I don't know if that's accurate, but

but this is also really important because you said, Erin, 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 8 to 12% 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 fecolith there, right?

So, a lot of that initial failure rate is when there was a poop ball that was causing the initial appendicitis.

And so, that wouldn't show up on imaging necessarily?

Sometimes it does.

40% of people with appendicitis on CT scan have a fecolith,

but I don't know if that means that 40% of people are having appendicitis caused by that or if it definitely there are some times that you might not see it, even if it's there.

Who are you not capturing?

Right.

Also, just like some people have fecaliths without having appendicitis, that's a thing too.

Yep.

Like incidentally, you can find it like 4% of the time.

Huh, I know, right?

But then there's also, even if you can treat that infection initially, then there is a concern, is it going to happen again?

You had appendicitis once.

Are you at 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 40%.

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 sick 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 re-operations, 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 poo chunks.

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

But when it comes to antibiotics versus surgery for appendicitis, the downsides of surgery are connected solely to the surgery itself and complications arising from that?

Or are there also downsides to not having your appendix, period?

What a fun question.

We don't know.

Are there downsides to not having your appendix?

We don't know, Erin.

Like, how do we not know?

We've had literally like so many decades, hundreds of years to figure this out.

So I was going to talk about this later, but there's some some really interesting data now on like the association between your appendix and things like ulcerative colitis.

Uh-huh.

And it actually seems that like in some small cases, like if you got your appendix out because you had appendicitis and if you got your appendix out before you were a certain age, then having your appendix out might actually be protective against ulcerative colitis.

Fascinating.

Right?

Weird.

It's not, that is not, well, I have studies that you can read more because it's not that straightforward.

but right yeah so what happens if you live without your appendix is there any complications other than surgical complications not that like we know of no okay and so they're really it used to be the case that like i remember working with an ob gyn 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.

Yeah, I mean, a lot like tonsils, a lot like tonsils, so much like tonsils.

Yeah, yeah.

But yeah, are there downsides to it aside from obviously surgical complications?

I don't know.

I don't have an answer to that.

Right.

Yeah.

So interesting.

So interesting, dude.

So, Aaron, tell me about the appendix.

Yeah.

I will do the best best that I can right after this break.

What do long-term residents of an Antarctica settlement, most astronauts, and Stephen Colbert have in common?

An appendectomy?

I don't know.

Yeah, you guessed it.

Wait, wait, wait, wait.

Most astronauts?

Hold on.

I have so many questions.

Uh-huh.

Uh-huh.

Do they do it prophylactically?

Some, some of the time, yeah.

What?

Okay, let's, yeah.

All of these people I just listed no longer have their appendix.

In late 2023, Stephen Colbert developed appendicitis and actually he taped a couple of shows before going to the hospital where they had found that his appendix had already ruptured.

Oh, dear.

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 move to Villa Las Estrellas, which is a long-term settlement in Antarctica, they have to have their appendix out before moving in, kids included.

Is that because of the one story?

It probably is.

I can't wait.

I love this story so, so, so, so much.

Well, you don't have to wait that long.

I'm telling it right here.

So, in 1961, a Soviet physician named Leonid Rogozov was stationed in Antarctica.

And at one point in time, he recognized the signs and symptoms of appendicitis in himself, and he proceeded to operate.

on himself.

On himself.

Quote, on the morning of April 29th, 1961, 1961, I did not feel well.

The symptoms 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 37.4 degrees Celsius.

It was clearly a case of appendicitis.

Wow.

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?

No.

Rogozov injected a 0.5% Novocaine 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

yep and he was a surgeon right he was i think later became a surgeon i think at the time i remember he was just like he was a general practitioner oh wow okay yeah

uh and by midnight the operation was complete and within a few weeks he was back to normal wow but things could have gone very poorly which is no doubt part of the reason for the no appendix policy at this, at this settlement in Antarctica via Las Estrellas.

But I just had to tell that story

because it's, it's one of, and the pictures are incredible.

He's just like, his abdomen is open.

And he's, I just, it's one of the most ridiculous stories.

Yeah.

Yep.

It's also not the only instance of self-appendectomy.

I know.

Yeah.

But it's the only one I'm going to tell today.

So

just give you a little something to Google later.

Do you remember?

I don't remember how much of the show.

What's the show with the Scottish Highlanders?

Outlander?

Outlander?

How much of that did you watch?

