Editor’s Note: This article is a reprint. It was originally published October 17, 2018.
You’ve probably heard that your appendix is a useless organ, an artifact from our ancient past when early humans had to digest tree bark and other fibrous materials.1 However, modern medical science has again proven your body does not contain superfluous organs that serve no useful function. Unfortunately, the idea that your appendix is little more than a nuisance and potential health risk has led to the routine removal of this organ. Many doctors will even suggest prophylactic removal of the appendix when you’re having some other abdominal surgery done. As noted in a 2017 paper:2
“Appendectomy is the most common emergency surgery performed in the USA. Removal of a noninflamed appendix during unrelated abdominal surgery (prophylactic or incidental appendectomy) can prevent the downstream risks and costs of appendicitis. It is unknown whether such a strategy could be cost saving for the health system.”
Based on hypothetical patient cohorts aged 18 to 80, the researchers concluded that people under the age of 30 could save about $130 over their lifetime by undergoing prophylactic appendectomy during other elective abdominal surgery. However, considering the potential benefits of keeping your appendix, saving $130 over a lifetime doesn’t seem very good value proposition.
Your Appendix Has an Immune Function
Your appendix is found in the lower right portion of your abdomen. This small, slimy, finger-shaped organ is attached to the cecum, a small pouch that’s part of the intestines (the cecum is considered to be the beginning of the large intestine) and is part of your gastrointestinal tract.3 According to scientists in France and Australia, your appendix actually plays an important role in your immunity. Published in Nature Immunology, their study showed that the appendix — with the help of white blood cells known as innate lymphoid cells (ILCs) — works as a reservoir for beneficial bacteria (probiotics), which are essential for good gut health and healing from infections.4
When certain diseases (or use of antibiotics) eliminate the healthy bacteria in your gut, the appendix works as a storage unit for some of these probiotics. The researchers say that these findings should make people rethink whether the appendix is “irrelevant” to their health. Once your body has successfully fought and rid itself of the infection, the bacteria emerge from the biofilm of the appendix to recolonize your gut, bringing it back to a healthy state. According to Gabrielle Belz, a professor at Melbourne’s Walter and Eliza Hall Institute:5
“We’ve found that ILCs may help the appendix to potentially reseed ‘good’ bacteria within the microbiome — or community of bacteria — in the body. A balanced microbiome is essential for recovery from bacterial threats to gut health, such as food poisoning.”
Despite such findings, other research6 suggests prophylactic appendectomy “is ethically justifiable, as there are few complications,” and “allows early detection of malignancies.” In this case, 10 cases of cancer were found as a result of prophylactic appendectomy on 173 patients. In the end, it may be an issue of personal choice after considering the pros and cons of removing this organ. Personally, I believe having the ability to repopulate your gut with beneficial bacteria after infection is a significant health benefit that I would be reluctant to eliminate unless absolutely necessary. And, research suggests surgery may not even be necessary in most cases of appendicitis either.
Two-Thirds of Appendicitis Cases Do Not Require Surgery
According to a Finnish study,7,8,9,10 nearly two-thirds of patients with appendicitis can be successfully treated with antibiotics alone. In the U.S., an estimated 300,000 appendectomies are performed each year, which means some 199,800 people undergo surgery unnecessarily. Not that antibiotics are without their side effects in damaging the microbiome, but it appears to be the lesser of two evils in this setting. Overall, the lifetime risk of appendicitis in the U.S. is 1 in 15.11 As reported by Live Science:12
“The study looked at data from more than 250 adults in Finland who had appendicitis … and were treated with antibiotics. This group was compared with another 270 adults who had surgery for appendicitis. All of the participants were followed for five years. At the end of the study, nearly two-thirds of people who received antibiotics (64 percent) were considered ‘successfully treated,’ meaning they didn’t have another attack of appendicitis. The other 36 percent eventually needed surgery to remove their appendix, but none of them experienced harmful outcomes from the delay … It’s important to note that all patients in the study had uncomplicated appendicitis, meaning their appendix had not burst, which was confirmed with a CT scan. (Patients with a burst appendix would indeed need surgery.)”
In an accompanying editorial,13 deputy editor of JAMA, Dr. Edward Livingston, noted that these findings “dispel the notion that uncomplicated acute appendicitis is a surgical emergency.” Interestingly, of the 100 patients in the antibiotic group that later went on to have surgery anyway, seven of them actually had no evidence of appendicitis at the time of surgery — a finding that hints at underlying skepticism and an ingrained idea that it’s better to just take the appendix out to be done with it once and for all.
Pros and Cons of Antibiotic Treatment
The antibiotic treatment group also had fewer complications than the surgical intervention group — about 1 in 4 surgical patients suffered some sort of postoperative complication, ranging from abdominal pain to surgical wound infections — and those who received antibiotics took on average 11 fewer days off from work (surgical patients took on average 22 days off from work). Cost is also a factor, as surgery is far more expensive than a round of antibiotics. In this study, antibiotic treatment consisted of intravenous antibiotics for three days, followed by oral antibiotics for seven days. On the downside, antibiotic treatment for suspected appendicitis could exacerbate the emergence of drug-resistant superbugs, so wanton use of antibiotics is not necessarily ideal either. Dr. Paulina Salminen, a surgeon at the University of Turku in Finland who led the study, told The New York Times:14
“If I have a CT scan, and I can see that the appendicitis is uncomplicated, I would discuss with the patient the possible results of antibiotic treatment alone or surgery. Then we would make a joint, unbiased decision about what would be best.”
Other Supporting Research
This isn’t the first time researchers have found antibiotics can do the job well enough that surgery becomes unnecessary. A 2014 study15 published in the Journal of the American College of Surgeons reviewed 77 uncomplicated cases of acute appendicitis that met certain criteria. Here, 30 of the patients were given intravenous antibiotics for 24 hours and oral antibiotics for a week instead of surgery. Those whose condition did not improve after the first 24 hours had their appendix removed surgically at that time. Of the 77 participants, only two required surgery within 24 hours, while a third needed an appendectomy after being discharged due to lack of improvement. However, none of the patients experienced complications. The other 27 participants who received antibiotics missed fewer days of school and went back to their normal activities much sooner than those who underwent an appendectomy. Nationwide Children’s Hospital professor of surgery and senior study author Dr. Katherine J. Deans said,16
“It’s so dogmatic to operate for appendicitis that it requires a huge paradigm shift. But there are choices. It may be safe to wait.”
Signs and Symptoms of Appendicitis
While the proper course of treatment may be up for debate, what’s clear is that appendicitis can be a serious condition that needs to be addressed. In short, appendicitis is inflammation in the appendix, usually caused by pathogenic bacteria. Once these harmful bacteria multiply rapidly, it can lead to swelling and formation of pus in the organ.17 Hallmark symptoms of appendicitis include intense and progressively worsening pain in the lower, right-side quadrant of your torso, nausea and vomiting. It can occur at any age, although people ages 10 to 30 tend to be more susceptible.18 If you suspect that you or someone you know is suffering from an inflamed appendix, do seek immediate medical attention. If not addressed, the swollen appendix can rupture and may be fatal. Just remember that surgical intervention may not be necessary if you have a case of uncomplicated appendicitis. A round of antibiotics may suffice in many cases.