Appendicitis without surgery?
An inflammation of the appendix in the appendix - called appendicitis by doctors - does not always require an operation. When medication can help
The appendix challenge: it is a problem child.If inflammation occurs, the appendix usually has to be removed. However, this is more important for the immune system than assumed
© W & B / Schöttger
It is only a few inches long. But it can cause a lot of trouble. If the appendix becomes inflamed, as the appendix of the appendix itself is called colloquially, there is a risk of a breakthrough. And that is still considered a life-threatening emergency today. So far, doctors have only had one option for an inflammation: get out of it!
For some years now, however, there have been increasing indications that there is another solution besides the radical one. Studies have shown that antibiotics can be a safe alternative. In Germany, many experts initially remained skeptical. But here, too, a rethinking is apparently slowly emerging.
If appendicitis is diagnosed in children or adolescents at the Berlin Vivantes Clinic Neukölln, this now only means in a few cases: immediately to the operating room! Only if the appendix has broken through or is about to be operated on does it need to be operated on. This also applies if foreign objects such as hardened feces clog the appendix.
In an uncomplicated case, as doctors call milder inflammation, the head of the Clinic for Newborn and Pediatric Surgery, Professor Bernd Tillig, offers the parents an alternative: treatment with antibiotics. The children are given pain medication and remain in the hospital for monitoring for about three days. "If the antibiotics don't work within 24 hours, we operate," says Tillig.
Surgery only in an emergency
This affects about a third of the children. However, the delayed intervention has so far never led to complications. The other two thirds are spared an operation for the time being. In some cases, however, the appendix becomes inflamed again afterwards, and then an operation is carried out. In principle, however, a new treatment with antibiotics would also be possible.
A clear diagnosis is crucial to avoid complications. In addition to the physical examination, the ultrasound in particular provides valuable information. "This gives very reliable results in children," says Tillig. However, there are big differences. In addition to the quality of the device, the experience of the doctor performing the examination is particularly important.
Overall, the results of this new approach are quite positive. According to Tillig, general medical recommendations cannot yet be derived from this. "These are the first approaches. The parents must be fully informed and agree," says the pediatric surgeon.
Part of the immune system
Tillig does not only find it sensible not to have the appendix removed because it saves patients an operation. If the appendix was previously thought to be a useless relic from the history of human development, the point of view has now changed. "The appendix is part of the immune system," explains Tillig. Among other things, it forms a reservoir for important intestinal bacteria. If the intestinal flora is disturbed, for example in the case of diarrhea, the appendix serves as a "bacterial reservoir". The regeneration is faster if the appendix is still present, as studies have shown.
This also applies to adults. Should one therefore try to preserve the organ with them too? Although antibiotic therapy has also shown good results in studies, experts are still reluctant.
The appendix challenge
One reason for this: the uncertainty of the diagnosis. The severity of the inflammation cannot always be reliably determined from the symptoms and blood count. "In adults, the results of the ultrasound are significantly worse than in children," explains Professor Albrecht Stier, chief physician of general and visceral surgery at the Helios Clinic in Erfurt. Often the inflamed intestine is inflated by air, or the appendix is simply not recognizable. Obesity also makes diagnosis difficult. The appendix proves to be a challenge even for experienced doctors. "You can't rely on anything with appendicitis," says Stier.
To be on the safe side, the doctors at the university hospital in Turku, Finland examined the patients in a computer tomograph (CT) before treating them with antibiotics. "This means a high level of radiation exposure for the patient," warns Professor Joachim Jähne, head of the Diakovere Clinic for General and Visceral Surgery in Hanover.
The stress of a CT scan of the abdomen is roughly the same as that of 500 chest X-rays. This can only be justified in the case of older patients, if the imaging can also clarify other possible causes of the disease.
Surgeon's advice, patient's will
Nevertheless, the surgeons Stier and Jähne do not completely reject the drug alternative. "If anesthesia is dangerous for the patient, there is a strong risk of bleeding or the diagnosis is unclear, then antibiotics can be tried," says Stier.
What does the patient want?
The wishes of the patient also play an important role for surgeons. Everything speaks in favor of a mild course of the inflammation and the person concerned wants to avoid an operation, a treatment attempt with antibiotics is entirely justifiable - if the patient is well monitored. Jähne: "If the symptoms get worse, that means go to the operating room immediately!"