Oh,

several seasons because they made it to America.

She does that to herself.

She doesn't, doesn't, isn't an appendectomy on herself that she does that?

I don't remember, but I wouldn't put it past her.

After the growing penicillin on bread,

I'm pretty sure that's what it is.

Yeah.

Anyways.

Anyways.

But I mean, I think that like what this reading about the appendix left me was this feeling that the appendix seems like an agent of chaos, right?

Disrupting plans at the very least and causing life-threatening injuries in more extreme cases.

If we can take it out with seemingly no ill effect or no apparent ill effect, why the heck do we have it anyway?

Shouldn't we all just get our appendixes out?

That was the leading vibe, like you said, Erin, about the organ for much of the 20th 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 an 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 CE 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

from the sepsis that ultimately developed.

Okay.

Peaceful is, 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 animals.

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.

This is the second time we've talked about wombats in like two weeks.

Wombats are all the rage.

And their poop is cube, cubular.

Maybe that helps contribute to the air.

Cubular areas to the fecolith.

I don't know.

In any case, it wasn't until the 15th and 16th centuries when dissection was back on the menu that anatomists identified and described the appendix somewhat sloppily and with no clear idea of what its purpose was.

Da Vinci illustrated the appendix in 1492, but it didn't get published until a couple hundred years later.

Andreas Vesalius also drew the appendix, but called it the cecum, 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, right?

Got it.

Iliac passion was one term used to describe what was probably appendicitis, which I love.

I'm using a little bout of iliac passion today.

My iliac is feeling very

iliac passion.

And advice for patients experiencing this type of passion was to manage it with big bouts of bloodletting, enemas that cooled or gave you diarrhea, you know, a cooling enema or a diarrhea enema, opiates, and something called warm animal compresses.

I don't know what that is.

I know what that is.

Maybe it's just putting a warm animal on you.

Oh my god, just snuggle with your pup.

Okay.

I do that every day.

It feels like it's something different than that.

I don't.

I think it's maybe a little more gruesome than just a cuddle sesh.

Yeah.

Yeah.

Perforated appendixes leading to abscesses also made appearances in medical texts.

And the first appendectomy followed one such perforation.

By the way, appendixes is the plural for appendix, like the human organ, but appendices is the plural for like an appendix, like a book appendix.

Oh, isn't that fascinating?

That is fascinating.

Yeah.

I learned that in a in a great YouTube video by Patrick Kelly, who has an incredible channel of YouTube videos on like the history of medicine.

Definitely check it out.

I watched this video on appendicitis, loved it.

Great, great stuff.

And that's where I learned about appendixes because I heard it and I was like, I'm pretty sure it's appendices.

And I was like, no, it's not.

So it was great.

Anyway.

In 1735, Claudius Ammiand treated an 11-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.

Oh my gosh, that's really

Awful, awful.

And so this guy, Claudius Amion, took the appendix out.

And from what I can tell, I actually find it hard to kind of piece together what happened afterwards.

The child survived the surgery.

Like I went back to find the paper.

But other cases of opportunistic appendectomies, like the surgeon took out the appendix during another procedure, but the appendix was not the initial target, these continued throughout the 1700s and into the 1800s.

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.

Yeah.

You would think, I mean, especially in the age of humors, something

black and gangrenous that seems like bad humor.

I don't know whether it was just like the frequency.

It's not like people were performing surgeries left and right in the 1700s.

That makes sense.

Yeah.

Yeah.

How interesting.

And two major developments in the 1800s eventually paved the way for physicians to point the finger of blame towards the appendix and its role in right lower quadrant pain, sometimes leading to death.

Anesthesia and antiseptics.

Okay.

Anesthesia and antiseptics meant people were more willing to undergo surgery and surgeons more willing to perform them since surgery was no longer as much of a death sentence as it had been in previous centuries.

And glossing over a lot of old white dude names and most of the 19th 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.

Okay.

And eventually, physicians and surgeons began to see the appendix as a surgical target in itself, not taken out just because you happen 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 1886, 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 sepsis 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 Dr.

Chapman replied, quote, a true vermiform appendix is found only in six animals, man, gorilla, chimpanzee, orang, gibbon, and wombat.

There can be no doubt, therefore, that the secal 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 Dr.

Morton in 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.

Okay, I have so many thoughts.

First of all, everyone's always picking on things like cherry pits.

First of all, who's eating cherry pits?

