Comment by crazygringo | Hacker News Reader

Comment by crazygringo | Hacker News Reader

I'm so confused. From Wikipedia:

> Appendicitis is caused by a blockage of the hollow portion of the appendix. This is most commonly due to a calcified "stone" made of feces. Inflamed lymphoid tissue from a viral infection, parasites, gallstone, or tumors may also cause the blockage... The combination of inflammation, reduced blood flow to the appendix and distention of the appendix causes tissue injury and tissue death. If this process is left untreated, the appendix may burst, releasing bacteria into the abdominal cavity, leading to increased complications... Acute appendicitis is typically managed by surgery. While antibiotics are safe and effective for treating uncomplicated appendicitis, 26% of people had a recurrence within a year and required an eventual appendectomy.

Given that bacteria are not even listed as a cause of appendicitis above, how do antibiotics help at all? Is there anything they can do to prevent "tissue death" in the appendix itself, and how? What about that "stone"?

Or are the antibiotics for dealing with an actual ruptured appendix (to kill leaking bacteria from the gut into the rest of the body), while the appendix presumably eventually resolves its blockage and heals itself on its own? Which sounds... scary, but of course I'm no MD.

Would love if anyone here knows how to explain what the article doesn't.

> Or are the antibiotics for dealing with an actual ruptured appendix

If your appendix ruptures, it is life threatening and has to come out.

Most appendix removals happen before the appendix ruptures. The conclusion of the study is that high doses of antibiotics is an effective way to prevent the appendix from rupturing without surgery.

I still have the question: what about the 'stone'? Do antibiotics cure that somehow? Or is that the reason that 30% of those treated with antibiotics ultimately have the surgery?

I thing it is the second one. I don't see antibiotic helping with that.

Just a guess, but maybe they can do the same thing they do with kidney stones with shock-wave therapy, though I feel like they would mention that somewhere in wiki or the article.

One of my kids had his appendix out last year, and I asked a similar question. My recollection was: Blockages can form and resolve on their own -- it's possible he'd had blockages before, felt pain, but they resolved before an infection could occur. You could be having this happen right now, but it could resolve later in the day and you never notice anything. Or the blockage could be too severe and never resolve on its own.

the actual study states that presence of a stone was an exclusion criteria

I think what he is saying is that "viral infection, parasites, gallstone, or tumors" doesn't include bacteria.

> If your appendix ruptures, it is life threatening and has to come out.

It is life-threatening, but it most certainly doesn't have to come out for full recovery. In some cases, it's impossible to remove due to the infection (inflammation, abscess) obfuscating its location. The treatment is aggressive intravenous antibiotics for a period of time, then oral antibiotics. The statics for recurrence after recovery I've had quoted as between 1/4 and 1/3 lifetime chance, and patients are advised on proactive surgery to remove what remains of the appendix.

Yes, this is exactly what happened to me. The only exception is that the nurse told me if they don't find pill antibiotics strong enough then I'd require daily intervenous antibiotics. However, I was glad they did find some.

> The conclusion of the study is that high doses of antibiotics is an effective way to prevent the appendix from rupturing without surgery.

I've been through a few million dollar surgeries and I had my appendix out as well. When you get a blocked appendix (appendicitis induced), you create scar tissue from the inevitably distended bile duct. Now you have an increased chance of it occurring again, and a weaker duct (scar tissue is generally weaker). This snowballs. Removal is the safe course after the first onset. This study assumes 2 things. First, that no major damage is done over the course of appendicitis attack(s). Second, the patient is compliant with a dietary restriction and an antibiotic course. Yes, you don't NEED to have your appendix out after the first attack if you eat right. The chances that a patient is compliant is less than 50% This is just a medical reality. People who take blood thinners have to be monitored, more for compliance than anything else, and there's a whole industry to the more dangerous conditions than appendicitis.

No, it's not a medical reality. It's a perception in the American system. Europe currently follows the high dosage antibiotic approach.

I would agree that it's "not a medical reality", in that it does apply only to the USA.

I think the antibiotics probably tone down the inflammation (not sure why) which resolves the appendicitis.

It's also possible our previous understanding of appendicitis (as documented on Wikipedia) needs to be updated in light of this study.

I thought the stuff in your gut wasn't feces until it'd been through at least the small intestine?

The appendix is right after the transition between the small and large intestines.

in general the presence a stone (appendicolith) would no longer qualify as uncomplicated acute appendicitis. I did not see if that was specifically mentioned in this trial, but I have seen similar trials enrolling in the US where this was the case

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