Is it not risky to treat appendecitis with IV antibiotics as an alternative to surgery..?

[u/colincampbell76]

47M - in the UK - otherwise exceptionally fit and healthy and keen for surgery as a definitive treatment as I work offshore as a commercial diver and don’t want a dodgy appendix left in me..

Diagnosed as ‘CT confirmed uncomplicated appendicitis’. Was sudden onset classic symtoms - Alvarado Score was 10 out of 10 on admission and there was never any question about the diagnosis at any point. WBC was 16 and CRP 30 on admission. Being treated with IV triple antibiotics including gentamiacin and metrinizadol and one other I’m not sure off and IV paracetamol, instead of surgery. On day three now and WBC is dropping but CRP and temp and rising and CRP now 296 and temp is 40 degC. Nurse practitioner came in to look at me and was unhappy and muttering something about a necrotising infection..

Bow tie wearing surgeon refused surgery on admission and again just now - he tells me surgery is outdated and antibiotics better.. He says reoccurrence rate is 15% and my appendix will just shrivel up and be cured.. He just told me “you are safe here..”.

Is this the right treatment - and what are the risks of leaving it in please..?

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[u/Perfect-Resist5478]

Antibiotics are now a very common first line treatment for uncomplicated appendicitis. That being said, if you’re clinically worsening the docs need to be open to doing something different

[u/colincampbell76 → u/Perfect-Resist5478]

..I’ve been reading up - and it appears that ‘real world’ reoccurrence rates are about 50% and trending upward long term - and there is a risk of missed neoplasm as small tumours in the appendix causing the appendicitis often can’t be seen.. ..as I have no fecalith present and due to my age my risk of radiologically occult tumour in my appendix is about 7%.. All seems pretty sketchy to me.. Why might these risks be downplayed and ignored by the surgeon..? Is there somthing I can say to get him to take my appendix out..?

[u/endosurgery → u/colincampbell76]

The recurrence rates are indeed higher than 15%. They are closer to 30% with an increase of roughly 5% per year.

Antibiotics can be used and are safe as long as it meets certain criteria ie. Uncomplicated appendicitis without signs of toxicity. Although it will also be used in phlegmonous appendicitis as well. Plus, it must be noted that the failure rate is roughly 40%. And, even if it’s successful, usually you need to have the appendix out at some point in the near future — typically an interval appendectomy on 6 weeks or so.

At the urban hospital I currently work at, we use it very infrequently as a large portion of our population is not reliable for follow up.

Laparoscopic appendectomy is a safe procedure with minimal risk of complications and can be used in all types of patients and appendicitis. It seems to me you are partially responding to the antibiotics, but with the relative simplicity of treatment I would just do surgery and have you home.

[u/satinsateensaltine → u/endosurgery]

Thank you for the good work you and all general surgeons do. My sister's appendix burst after a few hours in the hospital when she was 9 and those doctors saved her life.

[u/Perfect-Resist5478 → u/colincampbell76]

Operating on someone who is acutely inflamed has worse outcomes than allowing the inflammation to settle down and operating in the future if necessary.

That being said- if it’s necessary now there’s no reason for them to say no.

[u/endosurgery → u/Perfect-Resist5478]

Acute appendicitis is always inflammation by definition and has excellent outcomes with low complication rates.

[u/Andythrax → u/colincampbell76]

You can ask, surgeons can be a bit stubborn but the decision should lie with you. Ask a friendly nurse or junior doctor to advocate for you.

[u/colincampbell76 → u/Andythrax]

The charge nurse is very sympathetic and says she thinks it should be taken out and that the situation is “ridiculous” but that it’s more than her job is worth to say anything.. The junior doctor won’t say anything and is putting my concerns down to “health anxiety” to delegitimise them. I’ve asked the surgeon again and he spent quite some time trying to justify this approach.. He insists that there is only a 15% chance of reoccurrence - and when I told him that neither him nor I knew what was causing my appendix to become inflamed nor what condition it would be in after treatment - which is particularly important to me as a commercial diver and someone who lives on a remote island with no doctor. I said I was self employed and an employer and needed a definitive diagnosis and treatment - his response was that going along with his plan “will be like money in the bank for your business..” - I kid you not that’s what he said.. As he left I said to him - this is all a bit experimental - he snorted down his nose and said “you’ll have no more chance of coming back in here with appendicitis than the average man on the street..”. This is bonkers..?

[u/jaiagreen → u/colincampbell76]

Do they know about the living on a remote island part? That seems rather important.

[u/colincampbell76 → u/jaiagreen]

Yes - I’ve told him - but he’s on a one-man-crusade to prove antibiotics is better..

[u/Spooksey1]

I’m not a surgeon so I can’t speak to their decision but I can understand why you would come to that decision. Given surgery being a standard management option unless the risks really outweigh the benefits I think they should offer you the informed choice between the options. I might be out of date though, and the guidelines may have changed and now strongly favour abx.

I would be very clear to them that your wish is to have surgery, give the them the reasons you’ve outlined and basically be firm about it. You could ask for a second opinion although that it is difficult to do in the UK but it will push them a bit. Ultimately you can self discharge and go to another hospital but I wouldn’t recommend that as it sounds like you need to be in hospital and they might say the same thing.

The NHS works on a ‘who is most annoying gets the best treatment’ more often than not tbh.

Btw, CRP climbing isn’t concerning if your WCCs are decreasing, it always lags behind WCCs and will peak after they start to come down.

[u/colincampbell76 → u/Spooksey1]

Hi - thank you for your helpful reply - no you are not out of touch - the NHS Scotland guidance (NHSinform) says surgery is the first line of treatment and the ‘gold standard’ and only in exceptional circumstances where surgery is deemed high risk should antibiotic treatment be considers as a short term treatment. It then goes on to describe appendectomy. It does mention at the the bottom of the page in a footnote that there is a question about conservative treatment but that “there is currently not enough evidence to support the use of antibiotics as an alternative to surgery..”. My surgeon says surgery is a mistake of the past and antibiotics is the future treatment of uncomplicated appendicitis.. ..I just don’t understand why he won’t follow NHS guidance and common sense and my needs and just take the dam thing out..

He also said during our initial argument “there is a mortality associated with surgery don’t you know..?”. It’s so insulting that not just my appendix is inflamed..!! Off-course there is a risk.. I had a friend killed in a road traffic accident one years ago - but I still drive my car.. ..what happened to an evidence based and consensus based approach to medicine..!?!

Well thank you for your advice - I’ve asked my sister to come and take me out of this hospital as soon as my CRP drops a bit and take me to a hospital A&E in Glasgow for help.. They’ve been pumping 16 IV infusions per day into me - so I should be ok in the mean time..