Right.

But also, why

the fact that it's only in existence in some animals,

does that make it not functional in humans?

Like most animals don't have opposable thumbs.

And I think we can all respect that they're really important.

I think it is like human superiority.

So it's like, we don't need this.

Animals have this.

Why the heck would we need it?

Aaron, I'm not saying it's logical.

It's so illogical because it's also like, well, only a few have it.

So why did it evolve in the first?

I mean, they didn't have evolution, but still.

Well, I think this was, this was evolution.

This was post-Darwin.

But Darwin himself was like,

in 1871, wrote, quote, with respect to the alimentary canal, I have met with an account of only a single rudiment, namely the vermiform appendage of the cecum.

Not only is it useless, but it is sometimes the cause of death, 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 1800s, 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 effect.

Yeah.

So it's also probably because it's so small and little, like, how could it be important?

Right?

Do you think there's some sizeism going on?

No doubt, no doubt.

But yeah, I think, I think it was also like, you know, a handful of animals have it.

We have it, but we can remove it easily with no problem.

And we're better than animals.

Maybe it's like all of these different things together.

That's my guesses.

Weird.

Yeah.

And so Darwin's hypothesis was that it once served a function in early humans, but as diet shifted from leaves to fruits, it was no longer necessary.

This was again furthered by or like underlined by the fact that people who had their appendix taken out seemed to recover fine.

And then that pattern encouraged further appendectomy because it was like, might as well.

Right.

No big deal.

Yeah.

Well, also like appendectomy versus death.

It's an easy choice.

It's an easy choice.

Yeah.

A few famous appendectomy cases further popularized the procedure.

The most headline-worthy one was that of King Edward VII, the firstborn son of Queen Victoria.

After the queen's death in 1901, Edward was set to take the throne on June 26th in like coronation.

But on the 14th of June, 12 days before, he began to develop severe abdominal pains, was diagnosed with likely appendicitis.

He tried to delay the surgery and be like, we got to do the coronation first.

but then ended up having to delay the coronation to have the surgery.

For the first few decades of the 20th century, appendectomies were like tonsillectomies, right?

Like we said, just get them out.

It's fine.

No need.

No need.

But unlike tonsillectomies, 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 1931 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, end quote.

Hmm.

But has it?

Some researchers think perhaps not.

The introduction of antibiotics in the 1940s and the use of laparoscopic surgery in the 1980s 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 1870s stuck around like a bad habit for about 100 years or so, although a few people had their doubts for much longer, like a researcher named Barry, who reported in 1900 that the human appendix contains lots of lymphoid tissue.

Galt.

Galt!

Gut-associated lymphoid tissue.

And so Barry suggested that the appendix might play some sort of immune role.

Or, like Sir William McEwen, who wrote in 1904, quote, Is this body of ours so very imperfect that we require to submit it to the numerous rectifications which are sometimes recommended to be carried out after it comes into the world?

When a child is born into this country, some consider it necessary that he be circumcised.

A few years later, the tonsils are removed.

This is followed by the removal of the pharyngeal tonsil.

A few years later, the appendix becomes an ever-increasing terror, which is only allayed 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 the appendix really a useless organ?

End quote.

I really love that quote, Aaron.

Isn't that fun?

It was really good.

Why are we doing so much cutting?

Yeah.

And that question, which was posed in 1904, would only get a solid answer a hundred years later.

In the early 2000s, researchers at Duke University discovered that hiding within the appendix was a little concentrated cluster of beneficial bacteria mediated by the the host's own immune system.

Biofilms like this exist throughout many mammals' intestines, and they play a role in keeping the bad bacteria from 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.

Ha!

Researchers think that the appendix acts as a quote-unquote safe house for good gut bacteria so that when a bout of diarrheal illness wipes out the good microbes living in your intestines, they can be recolonized by the bacteria from your appendix.

I love that idea, Erin.

Isn't that really cool?

Have they, can I ask questions?

Sure, yeah.

Have they?

Because I know I was looking at some papers that looked at like whether there's a shift in your microbiome after an appendectomy and things like that.

And it seemed like it was minor.

Yeah.

So then have they looked at like following an appendectomy following a diarrheal illness?

Is there a shift that is for the worse if you've had an appendectomy versus not or things like that?

I wish I knew the answer to that.

The only, so there is some evidence of this in terms of like post-appendectomy and C.

diff infection.

So as we know from our C.

diff episode from a million years ago, People who have like a C.

diff infection, the bacteria just like colonize the entire intestinal tract and make it really difficult for any other commensal or like your good bacteria to recolonize in your gut.

Right.

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 C.

diff infection.

Okay.

And so it's thought that the appendix helps to initiate an immune response after exposure to C.

diff

as like one of these

gut bacteria that will just take all over.

I will also say that in the studies that have looked at antibiotics, because antibiotic use is one of the major risk factors for C.

diff infection, there does not seem to be an increase in C.

diff infection after antibiotics for appendicitis.

So if you're using antibiotics instead of surgery, there's not an increased risk in C.

diff.

So that's very interesting.

Yeah.

There you go.

And so Darwin, I think, got this one wrong, right?

The appendix certainly does serve a purpose.

Is that purpose essential to life or health?

No, but it does play a role, which begs the question: well, why don't all animals have them?

So earlier, 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 glires, which is a new word for me.

It means rodents and lagomorphs, like rabbits and hares.

Okay.

All have species within those groups that have an appendix.

And researchers estimate that the appendix has evolved independently at least 29 times in males.

29.

Okay, that alone, I feel like, tells you that there's some functionality going on.

Uh-huh.

And it's been lost 12 times, right?

So, like,

the balance is definitely in the favor of this being, having evolved multiple times.

Interesting.

This strongly suggests that this organ, this appendix, has been pretty important in evolutionary history.

But does it serve the same purpose in these different species?

Not necessarily.

And there doesn't seem to be a strong pattern in who has an appendix and who doesn't.

Like, is it influenced by diet, by environmental factors, by habitat, by other aspects of ecology, by life history characteristics?

We don't yet know.

Wow.

There's even variation within a species.

So in certain primate species, species, some individuals have an appendix and others don't.

Stop it.

What?

Right?

How?

Yeah.

What?

Don't know.

In general, people think that in humans and other primates, and maybe some rodents, the appendix serves this immunological function, like helping to protect us from invading pathogenic gut bacteria and sort of recolonizing when we do get a GI infection.

In marsupials, it might just be that the appendix acts as kind of like the more developed cecum found in other animals and in lagomorphs like rabbits it might trap sand like

oh my toddler needs a cecum just to trap sand yeah

maybe that's why it involved in humans maybe

just for toddlers just for toddlers

But yeah, I mean, it seems like we don't fully know why the appendix, like what purpose the appendix serves in these different animal species or groups, and is it the same?

Is it different?

Why Why do some organisms have it and others don't?

And there might not be one thing driving the evolution of the appendix across 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 might be on the horizon for appendix research?

Can you hit me with some global appendicitis numbers?

Oh, I would love to try right after this break.

Some of the papers that I read, a lot of the papers actually cite that acute appendicitis is the most common abdominal surgical emergency in the world.

With an incidence, this is an incidence that I think is based on U.S.

numbers, but I don't actually know.

But the incidence is estimated at 96 to 100 cases per 100,000 adults,

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 10 to 19 is tends to be the highest incidence.

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 10.

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.

It's just filled with sand still from.

Yeah, you can still get that mesenteric.

That's actually really funny.

You can still get mesenteric lymphatinitis, which is a separate entity, but is like when just like lymph tissue causes inflammation and pain in that area without actually causing swelling and infection in the appendix.

So maybe it's something to do with like, I don't know, I don't have an answer.

But, and I said, it's also slightly more common in those assigned male at birth compared to 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 in access to care as well as delays in diagnosis.

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 assigned female at birth, both adults and children, are more likely to have a delayed or misdiagnosis of appendicitis.

And socioeconomic status status itself, at least as measured by insurance type.

So in the U.S., people with private insurance tend to be of higher income compared to those on public insurance.

And people on public insurance are more likely to have appendicial rupture than people on private insurance.

So this is a huge issue of equity and discrepancies in access to care.

and social determinants 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 15 to 40%, depending on the study.

So then my question is, does the appendix go the way of the gallbladder?

Where ideally, if you have cholecystitis, which is infection because your gallbladder gets clogged the same way that your appendix 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.

It's interesting.

And then like, what are there instances where people who are treated with antibiotics, it's like for sure case of appendicitis, they're treated with antibiotics and then the appendix proceeds to rupture?

Does that happen?

Oh, yeah.

Like the, like the, like the antibiotics just don't work at all.

Right.

Yeah, absolutely.

That happens eight to 12% of the time.

Yeah.

Okay.

So like, it's, yeah, I do think that that is really interesting where it's like, ideally, let's schedule this surgery.

Let's pencil it in.

But what are the risks associated with that?

And those risks can be severe, right?

Not just high risk, but like high risk outcomes.

Like the risk, the outcomes are really bad.

Yes.

Yeah, exactly.

Yeah.

And then there's also the risks of surgery, which are not trivial, and especially depending on the person, what their other risk factors are, et cetera, et cetera.

Like it's, it is not a straightforward thing.

And that is why I think there is still such a,

I won't say debate, but just like, what is 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.

And 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 gallbladders 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, oh, your whole colon.

You can do it all and live without these organs.

But should we?

It depends.

Right.

Yeah.

Number one,

I have two thoughts.

One is a thought.

One is a question.

Let's do an episode on gallbladders because I want to know a lot more.

I know.

Yep.

About gallbladders for personal reasons, but also purely curious academic reasons.

Personal and professional reasons.

Exactly.

And number two,

why does appendicitis make you vomit?

Is it the pain?

That's a good question.

I have no idea.

Is it the pain?

Is it also just that like you have inflammation in your guts overall?

And so your response to that is like, well, but why do you vomit rather than have diarrhea or something?

You can have, absolutely can have diarrhea.

Oh, you could just be both.

Okay.

Yeah.

I feel like I don't as commonly read about the diarrhea part of appendicitis and mostly hear about the vomiting.

You can have diarrhea, you can have constipation.

And sometimes that can make it harder for somebody to diagnose it pinpoint as appendicitis because you're right.

The classic description doesn't include diarrhea or constipation.

Right.

And I'm sure that like part of what's contributing to all the confusion is that people hold very strong opinions about what is the right course of action to be done.

Well, and it's also like, we're talking about surgery versus non-surgery.

And if you're a surgeon, you're going to have a different opinion about that than if you are not a surgeon too, right?

Like,

or if you're the patient and you're like, I want surgery because I don't want to have to have this happen again and have to run to the ER.

And that's why it's such like at this point, and I think probably from this point forward, it is and will be an individualized decision.

It's not, it shouldn't be.

That is more and more the way that medicine is moving, right?

Is it's like there is not a one-size-fits-all approach because everyone is also going to have a different risk tolerance

for surgery and for not surgery.

Like there's so many.

Oh, so many.

I could keep going.

But if you want to just learn more, instead of hearing us blather on,

we've got sources for you.

We do.

I have a few different sources here.

So again, I want to shout out that video on YouTube by Patrick Kelly titled What Happened to Appendectomies.

Great channel overall.

Great video.

Loved it.

And then if you would like to learn more about the history of appendicitis and appendectomies, there is several papers.

One I liked called Historic Phases of Appendicitis from like 1931.

It's a little bit old, but kind of fun.

And then for the paper that discussed the function of the appendix, there's a paper from 2007 titled Biofilms in the Large Bowel Suggest an Apparent Function of the Human Vermiform Appendix by Bollinger et al.

Give it, give it all to us in the title.

I had a few papers, a bunch of reviews.

There was one from JAMA 2021 titled Diagnosis and Management of Acute Appendicitis in Adults, a review.

There were several reviews of the use of antibiotics versus surgery for appendicitis, which were really interesting, both in adults and in kids.

So, there's a couple different papers there.

Um, and then there's more.

Uh, that one where I briefly mentioned the connection between the appendix and ulcerative colitis.

That was from a nature reviews and gastroenterology paper from 2023 titled The Appendix and Ulcerative 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, thispodcastwillKillyou.com, under the episodes tab.

Thank you again, Molly, so much for sharing that story with us.

Just thank you.

Yeah.

Thank you also to Blood Mobile for providing the music for this episode and all of our episodes.

Thank you to Tom Breifogel and Liana Scolachi for the incredible audio mixing.

Thank you to everyone at Exactly Right.

And thank you to you, listeners.

We hope you enjoyed this episode.

Do you still have your appendix?

A lot of you have written in saying that you, in fact, no longer have your appendix.

Have your lives changed at all since having it out?

I actually never asked someone that question.

Curious.

Yeah.

Yeah.

And a huge thank you, as always, to our fantastic patrons.

We appreciate your support.

It truly does mean the world to us.

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